Health Insurance Reform - It's Not a Bumper to Bumper Warranty

We have some Healthcare reform in the US but we are still challenged with a system that is failing to deliver results. This piece recently: America Ranks No. 1 for Over-Priced, Inefficient Health Care featured the chart from the Commonwealth fund

That ranks the US last in a group of 11 industrialized countries.

As he puts it:

There is one way America is clearly exceptional:  we have a healthcare system that is dramatically more expensive than the rest of the industrialized world, but it doesn’t manage to make us any healthier.While  the Affordable Care Act attempts to address access it does little to address the cost of the system and the inefficiencies. This does not require a reduction in premiums it needs to address the costs built in to the system that we are all paying for in on form or another

Dr Hans Duvefelt wrote this piece on the healthcare blog: A Swedish Country Doctor’s Proposal for Health Insurance Reform that draws on his personal experience in "socialized medicine, student health, cash-only practices and government-sponsored rural health clinic working for an underserved, underinsured rural population."

His focus is as a primary care physician but most would agree this is one of the most challenging areas for reform with the shortage in clinicians and low reimbursement rates that is driving doctors out and certainly no encouraging our new generating of clinicians to dive into this essential area.

His main proposals center on basic services that are covered by a flat rate for populations

• Have the insurance company provide a flat rate in the $500/year range to patients’ freely chosen Primary Care Provider, similar to membership fees in Direct Care Medical Practices.
• Provide a prepaid card for basic healthcare, free from billing expenses and administration.

but importantly changing the responsibility and feedback on the cost from a central purchasing authority (the government for example) to the user themselves.

• Unused balances can be rolled over to the following years, letting patients “save” money to cover copays for future elective procedures.

And offers a pathway to specialty care with some appropriate oversight and appriroate levels of reimbursement.

• Keep prior authorizations for big-ticket items, both testing and procedures, if necessary for the health of the system.
• Keep specialty care fee-for-service.

 These are clever suggestions and would do much to encourage the patient engagement that will be, as Leonard Kish stated

Patient Engagement is the  Blockbuster drug of the century

He rightly points out that the current health “insurance” products are often poorly named - given that insurance that pays and copiers to identify diseases with screening but then stops short of paying to treat conditions and diseases when they are found through that screening. But most of all Insurance should be user driven and priorities and decision left in the hands of the individual and their clinician and not relegated to others who sit in offices emoted from clinical practice and focused on fiscal drivers not on care and quality fo life

Health insurance is not like anything else we call insurance; all other insurance products cover the unexpected and not the expected. Most people never collect on their homeowners’ insurance, and most people never total their car. Health insurance, on the other hand, is expected by many to be like a bumper-to-bumper warranty that insulates us from every misfortune or inconvenience by covering everything from the smallest and most mundane to the most catastrophic or esoteric.

His point about setting of priorities is important - no matter how you cut it there is no unlimited pot of money o resources to treat everything and everybody. These are difficult conversation and ripe for abuse by those with their own agenda’s through fear mongering and use of emotive terms like “Death Panels”.

None of this aspect of reform is simple but it needs to be addressed and included.

The United Kingdom’s National Health Service (NHS) may not be perfect but they have started this process of addressing the challenge of allocating resources in an open manner. They developed the the quality-adjusted life years measurement (QALY) out of the National Institute for Health and Care Excellence (NICE). There has been criticism and push back as there will always be but the concept and methodology use is not limited to the UK. While imperfect as Laozi (c 604 bc - c 531 bc) stated:
A journey of a thousand miles begins with a single step

There is lots of detail in this piece and I would encourage you to go over and read it

A Paper Towel as a Medical Record - Really! #safety #HealthIT #EHR #hcsm

I ran across this posting on Mark Hindle's Twitter account:

My Nan is in well publicised poorly performing hospital, this was in her notes last night - paper towel prescribing! pic.twitter.com/BdlLYy1gxD
— Mark Hindle (@mhindle2) August 15, 2013

The picture is shocking:

This is not just a hand written note as a simple reminder...this paper towel addresses the Pharmacy and says

"Please dispense Colecalciferol 20,000 units"

And it appears the pharmacy or maybe the nurses have dispenses this as evidenced by the "tick" over the top.

The Institute of Medicine published several studies including:

1999: To Err is Human
2001: Crossing the Quality Chasm

And the Journal of the Royal Society of Medicine Published a study in 2006; Poor handwriting remains a significant problem in medicine that stated:

Leape and Berwick called handwritten medical notes a ‘dinosaur long overdue for extinction

Yet here we are in 2013 and not only do we still have hand written notes but they are written on a paper towel......I'm left

The Future of Healthcare as Seen Through the Eyes of @kpTotalHealth with @Tedeytan #HealthIT

I posted a piece that was published on FastCompany site at the end of last month:

Could The Future Of Health Care Mean No Waits In Hospitals?

It included a link to an original concept from the innovative Kaiser founder Dr Sidney R. Garfield


I shared this with my wife who is an accomplished midwife (she stopped counting her deliveries after she hit 1,000) and we both shared a laugh but as she pointed out - at the time it was a brilliant compromise between two competing interest:

On the one hand you have healthcare wanting to help mothers rest after giving birth

On the other hand you have mothers who's genes are screaming at them - be with your baby

In this particular instance the National Health Service (NHS) in England was ahead of its time, guided by an experienced and well respected cadre of midwives who promoted and encouraged rooming in of babies when they were born. We experienced this with our children but our youngest was born here in the United States and at the time it was a fight to stop the nurses from removing our daughter from the room

I had the privilege of visiting the Kaiser Total Health facility and spent an invigorating few hours with Dr Ted Eytan, Physician Director in the Kaiser Permanente Federation (@TedEytan and his blog)

He was kind enough to reply to my article in a tweet:

And the details even appeared in the wall of knowledge with the background that I captured here:

Ted shared a link to the original history
KP’s ‘Baby in the Drawer’ Helped Turn the Tide Back to Breastfeeding Babies after World War II Which tells the story of the driver on this innovation centered around better outcomes from keeping mothers and babies together:

Sidney R. Garfield he had read an interesting article about the now famous Yale University School of Medicine research experiments with rooming-in for mothers and babies

Kaiser Permanente has continued their continued innovation - Small Hospital, Big Idea which continues and contributes to their impressive growth:

An Impressive and consistent increase in Patients

All this is embodied in the Kaiser Total Health Center that brings together existing and new technology in innovative ways. Everything from the large screen introduction:

 Through to the handheld ultrasound device:

It includes patient education with the explosion of the obesity epidemics - captured in this video graphic

The mock up health room 

Mock up Patient Examination Room

and placed working technology in the reach of innovators, patients and clinicians

3-D Visualization for Patient Engagment on Medication

 and simple technology - but so important - two hand sets for one phone so patient and health care worker can both listen in to the same conversation with immediate availability for language translation (I'm willing to be we won't need a telephone for this simultaneous translation in the near future)

and the room and facility continues to be updated:

No doubt Ted who is is currently exploring the GoogleGlass Innovation (you can read about his exploration here in his blog "The USA #ThroughGlass") will be including some of his google glass experiences as they learn more about this innovation

I believe

Paper and manilla folders will become a thing of the past relegated to museums

this will be true and perhaps when I am lying in my hospital bed will look back at this age and think

Mostly, I know that someday, someone in my same CMIO and MD shoes will think how silly it was that doctors actually hand-typed patient notes

News Round Up - July 20

Some interesting news pieces to review this week including

The Value of the EHR

"The Relationship Between Electronic Health Records and Malpractice Claims,” from the Archives of Internal Medicine on Jun 25 and featured in the AMED News: "EHR use linked to fewer medical liability claims" on July 16

A research letter published online June 25 in Archives of Internal Medicine found that the rate of liability claims when EHRs were used was one-sixth the rate when EHRs were not used. Researchers say their findings suggest there was a reduction in errors associated with EHR use.

That showed the following results before and after an EHR implementation:



A word about correlation and the fact this does not imply causality: …correlation between two variables does not automatically imply that one causes the other

But as the authors put it:

It’s entirely possible that there’s something still distinct and unusual about practices that adopted electronic health records earlier, and they just happen to practice in a way that reduces their risk of malpractice claims….But I think it’s equally plausible that there’s something about electronic health records that does reduce their risk.

Uncertain but an interesting positive development

High Price Variability in US Hospital Surgical Procedures

Calprig published a report "Your Price May Vary" that offered a view into the wide differences in pricing for the same procedure in California. For example for a knee replacement from $59,800 (Alameda County Medical Center) to $164,400 (Washington Hospital). But the variation doe snot necessarily track quality adn they pointed to an earlier study in the Archives of Internal Medicine that showed county hospitals usually charge the least and for-profit hospitals charge the most and did an an interesting analysis of the hierarchical model for percentage increase in median charge for various patient and hospital factors:


And the charges for Appendicitis:

The median hospital charge among all patients was $33,611, with a lowest observed charge of $1529 and highest of $182,955

Personal Health Records

This review of Kaiser's myHealthManager: Lab tests and knowing our numbers can inspire patient engagement:

Engaging patents and sharing laboratory data helping them understand their results can inspire patent engagement. As they put it it is not enough to share the data you have to engage with the patient:

That means patients need to knowing their numbers: what they mean, and how changing them can impact their future quality and length of life… where personal behavior change has the potential to do this

This is the start of patient engagement and one that I think we will see increase in the coming months and years

This and more on #VoiceoftheDr



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Save Money and Reduce Medical Errors

and improve the quality of healthcare!
HealthImaging featured a report Medical errors cost U.S. $17 billion in 2008 which estimated that

This figure amounted to 0.72 percent of the $2.39 trillion spent on healthcare that year in the U.S.

The study identified the sources based on medical claims estimating:

564,000 inpatient injuries (1.5 percent of all inpatient admissions in the U.S.) and 1.8 million outpatient injuries (0.15 percent of the estimated outpatient encounters nationwide)

Given the landmark publication "To Err is Human" from the IOM from November 1999 that estimated at that time:

...total costs (in­cluding the expense of additional care necessitated by the errors, lost income and household productivity, and disability) of between $17 billion and $29 billion per year in hospitals nationwide.

the progress remains frustratingly poor more than 10 years on. There is a top 10 list featured in the latest research that accounted for 69% of the costs

• Postoperative infections were the most costly error, ($3.3 billion)
• Pressure ulcers ($3.2 billion)
• Mechanical complications of noncardiac device implant or graft ($1 billion)
• Postlaminectomy syndrome ($995 million)
• Hemorrhage complicating a procedure ($678 million)
• Infection due to central venous catheter ($589 million)
• Pneumothorax (collapsed lung) ($569 million)
• Infection following infusion, injection, transfusion or vaccination ($566 million)
• Other complications of internal prosthetic device, implant and graft ($398 million
• Ventral (abdominal) hernia without mention of obstruction or gangrene ($342 million)

The list serves as a focal point for healthcare professionals and patients that offer significant opportunity for improvement in both costs and quality of care. With the announcement of Accountable Care Act (ACO) on March 31 by HHS will further focus the healthcare system on removing errors and delivering a more complete and holistic approach to care. There has been much written about the ACO concept with many commentators suggesting that organizations and healthcare facilities are not ready for these changes. I would suggest that we can neither afford as providers nor accept as patients any delay in a move towards fully accountable care that focuses on on putting the doctors and patients in better control of their care and linking reimbursement to outcomes

EHRs and their Impact on Quality of Care

Headlines this week have provided much confusion in the march towards digitization of healthcare that were based on a Stanford study published in the Archives of Internal Medicine: Electronic Health Records and Clinical Decision Support Systems with a conclusion:

Our findings indicate no consistent association between EHRs and CDS and better quality. These results raise concerns about the ability of health information technology to fundamentally alter outpatient care quality.

Needless to say a strong negative claim from a leading institution attracted a lot fo coverage (Medscape, Reuters, Health Data Management, iHealthBeat,  DotMedNews, Bloomberg.....and the list goes on). The power of the internet and the instantaneous nature of the news allows these stories to rapidly disseminate.

In fact some of this will add fuel to the HR408 Act  Spending Reduction Act of 2011 (the text of this can be found here). It is a far reaching bill attempting to reign in spending to the tune of 2.5 Trillion and includes several elements focusing on repeal of Healthcare IT stimulus spending S:302 which focuses on repealing the HITECH funding and investment - there was a good analysis in Health Data Management GOP Bill Puts Meaningful Use, HITECH Act in Peril that highlights the murky nature of the impact of this legislation.

But the power of the internet works both ways and there are several great articles that apply a sound analytical view on the study and highlight the limitations of the study. In this piece Dr WIlliam Hersh; Electronic Health Records Do Not Impact the Quality of Healthcare takes a long hard look at the study adn as he points out

Like almost all science that gets reported in the general media, there is more to this study than what is described in the headlines and news reports. The study was published in a prestigious medical journal by two Stanford researchers. The implementation of the research methods they used appears to be sound.

But as he points out there are serious limitations to this type of study based on the type of study and the data resources, in particular the study "used a data source collected for other purposes and he highlighted the following limitations:

1. A frequent challenge - the study looks at correlation, which does not mean causality
2. The quality measures used did not provide enough insight into actual quality improvement (process measures vs outcome measures)
3. No detail of the EHR's being used and if they had any decision support in place relative the the quality measures
4. THe care assessed was individual episodes of care and improvements in actual quality occur over multiple episodes of care (the longitudinal medical record)
5. Data analyzed was old (2005 - 2007) and in any field of technology including Healthcare Informatics this is old
6. No indication of the training and skill set of the clinicians being assessed and success and failure fo EHR's goes far beyond the technology and is closely tied to implementation and training

And there was extensive discussion that pointed to other articles and studies highlighting the benefits and in particular emphasize how early we are in this process. I imagine that for several other key inventions there was a similar response:

• The Electric light bulb
• Telephone

This 'telephone' has too many shortcomings to be seriously considered as a means of communication. The device is inherently of no value to us.

Western Union Internal Memo: 1876

• Automobile
• Microprocessor
• And even the internet and the world wide web

THis follow up piece by Clem McDonald: Clinical Decision Support and Rich Clinical Repositories: A Symbiotic Relationship that highlighted a range of other positive studies and identifies significant breakdown in the meta analysis that was carried out. As he states succinctly:

• First, and most important, the current article tells us nothing about which CDS guidelines were implemented in the systems that they studied. Practices and EHRs vary considerably in the number and type of CDS rules that they implement, and we do not know whether the CDS rules implemented by the practicesthat participated in the surveys addressed any of the 20 quality indicators evaluated by Romano and Stafford.
• Second, the current study and Garg and coauthors' review considered very different categories of guidelines. Most of the guidelines (60%) in Romano and Stafford's study concern medication use; none of them deals with immunizations or screening tests, which were the dominant subjects in the studies reviewed by Garg et al.3 Furthermore, in our experience, care providers are less willing to accept and act on automated reminders about initiating long-term drug therapy than about ordering a single test or an immunization.
• The third difference is that the current study examined the outcome of a single visit, while most of the trials reviewed by Garg and colleagues observed the cumulative effect of the CDS system on a patient over many visits.
• Finally, the data available from NAMCS/NHAMCS may be limited compared with what is contained in most of the EHRs used for Garg and coauthors' trials. For example, the NAMCS/NHAMCS instruments have roomto record only 8 medications, even though at least 17% of individuals older than 65 years take 10 or more medications.

The road to digitization of healthcare is long and filled with many ups and downs. This study adds the overall knowledge but should be taken in the context of what was studied and its contribution to guiding us down the correct path and not, as some would believe> halting the journey and returning to the dark ages of pen and paper.

Posted via email from drnic's posterous