32nd Infantry Brigade - Wisconsin

Dear Readers: Today, I received a letter from a friend that really made me pause and reflect on the bigger picture. The video clip below is from the 32nd Infantry Brigade (produced by one of their own) and shows excerpts from their work in Iraq. The friend who serves, I have not seen for several years, since, as you may expect he has been deployed in Afganistan and now Iraq. He has missed many of the greatest parts of his children's growing up years because of his (and his family's) selfless dedication to serving his country with honor. The last time I saw him was at a Christian family camp at Fort McCoy in Wisconsin. Please take a moment to thank those whom you know are serving in our military. These men and women deserve our respect.

HOW TO MAKE HEALTH CARE DELIVERY MORE EFFECTIVE, EFFICIENT, AND AFFORDABLE WITHOUT INSISTING ON ‘COOK-BOOK’ MEDICINE

A Message From Dr. Eric Radin to my colleagues for the benefit of our patients:


Few attempts by the government to reform health care delivery have been successful. Massachusetts-Health is proving everyone can’t be insured without lowering the cost of treatment. The debate over President Obama’s attempt to cover the uninsured has discovered the same thing. It is too expensive. This suggests it will require a cultural change of our heath care providers to accomplish reform.

In our current medical culture it’s almost impossible to control runaway health care costs. Attempts at spending caps were successfully blocked, appeals to professional pride didn’t work, and mandatory continuing medical education failed to make health care delivery more affordable.

To lower the cost, and hopefully to increase our national quality of care, we need to make health care more effective and efficient. But accepted practice protocols, although generally useful, should not be expected to include patients toward the ends of the bell-shaped curve that all biology is described by. What will it take to improve our clinical results and lower the cost?

First, since healthcare is acting like a business, treat it as a business. This idea, proposed in 2006 by Porter and Teisberg in their book Redefining Health Care, and recently updated in the lead article in the July 9th edition of New England Journal of Medicine (NEJM.361(2) ;109-112), are a business school critique of our health care system. It suggests a business-type solution, pay for value. Value in the marketplace has always been judged by consumer satisfaction, related to what was bought and what it cost. Porter and Teisberg recommend paying doctors bonuses for value received, defining value as clinical outcome divided by cost. To avoid paying for quick fixes and preventable relapses, pay some of the fee initially; pay the bonus for value when the outcome and total cost become apparent. This should encourage innovation and limit high-tech, high-cost treatments to those who require them.

Second, encourage real competition between providers as well as health care centers. Publicize success, by diagnosis, to the public on the Internet. Rank every practitioner and medical group practice. Public pressure and patients preferentially flocking to high value providers, plus substantial bonuses for increasing value should bring about the beneficial cultural changes needed. It is a concept that makes the medical profession shudder but would be a boon to the sick and injured.

How can outcome be fairly judged? It would seem best by using functional criteria: Has the patient returned to his/her expected full activity? What activities of daily living can the patient accomplish that he/she could not accomplish before the medical intervention? How have the appropriate clinical measurements responded to the treatment? How does the patient rank his/her recovery? It is important, as well, to publish the methods used by the innovators to increase value, so other practitioners and their patients and the system can benefit from the same measures.

So, instead of detailed protocols, those who deliver heath care would be able to rely on well-rewarded innovation and well-publicized competition instead of payment schedules, forced discounts by insurance companies and cookbook-like protocols. Research in evidence based medicine, best practices, comparative treatments, and team effort should all be energized by the value payment incentives. Rather than using these findings to hamstring medical practice, value payment incentives should free practitioners to use their judgment to practice value-driven care. Medical judgment could be maintained.

Widely advertising the value of their treatments by diagnosis, should make American health care more efficient, effective, and affordable without destroying the profession. Good medical practice will be allowed to remain something of an art, built on the scientific data of what works when.

The country wants affordable health care. Currently we physicians are the deciders of what treatment our patients receive and thus directly and indirectly control the costs. Wouldn’t it be better for the medical profession to decide how to lower the costs of care rather than have the government and other third parties do it? My colleagues need to admit that that time is running out for the status quo. Our present health care delivery system is no longer sustainable. By now, it should be obvious that health care delivery will be more closely regulated. If my colleagues and I don’t change our ways, someone else is going to do it for us.

Eric L. Radin, M.D.
Marion, MA

The author is orthopedic surgeon and an Adjunct Professor at Tufts University School of Medicine.

Reform Update

The lesson of health care reform of this week is that if The President, Al Franken, Peter Orzag, The House, AHA and a cast of thousands push too hard and too fast, the wheels start to fall off the reform bus.

Looks like the Senate is all but guaranteeing no action before the August recess...and maybe things will get just too busy to finish the job this year.

Look for much more compromise and juggling in the fall as the Dems try to salvage some victory.

Is there Health Care Reform in Your Future?

To Be or Not To Be, That is the Question;
Whether ‘tis nobler in the mission to suffer
The regulations and congressional acts of outrageous politics,
Or to take the balance sheet against the sea of credit troubles
And by opposing end them. To rest – to sleep,
No more; and by a sleep to mean we end
The heart-ache of a thousand budget cuts and layoffs
That administration is heir to: ‘tis a consummation
Devoutly to be wish’d. To end the senseless war;
To sleep, perchance to dream of a former time –
Ay, there’s the rub:

The above, though poorly transposed from Bill S. however, describes the results of a recent survey from a small panel of notables in the field of healthcare asking if they believe meaningful federal healthcare reform will actually happen this year. The majority indicated a firm belief that reform will crash on the rocks before we hit the summer (July) recess. Neither fiery debate nor the ramrod of reconciliation can result in reform according to the survey responses. Interestingly enough, of all the respondents a few (less than 30 % indicated reform will happen. Yet of these optimists most felt that reform will come via the parliamentary maneuverings of budget reconciliation…not much confidence that meaningful debate would actually yield thoughtful reform.

So, what do we make of this? Charge ahead and take to the sea with your healthcare venture as the domestic issues are far from clear. Even if reform does happen, promulgating regulations and the inevitable ‘adjustment’ period means that we are several years out from reform (again!).

Survivor

When the host comes out at the end of the show, after all the contestants finish their game for this round and have thoroughly thumped one another, it's time to find out who get's voted off the island.

These days, healthcare reform, competition and policy is more similar to Survivor than to a thoughtful and well crafted incrementalistic approach we all expected. Sometimes it just doesn't work out that way.

For about the last 18 months or so, we've been wondering with more than passing speculation who will survive. Due to a confluence of completely unexpected events (credit debacles, major recession) and some expected results (sea change in Washington) change does appear imminent.

So, we asked a panel of experts who survives and who gets voted off the island.

First, the survivors. Our experts predict that Large Integrated Health Systems and the Federal Government will be the two surviving entities. These two organizations (if that is the correct term) were the #1 and #2 vote getters in our poll. A distant third place was single specialty group practices. What is even more interesting is that the younger experts (20's, 30's and 40's) tended to favor a government run system whereas the older (AARP eligible) experts anticipated the continued rise and dominance of integrated health care delivery systems.

No one thought that niche hospitals or large national managed care companies would carry the day. If you find yourself in one of 'these'...perhaps it's time to get your lifevest and consider paddling to the next island.

Health Care Resources - Useful Websites 3

The Medicare Payment Advisory Commission (MedPAC) was formed as part of the BBA of 1997 and functions to advise Congress on issues effecting Medicare - primarily payment issues, yet also reviews and advises on the broad topics of access, quality and other factors effecting Medicare.

The Commissioners, 17 in number and serving 4-year terms, bring a range of expertise and interests from policy to financing to health services delivery.

MedPAC issues two major reports each year, holds public meetings and seeks input from a very broad sector of government, academia and interested individuals. Occassionally, I've been asked for input on these policy papers and find that the commissioners are truly seeking solutions that work yet are mindful of the realities in which Medicare policy is formed and executed.

MedPAC reports tend to be 'leading' indicators of future potential policies effecting Medicare. Such as the future of IDTF imaging reimbursement, SGR changes and the like. The lag time can be 6 months to never for implementation of MedPAC findings. For those who are attempting to predict or influence the future of Medicare financing policy, pay attention to MedPAC.

There is a special section on the website to sign up for electronic mailings. Strongly recommended.

Health Care Resources - Useful Websites 2

The National Academy for State Health Policy provides a nice cross sectional view of health policy concerns and solutions at the level of state policy (often given short shrift with the overly abundant emphasis on national health policy). So often, leading indicators of significant policy shifts are developed and executed at the state level, that any health industry person would be well advised to become familiar with the key issues and possible solutions occurring at the state level. Lest we forget, it was only 2 years ago that Massachusetts broke the mold and created a universal health plan (at the state level at least) and not that long ago that state funded rationing experiments were implemented in Oregon.

The website hosts a number of policy papers, notices of conferences and exploratory topics.

Health Care Resources - Useful Websites I - Dartmouth Atlas

The Dartmouth Atlas website [link: http://www.dartmouthatlas.org ] provides a wonderful capstone to years of research in small area analysis. Not only does the website review the famous atlas of health care, but it also interactive programs for comparative analysis, research articles, lectures and presentations, many tools for data review and analysis as well as detailed instructions on how to use key functions.

How can you use this information? Estimating community health use is possible for regional areas particularly if the analysis isn't overly sensitive to very discrete areas. The above graph, for example, can help provide a quick estimate of physician visits for end of life care compared across regions.

Take a tour of the site -- quite helpful to get a good understanding of health services variation along a number of dimensions.

Health Care Resources - Useful Websites I

Over the years, we've come across a wealth of useful websites for those working in Healthcare. Covering Health Policy, Performance Improvement, Marketing, Operations Management, Law and Human Resources. This series is intended to provide a review of websites and will be amended from time to time. We hope you enjoy!

Accountable Healthcare Organizations - Reader Poll

Dear Readers:

The notion of accountable healthcare organizations (ref: Elliott Fisher, et. al.) creates the possibility of yet another oganizational model for improving VALUE (quality and cost) for health services delivery...or is this just a re-hash of former policy gone bad? What's your view?

Opinion Polls & Market Research

Is Medicine Being Practiced with an Inappropriate Business Plan?

The health care delivery market is overrun with specialists and super-specialists resulting in high-tech doctors offices and cookie-cutter general hospitals, a plethora of unnecessary diagnostic and therapeutic procedures, soaring costs, and long waits for patients to get an appointments and then, arriving for it be seen. Separating patents on the basis of the difficulty to diagnose and treat their health problems would seem a sensible approach to trying to increase efficiency and lower costs, while at the same time, allowing increasing quality.

Most problems that patients present to health care providers officers and clinics are simple and straightforward, easily recognizable from training and experience. (1) In these cases the diagnosis is made by pattern recognition (2) and the treatment can follows protocol. It has been shown that less sophisticated providers treat patients less expensively than specialists, provided the providers have been trained to recognize and successfully deal with the problem the patient has. [3].

Stratification of care can make health care delivery more cost-efficient and consumer-friendly. In addition stratification, by unloading the more sophisticated providers, allows them to devote themselves expeditiously to patients who require a higher level of expertise. [ref.] Patients with simple, common medical problems, treated by properly trained NP's and PA's, should improve the efficiency of health care delivery without damaging its quality.

But how to define whom NP's and PA's can safely treat unsupervised? One of the doc-in-the-box companies has apparently found an answer. MinuteClinic has a list of what its providers will treat. This definition makes MinuteClinic's NP's and PA's consistent and reliable. The list of what they will do is listed below.

Obviously doc-in-the-box care is at the bottom rung of a health care delivery stratification ladder. But for what it does it's quicker and less expensive than an ER and patient satisfaction is high. I don't know if they train their practitioners to recognize medicine's "red flag" diagnoses, those life or limb threatening conditions that require immediate or at least urgent care. This knowledge should be part of the training for all practitioners at al levels of expertise.

One assumes the doc-in-the-box patents are quite able to get around and are not seriously ill. It is interesting that MinuteClinics do not deal with trauma. For what they do, it seems like a more efficient "way to go" for those with appropriate insurance. The hospital walk-in urgent care clinics are more comprehensive but the waiting times to see someone is frequently long. This is because we are mixing the seriously ill with the mildly sick.

There is no question that our current health care delivery business plan is inappropriate for most patients. Clayton Christensen, the Harvard Business School guru chronicled the fall of over-bloated sophisticated commercial enterprises felled by innovators with simpler business plans. In his book, "The Innovator's Dilemma" (1997), he discusses how industries, based on ever-improving technical advances, eventually become too sophisticated and expensive for the majority of their customers. Christensen thinks health care delivery has reached that point. So do many others.

There is no doubt that pattern recognition alone will not make all diagnoses, but it will make a large number because he majority of problems patients come with are common and easily recognizable. And in these straightforward cases, the best-practices treatment protocol will work almost all the time. Only patients with more sophisticated problems need to see more sophisticated practitioners.

To maintain quality we need to define what the various levels of primary care practitioners should be able to diagnose and treat and train them accordingly. We need diagnosis-based job descriptions at all levels of medical practice, which we teach to.

Most patients do not require health care practitioners with 11 or more years of training after high school, including 2 years of advanced basic science study and 3 or more years of years of residency. To be efficient, our health care business plan should save specialists for the patients who need them.

A word about hospitals and efficient, cost-effective care

Except in rural areas, the general hospital trying to be as many things as it can to all patients is no longer a viable business plan for efficient, quality care, for the majority of patients. Of course we need tertiary medical centers, to can deal with patients with serious multi-organ problems but we don't need so many. Most are clustered together in big cities. Many specialty hospitals, focused ambulatory clinics, freestanding surgi-centers and doctor's offices, and disease-specific treatment teams are delivering greater value (long-term outcome divided by cost) then the medical centers. We need to stop blindly defending the general hospitals and medical centers and insist that all providers and in-patient facilities compete on value.

Eric Radin, MD
Marion, MA

MinuteClinic treats Allergies (ages 6+), Athlete's Foot, Bladder Infections(Females, ages 12-64), Bronchitis (ages 10-64), Cold Sores (ages 12+), Deer Tick Bites (ages 12+), Ear Infections (ages 5+), Impetigo, Minor Burns- Rashes- Skin Infections- Sunburn, Pink Eye and Styes, Poison Ivy (ages 3+), Ringworm, Sinus Infections, Strep Throat, SwimmerÂ’s Ear (ages 3+), Swimmer's Itch, Warts (ages 5+), will test for Flu, Mononucleosis, and Pregnancy, and offers vaccinations.

Commentary on Elliott Fisher's Proposal for Medicare

There is a suggestion by Elliott Fisher of Dartmouth Med School that the Commonwealth Fund recently put on the web as to how to cap Medicare costs, diminish unnecessary tests and procedures, and take geographical diversity into consideration.

Fisher would consider the hospital and the patient’s principle doctor as a unit and, as I understand it, compare their combined charges per DRG with those of the region they are in. Those units coming in under the mean would be rewarded; those over we not be rewarded. It is thought that this would simplify the billing and evaluation processes by greatly reducing the number of providers by looking at hospitals including their providers rather than hospitals and providers separately. . All the treating and referring docs in one hosp plus the hosp would be evaluated as one team. Medicare will like that.

The idea is to diminish costs by rewarding those who treat efficiently and don’t run up costs with unnecessary tests, procedures and admissions. Not a new idea- one can consider cost caps, as as an incentive to efficiency. What has resulted from cost caps are cutbacks in servies, increases in complexity of treatment, and other cost override games. And without good metrics of severity and complexity and a strong outcomes measures in place, this program would might lead to a deterioration of care as the team makes sure they do the stuff on the lists: mammograms, colonoscopies, vaccinations and beta-blockers, but scrimps on the rest to come in below the mean cost. In addition the complex patients might all find themselves underserved or dumped into another unit, or as Fisher calls them, extended hospital medical staff, (EHMS). We would be rationing care to make the cut, as teams.

The plan, since it’s measures success regionally and relatively, might tend to promote the regional excesses of intervention so stunningly revealed in Wenberg’s Dartmouth data.

The teams, the EHMS, would seem a good idea but with qualifications. First, the team members must be monitored individually by its EHMS, to wean out incompetents and privateers. The overall system should rapidly rank the units. It is a must that the variations in the patients being cared for are fairly calculated so comparisons are just. That will require some fancy date collection and analysis of date, possible with today’s computers. Outcomes should be part of any payment scheme. In a non-fee-for-service circumstance, such as DRG’s create, it is frequently better to under treat than to fully treat since outcome ignored. We collect readmissions but do little about them reimbursement-wise. And Fisher’s plan would be even more attractive if it got away from regionalism and let all Americans have a chance to go somewhere better for treatment. Let the units compete nationally, as Porter and Teisberg have suggested. And as they have said, we should reward value.

Prof. Fisher’s plan needs to be more fully sketched out, but with qualifications it seems a progressive step. Medical individualism has proven itself to be too expensive. Team innovation may be the answer.

Eric L. Radin, MD

The Fisher proposal is described at: (http://www.cmwf.org/healthpolicyweek/healthpolicyweek_show.htm?doc_id=424115&#doc424117)

Pharmacogenomics and Biotechnology - What Price Personalized Medicine?

Kathryn Phillips' recent article in Health Affairs (Sept/Oct 2006, vol. 25, no.5) explores the new frontier of personalized medicine using pharmacogenomics. That Dr. Phillips is on the right track of a new trend is beyond question. She makes a great case for the emergence of personalized medicines based upon genetic information -- targeted treatments akin to the having your suit made to fit versus buying off the rack. New and therapeutic treatments are not only possible but clearly within grasp for researchers and applied scientists.

The bigger question -- can we afford this?

In a seemingly unrelated event, Wal-Mart announced this week that sales of generic medication via Wal-Mart's own version of personalized sales (we presume it is branded as Wal-nerics or something like that) have tripled -- exceeding even Wal-Mart's lustful desires. Why?

Because the constant drumbeat these days isn't better quality, but rather health care cost containment. In our opinion, the market for personalized pharmacogenetics will remain wide open for the near term. There is a season for all things and this ain't yet time for high cost, low volume, low market-share personalized medicine.

Revision to Medicare QIO's

For years, state QIO's have had a strained relationship with the physician groups they've been asked to regulate (or help).

In a recent report from the Institute of Medicine (IOM) under contract from HHS, a new day may be dawning for state QIO's.

Historically, QIO's have performed a number of functions including review of complaints from Medicare beneficiaries, promoting health care quality, assurance that hospitals/doctors meet essential quality standards, and the like. Yet, at the core, most provider organizations haven't experienced QIO's as the one's to turn to for genuine help in measuring and improving quality.

In a new role, QIO's could become a source of technical assistance to health care organizations and practitioners. With an anticipated surge in pay for performance contracts (private and public) and increasing demand to report outcome measures as part of the transparency movement, QIO's may be in a position to actually help practitioners (particularly smaller groups).

And now for the punch line...the regulatory limb of the QIO's would have to be moved to another party (hence the conflicting responsibilities removed).

What's in it for QIO's? Well, for starters, QIO contracts would be open to bid for minimum of 5 year terms. Groups like the Iowa Foundation for Medical Care and MetaStar(QIOs well know true quality approaches) would likely be quite successful in an open bid process to the betterment of several state QIO programs.

Looking ahead, we're optimistic!