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Thursday, May 3, 2012

Let a Thousand Flowers Bloom

I downloaded Joe's new book last night. I'm about 40% of the way through it. Very, very nice.
'The reality is that we have a system that rewards people all across healthcare for doing shoddy work at high prices, for ignoring what must be done and doing only what is profitable, for sloughing off the hard, years-long work of getting it right and instead concentrating on getting paid. We pay them to do this, and people will do what they are paid to do.

Most doctors and nurses are highly trained professionals who want to do nothing more than care for their patients in the best possible way—but they are caught in a system that rewards volume over quality, doing more things instead of doing the right thing, a system that overworks and distracts them while it squanders their time and skills. The incentives driving the decision makers of hospitals and health systems, of health plans, of pharmaceutical companies, and of medical suppliers have been similarly skewed. When they can see a better way to do things, they can usually also see that they would be penalized for even trying. Employers, who pay for much of the private side of healthcare, have not yet found a way to demand of healthcare providers the same constraints of cost and quality they would demand of any other suppliers to their businesses. And over the decades, the different segments of the industry have learned to protect themselves by skewing legislation, regulations, and payment systems even more in the direction of these perverse incentives, building up their sense of their own safety and stability rather than seeking solutions that are better for the whole system and for the hundreds of millions of Americans that they serve." Flower, Joe (2012-04-24). Healthcare Beyond Reform: Doing It Right for Half the Cost (Kindle Locations 455-466). Taylor & Francis. Kindle Edition.

Yeah. I wrote this on one of my blogs 3 years ago:


I will by no means be the first to note that our medical industry is not really a "system," nor is it predominantly about "health care." It is more aptly described as a patchwork post hoc disease and injury management and remediation enterprise, one that is more or less "systematic" in any true sense only at the clinical level. Beyond that it comprises a confounding perplex of endlessly contending for-profit and not-for-profit entities acting far too often at ruinously expensive cross-purposes.

Another quick personal story:

During my first tenure (early 1990's) serving as an analyst for the Nevada/Utah Medicare Peer Review Agency (they're now called "QIO's" - Quality Improvement Organizations), in addition to our core Medicare oversight work, we had a number of small sidebar contracts, one of which involved ongoing analytical assessments of the Clark County Nevada self-funded employee health plan. One morning I accompanied my Sup, our Senior Analyst Dr. Moore, to a regular meeting of the plan's Executive Committee, wherein we would report on our latest plan utilization/outcomes evaluation.

A portion of the morning -- perhaps a half-hour, IIRC -- was always devoted to hearing claims denials appeals brought by Clark County employees. This day, two appeals were heard: one regarding an outpatient medical claim, the other concerning a dental encounter. The total sum at issue was about $350. Both appeals were denied, thereby "saving" the plan this nominal amount.

Bored by this administrative tedium, as I sat at the conference table, I did a quick, rough estimate back-of-the-envelope calculation. About a dozen executive/professional people consumed a half hour adjudicating these disputes, or, equivalently, 6 FTE hours. Assume a plausible blended G&A-multiplied cost estimate of the total compensation time for all these folks, plus all of the clerical/administrative time consumed in the processing (and subsequently denying) of these minor claims from the moment of their filing to this very hour.

Clark County easily spent well in excess of an additional $1,000 to "save" $350 at the expense of these two hapless employees, by my reckoning.

Similar scenarios -- public and private -- surely play out every day within our "health care system." Clark County would have been way ahead to have simply vetted the initial claims for fraud and then paid them! (This is one observation implicitly at the heart of the "Universal Coverage / Single Payer" model.)

But, as my Senior Medical Director was fond of pointing out, "every misspent dollar in our health care system goes into someone's paycheck."

"16% OF GDP"

And soon to rise to 20% and beyond, it is asserted -- lest we find the political will to rein in the nationally and personally eviscerating cost of "health care" in the U.S.

Question: in my foregoing Clark County Health Plan anecdote, beyond the two denied employee claims I cited that totaled about $350, is the extra thousand or so administrative outlay also placed on the "health care" expenditure ledger? So that what should have cost $350 (plus minimal initial clerical claim processing overhead) ended up as ~$1,350? (Note that the ~$350, while denied by Clark County, still had to be paid by the respective employees.)

We really have no clear picture regarding episodes such as this. And, we have no clear picture as to how prevalent are such ongoing wheel-spinning, sand-in-the-gears activities, and to what expense ledger they get posted...
Some coherent and effective paths forward seem evident via the works of people like Joe, Dr. Toussaint ("Potent Medicine," "On The Mend"), J.D. Kleinke, Lawrence and Lincoln Weed ("Medicine in Denial"), Atul Gawande, and others I have cited (and have yet to cite) on this blog.

More Flower's:
“Okay, so how do we do that? What can we imitate in other parts of the system? What’s really working here? What’s the enduring, transportable principle, and not just a fad or a quirk or a cultural pocket?”
When I started asking those questions 30 years ago, I did not yet know what I have come to see now:
First: There is no one way to make healthcare work better, no single business model or government program that fits all situations. Nor, apparently, is it necessary to find one overarching model for everyone everywhere. When I speak around the country, when I have conversations about healthcare with experts, with people in the industry, and with nonexperts as well, I find we all have a tendency to reach for a single, simple, overarching solution to this highly complex situation, whether it is “single payer” or “more competition” or “mandates” or “the free market.” Yet none of these answers, and no single answer of any kind, can solve the whole problem. In fact, no single, simple solution even solves a single slice of this complex, highly interconnected system. Blunt instruments cause unnecessary damage.
What’s important to recognize is that healthcare is a complex dynamic system. You can’t operate on one part of the system without reckoning with the impact on the rest of the system. At the same time, because of healthcare’s complexity, no one solution will fix the whole system. Now, we all prefer simple solutions. It will be difficult for many people to settle for anything less. Bear with me, though, because I will show you what I mean in the following sections.
Second: While no one system is right for all, we do find that the examples that work—that actually produce better healthcare and better health for more people at lower cost—have certain elements in common. In one way or another all of these usually new and successful projects incorporate all of the key elements. Drawing on my research on complex systems, the experimentation of courageous healthcare organizations, and the successes and failures of many, I have deduced five core strategies that must adopt to rebuild the entire healthcare system. These are:
Explode the business model. In one way or another overturn, subvert, supplement, or rework the commodity-based, insurance-supported, fee-for-service model that dominates the healthcare market in the United States. Share risk in much more measured ways across healthcare, putting some financial risk on the customer, and some on the medical provider, not all of it on the payer.
Build on smart primary care. Every example where healthcare works better and cheaper is tightly organized around smart, efficient, well-incentivized primary care.      
Put a crew on it. Every example that works in every part of healthcare is a true team effort, not part of the siloed, blinkered, uncommunicative past of medicine.
Swarm the customer with help, information, advice, resources, hand-holding, early, often, and as close as possible. Target special help for those who are costing the system the most.
Rebuild every process. The processes of most parts of healthcare are still archaic. Every process must be rebuilt—and the data to drive it must be derived from a fully digitized and transparent healthcare that is ready to become the most massive learning organism in history.
We need all five, but we need only these five. These five strategies are interdependent. Each one of them, on its own, brings a measure of success. Each one of them works better if combined with other strategies. Some of them cannot be implemented alone. All five of them working together will create a synergistic, virtuous spiral, an intertwined set of positive and negative feedback loops that will greatly improve results, drive down costs, and widen access for everyone.
If every organization in healthcare, or even most organizations in healthcare, rebuilt themselves on these five principles, healthcare in the United States would cost far less than it does today, and work far better. It would deliver better health and longer lives, and exact far less pain, suffering, premature death, bankruptcy, and poverty from the American people in the process..."
A great read thus far. More to come.

A very busy and tuned-in contributor. Added her to my Blogroll.


Tons of information here.
The Medpedia Project is a long-term, worldwide project to evolve a new model for sharing and advancing knowledge about health, medicine and the body among medical professionals and the general public. This model is founded on providing a free online technology platform that is collaborative, interdisciplinary and transparent.
Nice. I signed up today.


Hard to know where to continue in citation, it's all so good. Just buy the book, OK?
Chapter 13
There Ought to Be a Law
This book begins with the declaration that “most of the changes we need are not political or legislative at all.” Our theme here has been: How can the industry change itself to run leaner, faster, better, cheaper, for everyone? Our theme has been: Stop looking to Washington, to your state capital, to politicians to fix the industry. Politicians are unlikely to fix the industry, because they don’t understand the industry, because they are in the thrall of various segments of the industry fighting for financial supremacy and ease, and because a problem is a political asset, while a solution is not. (Kindle Locations 4494-4502)
As we shall see when I triangulate this with Dr. Toussaint's new book "Potent Medicine," the works of J.D. Kleinke, the Weeds' "Medicine in Denial," and a number of others currently amid my reading list, there's a consistent riff developing here, one that gives me particular pause in the context of my federal contractor work. Joe continues:
But now we come to that qualifying word: most. Some needed changes do need legislative action. Some changes in the law are needed to allow these new business models and arrangements to take place. Current law in many details encases current practices in legal frames and effectively make it illegal to be more effective and efficient in healthcare. Other changes in the law are needed because any that does not make such changes cannot call itself reform with a straight face. (ibid.)
This is all great, thought-provoking stuff.

BTW, backing up just a bit:
Measure It—and Get It Right

Brent James is the chief quality officer of Intermountain Health, a large system based in Salt Lake City, with 23 hospitals and dozens of clinics throughout Utah and Idaho. For years, as head of the Institute for Health Care Delivery Research at Intermountain, he has been attacking one clinical problem after another. Over and over, he urges the doctors at Intermountain to stop arguing about the right way to do a particular procedure and just pick one. He tells the Intermountain doctors, “Guys, it’s more important that you do it the same way than what you think is the right way.” If they do it the same way, they can measure the results, tweak what they are doing, and measure again, until they arrive at a provably better result...
...At his institute, James runs an advanced training program, a four-month course teaching people from across healthcare how to use statistical analysis and quality management to find out what works and what doesn’t in healthcare. Over the last decade, his students have opened their own institutes and courses at 35 major teaching hospitals across the country, spreading a gospel of applying scientific techniques to examining the actual processes of medicine. (Kindle Locations 3371-3373)
Yep. And, in that regard, this is one of my prized possessions. I still have my course binder.

Check this out. Courtesy of Joe's book (location 3867, Kindle edition).


Saturday night in Vegas, and I'm reading this stuff and blogging it. I have No Life. But, this goes directly to our REC work.
Appendix A: 
Stupid Computer Tricks: How Not to Digitize Healthcare
The digitization of healthcare—making everything electronic, computerizing all processes—does not in itself make anything more efficient or more effective. Make a stupid workflow electronic, and it’s still a stupid workflow. And in healthcare, a stupid workflow doesn’t just cost money and waste people’s time, it kills people.
Ask doctors about their experiences with using electronic medical records, and you’ll get an earful. Enterprise software for healthcare systems is enormously complex. Most big healthcare systems buy from a big vendor, and have it customized to their own specifications. Some EMR installations are great, once the doctors get used to them. Others get in the doctors’ way. It is not uncommon for doctors to refuse to use them, for sound clinical reasons.
One doctor detailed for me in email how seemingly unremarkable details of computerized record keeping can so frustrate physicians that the software becomes a danger to patient safety. In reproducing her emails here, I have redacted the physician’s name, the name of her institution, and the names of the programs and the vendors who built them, for two reasons: so that she can speak freely, and because her complaints are not peculiar to her institution or to these suites of software. They are, in fact, similar to what I hear from many doctors working with different software suites in healthcare systems across the country. She works in two major academic institutions, and the several different vendors she mentions are among the top companies selling healthcare software systems right now, as the great majority of healthcare systems are attempting to “go digital” over the next few years:
Encounter-based records: My favorite asinine stupidity related to the EMR, that dominates and dramatically limits the usefulness of both the systems at my present hospitals, is that they are built around “encounters.” “Encounters” are each time you set foot in the hospital, and what happens after that; they’re designed for billing purposes. I have no problem with encounters as a necessary evil for someone to be aware of and monitor. But both of these systems parse the results for patients by “encounters” so that I have trouble correlating the data across “encounters,” graphing lab results, reviewing which medications were given, and following trends in vital signs. decent system would make the “encounter” part of things invisible to me, and give me a seamless, longitudinal patient history—because I treat patients and not “encounters.” These encounter-based systems are built for the billers who buy them; their use in the clinical environment is indecent and unconscionable.
 Similarly, I can review orders in the computer and sort them several ways, but they only come up one encounter worth at a time. So imagine that I want to enter a complex set of orders—say, someone receiving chemo for severe lupus kidney disease. I want to remember which version of a saline solution I used last time vs. the time before that, and what the flow rates were each time, and which time they needed an extra boost of Lasix because they didn’t handle it as well. To do this I have to repeatedly go back and forth between encounters so that I can see the different orders in each encounter.
No way to input approximate or variable information: In [this widely used software system], I must enter an order in the right encounter, or the lab or pharmacy cannot find it. My outpatient lab wants all orders entered in the computer. They will accept a script that says “please draw a CBC with diff one time between 5/6 and 5/9/11,” which is what I want for someone who received a dose of cyclophosphamide on 4/25/11 and whose white blood cell count will reach its nadir between those two dates. I cannot create encounters, only my administrative staff can do that, because an “encounter” is a billable session, not a clinical definition. The encounter must be created for the exact day on which the patient will come in for the lab draw, and only then I can finally enter my order into that encounter...
This goes on a good bit longer. Rather scathing. Get the book and you'll see.


More Flower's:
Our Shaky Equilibrium Systems get stuck. In economic game theory, the technical term for this particular way of Our Shaky Equilibrium Systems get stuck. In economic game theory, the technical term for this particular way of getting stuck is a Nash equilibrium, named for the mathematician who formulated it, John Nash (portrayed in the 2001 film A Beautiful Mind). Systems consist of a number of different interacting players. In the healthcare system, for instance, there are hospitals and health systems; doctors and physician groups; and other providers, health plans, employers, government payers, politicians, pharmaceutical companies, various suppliers and manufacturers.
In any system, individual players seek what is best for them, to survive and grow and do what they are there to do. But we can’t think about them in isolation, because individual players think about, and act on, what they think the other players’ strategies will be. They fight to a position that is the best they can do with the information they have, against the strategies of the other players as they understand them. What that means is that the best position they can fight to is not their best possible position; in fact, they are usually far from the best possible due to actual and perceived limitations...
Medical economist J.D. Kleinke would point out that the prevailing U.S. health care economic paradigm comprises "Prisoner's Dilemma" writ large. Suboptimal outcomes are an inevitable consequence of what Joe describes here. "Gnashing" of teeth in pursuit of proximate-term survival.

Kleinke sees progress, however, given that organizations are increasingly "managing the bottom line by actually managing disease, not just money, the dominant strategy of faux managed care in the 1990s.”

Precisely to Joe's point, which is also echoed in Dr. Toussaint's new book (Which I will get to shortly).

None of it will be easy.



Public review and comment period for Meaningful Use Stage 2 Proposed Rule (RIN: 0938-AQ84) and 2014 EHR Certification Proposed Rule (RIN: 0991-AB82) ends tomorrow night. A quick ad hoc sampling from the many hundreds of submissions (gotta love the first one below; moreover, I've left in all the typos):
  • The EHR Stage 2 implementation goals are fundamentally flawed. They appear to have been devised by third year medical students rather than "seasoned practitioners". Above all they indifferent, if not contraproductive [sic], to the physician-patient interaction. Please ask for "non-IT" oriented physicians to assist in making these guidelines. (Until 100% accurate voice-actuated EHRs are available keyboard/mouse input are a waste of valuable time better spent with directly communicating with the patient. Ed O'Neill, M.D. FACS 
  • I am a family doctor whose office uses an electronic medical record and who has met the stage I criteria for meaninful use. I am not sure that my office will attempt to meet stage 2 criteria as to meet stage 2 criteria I need to have an electronic interaction with my patients. Who will pay for my time to have an electronic interaction with my patients? So far Medicare does not pay for any interaction between patients and physicians that is not part of some sort of visit. If I continue to participate in Medicare (not a sure thing at present due to SGR issues), can I bill my Medicare patients for electronic interactions as these are not covered by Medicare? 
  • More than 10 percent of all unique patients seen by the EP during the EHR reporting period (or their authorized representatives) view, download or transmit to a third party their health information. As Meaningful Use requirements are specific to care providers utilizing EHRs to meet the objectives, and as providers can not force patients to interact with any system, this requirement is unattainable and should be removed. Any requirement that measures what a patient does will similarly be unattainable and should be removed. Providers should not be punished due to their patients' actions or failure to take action outside of the healthcare delivery environment. 
  • Commenting on proposed objective: A secure message was sent using the eletronic messaging function of certified EHR Technology by more than 10% of unique patients. We are striving to meet our meaningful use requirements but relying on patients to use electronic messaging is unfair to the providers. 
  • "Our office attended the CMS conference today regarding the proposed rule for stage 2 meaningful use. In the proposed rule there were two measures that made EP's responsible for their patients use of accessing their health information on-line as well as sending their providers secure messages. Our clientele is made up of mostly geriatric patients and our concern is that we will not meet the above mentioned measures due to this. It doesn't seem fair that our fate of meeting meaningful use stage 2 is guided by something that is out of our control; such as being dependent on our patients use of on-line resources. How can stage 2 make the EP's responsible for what the patient's do or do not do, especially EP's whose main patient base are geriatric patients?" 
  • There is an overwheming trend with implementation of EHRs to have the provider entering information to format the patient's information in such a way that is structured force the user to meet the computers needs. This is contrary to the Institute of Medicine's vision outlined in The Computer Based Patient Record, which states input into the systems should be as easy as writing, and use natural language processing - using the computer to meet the user's needs. This restructuring forced upon the clinician disrupts work flow, increasing the likelihood of errors, and decreasing provider efficiency. In order to meet Meaningful Use, the CMS should require that EHRs adhere to the original I.O.M. vision of being intuitive and as easy as writing. The current trends are toward worse patient care and more computer record keeping. 
  • Radiologists, lab pathologists, anesthesiologists and other specialists who do not have the ability to define face-to-face encounters should be exempt from the meaningful use penalty in 2015 or have exclusion criteria and/or measures that can directly apply to their practice. 
  • Patient Reminders, We do colonoscopy some are done once every ten years. It would be hard to send a patient reminder 8 years in advance.
There were many submissions comprised simply of voluminous uploaded documents expressing detailed stakeholder interest groups' organizational POVs.

My fav was the one in which a physician simply uploaded his resume without comment, along with a half-dozen other PDFs.


Yesterday, Dr Paul Levy put up a post on The HealthCare Blog entitled "The Great Experiment," titled after a new book bearing the same name.

He waxed effusive in praising it.
If you read only one book about state and federal health care policy, it should be The Great Experiment: The States, the Feds and Your Healthcare.  Published by the Boston-based Pioneer Institute, it is the most articulate and rigorous presentation of issues that I have seen, a stark contrast from many papers, articles, and speeches that slide by as “informed debate” in Massachusetts and across the country.  I learned more about health care policy from this book than from anything else I have read in the last decade...

...Liberal readers may shy away from this book, for the Pioneer Institute has a reputation of being a conservative think tank and advocacy group.  I suggest you judge the content on its own merits rather than applying political biases to the question of whether or not you should read the book.

With exhaustive and thoughtful arguments, the authors argue that the national health care legislation should be modified.  Notably, the book does not just take potshots at the federal law...
Well, yeah, not "just," but they get around to it fairly well as the book goes on.

The Kindle edition is only $4.99. I bought it immediately and read it. Worth the money. Pleasantly written and well documented. Reads like a lengthy Atlantic Monthly article.

I found this interesting.
It takes the distance of a few years to understand any reform. Pioneer Institute waited until 2009 to begin evaluating Massachusetts’ 2006 law entitled “An Act Providing Access to Affordable, Quality, Accountable Health Care.” (Kindle Locations 2126-2128)
Perfectly charitable. But, curiously, it's otherwise perfectly reasonable to diss pieces of the PPACA a priori:
The present and future failings of the PPACA’s high-risk pool component are functions of its careless design, not an indictment of the fundamental concept. A more effective solution to our enduring problem in dealing with insurance coverage of some individuals with high-risk/high-cost health conditions remains a better-designed, robustly funded, and more narrowly targeted system of state high-risk pools — not the new law’s massive and misguided transformation of American health care. (Kindle Locations 730-733).
The "present and future failings"? Of a law that has yet to really kick into force? OK.

At least "Meaningful Use" gets a shout (though in lower case, and in a rather question-begging context:
State government institutions have not demonstrated any particularly greater comparative advantage in making more refined and sophisticated assessments of health care value, but their role in paying health care bills, administering health benefits programs, and assembling claims transactions data could contribute greatly to improving the scope and predictive power of efforts by other parties to do so. States generally run two of the largest health care programs in their region – a state Medicaid program and health insurance plans for state government workers. Most of them also are involved in guiding, if not directly operating, an all-payer claims database in their state. So they already possess a large supply of underlying data about health care costs, quality, and value in their market areas, but they generally fail to do much with it to help generate more useful and usable information for health care purchasers and providers.
Aggregation of as much health care data as can be accurately and securely derived from multiple sources is a key early step in the process of developing a more transparent health care system. Such data – whether from administrative processing of claims, medical charts, prescription drug transactions, clinical lab findings, patient registries, or electronic health records – needs to be collected just once, but then used often. While other efforts continue at the federal level to help make more provider-identifiable Medicare data available to qualified intermediaries that can best assess its meaning and to substantially increase the adoption rate and meaningful use [emphasis mine] of electronic health information tools, states can make an important contribution to the data collection and data sharing process.
Much may depend on the composition of a particular state’s overall health care system and the sophistication and capabilities of its current all-payer claims database (APCD) before presuming how large a role in improving and expanding health care transparency the latter can play. (APCDs are usually created by state mandate and generally rely on data derived from various medical claims, along with eligibility and provide files, from private and public payers.) Although some states have created various types of hospital report cards on cost and quality or web portals with price and quality information ranging from health insurance options to select medical treatments, the assumed scope, scale, and predictive power of their respective APCDs can easily be overestimated. The current limits of the billing and discharge records on which they generally rely falls short of the type of patient-identifiable clinical information or data on health care outcomes that some policymakers, providers, payers, and patients envision. Lag times between initial data collection and its release to other users can limit real-time analysis of cost and utilization patterns. The costs to collect more comprehensive information about all health care delivered in a state may exceed the likely payoff. And data that travels too far from its originating source may be prone to misinterpretation. Other potential data sources such as self-funded health plans and negotiated hospital charges subject to contractual “gag clauses” may remain outside the reach of state-level APCDs. (Kindle Locations 1076-1100)
The book, while containing a nice history of "RomneyCare," is in significant measure a long compendium of at once effusive and guarded broad speculations on the right theoretical (ideological?) mixes of federal-state-private market Kumbaya. As I commented on Dr. Levy's post:
'I haven't encountered so many hedges since "The Shining." '
Nonetheless, it is indeed a worthy read -- the usual Straw Man characterizations of the PPACA notwithstanding. But, I remain unpersuaded that market "effectiveness" and "efficiency" fully comprise the sine qua non of our health care system.

None of which is to endorse poor quality and waste, by any means.

My recommendation? If you can only read one book about health care policy, read the new Joe Flower book I cited at the outset of this post, "Healthcare Beyond Reform." Much better value.

More to come...

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