Category Archives: Physicians

Office of Recovery: Avellone proposes strong response to substance abuse (transcript)

Joe Avellone (D), candidate for Governor

Joe Avellone (D), candidate for Governor

This is the transcript of my recent podcast interview with Joe Avellone, Democratic candidate for Governor of Massachusetts.

David E. Williams: This is David Williams from the Health Business Group. I’m speaking today with Joe Avellone, Democratic candidate for Governor of Massachusetts. We spoke previously about healthcare policy in general. We’re going to speak today about substance abuse.

Joe, it’s great to have you on today.

Joe Avellone: I’m pleased to be here. Thank you.

Williams: Joe, why are you making substance abuse such a high priority issue in the campaign?

Avellone: Well, this is an issue that is quickly becoming a major healthcare crisis in our state. We’ve always had addiction problems, of course, of various types. over our history. But with the development of the new powerful health, the new powerful oral narcotics that had been in the market for the past 15 years, we’ve seen a huge acceleration of young people who are very quickly addicted to these painkillers either by using them recreationally or if it’s just happening or even starting out with sports injuries. And from there, becoming so quickly addicted they move on to other things, in particular, heroin.

And this has been a new phenomenon. Over the past 15 years, the rate of prescribing these drugs had gone up 300% and the rate of actual overdose deaths and prescription pills had gone up 300% in the same time period. So we’re seeing something that is reaching significant public health crisis proportions. It’s really being driven by the use of these powerful oral prescription drugs that then lead to other kinds of addiction.

I have seen the human face of this all throughout the Commonwealth over the last year. I’ve been running for over a year and I’ve been in 130 cities and towns. It really comes up in lots and lots of communities. So it’s affecting lots of communities all across the Commonwealth, certainly in our big cities but also in our smaller towns. And it’s in particular affecting children at relatively young ages in their early to mid-teens. So they first experience this and often are addicted within weeks of starting to take some of these kinds of oral medicines.

Williams:   Talk a little bit more about this heroin issue because I’ve heard this as well. People start with oxycontin or something similar and then when their prescription runs out and they found out how expensive it is to buy those pills on the street, they end up on heroin. Is this just something people say for shock value or is it really happening in any significant numbers?

Avellone: No, unfortunately, it’s really happening in very significant numbers. The addiction potential for these powerful oral narcotics – oxycontin, even Percocet, the other kinds of new opiates – is so strong that within weeks of either experimenting or taking for a mild medical problem, the young people in particular are often addicted. And then, they start down this road of taking them out of their parents’ medicine cabinets or their neighbors, et cetera, and using them at parties. But soon, at $30 a pill, which is about what these things cost on the street, they become so addicted that they move to heroin. And heroin to them does not hold the fear that grips all of us who are a little older. It’s much cheaper than these pills at $7 a bag versus the $30 for a pill. It’s now so plentiful and easier to use than it used to be. So there is a very quick transition and before you know it, you have a lot of young people from middle class families who were playing by all the rules and, all of a sudden, went off the rails with taking these prescription drugs and then end up on heroin within months.

And then, the heroin itself, as you know, ushers in all kinds of other issues especially if it’s using needles. You’re exposed to all the blood-borne diseases and also the heavy addiction and the need to find more heroin.

Williams: Now, clearly, the state’s been paying some attention to substance abuse. What are we doing right and what are we doing wrong on this topic in Massachusetts at the moment?

Avellone: Well, we have a substance abuse department in our public health department and we have a drug monitoring program for these prescription drugs. But all of it is not nearly enough to be effective to combat what is really an epidemic.

And I think that’s the point and that’s why I formed the Office of Recovery. In the end, we’re going to need a lot more capacity. We need to do multiple things that we’re not doing now and we’re certainly not doing on the scale in order to meet the need that is out there.

Williams: Have you seen other states or other countries that are doing things better? Are we a laggard here or is it just that the problem has come up so quickly that others have not come up with a good response either?

Avellone: No, I don’t think we are a laggard in the traditional sense. I think if we’re viewing this as a traditional problem at the level that which we all thought it was affecting our population, our Bureau of Substance Abuse is doing an adequate job. But that is not where we are. What is happening is this is mushrooming, it’s affecting many more people. And we are not at all treating it in the way that we should: dealing with it as a crisis, which is really what it is.

Williams: You’ve announced a plan for this area. What are its key components?

Avellone: I’ve announced the formation of Office of Recovery. This will have to be at the state level because it affects so many towns and cities across our Commonwealth.  It has to be high in the Office of Health and Human Services, so it will be a direct report in the Executive Office. We’ll take in the current Bureau of Substance Abuse because those traditional roles that are being played there would need to continue, but we need to expand it.

The Office of Recovery will, first of all, increase our capacity. We do not have nearly enough capacity to deal with either detox or rehab or the sober houses along the spectrum. We need to reimburse our providers more to bring more capacity on line. Increasing capacity is the first part of this.

This Office will have a whole series of regional coordinators that will, in a very publicized way, make it possible for people to have one number to call and they know to call this number when they need treatment. One of the problems of intervention is making sure that the treatment is available and that people can get into treatment right when they need it, right when that window is open.

And we know that window’s not open very long. People, when they finally get the resolve that they can actually treat themselves, they have to move on to make a big change and we need to find them and they need to find treatment then. And that’s what the regional coordinators will do.

In addition, I’d like to staff them with people who’ve been in recovery. There’s a large recovery community that can be very helpful to people who are suffering from addiction and really help them clear the course and get into treatment.

In addition to standing capacity and the regional coordinators, we need to change the way insurance coverage works. Right now, part of the problem is gaps in insurance coverage and slow approvals. And that, once again, creates roadblocks in the system where people are stuck in detox because they can’t get to rehab or they’re stuck in rehab because they can’t get into the next step. Or they have to wait for approvals and if the approvals don’t come, once again, they fall back into their addiction and are lost.

Another key component of this is to move away from putting minor drug offenders in jail. Right now, we have many thousands of people in our county jails; about 75% of them are there for drugs or drug-related problems; and a large percentage of those are addicted. The males are in jail in these county jails for approximately a year, and they cost about $46,000 a year. If we were not putting people in jail and were using that money differently, which we will in my administration, that would cover a lot of treatment.

The vehicle for doing this is drug courts. We have about 21 drug courts around the Commonwealth. We need to have about 50, people estimate. We need to make sure we have it in every jurisdiction. These drug courts operate specialized programs that help people not only not go to jail but then move through their recovery and guide them through their recovery. Specialized courts cant do that.

And finally, we need to much more aggressively step up our drug monitoring. We do have a drug monitoring program but obviously, the prescribing patterns are not what they should be. We are over-prescribing either wittingly or unwittingly in a large amount. There are so many of these pills sitting around unused in medicine cabinets. That’s how the diversion occurs, especially with these young people.

I have heard so many stories from mothers and parents of addicted children, of the fact that they were getting prescriptions for wisdom teeth or other relatively minor ailments that they don’t even want. They have so many pills and would have these pills sort of sitting around. And this is a big problem.

So we have to be much more vigilant about our prescribing practices. I’m going to work with the Massachusetts Medical Society on education programs and also with the Board of Registration in Medicine to make sure we have people who are knowingly prescribing the things that they are appropriately dealt with.

So, these are the major components of my Office of Recovery but I want to go beyond that. I think we need to deal with this as a region as well.

Williams: Joe, we’ve been talking mainly about how these prescription narcotics are causing problems in terms of addiction leading to heroin. I want to ask you about two other substances and how and if they fit in here. One is alcohol, the other marijuana. I’ll separate those out.

Alcohol, often people talk about the large impact that it has relative to higher profile and scarier sounding substances. And then on marijuana, we seem to be on a path toward outright legalization as we’ve seen elsewhere, which seems to be going sort of in the opposite direction from a public health standpoint.

How would you view those substances fitting into the Office of Recovery?

Avellone: I think alcohol should be incorporated in that. I spent a fair amount of time in the treatment facilities, for example, the Dimock facility in Roxbury and also SSTAR, which is a wonderful facility in the Fall River area. And clearly, they treat alcohol as an addictive substance like the other drugs that they deal with. There are some differences but they accommodate those differences in the program. It clearly destroys lives just as surely as these powerful opiates do. So I do think that this is part of our issue and a problem that ought to be addressed to the Office of Recovery.

I feel a little bit different about the marijuana. I don’t think that would be the main focus of this right now because I want to deal with the more powerful and addictive drugs that are essentially killing people and ruining lives and destroying families right now. And that’s why, alcohol and in particular, these opiates, especially prescription drugs and then heroin.

Williams: When you put these plans in place for the Office of Recovery, what would be realistic or aspirational to expect the impact to be? Is it possible to really take this problem on or are we really just talking about taking a little bit off the edges of it?

Avellone: No, I think it really is possible. I think we have to understand how acute the problem is right now. Now, just to deal with the overdose deaths alone, which is certainly the tragic end state of this, we have had 11 overdose deaths per 100,000 of the population. So, that’s over 600 a year. And we know that’s just the tip of a very large iceberg of people whose lives are destroyed or being destroyed but are living and going through a living hell every day.

But just dealing with overdoses, those are the statistics. They’ve gone up to 11 per 100,00 from 7 1/2 per 100,000 just ten years ago. So, it’s rising rapidly. That’s a big change. We heard about the fact that we had 185 overdose deaths just in the last three or four months, and we know that was a very incomplete number because it didn’t even deal with Boston and Springfield, our major metropolitan areas. We know that even at 11 per 100,000, which has been released as statistics, it’s certainly going to be more than that next year and rising relatively rapidly.

So, I know this is an issue that we can definitely, if we treat it aggressively, do something right. We know that treatment plan works and we also know that right now, we’re not treating it adequately at all.

The biggest thing of all the Governor can do and which I would certainly do is to take the stigma away from addiction. I think part of why we treat this inadequately and why people don’t seek treatment is because of our attitude about it.

However, I think we now recognize that this is a health problem and this is something that the Governor needs to take the lead in. It’s not a moral issue. It’s a health issue and we have to treat it that way. If we can remove the stigma, then a lot of things become easier. Getting people into treatment, moving people away from jail sentences and enabling people to rebuild their lives, which they can if we can get them the right treatment.

Williams: Joe, you talked about the societal cost here and even some hards cost in terms of the cost to incarcerate someone. But in setting up an Office of Recovery like this, I’m sure there are new budgetary expenditures that are needed. What’s the order of magnitude of those and how do you finance such an effort?

Avellone: The cost is about $1,000 per person but the benefit to cost ratio of treatment is huge. Many studies show that it’s something like seven to one. And those benefits come from several different sources. First of all, let’s just start with jail. Right now, we’re putting literally thousands of mostly young people in jail for minor drug offenses related to their addiction. That’s at $46,000 a year because as I said, in the county jails, the males are there for about a year.

If we just, next year, incarcerate 500 less, then that’s a fraction of the 10,000 people that are in the county jails. That’s $23 million plus for treatment. So that covers an awful lot of treatment. Literally, incarcerating people less almost covers the whole total cost of the treatment. In addition to that, the healthcare cost is much less. If people are successfully treated, there are many fewer trips to the emergency room and they have many fewer other high costs due the healthcare issues that the population with addictions have.

So this is more about moving money in the budget that we already have because of new expenditures that we’re not incurring. And I believe that we can do this without a big increase in the budget. That’s why it has to be done as a high priority in the Governor’s Office because it’s going to take moving dollars away from some parts of our budget and into others. And doing that in a very, I would say, calculated way. It’s going to take leadership to do it but I think the analysis will bear us out that we can move the dollars and accomplish much.

Williams: Joe, you have been having a quite a comprehensive discussion here about issues of substance abuse in a Commonwealth and in your plans that will be able to address it. Are there topics that we have not addressed that we should do today?

Avellone: Thank you, David. I would like to talk about the regional initiative I’m proposing. I’m going to, once elected, pool together the other Governors and the whole Congressional delegation in the region. So with six states – that’s six governors, 12 senators and 21 congressmen – I believe that we can be more successful in some respects with this operating as a regional initiative.

And the first is to go put a lot a pressure in the FDA. The FDA needs to have a much higher safety profile when approving new narcotics. And I think this is a failing. I think they were essentially suffering now from something that they should have done ten years ago. I think going forward, we have to make sure that they’re not approving narcotics that are powerfully addictive and yet easily available. That really is what has led to this great acceleration.

I also believe we can put some pressure on the pharmaceutical industry as well.

As a region, we have a lot more clout to deal with the FDA and with the pharma industry. I also think we can work together to cut down on the smuggling of heroin. The second half of this is the fact that heroin is so available and young people in particular moved to it as prescription drugs become harder to find than the heroin. We need to shut down the heroin pipeline and I think we can do that more effectively as a region.

I think also as a region we can learn best practices from each other and potentially even share facilities to deal with the ups and downs of our capacity needs. So, I believe this is something that we can effectively treat as a region and I intend to lead our efforts to do that.

Williams: This is David Williams of the Health Business Blog. I’ve been speaking today with Joe Avellone. He’s been talking about substance abuse and has proposed an Office of Recovery to address these issues.

Joe, thank you so much.

Avellone: Thank you very much, David. It’s my pleasure to be here with you.

By healthcare consultant David E. Williams of the Health Business Group

Office of Recovery: Avellone proposes strong response to substance abuse

Joe Avellone (D), candidate for Governor

Joe Avellone (D), candidate for Governor

Dr. Joe Avellone, Democratic candidate for Governor of Massachusetts, is very concerned about the impact of substance abuse. In particular, he’s zeroed in on addictions to narcotics and heroin that have arisen out of the widespread prescribing of powerful painkillers for serious and not-so-serious conditions.

His Office of Recovery would have high visibility in the Executive Office of Health and Human Services and focus on getting individuals into treatment during their window of opportunity.

In this podcast interview, Avellone describes why he’s making this issue a priority, how his plan would work, and how it compares to efforts elsewhere.

Earlier I interviewed Avellone and all other candidates for Governor about healthcare policy.

By healthcare consultant David E. Williams of the Health Business Group

15 minutes could save you… nothing in medical bills

Two medical bills arrived in the mail over the weekend. One requested $525 for a specialist office visit, another $250 for a routine colonoscopy at a hospital. Since I don’t think we owe for either of these and the numbers are pretty big I decided to tackle them.

The specialist bill was odd because it didn’t appear that the insurance company had been billed. We go to this specialist frequently and have had the same Blue Cross Blue Shield of MA plan for a long time so I wondered what happened. After going through the phone tree, being kept on hold and listening to a recording about “higher than normal call volume” I was connected with a customer service rep. She said, “actually looks like insurance just paid. Your balance is $5.” On the one hand I was happy but on the other hand if I had just waited for the next bill it sounds like I would not have had to call at all. I’m still not sure why they sent the bill to me without any indication of billing the insurance company.

For the colonoscopy I decided to call my health plan first to check whether I had full coverage. They had “higher than normal call volume,” too, which I think must be normal. They were surprised to hear about the request for $250 but then looked at the bill and said it had been submitted as an outpatient surgical procedure (for which I would owe $250) rather than as a routine preventive screening.

I then called the hospital and had a long wait on hold, although they didn’t say anything about it not being “normal” call volume. I explained the situation, the rep then went to do a bit of research and came back to tell me it was billed properly –but not as a routine colonoscopy– and could I please pay the $250. I said no, hung up the phone, and spoke to the patient who assured me it was in fact a routine, every 5 year screening.

Not exactly what to do next, I decided to send an email to the hospital (conveniently, there is a billing email on the bill) presenting the information I have. I was happy to receive a reply within one business day letting me know they were checking with the physician to look into it.

So bottom line: I spent about 45 minutes on these bills and don’t have a lot to show for my effort so far. On the other hand I have helped drive up administrative costs by prompting action from my specialist’s billing office, health plan customer service, hospital billing office and now a doctor.

By healthcare business consultant David E. Williams, President of the Health Business Group

Cut-rate concierge medicine? One Medical resorts to discounting

Good stuff, cheap

Good stuff, cheap

I have mixed views about concierge medicine. On the one hand I like the idea of higher service levels for patients and the ability for doctors to practice medicine the way they think is right without feeling like hamsters on a wheel. But overall I’m pretty skeptical.

  • I’m worried that concierge medicine may draw in physicians who are more concerned than average about their own lifestyles. My non-concierge doc works 80 hours per week and answers my electronic messages right away for no extra charge
  • It’s far from clear that the best primary care docs are concierge docs
  • Many concierge offices are just like regular primary care offices in that they make use of physician extenders: nurse practitioners and physician assistants. I have nothing against these professionals but it’s not what I’m looking for in a premium offering
  • The practices may make primary care more convenient and comfortable but I’m skeptical that they achieve anything special for patients who are really sick and end up in the hospital or under the care of a specialist

It is interesting to see just how inexpensive concierge care has become. One Medical Group in Boston charges only $199 per year for its concierge services. To put that in perspective it’s less than one percent of what my firm pays in premium for family coverage. And yet even at that rate the company seems to be having trouble attracting customers.

I had to chuckle when I received a brochure in the mail yesterday offering a $50 discount –actually a Whole Foods eGift Card– for new customers. Apparently even $199 is too expensive to draw patients in.

Maybe another way to look at it is that regular primary care in Boston is pretty darn good. You can get a same-day appointment if you need it, the doctors will spend the time with you when it’s called for and will go out of their way to help you get in to the proper specialist when required. Many will communicate by electronic message and return phone calls.

I’d actually be happy to pay an extra $199 or even more for a real improvement. And if my current doctor switched to a concierge practice model I’d go with her and pay more. But the concierge model as a whole has a lot to prove before it really catches on.
photo credit: Daquella manera via photopin cc

By David E. Williams of the Health Business Group.

When using a free health care website, consider the business model

Is a free lunch worth the price?

Is a free lunch worth the price?

When Google first came along I assumed that their business plan was to get users addicted to search and then start charging for searches. But it turns out they were a lot savvier than that. Instead of thinking of Google as a service to help users search out content, they thought of it as a service to help advertisers target customers. Users revealed their interests through their search habits, and Google delivered relevant customers to advertisers. Brilliant!

For a long time now Internet users have expected useful sites to be free. That’s true of consumer sites and it’s also true of professional sites. But before getting too involved with these sites it’s worth stopping for a moment to ponder their business models. That’s especially important for medical sites, where privacy is often a concern.

iMedicalApps  reveals the business model behind popular websites used by physicians:

Many free apps aren’t really free, though. We talked about the hidden price of free medical apps about two years ago, an issue that was later highlighted in the New York Times as well. In essence, the price of these apps is that we share enough personal information to enable targeted advertising, surveys, and so on.

What may come as a surprise to many healthcare professionals is that many apps they frequently use like Medscape and Epocrates share users’ names, NPI numbers, and other identifying information with pharmaceutical advertisers. As it turns out, Facebook and Twitter have stricter privacy policies than some of your favorite free medical apps.

The comments section is interesting. Most of those posting profess not to care if their information is shared. Maybe that’s reasonable, but at least it’s worth knowing that it’s occurring.

If you stop to think about it, it’s kind of obvious that “free” apps are leveraging user data to make money from other parties. Even so, many people are surprised when they learn about these business models. But even when the user pays there’s no guarantee that their data will be protected. Marketers are eager for information on doctors and others regardless of whether the user is getting a freebie. If anything, marketers are more interested in obtaining information about users with a demonstrated willingness to pay. And the purveyors of the information see no real reason not to double dip.

Edward Snowden’s revelations about NSA spying are having an interesting effect on the market. Snowden has raised awareness that information is often improperly used. Theoretically that might make people wary of signing up for sites that disclose their information. On the other hand, some may reasonably conclude that since the government is looking at their information anyway there’s no reason to try to protect it.

photo credit: webted via photopin cc
By David E. Williams of the Health Business Group.

Wall Street Journal shames itself with health policy coverage

The Wall Street Journal’s Op/Ed page has always been very conservative, but traditionally the news sections have been balanced and objective. When Rupert Murdoch took over the Journal a few years back, an Australian friend warned me that objectivity in the new section would soon be out the window. Overall I have been fairly happy with the Journal under Murdoch’s ownership. Obviously it would have been unrealistic to expect everything to stay the same; Murdoch’s team has done a good job of adding new features even if some of them are a little fluffy.

But in recent months I’ve noticed that the Journal is going out of its way to undermine the Affordable Care Act on the news pages. Sometimes it’s by slanting real news stories negatively. Other times –like today’s front page article Patients Cram In Tests Before Health-Law Start, it’s by making up news out of nowhere.

Here’s the lead:

Thousands of people are cramming in tests, elective procedures and specialist visits before year’s end, seeking out top research hospitals and physician groups that will be left out of some 2014 insurance plans under the new health law, health-care providers say.

Many insurers offering plans under the law are slimming down their networks of doctors and hospitals in a bid to lower the cost of policies, which begin coverage Wednesday.

The article continues with a discussion of how more of the plans being sold on exchanges feature narrow networks and often exclude high-priced academic medical centers. The story includes a few anecdotes supplied by high-priced hospitals about patients deciding to get surgery or a colonoscopy this year instead of next, but there’s no data presented to back up the assertions.

The implication is that patients are rushing to use their “good” health insurance before Obama takes it away. But this really doesn’t make a lot of sense. Reading between the lines –or more literally the first word “thousands”– I don’t think the editor actually believes this is a real story either.

Think about it. There are more than 300 million people in this country. It’s front-page news that “thousands” are supposedly getting care a little sooner than planned? In addition, the logical chain is pretty weak. Every year people rush to use up their benefits or just push to get things done around the end of the year when they have time off of work. Many of the people getting coverage on the exchanges are newly insured –so their access is increasing, not narrowing. Even those who are getting narrower networks are likely saving significant dollars on their premiums. And isn’t it actually a good thing that the Affordable Care Act is increasing competitive pressures on high-priced providers, who now must do more to show that they are actually better or be forced to bring their pricing into line?

It’s sad to see the Journal fall to this level.

By David E. Williams of the Health Business Group.

Medical child abuse: Making sense of the Boston Globe stories on Children’s Hospital

The Boston Globe caused quite a stir with its two-part story on Justina Pelletier, a 14 year-old girl taken from her parents and kept at Children’s Hospital in Boston for months after doctors there suspected her parents of “medical child abuse” and got the state child protection office to take emergency custody. The stories ( part I and part II) are well documented and disturbing, but I’ve been around the media and health care long enough to know that you can never be 100 percent sure of the real situation just by reading about it.

There are a couple points that stand out for me, however:

  • It is concerning that Dr. Mark Korson, the referring physician from Tufts –who is a knowledgeable and level headed guy– was not allowed to take part in the process after Justina was confined and that the patient did not get to see the gastroenterologist Korson referred her to. Children’s really needs to explain that part of the story
  • There are definitely cases where child abuse is wrongly asserted by physicians and the consequences for kids and parents can be absolutely devastating. When a child is seriously ill, some parents may lose it and act somewhat crazy, adding to the suspicion that they are causing the problem in the first place. I can empathize with the families while at the same time understanding where the doctors are coming from

Child abuse is real, but there are also physical illnesses that look like child abuse. And there’s no guarantee that physicians will sort out the true diagnosis. There is a helpful article (The Differential Diagnosis of Child Abuse) by Michael Segal, an MD PhD pediatric neurologist. It should be required reading for anyone in a position to make allegations of abuse. The article covers findings including lethargy/coma, bleeding and bruising, failure to thrive, immunodeficiency, high muscle enzymes, broken bones and recurring odd complaints. For each finding there is an explanation of potential underlying reasons other than child abuse.

However the Pelletier story comes out, I’m glad that we still have an independent, local newspaper that puts real resources into these investigations.


By David E. Williams of the Health Business Group.

Avoidable emergency department visits: Lessons from the Robert Wood Johnson Foundation (transcript)

This is the transcript of my recent podcast interview with Susan Mende of the Robert Wood Johnson Foundation.

David E. Williams: This is David Williams from the Health Business Group. I’m speaking today with Susan Mende, senior program officer at the Robert Wood Johnson Foundation. Susan, thanks for joining me today.


Susan Mende: My pleasure.


Williams: Susan, let’s talk about avoidable emergency department visits. I know that the Foundation has been funding work on that topic. So, first question: how big of a problem is avoidable emergency department visits?


Mende: It’s a pretty big problem. It’s a problem for patients, for overcrowded emergency departments and for costs. We’re finding that there are increasing numbers of emergency department visits and that patients’ demand for the emergency department is increasing at the same time that the number of hospitals with emergency departments is decreasing.


We found a 20% rise in emergency department visits between 2000 and 2010, but at the same time we see an 8% decrease in the number of hospitals with operating emergency departments between 1991 and 2010. So, what happens is that we are seeing large numbers of patients in overcrowded emergency departments waiting longer and longer.


Williams: Why isn’t the solution just to build more emergency departments? You talk about avoidable visits, but is the goal to just avoid these visits? What does that mean?


Mende: We all want emergency departments to be there in real emergencies. Certainly, for you or me, for our families, we want to know that if we are facing something life-threatening or something that seems really, really scary or really, really acute, that we want to know that the emergency department is there.


The problem is we’re finding that 70% of emergency department visits are not true medical emergencies. If these patients had been able to get to effective primary care in the time that they need it, they could have avoided going to the emergency department.


If you go to the emergency department there is often a very long wait time and still all of your problems and complex medical issues or social issues that you’re facing might not get addressed. Because emergency departments are really, really busy places where the idea is to diagnose, treat and move on to the next patient.


So first of all, people are not getting comprehensive care there. It’s not getting coordinated. If they show up at the emergency department over and over again, they’re probably going to be seeing different providers. A lot of the information about what happens with patients in the emergency department doesn’t get transmitted to their primary care doctor, so the doctor might not know that a medication was changed, that a test was done. And vice versa, the emergency department doesn’t necessarily know what kind of medications the patients are on, their whole medical history or what kinds of tests or procedures were already done. So, we can have a lot of duplication.


So there’s a question of quality and a question of cost as well. When a patient receives care in the emergency department that’s not really emergency — that is unnecessary — we all pay the price. We found that in 2007, the average cost of a visit to the ED or Emergency Department was $767.  At the same time, if you went to an office-based visit, the cost is $187. That means a cost difference of $580. So the healthcare system could save about $38 billion if we can eliminate all the unnecessary emergency department visits.


Williams: Susan, I understand the foundation has been funding some efforts to do just that; to look for opportunities to reduce these avoidable visits. Can you describe the sort of projects that have been funded and what sort of results you’re seeing?


Mende: The Robert Wood Johnson Foundation has a program that called Aligning Forces For Quality or AF4Q. It’s our signature program. This 10-year initiative works to improve the quality of care in 16 communities – some of them small, some of them big – all across the country. The idea is that we work to improve the care and the quality of care in these communities and also develop models and resources for other communities to learn from and to follow. A number of these Aligning Forces For Quality communities have been involved for many years in targeted efforts to reduce inappropriate emergency department use.


Williams: Have you found that the same kind of best practices work in different places? I understand that the AF4Q communities are in diverse settings, some urban, some more rural and in different parts of the country with different characteristics. Is it the same sorts of things that work in different places or are there all different kinds of answers and responses?


Mende: What we’re finding is that some of the issues are the same across the country, such as people showing up in emergency departments for conditions that would be much better treated in the primary care setting. But what we’re finding is that each community comes up with a solution that works for its own local circumstances.


For instance, one of the communities we worked with is Detroit. The group there is called The Greater Detroit Area Health Council. In Detroit they worked with their primary care practices to reduce the number of unnecessary ED uses. They work through the Greater Detroit Area Health Council with the Blue Cross network of Michigan and through Oakland Southfield Physicians, which is an independent primary practice association.


They implemented straightforward, low-tech interventions to reduce visits. For example they provided practices with scripts to use. The scripts would give them advice on how to do after-hours telephone recording and to telephone triage to direct patients to the appropriate providers. As a result every practice didn’t have to develop these on their own.


We wanted to reduce the barriers of patients getting through to primary care and having to go to the emergency department. So they gave advice about scheduling policies that allowed for patients to come in to see the doctor the same day as well as scheduling to allow patients to come in evenings and weekends, which is when a lot of patients go to the ED because they can’t get in to their primary care provider at that time.


Also, they felt that it is really important to follow up with patients who recently visited the ED. They wanted to remind patients that they should schedule a follow-up appointment with their primary care doctors after the ED visit. And they also wanted to tell them, “Listen, we’re here beyond 9:00 to 5:00.” We want to tell them that there are after-hours and weekend availability.


And for every new patient who came in, they developed what they call a welcome letter. And that would lay out what the practice was offering, their office hours, their scheduling policies, their after-hours contact numbers and how patients could get a hold of them after hours.


They found that before they started these different interventions, they were seeing the rates of emergency department use increase for conditions that should really be better treated at the primary care office. They had a high of 49 visits per 1,000 patients affiliated with their Blue Care network members.


After they did these interventions –starting in 2010– they found quite a dramatic decrease. They recorded a decrease to 7.43 visits per 1,000. So that was from 49 to 7.3. They were very pleased with that success and those results.


Williams: Some of the demand for ED visits is based on patient preference. But some demand seems to be driven, at least in my own experience, from the provider side. In other words, patients may call the provider especially off-hours and the provider may suggest going to the emergency department. Do you find that to be a key factor or is my experience unusual?


Mende: I think that factor is present in a number of communities. And I think that some of the work that we just talked about in Detroit really addresses that. There is a responsibility on the part of the primary care providers to not only educate patients about what is an emergency, what’s really appropriate to go through the emergency department about, but also they have to do things to increase access to their practices – things like same day scheduling. Sometimes people go to the emergency department because they just could not get off from work. And by the time they get off of work, their primary care practices are closed. And so a number of primary care practices are extending their hours or staggering their hours, changing their hours, offering weekend hours. And so I think there’s really responsibility from the primary care practice point of view to educate and to make themselves accessible.


Williams: In addition to the best practices that you are putting forward, are there changes that are needed to reimbursement or other kinds of rules and incentives in order to enable this? Some of the things you’re describing, for example, that a primary care practice might do sound like the right thing to do, but may not contribute to the bottom line.


Mende: Yes. I think that these kinds of changes, for primary care practices, certainly do have some financial implications. There are a number of initiatives around that are trying to address this. There’s something called Patient Centered Medical Homes, where practices get paid a certain amount of money per member per month to increase their accessibility, to provide better care coordination, and to provide better patient education.


And that’s just one example of the kinds of payment reforms or different ways of paying practices to increase their access and improve the quality of their care.


Williams: Are there ways for people who are not in communities that have Aligning Forces for Quality alliances to get access to some of the resources that you’re making available, whether they’re patients or whether they’re providers?


Mende: Yes, absolutely. We’ve learned a great deal from our work with Aligning Forces for Quality communities over the past seven years, about what works and what doesn’t work to reduce ED overuse. And so we packaged these lessons into a series of materials that are straightforward, that people can use as a guide and that they can adapt in their own communities.


We have issue an brief that talks about the role of better coordination with primary care settings in reducing inappropriate ED use. We have a wide compendium of resources that provide links and additional information for providers and organizations. We have a series of three case studies, one of them which is from Detroit that I mentioned. We have case studies from New Mexico about some public service announcements and public education that they did around this issue. We have resources from Wisconsin. Really detailed information about how communities tackled this issue. We have a guide for primary care practices on working with their patients to reduce avoidable ED use and a webinar. We have interviews about simple steps that you can take. And all of these materials are available free for charge if you come to our website.


Williams: Susan, final question. As you mentioned, the level of emergency department visits had increased over the past decade. You’re certainly taking some steps here that are meaningful in order to reverse that trend, especially to reduce some of those avoidable visits. What is your overall level of optimism or pessimism about where this is headed? Are we going to look in another 10 years and see that the avoidable use of emergency department has continued to increase? Is it going to level off? Are we going to see potentially a dramatic reduction?


Mende: I’m very hopeful about tackling this problem. It’s certainly not going to happen overnight. It’s a very complex problem due to many of the factors that we’ve talked about. But I think that patients are feeling the pinch. Many of them have higher deductibles if they do have insurance cover. For some of them, the health plans are not paying or not paying the full cost of the visit if the health plan considers it a non-emergency. And patients are concerned because they don’t know how much it’s going to cost them if they walk in to the emergency room. They don’t know what the bill is going to be when they walk out and they certainly don’t know how long they’re going to have to wait. And they certainly don’t know whether or not they’re going to get the care that they need and care that’s coordinated with their primary care providers.


So I think that patients are feeling the pinch in many ways. I think there is a great deal of public service analysis, a lot of patient education around this issue and around getting alternatives that patients can take. I think a number of practices are taking very bold steps to educate their patients and to make themselves more accessible.


A number of hospitals and primary care providers are working together. For instance, a number of hospitals and healthcare systems have made agreements with primary care providers so that they share the data on which patients are coming to the emergency department and the practice can look through the data for their own patients, for their own panel of patients. They can see who came to the emergency department, they can follow up with them. They can identify patients who go to the emergency department over and over again and do a deep dive with these patients, find out why they’re going there, do they need to better coordinate their care; are there medical problems or social problems that are not being addressed?


So I think there were are many different ways that we are tackling this problem. And I think it’s gotten more and more attention as being both a quality problem and a cost problem. And so I am quite hopeful that we are going to make significant improvements.

By David E. Williams of the Health Business Group


Avoidable emergency department visits: Lessons from the Robert Wood Johnson Foundation (podcast)

Susan Mende, Sr. Program Officer

Susan Mende, Sr. Program Officer

Only about 30 percent of patients treated in hospital emergency departments need to be there. The other 70 percent might be better off in primary care, where care could be better coordinated and costs are about one-quarter, according to The Robert Wood Johnson Foundation (RWJF). In recognition of this issue, RWJF has been funding programs to tackle the problem of avoidable emergency department visits.

In this podcast interview, RWJF Senior Program Officer Susan Mende discusses the work of Aligning Force for Quality grantee communities in identifying the root cause of avoidable visits and developing interventions to help primary care practices achieve their missions. Resources are available for free on the RWJF website.

Susan is optimistic that there will be significant progress in addressing this issue over the next few years.


By David E. Williams of the Health Business Group.

Doctor’s office of the future meets office of the past

Doctor patient tablet

I went to an appointment today with a doctor in a high-paying specialty who presumably has the resources to organize his office the way he wants. I was very satisfied with the doctor’s thoroughness, empathy and communications skills –which for me were the key things I was looking for. But I was also struck by the mix of modern, sleek information technology with some old-fashioned (even retrograde) administrative processes.

The nurses and medical assistants had iPads, which they used to call patients, record information and manage the workflow. The electronic medical record was clearly a bit clunky so the doctor made use of a medical scribe to whom he dictated information as he performed the exam. It’s kind of crazy that he needed to add a person to the process when the EHR was introduced, but I’m glad he did because it meant he could focus completely on the exam and not at all on the computer. That definitely helped the doctor/patient experience. I also noticed that the scribe was trained to turn away when the doctor cued her that private parts were going to be exposed.

Meanwhile, the check-in process reminded me of 1975. I received a clipboard with a set of forms that looked like they had been photocopied a few times. There was a space for my Social Security Number. I left it blank and you should, too, unless you want to open yourself up to identity theft. They asked for my insurance information even though they had photocopied my card, they wanted my pharmacy information in two different places and asked redundant questions about my medical history.

I’ve learned from experience not to bother complaining about the Social Security Number question –better to let them bring it up if they insist- but I did ask if I really had to fill out the pharmacy information multiple times. They said yes: one copy for my medical record and one for some other file they maintain.

These are small annoyances in the scheme of things, but they are noticeable in a customer-service oriented world where websites like Amazon and devices like the iPhone are engineered with the convenience of the consumer in mind.

photo credit: juhansonin via photopin cc

By David E. Williams of the Health Business Group