Category Archives: Patients

Evidence based defensive medicine

 

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Defensive medicine –when physicians provide or recommend unnecessary treatment or testing in order to reduce their chance of being sued– has always bothered me. It harms the patient, drives up costs, and can be self-serving by generating more income for the provider. I’m also skeptical about whether “defensive” medicine really reduces the chances of being sued.

So I was very interested in a Today’s Hospitalist article (Does defensive medicine work after all?) that reports the results of an intriguing study of hospital admissions in Florida. The study, conducted by a Harvard Medical School professor, revealed that physicians who were responsible for the most expensive hospitalizations also had the lowest likelihood of being sued (0.3% vs. 1.5%).

There are plenty of limitations –correlation isn’t causation, it’s based on hospital admissions only, maybe the doctors in the high and low spending groups aren’t comparable, etc. — and yet it does give one pause. Maybe doctors who order more tests and treat patients more intensively really do get sued less. Could it be that patients and families are less likely to sue if they feel that everything has been done for them?

The findings have serious implications, especially as we leave the era of fee for service medicine and enter the age of accountable care and capitation. Will it be possible to get physicians to be less defensive in the name of cost savings? Is it fair to do so? What role should the patient and family have? Do we in fact need some kind of liability reform?

Dr. Anupam Jena, lead author notes that malpractice is bother under and over-stated. Malpractice costs are routinely reported at only 3-5 percent of total costs, yet physicians also say malpractice is a major concern. My own suspicion is that there’s only a limited correlation between real malpractice and what physicians actually get sued for.

Image courtesy of stockimages at FreeDigitalPhotos.net

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

 

Free market for surgery: interview with Allevion CEO Arnon Krongrad, MD

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Surgery can be expensive, scary, dangerous and even deadly. Yet it’s hard for patients and even for referring physicians to navigate the system. So I was intrigued when I was contacted by Dr. Arnon Krongrad , CEO of Allevion, Inc., a healthcare logistics company that markets surgery packages. The company’s Surgeo online marketplace let’s patients shop for the surgeon of their choice.

I explored the topic in depth with Dr. Krongrad in this email interview.

What are the limitations of referrals to surgeons by primary doctors?

Conventional surgeon referrals by other doctors, such as primary physicians, rely upon limited knowledge about a limited number of surgeons. For example, primary physicians tend to know a relatively small handful of surgeons for specific procedures, such as vision correction. The simple reality is that in today’s environment, when primary doctors are pressured to churn patients, type into EMRs, and speak ICD-10, they have little time to sort through choices of surgeons. They will reflexively refer to the familiar, which may or may not be optimal. Primary physicians, like the rest of us, might welcome systematic, easy access to knowledge about choice of surgeons.

It looks like your surgeons are selected based on the opinions of their peers. Are there more objective, quantitative ways to rate surgeons?

Surgeo’s purpose is to simplify access to quality care. In surgery, quality comes from the surgeon. The question, then, is how to qualify surgeons. This is an urgent question as our increasingly consumerist ecosystem demands transparency regarding cost and quality. It is a question with obvious and easy answer but a conceptual framework will help us to manage and make progress.

First of all, no, there are no objective, quantitative ways to rate surgeons. We should be clear. We are not talking here about waiting room times or adequacy of parking. We are talking here about clinical quality: blood loss, rectal perforation, positive margins, and the like. A system that has not produced an objective, quantitative way to transparently, uniformly, and broadly present cost – a much more cleanly quantifiable dimension of care – has only just begun to think about objective, quantitative ways to present surgeon quality.

As we think about surgeon quality, we should recognize that surgeons do not operate in a vacuum. Most critically, they operate on patients, who are varied, and produce outcomes that are varied. Let us use prostate cancer surgery as an example. The factors other than surgeon skill that affect various outcomes vary. For example, cure is affected by cancer grade and preservation of erections is affected by diabetes. So which outcome – cure, erections – are we looking at when we ask about surgeon quality? Once we decide, have we collected patient data in a way that would permit us to explain variation in outcomes between surgeon A and surgeon B? No, we’re just not there yet.

Secondly, formulaic objectivity, laudable as it might be, is not the only way to go. The other way is subjectivity, the argument for which was previously laid out in this article. In brief, the principle relates to the instantaneous ability of subject experts to detect artistry when they see it. It argues that surgeons know quality surgery when they see it. As one very senior surgeon who has taught surgery all around the world said it: “I can tell within a minute of skin incision if a surgeon is good.”

There are data, most notably in bariatric surgery, to show that subject expert peer credentialing correlates with objectively measured outcomes, such as hospital readmission. In other words, we think we can do well by patients and payers by applying the collective, subjective wisdom of surgeons.

Do other factors affect surgeon qualification? Any surprises?

Yes. Surgeo’s surgeons are qualified using a published, multi-factorial surgeon credentialing process that includes but is not limited to peer input. The idea is to try to get as close as possible to surgeons who know what they are doing and who exemplify the high standards of service and mission.

The additional steps have yielded some surprises. For example, Surgeo recently rejected the application of a very well known, very high volume, well published surgical specialist whose peers think highly of him. We rejected the application upon discovering what his peers did not know: that he has a history of numerous high-dollar malpractice payouts, including one incomprehensible loss at jury trial. This example relates to the opening comments: doctors do not investigate surgeon qualifications as fully as they might if given motivation and time. Surgeon qualification takes time, effort, and more than one criterion.

What do surgeons think of your approach?

Doctors generally are under siege. They are all looking for simplicity, fairness, and respect for their abilities and integrity. Surgeo delivers those and surgeons love the surgeon driven, clinically rational product design and administrative approach. The model works because it satisfies patients and providers. It has also satisfied payers, as when we used it in a previous chapter to satisfy Blue Cross and develop surgery bundles for the network.

What has been the most surprising reaction of your surgeons?

Surgeons are often paralyzed by the freedom that Surgeo offers. They have no idea how much to charge for their services because nobody has ever asked them before. Surgeo does not negotiate prices with its downstream vendors. Surgeo does not set allowed amounts or ask for discounts. This is unfamiliar to most doctors. This seems bizarre. Have you ever met a lawyer who has no idea what his hourly rate is?

What’s the history of Surgeo? What is its future?

One day, two things happened: Congress said everyone was getting healthcare and a man with cancer told me he could not get healthcare: surgery for his newly diagnosed cancer.

I tried to help him and ran into inflexibility and apathy. The solution ultimately involving sending him from Oregon, my surgical team from Florida, and a surgical robot spot purchased on eBay for 1% of retail from Colorado to an operating room in Trinidad. The exercise delivered a flat-fee surgery package at a price he could afford and worked for all involved. We then developed the model domestically and sold surgery packages to individuals and large payers. You can see a presentation of that case here.

Surgeo is a public, interactive, online face of surgery packaging and pricing software engine that was designed in-house under the direction of Kimberly Langer, our Chief Product Officer. Kim was formerly with a large payer, where she designed large enterprise claims related software. She built Surgeo to scale in a way that can work with payer EDI streams for easier network integration and for presentation to members of service choices and out-of-pocket costs. Kim also built it to accommodate our customers who want privately labeled software by which to market their own surgery packages. We’re seeing demand for that from financial and provider organizations.

You cover a variety of surgeries. Are there any surgeries that have been more popular than expected?

Penile implant surgery. We did not even think about this when we first set out. It turns out that there are huge problems related to this procedure. First of all, authentic conversation about male sexuality and erectile function is in very short supply and men with diabetes, cancer, and other conditions associated with erectile dysfunction have very few places to turn for substantive learning. Secondly, the pharmaceuticals for erectile dysfunction have taken over the airwaves and displaced much of the conversation about other, very effective treatments. We were amazed, for example, that one national network of diabetes activists, whose constituents have up to 70% prevalence of erectile dysfunction, has not discussed erectile dysfunction in 10 years!

What makes the challenges even greater is that penile implant surgery is often not covered by payers. We hear regularly from patients who thought they had what they call “really good insurance” that penile implant surgery is not covered. The way things are going, with CMS having dropped covered for vacuum erection devices, it won’t surprise us if penile implant surgery is just uniformly dropped.

We are getting sad, pleading calls from men with diabetes, obesity, cancer, and others who would like to restore their erections, relationships, marriages, and mood. These men are finding a delivery system that is broadly opaque and unhelpful. In response, we built in response is a national penile implant surgery package network. It features peer credentialed surgeons, comprehensive flat-fee packages, finance navigation, and financial protection in the event of complications. It offers plenty of choice.

The risk protected, flat-fee penile implant surgery package network is a model for efficient delivery of non-covered services. It can help payers to help direct members who do need those services.

What do you mean by financial protection in the event of complications?

Surgeo packages protect surgical patients against financial surprises by bringing in qualified surgeons. This is not a guarantee of elimination of complications but it helps. The second protection is inclusion in the flat-fee package of ancillary procedures. For example, gastric sleeve surgery includes hiatus hernia repair if it is needed: no surprise bill. In some cases, such as penile implant and laparoscopic hysterectomy, we are able to also include third-party products that take financial responsibility in the event of surgical complications. Think of it like getting collision insurance when renting a car.

What explains the variations in package prices?

We are just now starting to see a geographically distributed free market of uniformly defined surgery packages. Surgeons in Houston are looking and seeing prices in Birmingham and adjusting accordingly. So some of the variation is explained by the absence of a transparent market. Variation will probably shrink as price transparency sets in as it has on Surgeo. We see surgeons routinely not wanting to the most expensive.

Image courtesy of David Castillo Dominici at FreeDigitalPhotos.net

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

Should patients choose doctors who are friends?

Come with me?

Can I help you?

In the social media era, it’s common to read articles discussing the blurring boundaries in the doctors/patient relationship. Usually it’s some version of, “Should a doctor accept friend requests from patients on Facebook?” or “Is it ok for doctors to Google their patients?”

The Wall Street Journal (The New Boundaries Between Doctors and Patients) explores these issues and goes on to explore what happens when patients and doctors become friendly during the course of treatment. In the midst of this there’s a throwaway paragraph:

“Some boundaries are clear. Professional medical organizations have strict rules against sex and romance with patients. Doctors are also advised not to treat family or close friends, situations that could compromise objectivity and judgment.”

I have no problem with the part about sex and romance. I also kind of understand the family issue. But the friend one is more interesting to me.

I read a few pieces that discuss this topic. (Here, here and here.) The typical scenario is a friend asking for medical advice in a casual setting, often on a topic that’s not related to the doctor’s specialty. I get why that’s a bad idea.

In my own case I know many practicing physicians socially, and most are in the prime of their careers: mid 40s to early 50s. A couple years ago when I was having trouble finding a new primary care doctor after mine retired, I asked physician friends who they went to. That was a little too clever on my part, since I forgot to account for the fact that physicians get treated differently than regular people when they go to the doctor’s office. No NPs for them!

But after some so-so experiences with a particular medical specialty, I decided to ask a specialist friend if he would be comfortable being my doctor. He said yes and I started seeing him. He’s a longtime friend but not an extremely close friend. I’ve been extremely satisfied with the experience. Partly because he’s an excellent doctor but also because I feel he understands me better and may even provide a little extra attention. He trusts me enough to exchange detailed emails. I’m not embarrassed to share personal medical details that I wouldn’t be comfortable with sharing someone who’s just a friend. Honestly, for me I don’t see the downside.

I did the same thing when I a needed a new dentist and that’s worked out well, too.

I hope I stay reasonably healthy and then die peacefully in my sleep when I turn 100, so I don’t have to spend a lot of time as a patient. But realistically it’s likely that I’ll be seeing more specialists as time moves along. I’m definitely planning to keep friends in mind when it comes time to find people to treat me.

Image courtesy of stockimages at FreeDigitalPhotos.net

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

A wakeup call from the nanny state

Amber alert alert

Amber alert alert

My cellphone was off Friday night so I was lucky enough to miss the Amber Alert that was sent out at 1:45 am when a mom decided to drive home from Pennsylvania to have her son treated at Boston Children’s Hospital. I heard about it Saturday night from some friends who couldn’t believe this had occurred and were annoyed at being awoken.  From where I sit, the only good thing about it is that it’s literally a wake-up call to the whole community about how the system treats vulnerable people.

It’s hard to say exactly what happened. But from what’s been written, it goes something like this:

  • A nurse practitioner in Wilkes-Barre, PA told a mom to take her 2-month old to a nearby emergency room for treatment of severe dehydration
  • Mom felt she had gotten “the runaround” from the Pennsylvania clinic and decided to drive to Boston Children’s Hospital to have her son treated there. She is from Boston and apparently has a relationship with a doctor there
  • On the way back she dropped off her older son with a niece in Waltham so she could focus on the infant
  • Somewhere along the way, someone in PA decided to issue an Amber Alert –meant to be used when a child is abducted and “believed to be in imminent danger of death or serious bodily injury”
  • The Amber Alert went out, waking everyone up
  • Infant made it to Children’s, where he’s been admitted and is improving –but now in custody of DCF (protective services)
  • Other child was also taken by DCF
  • Mom was arrested in MA as a fugitive from justice in PA. Judge listened to her story and released her on a token $250 bail

As I mentioned I don’t know exactly what happened. But I tend to give the mom the benefit of the doubt. In particular:

  • Who knows the quality of care and clarity of instructions the woman received at the clinic in PA?
  • A general ED is no place for a 2-month old. Many are still totally unprepared for kids, never mind babies
  • Boston Children’s is rated the #1 pediatric hospital in the country and she may have relationships there already. Depending on the kid’s condition, who wouldn’t at least consider making the drive?
  • It’s hard to drag a toddler all over the place during an emergency, so why not drop them off at a relative’s house along the way?

The mom apparently has some moving violations and a charge for prostitution. I wouldn’t be too quick to judge her for those things.

It’s hard to know what to do when your kid is sick and you’re trying to navigate the healthcare system. That’s true even for a well resourced, well educated dad like me who works in healthcare. Without those privileges it appears all too easy to end up with Amber Alerts, arrested moms, and kids taken by the state when a mom tries to do what’s best.

I don’t like it.

Image courtesy of mrpuen at FreeDigitalPhotos.net

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

Let’s stop calling flu vaccine for the elderly “High Dose”

How high is that dose?

How high is that dose?

From everything I’ve been reading, the higher dose flu vaccine is very effective for older people. But I’m concerned that the name, officially Fluzone High-Dose, may scare people away. I spoke to my friendly, informative Osco pharmacist when I got the flu shot a few weeks ago. She told me that she was recommending High-Dose to older people but that some were nervous because it sounded like maybe it would be too strong for them. The pharmacist lamented that she had to call it High-Dose since that’s its name.

I’m not in the habit of giving free advice to drug companies like Sanofi-Pasteur, maker of Fluzone High-Dose, but in this case I’ll do so for the public good! Here are a few ideas they could feed to their branding consultant:

  • Fluzone Senior
  • Fluzone Senior Protect
  • Fluzone Plus
  • Fluzone Silver
  • Fluzone 65+

Image courtesy of renjith krishnan at FreeDigitalPhotos.net

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

Why do sick people quit their Medicare Advantage plans?

Heading back to Mama Fed

Heading back to Mama Fed

Health plans don’t like sick people. They rack up big medical expenses, drive up health plan administrative expenses, and generally knock down profitability. In the bad old days of Medicare managed care, some plans went out of their way to make sure their membership rolls were filled with healthy people. My favorite tactic from those times? Putting the enrollment office on an upper floor of a no-elevator building to keep out the frail.

Plans are supposed to have fewer incentives now to avoid the sick. The government pays Medicare Advantage plans on a risk-adjusted basis, so in theory plans are indifferent to member health status. But a new study in Health Affairs (High-Cost Patients Had Substantial Rates of Leaving Medicare Advantage and Joining Traditional Medicare) shows that when Medicare Advantage patients get sick they tend to drop out and put themselves back in the arms of the government.

What’s going on? The authors aren’t certain, but they float some ideas:

  • Plans lack incentives to spend their enhanced payments for the sick. (Maybe they just pocket some of the extra funds)
  • Plans are inexperienced managing post-acute and long-term care
  • Risk adjustment factors aren’t high enough
  • Plans impose too much cost sharing
  • Provider networks are too limited

These explanations are all reasonable and –like other findings– raise questions about the value of Medicare Advantage plans and of health plans in general. They spend a lot of money on various administrative functions and generate friction with providers and members. But at the end of the day they don’t tend to add a lot of value in cost management or quality improvement, and patients who use the system a lot would rather take their chances in a government-run program. Some plans actually realize this, which is one reason they lobbied so strongly against the “public option” in the Affordable Care Act.

Health plans, including Medicare Advantage plans, have a long way to go to prove themselves, and I have my doubts about whether they’ll make it. I’ll be interested to see what happens over the next decade or two. Will providers (in the form of accountable care organizations or similar) take over the role of health plans and will they be more effective? Will we eventually move to a single payer system that does away with health plans?

Stay tuned.

Image courtesy of Stuart Miles at FreeDigitalPhotos.net

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

What can we do about overuse of emergency rooms?

Come and get it!

Come and get it!

I’d expect an emergency physician with 35 years of experience to have some solid insights on why people come to the emergency room. Sure enough, Dr. Paul Auerbach delivers the goods in his Wall Street Journal opinion piece (Why ER Visits for Non-Emergencies Aren’t Going Away). In particular:

  • Patients can’t easily distinguish between true emergencies and non-emergencies
  • You can’t teach economics lessons to people when they are sick
  • Patients have learned they can get care in an emergency department more conveniently and quicker than in a community setting
  • Ambulatory physicians are culpable, because they encourage patients to go to the ER and don’t offer convenient hours
  • Emergency room use will continue to be heavy until key deficiencies in care delivery are addressed

So it was interesting that the Journal published five letters from people with different ideas. I disagree with four (all by doctors), and note that the fifth idea (by someone who may be a dentist) is already being implemented.

  • Dr. Ainslie thinks that “if ERs were forced to post prices, patients could decide what services they wanted to use.” That might work for an elective knee replacement, but doesn’t square at all with my experience in the ER. Am I really going to pick out what emergency services I want and exclude others? Who is going to have the time to discuss the costs and tradeoffs? Am I going to try my luck at a different ER if I don’t like the pricing at the first? Ridiculous
  • Dr. Dunn complains that primary care physicians like him spend half their time filling out documentation that offers no value add for the patient. He thinks docs should be paid “for the service they provide (without having to battle for reimbursement) and eliminate the non-value-added documentation.” This would boost the capacity of primary care physicians and reduce the need for emergency room use. I’m sympathetic to the paperwork complaint but I don’t think we can replace it with no questions asked fee for service. If Dr. Dunn is ready to take on global capitation for his population of patients then his idea might work. Even then there will be some paperwork
  • Dr. Geehr blames ObamCare. “ObamaCare, like its predecessor RomneyCare, promised fewer ER visits and more primary-care access. Government always fails to account for the unintended consequences of vast, new entitlement programs.” Actually, some proponents of ObamaCare (including me) did foresee the rise in ED utilization. Opponents didn’t think of this argument ahead of time, since they were so busy blaming the uninsured for clogging up the emergency department.
  • Dr. Brotherton writes, “the best way to reduce ER visits is for insurers to pay adequately for primary care.” Somehow –he doesn’t explain how– this will cause patients to go to their primary care doctors instead of the emergency room. I’ll give him the benefit of the doubt and suggest that he means higher payments will induce more physicians to practice primary care, but that would take quite a while to play out and still doesn’t address patient behavior.
  • David Lieberman wants hospitals to put urgent care clinics alongside emergency departments to keep the non-emergencies out. Not a bad idea and some hospitals are actually doing this. It works best when hospitals have a financial incentive to hold down costs

Image courtesy of Stuart Miles at FreeDigitalPhotos.net

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