Category Archives: Patients

MedSentry: Adherence for complex drug regimens (podcast)

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Medication adherence is a tough challenge, especially for high-risk patients, whose complex drug regimens often feature more than a dozen pills. MedSentry is rolling out an end-to-end closed loop adherence system for this population. Although it’s not a large group, it is responsible for a disproportionate share of medical costs.

In this podcast interview, CEO Adam Wallen and I discuss the following:

    1. (0:11) Adherence is a big problem in healthcare. What does it mean? What’s the nature of the problem?
    2. (0:57) Are there multiple reasons for lack of adherence?
    3. (4:05) There are a number of adherence solutions in the market. How well do they work?
    4. (7:46) What is the MedSentry approach? How is it different?
    5. (11:57) What evidence is there that this approach is effective?
    6. (13:17) You have focused on the most complicated patients. Will that continue to be your niche as your commercialize?
    7. (14:55) Do you have a scale-up plan?

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

Dr. Joshua Newman, GM for Healthcare at Salesforce, discusses telehealth solution

Dr. Joshua Newman, MD, MDHS, Chief Medical Officer, Salesforce

Joshua Newman, MD –Salesforce’s Chief Medical Officer

I really like Salesforce’s Health Cloud approach to patient engagement and am excited to see the company add telehealth to the platform. I caught up recently with Dr. Joshua Newman, who is Chief Medical Officer for Salesforce and also General Manager of Healthcare and Life Sciences.

In this podcast interview we discussed the following:

  1. (0:12) How has the rollout of Health Cloud gone since our last discussion about a year ago?
  2. (2:03) There are other telehealth offerings on the market already. Is the new Health Cloud offering different or better?
  3. (4:21) Who is the target user? Is the telehealth solution aimed at particular types of providers or patients?
  4. (6:55) Is there a return on investment? What drives it?
  5. (9:02) Is this mainly a mobile solution?
  6. (9:55) How does the telehealth solution fit with other Health Cloud offerings?
  7. (12:38) What else can we expect from Health Cloud over the next year?

I came away with the conviction that there is the potential for significant impact as the platform matures, health care-specific partners are brought on board, and as customer/patient engagement practices in healthcare catch up with the rest of the economy.

I’m looking forward to hearing more, especially with the big Dreamforce conference coming up in October.

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

Are men comfortable with female physicians? Other factors to consider

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Nuzzel showed me that my friends have been sharing a new athenainsight: Are male patients comfortable with women doctors?  The post uses athenahealth billing data to demonstrate that male patients are less likely to return to female physicians than they are to male physicians, but for female patients the sex of their doctor doesn’t make a difference.

Athena’s conclusion is that men may be “less enthusiastic than women about seeing physicians of the opposite” sex. The article links to a Quora exchange, where all the respondents indicate that as patients they are equally comfortable with women as they are with men.

These findings are interesting, but I don’t think they tell the whole story.

When my long-time primary care physician retired I looked for a new doctor. I believe in the value of long-term relationships so wanted to pick someone I could be with for 15 years or more. I wanted someone affiliated with my preferred health system, with excellent clinical and at least decent communications skills, and around my age (late 40s).

My retiring physician recommended a female colleague in a practice close to where I live, who fit the bill. He had been involved in her training and had worked with her.

Like the Quora respondents, I was comfortable with being examined by a female physician. As I’ve written, I’m also comfortable being examined by a physician who is a friend.

But, although it was further down my list of criteria, I did have the sex of the physician somewhere on my list of factors. Why? Because at least on average, men work more hours and retire at an older age, making them more likely to be available to patients when needed.  One survey showed that 44 percent of female physicians worked part time, compared with 22 percent of men. Another showed 25 percent of women compared to 12 percent of men.

My personal experience reinforces those statistics. The recommended primary care doctor works part-time. Other  female physicians my family sees have taken time off to care for sick family members and attend to other family issues. One retired in her 40s to take care of sick parents. Working less or taking time off doesn’t make them bad doctors or bad people –quite the contrary, it may even keep them fresh or help them stay connected with patient needs– but it does have an impact on availability and longevity of the relationship.

In the end I chose the female primary care physician my retiring doctor recommended, and I plan to stay with her. But I’m also adjusting my expectations about primary care. For one thing I’m focused more on the relationship with the overall practice, rather than just with my personal doctor.

The practice seems to do a reasonable job of working together as a team, and I hope this will serve its patients as well or better in the long term than the more traditional and familiar one-on-one doctor/patient relationship. If it doesn’t turn out that way then my likely next step is to switch to a concierge practice rather than seek out a male physician.

Image courtesy of stockimages at FreeDigitalPhotos.net

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

Smoking and the ACA

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The Affordable Care Act (ACA) has created a wonderful laboratory for studying the impact of changes in healthcare policy. One of the more interesting papers on the topic appears in the latest Health Affairs (Evidence suggests that the ACA’s tobacco surcharges reduce insurance take-up and did not increase smoking cessation). (You’ll need a subscription to read the full article.)

Health plans can’t charge higher prices to people who are sicker, but they can tack on surcharges of up to 50 percent for tobacco users. States can limit or ban the surcharges, and some do. Not surprisingly, people subjected to high surcharges are a lot less likely to purchase insurance, especially because the way the surcharges work has a very significant impact on their out of pocket costs.

Beyond the headlines, there were several additional findings:

  • When smokers faced no, moderate or high surcharges rates of smoking cessation were unaffected
  • Low surcharges significantly reduced the degree of smoking cessation
  • Young smokers were much more likely than older smokers to be deterred from health insurance coverage by the imposition of surcharges
  • Surcharges were typically higher than the extra medical costs incurred by smokers

These findings have some interesting implications:

  • If the goal of the surcharge policy is to get people to quit smoking, then it doesn’t seem to be working very well. The least effective approach of all is to impose low surcharges. The authors speculate that the low surcharge smokers may feel they are being fairly charged and therefore don’t have an incentive to change. This is like the parents who are more likely to pick up their kids late from day care when a small fine is imposed
  • Surcharges knock younger people out of coverage disproportionately, which may destabilize the risk pools since younger people are generally more profitable than older people
  • The rising penalties for not purchasing insurance may not have much effect on smokers who face surcharges. Many low or moderate income smokers will be exempt from the penalties because the premiums –with surcharges– are deemed unaffordable
  • Patients with mental health problems are being discriminated against because they have much higher smoking rates than the general population. (I have been making similar arguments since 2007)

The authors mention in passing that high surcharges may encourage people to quit in order to obtain affordable coverage. They also note that the smoking surcharge isn’t always apparent on the exchanges, so smokers may not understand that they are paying more or how much.

I’d like to see the law tweaked to make the financial consequences of smoking more apparent to smokers. Surcharges could be displayed more explicitly, and the bar for being exempt from the insurance coverage requirement could be raised. Exceptions could be made for those with a mental health diagnosis.

These changes won’t necessarily be easy to achieve. Congress so far shows no signs of being willing to improve the law –though that may change if the Democrats retake Congress. Another issue is that tobacco use is generally self-reported for exchange customers, so we don’t know how many people are classifying themselves as non-users when in fact they are not.

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

Uber the ambulance chaser

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Uber and to a lesser degree Lyft have decimated the taxi industry with a disruptive model that lowers costs, improves service, and identifies the few bad apples among drivers and passengers. Now both companies are venturing into a niche market that’s in need of serious reform: medical transportation.

Some patients need help to get to their medical appointments and Medicaid and Medicare step in as needed to pay for transportation. However, too often a patient is transported in an expensive limo or even an ambulance when a regular car would have been fine. The government recognizes the problem and has taken some steps to clean up the business, but it’s tough going.

I’m not exactly sure how Uber and Lyft will tackle the intricacies of the business, but they are diving in:

  • Boston Children’s John Brownstein has helped form Circulation, which will use the Uber network to provide rides to medical visits to seniors and those with disabilities. Medicaid will provide coverage
  • In New York, Lyft has been working with the National Medtrans Network on a pilot program

These services will be valuable in their own right because they are likely to reduce costs and improve service. But the downstream value to the healthcare system is even greater: if patients can get to and from appointments more reliably it may well reduce overall medical costs and improve outcomes.

Finally, it’s helpful for patients to have their medical appointments bracketed by state-of-the-art service experiences, since it will encourage patients and maybe medical offices to strive for the same service levels in their medical care. Kind of like how Disney pulls up all customer service in the Orlando area.

Image courtesy of vectorolie at FreeDigitalPhotos.net

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

 

Most young men don’t know about emergency contraception. Is that ok?

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About 40 percent of adolescent boys and young men know about emergency contraception, aka the “morning after pill” or Plan B according to a Journal of Adolescent Health study. Women who take the pill within a few days of unprotected sex or a condom break can avoid an unwanted pregnancy because emergency contraception prevents ovulation.

So how should we think about the 40 percent number?

The authors are pleased that the number is as high as it is, and take it as proof that educational campaigns are working. They’d also like to see the number go higher so that boys and men take responsibility for contraceptive planning. In an ideal world that’s undoubtedly true, but I wonder whether it would be better if men were less aware of emergency contraception rather than more.

After all, the possibility of pregnancy is not the only reason to avoid unprotected sex. Prevention of sexually transmitted diseases is right up there as well. If boys and men know that emergency contraception is an option, they may be less careful about protection and more likely to pressure their partners into having unprotected sex in the first place.

I’m not actually advocating for purposefully keeping people in the dark, but I’d focus the awareness message heavily on girls and women.

Image courtesy of Stuart Miles at FreeDigitalPhotos.net

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

Mass Health Quality Partners releases patient experience results

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Massachusetts Health Quality Partners is a national leader in reporting on patient experience in primary care. Its latest data release at healthcarecompass.org provides valuable information for patients looking for a physician and for practices seeking to understand how they perform in absolute terms and in comparison with others.

You may be familiar with the adage, “What gets measured gets done,” so it really is important what we decide to measure and to publicize. Some patient experience topics, like communication, have been measured and reported for some time. The average score is now 93.5 out of 100 –which is great, but it also means that it’s hard to improve from there and that communication may not be a great way to choose between practices.

By contrast, some of the newer categories demonstrate opportunities for –and evidence of– improvement. This is just the second year asking about behavioral health screening –an important topic since so many behavioral issues first present in primary care. Scores on that measure have risen from 53.1 to 56.5 from 2014 to 2015, while some practices have shown improvements of up to 20 points.

Self-management, a new topic this year, comes in with a score of 54.0 for adult practices and 43.6 for pediatrics. Look for that one to rise in the coming years as well. Statewide results are summarized on the MHQP website.

Most of the scores are reported as Harvey balls, with four levels of differentiation. It’s easy to compare practices against one another on specific measures, but on the other hand it’s difficult to figure out how any given practice rates overall. That’s partly because unlike commercial rating sites, MHQP is a collaborative that needs to keep the providers on board.

A shorthand way to make comparisons is with the “willingness to recommend” score that’s reported as a percentage. I asked MHQP spokesman Joe Ternullo about this measure and how to use it:

How can patients use this measure to chose a physician?

People often ask others for a recommendation when choosing a new doctor. To learn more about this, MHQP asked patients:   “Would you recommend this provider to your family and friends?”  MHQP suggests that patients look at all available information before choosing a new doctor. This is because no single rating by itself can give a clear picture about a healthcare provider’s quality of care.

Can a consumer use that measure to make a decision when the information is presented at a practice level?

Yes. A consumer should use the ratings at healthcarecompassma.org to see how his/her primary care practice fares, or to look for practices in their region that have scored particularly well.  In either case, focus on two things. First, look at the percentage of patients who said they would recommend the doctor. Don’t focus too much on minor differences, such as between practices with scores from, say, 86 to 89. Second, look at its scores for individual aspects of performance, such as communicating with patients, coordinating care, and getting timely appointments.  These measures are a guide to help patients assess certain aspects of patient care. No single measure reveals everything about the quality of care at a provider’s office.  Different practices may excel in different areas. But a low score can point out certain aspects of care that a doctor’s office needs to improve.

And as a follow-on, how do practices use that information with their own providers?

Medical care is complex, and patient experience is only one measure of quality. For example, it is important to know how well as doctor helps patients manage conditions like arthritis, diabetes, high blood pressure or high cholesterol. But patient experiences can affect those clinical measures. Many practices have used the MHQP statewide patient experience survey results to improve how they interact with their patients.

The MHQP patient experience survey is a valuable community resource that we are fortunate to have in Massachusetts. The survey is supported by leading health plans and provider organizations.

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