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Online Physician Ratings: What Is The Value Proposition For The Respondents?

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I’d like to point out an error I made during a more optimistic time in my online career. Last year on my blog I suggested that physician ratings were “here to stay” so physicians should “embrace the inevitable.” What I hadn’t thought through at the time was the fact that virtually no one would use the ratings tools. I had made a fairly narcissistic assumption: that everyone cared so much about their healthcare experience that they were dying to describe it online.

The truth is that any online tool, portal, social network, or health 2.0 application must deliver a compelling “value proposition” to the user, especially if participation requires any degree of effort. It is human nature to take part in activities that reward us for our time. For example, we may slave over a hot stove because we stand to gain a delicious, satisfying meal in the end; we continue to work at jobs that we dislike because the paycheck makes it worthwhile. But why would a patient fill out a lengthy survey about his or her doctor when there’s no obvious value to them in doing so?

A recent article in Slate (h/t to the ACP Internist) makes a compelling case for why physician-rating sites have such low participation rates as to be fairly useless. The return on investment (time spent filling out a long questionnaire) is extremely low, and is worthwhile to only the most irritated patients. And of course, there is no policing of contributions – physicians can rate themselves into the highest quality rankings by logging in as fictional patients.

So does this mean that there are no worthwhile physician rating tools online? The Slate author would have you believe that there are none. However, I would suggest that Castle Connolly’s America’s Top Doctors list is a reliable, if somewhat limited source. Why? Because teams of staff (who are paid by Castle Connolly) do the heavy-lifting, requiring no effort from patients or online raters. Castle Connolly reviewers first request nominations for physician excellence from within a given specialty and region. Peers nominate others for the honor and then the Castle Connolly staff seek corroborative data from surveys sent to physician peers, hospital administrators, and support staff to ensure that nominated physicians are indeed highly esteemed by many of those with whom they work. In the end, about 10% of physicians are fully vetted and included in the list - and I’d say that the selection process is quite sensitive but not specific. In other words, a physician listed in America’s Top Doctors is likely to be excellent, but many excellent physicians are not captured by the methods.

I spoke to John Connolly in a recent interview about how to find a good physician and you may listen to the podcast here. Locating a good doctor is not too difficult – but finding one that will take your insurance (or still has some slots available for new patients) is another story.


The Cost of Universal Coverage: Can We Afford It?

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I don’t subscribe to many newsletters, but the Galen Institute’s Health Policy Matters is always a provocative read. Here’s an excerpt from this week’s newsletter:

Incoming White House Chief of Staff Rahm Emanuel said this week that universal coverage will be an early, top priority of the Obama administration.

But where is the money going to come from to pay for these massive reform agendas, which were developed before the meltdown of Wall Street, the $700 billion rescue package, and a projected $1 trillion deficit?

The Obama plan is estimated to cost an additional $100 to $160 billion in the first year alone, yet the president-elect made fiscal responsibility a big part of his campaign platform. If the White House is going to extend the plan to mean universal coverage, the bill will be even more expensive.

Mr. Obama also will be facing the huge flood of red ink in Medicare, with the program starting to run out of money in 2017, about the time a second Obama term would end.

It’s impossible to make predictions in the current topsy-turvy political and economic climate, but these power political power centers, fiscal realities, and the urgency of other issues, including Detroit’s looming bankruptcy and an unstable geo-political climate, make these dreams of sweeping health reform a major challenge.

Mr. Obama will likely use the pending expiration on March 31 of the State Children’s Health Insurance Program (which will be renamed) as a vehicle to expand health coverage to all children and possibly even enact his mandate for children’s coverage. That probably means funneling more money to the states through Medicaid since they must pay part of the costs.

After SCHIP, Congress will take the lead on major health reform legislation from there.

We need to remember that 82% of the American people are happy with their own health care and only a minority is willing to pay higher taxes to get to universal coverage. Also, the employer mandate is a new tax, and it is going to be especially difficult to impose during the economic crisis. And can we really tell people who have lost their jobs that now, in addition to everything else, they are going to be forced to buy health insurance?

Tom Daschle Will Be Next Secretary of HHS: What Does This Mean For Healthcare?

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Tom Daschle - Photo Credit: CBS News

I’ve had my eye on Tom Daschle for many months – and attended a healthcare conference in June ’08 in which he was the keynote. I blogged about his ideas previously, but thought it would be valuable to repost them here (h/t to The Healthcare Blog):

Tom Daschle, former Senate Majority Leader from South Dakota, was the keynote speaker at the Fighting Chronic Disease: The Missing Link in Health Reform conference here in Washington, DC. His analysis of the healthcare crisis is this:

US Healthcare has three major problems: 1) Cost containment. We spend $8000/capita – 40% more than the next most expensive country in the world (Switzerland). Last year businesses spent more on healthcare than they made in profits. General motors spends more on healthcare than they do on steel.

2) Quality control. The US system cannot  integrate and create the kind of efficiencies necessary. The WHO has listed us as 35 in overall health outcomes. Some people ask, “If we have a quality problem, why do kings and queens come to the US for their healthcare?” They come to the best places like the Mayo Clinic, the Cleveland Clinic, or Johns Hopkins. They don’t go to rural South Dakota. We have islands of excellence in a sea of mediocrity.

3) Access. People are unable to get insurance if they have a pre-existing condition. 47 million people don’t have health insurance. We have a primary care shortage, and hospitals turning away patients because they’re full.

His solutions are these:

  1. Universal coverage. If we don’t have universal coverage we can’t possibly deal with the universal problems that we have in our country.
  2. Cost shifting is not cost savings. By excluding people from the system we’re driving costs up for taxpayers – about $1500/person/year.
  3. We must recognize the importance of continuity of care and the need for a medical home. Chronic care management can only occur if we coordinate the care from the beginning, and not delegating the responsibility of care to the Medicare system when the patient reaches the age of 65.
  4. We must focus on wellness and prevention. Every dollar spent on water fluoridation saves 38 dollars in dental costs. Providing mammograms every two years to all women ages 50-69 costs only $9000 for every life year saved.
  5. Lack of transparency is a devastating aspect of our healthcare system. We can’t fix a system that we don’t understand.
  6. Best practices – we need to adopt them.
  7. We need electronic medical records. We’re in 21st century operating rooms with 19th century administrative rooms. We use too much paper – we should be digital.
  8. We have to pool resources to bring down costs.
  9. We need to enforce the Stark laws and make sure that proprietary medicine is kept in check.
  10. We rely too much on doctors and not enough on nurse practitioners, pharmacists, and physician assistants. They could be used to address the primary care shortage that we have today.
  11. We have to change our infrastructure. Congress isn’t capable of dealing with the complexity of the decision-making in healthcare. We need a decision-making authority, a federal health board, that has the political autonomy and expertise and statutory ability to make the tough decisions on healthcare on a regular basis. Having this infrastructure in place would allow us the opportunity to integrate public and private mechanisms within our healthcare system in a far more efficient way.

What do I think of this? First of all, I agree with much of what Tom said (especially points 2-7) and I respect his opinions. However, I was also very interested in Nancy Johnson’s retort (she is a recently retired republican congresswoman from Connecticut).

Nancy essentially said that any attempt at universal coverage will fail if we don’t address the infrastructure problem first. So while she agrees in principle with Tom Daschle’s aspirations and ideals, she believes that if we don’t have a streamlined IT infrastructure for our healthcare system in place FIRST, there’s not much benefit in having universal coverage.

As I’ve always said, “equal access to nothing is nothing.”

I also think of it this way: imagine you own a theme park like Disney World and you have thousands of people clamoring at the gates to enter the park. One option is to remove the gates (e.g. universal coverage) to solve consumer demand. Another option is to design the park for maximal crowd flow, to figure out how to stagger entry to various rides, and to provide multiple options for people while they’re waiting – and then invite people to enter in an orderly fashion.

Obviously, this is not a perfect analogy – but my opinion is that until we streamline healthcare (primarily through IT solutions), we’ll continue to be victims of painful inefficiencies that waste everyone’s time.  It’s as if our theme park has no gates, no maps, no redirection of crowd flow, no velvet-roped queues, and the people who get on the rides first are not the ones who’ve been waiting the longest, but the “VIPs” with good insurance or cash in the bank. It’s chaotic and unfair.

Quite frankly, I think we could learn a lot from Disney World – and I hope and pray that next year’s healthcare solution is not simply ”remove the gates.”

What do you think?


Consumer-Generated Clinical Trials? Research Minus Science = Gossip

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The internet, in democratizing knowledge, has led a lot of people to believe that it is also possible to democratize expertise.

- Commenter at Science Based Medicine

Regular readers of this blog know how passionate I am about protecting the public from misleading health information. I have witnessed first-hand many well-meaning attempts to “empower consumers” with Web 2.0 tools. Unfortunately, they were designed without a clear understanding of the scientific method, basic statistics, or in some cases, common sense.

Let me first say that I desperately want my patients to be knowledgeable about their disease or condition. The quality of their self-care depends on that, and I regularly point each of my patients to trusted sources of health information so that they can be fully informed about all aspects of their health. Informed decisions are founded upon good information. But when the foundation is corrupt – consumer empowerment collapses like a house of cards.

In a recent lecture on Health 2.0, it was suggested that websites that enable patients to “conduct their own clinical trials” are the bold new frontier of research. This assertion betrays a lack of understanding of basic scientific principles. In healthcare we often say, “the plural of anecdote is not data” and I would translate that to “research minus science equals gossip.” Let me give you some examples of Health 2.0 gone wild:

1. A rating tool was created to “empower” patients to score their medications (and user-generated treatment options) based on their perceived efficacy for their disease/condition. The treatments with the highest average scores would surely reflect the best option for a given disease/condition, right? Wrong. Every single pain syndrome (from headache to low back pain) suggested a narcotic was the most popular (and therefore “best”) treatment. If patients followed this system for determining their treatment options, we’d be swatting flies with cannon balls – not to mention being at risk for drug dependency and even abuse. Treatments must be carefully customized to the individual – genetic differences, allergy profiles, comorbid conditions, and psychosocial and financial considerations all play an important role in choosing the best treatment. Removing those subtleties from the decision-making process is a backwards step for healthcare.

2. An online tracker tool was created without the input of a clinician. The tool purported to “empower women” to manage menopause more effectively online. What on earth would a woman want to do to manage her menopause online, you might ask? Well apparently these young software developers strongly believed that a “hot flash tracker” would be just what women were looking for. The tool provided a graphical representation of the frequency and duration of hot flashes, so that the user could present this to her doctor. One small problem: hot flash management is a binary decision. Hot flashes either are so personally bothersome that a woman would decide to receive hormone therapy to reduce their effects, or the hot flashes are not bothersome enough to warrant treatment. It doesn’t matter how frequently they occur or how long they last. Another ill-conceived Health 2.0 tool.

When it comes to interpreting data, Barker Bausell does an admirable job of reviewing the most common reasons why people are misled to believe that there is a cause and effect relationship between a given intervention and outcome. In fact, the deck is stacked in favor of a perceived effect in any trial, so it’s important to be aware of these potential biases when interpreting results. Health 2.0 enthusiasts would do well to consider the following factors that create the potential for “false positives”in any clinical trial:

1. Natural History: most medical conditions have fluctuating symptoms and many improve on their own over time. Therefore, for many conditions, one would expect improvement during the course of study, regardless of treatment.

2. Regression to the Mean: people are more likely to join a research study when their illness/problem is at its worst during its natural history. Therefore, it is more likely that the symptoms will improve during the study than if they joined at times when symptoms were not as troublesome. Therefore, in any given study – there is a tendency for participants in particular to improve after joining.

3.  The Hawthorne Effect: people behave differently and experience treatment differently when they’re being studied. So for example, if people know they’re being observed regarding their work productivity, they’re likely to work harder during the research study. The enhanced results therefore, do not reflect typical behavior.

4. Limitations of Memory: studies have shown that people ascribe greater improvement of symptoms in retrospect. Research that relies on patient recall is in danger of increased false positive rates.

5. Experimenter Bias: it is difficult for researchers to treat all study subjects in an identical manner if they know which patient is receiving an experimental treatment versus a placebo. Their gestures and the way that they question the subjects may set up expectations of benefit. Also, scientists are eager to demonstrate positive results for publication purposes.

6. Experimental Attrition: people generally join research studies because they expect that they may benefit from the treatment they receive. If they suspect that they are in the placebo group, they are more likely to drop out of the study. This can influence the study results so that the sicker patients who are not finding benefit with the placebo drop out, leaving the milder cases to try to tease out their response to the intervention.

7. The Placebo Effect: I saved the most important artifact for last. The natural tendency for study subjects is to perceive that a treatment is effective. Previous research has shown that about 33% of study subjects will report that the placebo has a positive therapeutic effect of some sort.

In my opinion, the often-missing ingredient in Health 2.0 is the medical expert. Without our critical review and educated guidance, there is a greater risk of making irrelevant tools or perhaps even doing more harm than good. Let’s all work closely together to harness the power of the Internet for our common good. While research minus science = gossip, science minus consumers = inaction.

The Wounds Of War Are Not Always Easy To See

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“My daddy’s in Iraq, but he’s not dead yet.”

– 5-year-old son of a US Marine

Photo of FDA

Roughly 1.7 million Americans have been deployed to Iraq so far. An estimated 320,000 US military have received a traumatic brain injury in the Iraq war. Another 300,000 suffer from major depression or post traumatic stress disorder. The VA is not equipped to handle the mental health needs of all returning veterans and their families. What can we do?

The Give An Hour organization has challenged mental health professionals to donate 1 hour of their time/week to serve the needs of the military. If only 1 in 10 providers joined the program, there would be enough hours to cover the unmet needs.

I met with Dr. Barbara Romberg today to discuss her plans for the program. She envisions an in-office, phone, and online platform for Give An Hour. I sure hope that I can help out with the online platform one day.

If you’re a mental health professional, please consider joining the Give An Hour initiative. Our troops risked their lives for us, and others have sustained life-long injuries – some visible, some invisible.

And there are little boys out there, wondering if this is the day their daddy will die.

Let’s consider how we can be of comfort to those who are suffering on this Veterans Day.

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

***

Click here for a musical take on over-testing.

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Unaccountable: A Book About The Underbelly Of Hospital Care

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