care coordination

The New England Journal of Medicine just published a great article about physician stewardship as it relates to medical spending. The piece, called "Cents and Sensitivity—Teaching Physicians to Think about Costs," discusses whether or not we should be training physicians to consider the bills patients will face when making decisions about what treatment to choose. (Aaron Carroll’s treatment of this piece is here.) The authors propose that teaching physicians to be more cost-conscious will increase their capacity to care for the whole patient, not just their symptoms:

"Whether it’s lack of time, fear of “missing something,” or simple ignorance, the incentives to do more often overwhelm our impulse to use resources wisely. Now some educational reformers are offering us an added ethical incentive. Put simply, helping a patient become well enough to climb the stairs to his apartment is meaningless if our care leaves him unable to afford that apartment. Protecting our patients from financial ruin is fundamental to doing no harm."

We agree that overtreatment is a problem, and we applaud the NEJM for addressing it. It says a lot about how far we have come from even five years ago when everyone was thumping their chests and talking about how we have “the best healthcare in the world.” But we believe that there’s an even greater reason to address the topic of overtreatment: because it is dangerous. Starting with the Institute of Medicine’s 1999 report, “To Err is Human,” the research has continued to demonstrate that more does not always mean better. 

So yes, physicians should consider what patients can afford, but even before that, physicians need to realize that doing nothing is often safer than putting patients at risk with treatments that don’t work. Fiscal responsibility—making sure we aren’t sending Grandpa Frank from the ICU to the poor house—will be the natural consequence.

Here's our wrap-up of last week's articles by our own Shannnon Brownlee and Joe Colucci:

Letting Big Pharma Review Its Own Drugs — What Could Go Wrong? (The Atlantic Health Channel):

Earlier this month GlaxoSmithKline agreed to pay a record breaking $3 billion fine for a slew of criminal and civil violations. But is a fine really enough? In a piece in The Atlantic, Shannon Brownlee and Joe Colucci argue that we need to stop letting drug companies track the post-market safety of their drugs and establish an external automatic review system. 

 

12 Ways Health Care Could Be Improved If the House Wanted to Hold More Than Symbolic Votes (The Atlantic Politics Channel):

In the wake of the House's 33rd vote to repeal/defund Obamacare, Joe and Shannon propose a list of 12 things the House could have done to make a better use of tax payers' dollars and actually improve health care. In the article in The Atlantic the proposals range from enacting a less intrusive mandate to funding after school programs to teach kids how to cook. Any of them would have worked better than another "symbolic vote."

 

Why The ‘Best’ Hospitals Might Also Be The Most Dangerous (TIME Ideas):

We've all seen them—the U.S. News Rankings of everything from colleges to cars. How do their hospital rankings look? In her latest article for TIME, Shannon argues that, based on new rankings by Consumer Reports, many top-name hospitals fail to measure up in terms of safety. Hospital rankings would be a lot more useful if they considered how medical care affects most patients, not whether a hospital performs some cutting-edge procedure on three patients per year.

The number of the day is 222—the international dialing code for Mauritania.  More interestingly, 222 is the number of nationwide ER visits per minute in 2011, according to the 2007 Emergency Department Summary from the National Hospital Ambulatory Medical Care Survey (NHAMCS). Across the year that amounts to “116.8 million ER visits or 39.4 visits per 100 persons.”

Last Monday the Alliance for Health Reform held a Briefing addressing this topic: "The Right Care at the Right Time:  Are Retail Clinics Meeting a Need?" The briefing was sponsored by the Alliance and WellPoint, Inc. to examine the question of whether urgent care clinics and retail care clinics (together called convenient care clinics) are meeting a need in the health care system. The panelists at the event included physicians from WellPoint, RAND Health, and the American Academy of Family Physicians (AAFP). The president of the trade association for retail clinics, the Convenient Care Association, was also on the panel. The conclusion of everyone present was that convenient care clinics are meeting a need. In a broader sense, their findings also presented a strong case for a reinvestment in and retooling of the primary care system, as a whole.

The use of emergency departments has been on the rise for many years. Contrary to popular belief, a Senate hearing reported that the main increase in traffic is not due to increased utilization by uninsured patients. Instead, the largest increase has been seen in those with private insurance.  The report also listed that "physician office visits have increased at an even higher rate than emergency department visits." They suggest that the concurrent increase in ER visits reflects a growing increase in demands for ambulatory care services, and that some of that demand is spilling over into the ER.

Urgent care clinics, like NextCare Urgent Care, and retail care clinics, like CVS’s “Minute Clinic,” are perfectly poised to benefit from this spillover (and the numbers show that they have).  They are open more hours than primary care offices, and cost less than the emergency rooms.  Granted, if you suddenly lose feeling on the left side of your body and start to slur your speech you are not going to stop to consider this dilemma, but ERs across the country already see a steady stream of people who are not in such life or death situations (ask any ER doc).  In fact, one of the panelists pointed out that nearly 25% of ER visits could be safely seen at other sites.  For the working single mom, whose daughter developed a fever of 101 on Saturday night, a quick Sunday morning visit to the nearest urgent care clinic will no doubt be preferred over an expensive 4 hour long ordeal at the ER.  And their transparent prices make it a feasible option for the cost conscious patient.

Rick Kellerman, former president of the American Academy of Family Physicians (AAFP), was the panelist representing traditional family physicians. As one might expect, family physicians initially felt threatened by the convenient care movement—especially by retail clinics, which are usually staffed with physician assistants or nurse practitioners. While many of their concerns (fragmentation of medical care, decreased care coordination, “medicalization of symptoms”) persist to this day, Kellerman said that the AAFP eventually told their members that they needed to wake up to the demands of their patients: “If you don’t like retail clinics, change the way you practice.” Subsequently, many physicians responded by offering changes such as extended hours, open appointments for call-ins, “quick clinics” for walk-ins with minor problems, and group appointments for chronic disease management. Many of these doctors have embraced the movement by partnering with clinics in order to get referrals or becoming supervisors of clinics. In forming such partnerships, these physicians are offering their patients a way to get setting of care that hopefully will combine the cost-consciousness and convenience of an urgent care clinic with the benefits of a long-term doctor-patient relationship and better-coordinated care.

While disagreements remain, the facts show that convenient care clinics are increasingly common, while the number of medical students going into family medicine is decreasing.  The convenient care movement has flourished in part because the status quo in health care is failing.  Regardless of what happens to the Affordable Care Act in the upcoming days, policy makers need to work toward a solution to the primary care problem—a solution that includes both convenient care clinics and traditional primary care. Everyone--primary care docs, retail and urgent care clinics, ER docs, and patients can benefit from making sure people are treated in the right place at the right time

If you want to find out more, here’s a link to the materials from the briefing.

We've been pretty quiet here at New Health Dialogue recently, but rest assured that our blogging will resume apace in the next couple of months. We've been busy working on a few projects, and I want to share one of them with you now. You'll hear more about the others soon...

If you follow our Twitter account (you should!) or Chelsea Conaboy of the Boston Globe, you've heard about the Avoiding Avoidable Care conference that we're hosting with the Lown Cardiovascular Center next month. (Chelsea did a great writeup on the conference over at the Globe's White Coat Notes blog.)

The agenda for the conference is up! We're thrilled to have such a great set of speakers, moderators, and panelists--it's going to be a great conference. While the meeting is by invitation only, we'd love to hear your comments on the agenda--post them here, and look for more in late April when we tell you about what the meeting covered.

Rosa Brooks and Charles Kenny discuss the challenges facing the US military in Afghanistan after reports of Korans being burned, the role of humanitarian aid in conflict zones, and the status of the UN’s Millennium Development Goals. Pamela Chan hosts.

Editor’s Note: This is part of a series of posts contributed by Andrew Wickerham, who attended the 139^th Annual Meeting of the American Public Health Association this week in Washington, DC.

Think back to high school or college when a teacher would offer comments on a test or essay, along the lines of,  “B-, could have included more background on FDR’s reason for passing Social Security.”  That's not far off from the exercise the Department of Health and Human Services (HHS) undergoes periodically as part of its HealthyPeople Leading Health Indicators (LHIs) program, only the note to the country is more alongs the lines of,  “C-, work on diet, exercise, and making sure people with high blood pressure take their medication.” 

Unfortunately, most Americans, like bored, uninterested students in history class, don't seem to care. We have yet to make improvements to our health—and by many measures are worse off than we were a decade ago. So why does the federal government bother with the regular (read: expensive) process of revising the HealthyPeople guidelines?

HealthyPeople (HP)  started with a 1979 Surgeon General’s report intended to focus America’s public health agenda, prevent disease, and promote overall wellness. Three reports—HP1990, HP2000, and HP2010—followed, offering a decennial update to the national health improvement framework. Each report listed a series of LHIs, with the intent of focusing efforts for the coming decade. HP2020 launched in December 2010, and on Monday, HHS Assistant Secretary for Health Howard Koh, MD, MPH announced the newly updated list of 26 LHIs during a press conference at the American Public Health Association annual meeting.

Now, goals and objectives are certainly good things—they can serve to guide policy and reinvigorate practice. “The Leading Health Indicators imply priorities,” former Texas Commissioner of Health Eduardo J. Sanchez, MD, MPH, said at Monday’s event. Yet, the process of setting new goals for HealthyPeople seems rather conflicted.

Early reports on the relative successes and failures of HP2010 suggest that only a few hundred out of almost 1,000 HP2010 goals were achieved, and that ground was lost in the critical area of chronic disease management, with Americans suffering higher rates of obesity and hypertension. Nevertheless, HP2020 rolls out hundreds of new goals and objectives, in addition to the new LHIs.

There was one bright spot at the meeting. For the first time HP2020 includes consideration of the social determinants of health—the non-clinical factors that affect human health—as part of the LHIs. Socioeconomic disparities are widely recognized health indicators because disparity affects ability to access health care, self advocate, and make healthier behavior choices.  High-school graduation rates will be tracked as an LHI under HP2020 as a way to study the socioeconomic factors that influence health, and to encourage policymakers and providers to take a more holistic approach to improving population health.

The Dartmouth Atlas has long made a mission of pointing out the variation in medical practice across the US, and in the process, the Atlas has gained a reputation for innovative, incisive research. Among health policy geeks, its maps are legendary.

That explains the general dismay over “After Hospitalization,”  the most recent Atlas report, which came out last Wednesday. According to the report, the hospital community has done a lousy job of making sure patients don’t land right back in a hospital bed after they’re discharged. Preventable readmissions are recognized as a serious problem, taking patients out of their homes and costing billions of dollars each year. Medicare has decided to link hospital payments to success in meeting a readmission standard, and that means a lot of hospitals have a big problem according to the Dartmouth Atlas.

Efforts to reduce readmissions thus far have sputtered. According to the Dartmouth report, surgical and medical readmission rates between 2004 and 2009 were essentially constant. Poor coordination of care between hospitals and post-hospital recovery are the primary reason for readmissions. When chronically ill patients leave the hospital, their medical needs are often far from complete—they require medication, follow-up, and management over an extended period. Even knowing that, many patients still don’t see a primary care doctor within two weeks of their discharge—a step that Dartmouth and others see as crucial to proper care management.

Health Wonk Review, Muppet Edition!

Hello all, and welcome to another exciting episode of Health Wonk Review! (Regular readers will note that yes, I used line last time. I have half a mind to make Alistair Cookie the official HWR mascot, here at New Health Dialogue.) In honor of what would have been Jim Henson’s 75^th birthday last week, I bring you the Muppet Edition of Health Wonk Review!

Now, without further silliness, the articles!

Quality Care

Here at New Health Dialogue, we’re exulting in doctors’ acceptance that yes, they do overtreat patients! Now, getting them to accept that money is part of the reason why…

Jonena Relth of Healthcare Talent Transformation draws attention to the cool new physician payment system being tried at Fairview clinics in Minnesota: payments are based on patient satisfaction and health, rather than by the number services provided.

David Williams draws a parallel between diagnosis and management consulting: experienced clinicians need to be wary of “early closure,” and avoid becoming like the “more experienced managers [who] are satisfied with two data points – after all, that’s enough to make a line, [or the partners who] just need one data point – they can assume the slope.”

Jessie Gruman, at the Prepared Patient Forum, wonders if the collaboration between HHS, the Robert Wood Johnson Foundation, Dr. Oz, and others will help Americans learn to pay attention to their medical care and improve communication with their providers.

Chris Langston points out that there are fewer people entering training for geriatric specialties—a workforce that may be critical in addressing the communications issue Jessie discussed.

The 1940 biopic Dr. Ehrlich’s Magic Bullet made famous both the physician who found a treatment for syphilis and the idea there was a single cure for every disease. Most of the old infectious killers have been eradicated, or nearly so, by drugs and vaccines, but the era of the magic bullet is coming to a close. Today’s medical challenges are chronic diseases like diabetes, heart disease, cancer, and Alzheimer’s – diseases that can’t be cured, but only prevented or managed – and we’re trying to address them with a health care delivery system made inefficient in part by the fact that it is caring for chronically ill patients as if they had acute ailments.    

Yet the notion that there’s a single solution to the conundrum of today’s health care delivery system lives on. Proponents of ideas like consumer-driven health care, electronic medical records, the patient centered medical home, comparative effectiveness research, ACOs, and training primary care doctors like to imagine that their preferred solution is the magic bullet, the one technocratic fix that’s going to bring down costs and improve quality.

Maybe it’s time to take a hint from another complex problem: climate change. In a paper published in Science in 2004, climate scientists Robert Socolow and Stephen Pacala argued that rather than waiting around for some new innovation that will magically make all that excess carbon go away, we should be tackling carbon emissions with existing technologies.

Socolow and Pacala called their seven intervention ideas “wedges” because of their shape on the graph (left). Each intervention has a small effect on the level of carbon dioxide emissions, and each effect shows up on the graph as a slice of the stabilization triangle, shaped like a wedge. Put into effect simultaneously, there are enough emissions-reducing technologies–such as carbon capture and storage at power plants and broader use of solar, wind, and nuclear power—to stabilize carbon dioxide levels in the atmosphere for the next 50 years.

In a speech last week at a Health Affairs briefing on “The New Urgency of Cost Control,” Don Berwick, the Administrator of the Center for Medicare and Medicaid Services, applied Socolow and Pacala’s idea to health care costs, arguing that we need to look at a broad range of existing delivery and payment system reforms—each of which is too small to stabilize medical costs individually, but that meet that goal when taken together.

Overcrowding in emergency rooms and departments costs lives.  A 2009 Government Accountability Office report found that “emergent” ER patients – those who need treatment in 1-14 minutes – faced an average wait time of 37 minutes. Patients have to wait longer than recommended over 50% of the time.  One in four hospitals even diverted ambulances to other emergency departments at least once in 2006.  In New York City, periods of ambulance diversion increased the heart attack mortality rate by 47%.

This blog has covered the issue a number of times, looking at ambulance diversion, emergency care state grades, the multiple reasons behind ER crowding, ER “super users,”  and more.  But we were given a stark reminder of the delays plaguing many emergency departments across the country when we read Dr. John Maa’s article “The Waits That Matter” in this month’s New England Journal of Medicine.

In his piece, Maa describes the story of his 69-year-old mother with mild heart disease.  After feeling slightly short of breath and noticing an irregular heart beat one morning, she had her husband drive her to the local hospital – “one of the most highly regarded academic medical centers on the West Coast.”  At the ER, she waited an hour to be seen, eventually being diagnosed with rapid atrial fibrillation and admitted into the hospital.  She receives an IV for anticoagulation drugs and is scheduled for an electrical cardioversion procedure the following day.