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Accountable Care Organizations: The Gathering Storm?

Those of you who’ve read this blog for any length of time know that I have been a pretty strong advocate for healthcare reform. This has been primarily motivated by my passion for universal coverage, but also with my frustration with the cost of the current healthcare system, the generally crummy outcomes, and the overall level of fragmentation in the whole affair.

Even today, I had to repeat blood tests on a cancer patient who came to the ER. He had had blood tests at the cancer center ACROSS THE STREET before presenting, but, so sorry, our computers don’t talk to theirs and it’s after 5pm now, so forget about getting those results. 

So it’s with a mixture of enthusiasm and dread that I consider the coming onslaught of accountable care organizations (ACOs). What are ACOs? They’re the buzzword of the day, that’s for sure. Everybody knows they’re the next big thing. They’re coming. We’ll all be in an ACO by next Tuesday for sure. It’ll be nirvana. Right? Read more »

*This blog post was originally published at Movin' Meat*

Mobile Health: Joy Or Dismay?

Last month, PricewaterhouseCoopers (PwC) issued a report, Healthcare Unwired, examining the market for mobile health monitoring devices, reminder services, etc. among both healthcare providers and the general public. One of the big take-away points seems to be that 40% of the general public would be willing to pay for mobile health (or “mHealth”) devices or services ranging from reminders to data uploads — and the reaction by insiders is either joy (40% is good) or dismay (40% is not enough).

PwC estimated the mHealth market to be worth somewhere between $7.7 billion and $43 billion per year, based on consumers’ expressed willingness to pay. Deloitte recently issued a report on mPHRs, as well — and there is tremendous interest in this space, as discussed in John Moore’s recent post over at Chilmark Research. I agree with John’s wariness with respect to the mHealth hype — there is certainly something happening out there, but significant questions remain: What exactly is going on? Is there reason to be interested in this stuff or is it just something shiny and new? Can mHealth improve healthcare status and/or healthcare quality and/or reduce healthcare costs? Read more »

*This blog post was originally published at HealthBlawg :: David Harlow's Health Care Law Blog*

How To Reduce Costs And Improve Quality In Healthcare: A Legal Approach

By Jeff Segal, M.D.

I often attend health policy discussions. I am usually the only physician in the room. My colleagues lament they just do not have time to make their voices heard. As healers, our first duty is to care of the sick and disabled; and to provide comfort when we have little else to offer. I hope the public will listen to one doctor’s voice.

We have many problems to solve: access to healthcare for the uninsured; affordable premiums for those with coverage; outcomes that provide value and keep patients safe. These goals can be realized.

Let me set the stage for a proposed solution; one that can easily complement any number of other proposals.

This year, tens of thousands of physicians will receive a sobering letter. The summons will claim the doctor recklessly, negligently, and with wanton disregard for safety injured his patient. The poor doctor will not recognize this butcher in print and might not even remember the patient, now a plaintiff. The doctor will never forget this day. And this day will have expensive consequences for all of his future patients.

Fear of litigation is ubiquitous. The experience is so odious we physicians will do almost anything to avoid repeating it. We will order tests, perform procedures, and recommend referrals, all to prevent sitting in front of a jury. As one ER physician put it, “I will scan patients until they glow if it will keep me out of court.” And there are 800,000 of us who are fully capable of ordering just as many tests and referrals as the fictional TV character, Dr. Gregory House. We euphemistically label it defensive medicine.

Defensive medicine eludes easy definition, but it is pervasive. Some defensive tests provide value to the patient. Some paradoxically put the patient in harm’s way. Most of the time, no value accrues, just cost and inconvenience.

Combine defensive medicine with a sub-critical mass of health information technology, and the formula is complete for overpriced, idiosyncratic, fragmented care. That said, we can harness the tremendous emotional energy surrounding litigation for more positive ends, benefiting all stakeholders. Let me explain.

Healthcare is a partnership between stakeholders (patients, physicians, and payers); each with different needs and wants.

Patients want lower health insurance premiums without sacrificing timely access to physicians or safety. If something untoward happens, they do not want to lose their home.

Physicians want protection against meritless lawsuits, lower professional liability premiums, and to be front and center in developing the care pathways for managing patients. If they deliver superior outcomes, they want to be paid more.

Payers (insurance carriers, business, and the government) want care delivered in the most cost-effective way possible.

These goals are not mutually exclusive.

We proposed a model which relies on a contractual interaction between the various stakeholders. Patients (consumers) purchase a modified health insurance policy. That policy includes transferring a potential future right to sue – to the payer- or more accurately- to a neutral third party. In exchange, the patient receives not only health insurance, but a disability and life insurance policy. If a patient is injured, he receives a near-term predictable remedy. Not a lottery jackpot, but enough to carry on. He also pays a lower premium. And the system guarantees implementation of health information technology, including patient safety systems.

The payer (neutral third party) now has the ability to sue the doctor down the road if something goes wrong. To minimize any untoward outcomes, payers enter into an agreement with physicians. If the doctor follows cost-effective algorithms, developed bottom up with substantial physician input, the physician is effectively immunized from litigation. If these algorithms are not followed, the doctor could document why. It is only the combination of the physician ignoring the pathways, associated with a breach in the standard of care causing damages, that puts the physician at risk for litigation. Some or all of an award from such litigation could be passed back to the patient.

Physicians would be armed with knowledge of how to predictably avoid an adversarial legal process. The conventional tort system remains as a backstop incentivizing the doctor to voluntarily embrace efficient best practices. Care will be more consistent and patients will be safer. Dollars will be saved.

How much? We ran a sophisticated financial analysis on such a proposal. The system saves enough cash to bundle the disability and life insurance policies at no extra cost; pay for health information technology infrastructure and maintenance; with enough money left over to buy a health insurance policy for every uninsured American. The model ran Monte Carlo simulations that demonstrated if physicians are properly incentivized to follow efficient best practices, there is enough money left over to prefund these initiatives. Monte Carlo simulation is a computer model that generates thousands of probable future outcomes. The simulation looks at a number of inputs combined in ‘‘random’’ order. As a result, it is designed to account for the uncertainty inherent in complex systems such as health care.

The simulation concludes that by providing a formula for decreasing frequency of litigation, patients can paradoxically be safer, have better access to care, and have broader remedies if they are injured. Where the conventional tort system arguably has failed, namely in maximizing patient safety and making those who are injured whole, a reformed system that more often than not keeps doctors out of court could succeed.

While on first blush, the system is financed by decreasing or eliminating the practice and the costs of defensive medicine, the opportunity is much broader. Intertwined with the concept of defensive medicine, but separate, is savings associated with implementation of efficient best practices. Across the country there is considerable variation in practice patterns. This variation imposes considerable costs without a requisite improvement in outcomes. For example, at the population level, Medicare patients with severe chronic illness in higher-spending regions receive more care than those in lower-spending regions but do not have improved patient survival, quality of life, or access to care. In fact, their outcomes appear worse.1 It is reasoned that embracing best practices would improve clinical outcomes at a lower cost; in other words, improve patient safety at a lower cost. Although pay-for-performance programs have been proposed as one way to coax physicians to embrace efficient best practices, an equally powerful incentive would include a solution to litigation.

This model has been vetted and received warmly by those on the left and the right. I want to address three concerns.

In the model, what happens to dangerous doctors? Most doctors who are sued are not repeat offenders. To the extent individual physicians pose a recurrent danger, their care would be reviewed, and action would be taken, on an administrative level.

Isn’t the model cookbook medicine? No. Almost no clinical algorithm is applicable 100% of the time. Nonetheless, physicians must use their judgment 100% of the time. Physicians need latitude to deviate from algorithms. The proposed model allows such deviation if, in the physician’s clinical judgment, it is the right thing to do. There, the physician has contemplated the algorithm and consciously avoided its use with his patient. In such a setting, he is presumably doing so because he believes it is in his patient’s best interest. Such deviation will not trigger litigation.

How will plaintiff’s attorneys react? This model has been reviewed by a number of seasoned veterans. To their credit, those surveyed find much to like, preferring a bottom-up contract based approach to a top-down legislative dictate. Further, the current paradigm is a high stakes, high risk, long term game of poker. By the time a case gets to trial, an attorney has spent tens of thousands, sometimes hundreds of thousands, of his own money. He has to hire experts, attend depositions, file motions, and more. And, he often loses in court. If the system were more predictable and transactional, even attorneys could find a great deal to cheer about.

The outline sketched above just scratches the surface. There are many more details. We live in a time of great change. Any model that earns the support of physicians, patients, payers, and attorneys might actually be the change we have been waiting for.

***

1.  Fisher E, Wennberg D, Stukel T, Gottlieb D, Lucas F, Pinder E. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138:288–298.

Dr. Segal, a neurosurgeon, is the founder and CEO of Medical Justice Services.
Medical Justice Services is a member organization of Center for Health Transformation.

Patients Aren’t Looking At Hospital Quality Data – But They Should Be

Photo of Dr. Michael Shabt

Dr. Michael Shabot

I recently interviewed Dr. Michael Shabot, Memorial Hermann Hospital System’s Chief Medical Officer, about how his hospital is taking steps to improve patient safety and healthcare quality. His hospital was awarded the 2008 National Health System Patient Safety Leadership Award at a ceremony at the National Press Club.

You may listen to your 20-minute interview here, or read my summary of it below.

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Dr. Val: Tell me about what Memorial Hermann has been doing in the area of hospital quality and safety.

Dr. Shabot: We operate Memorial Hermann Healthcare System on the premise that all patients, visitors, and staff will have an absolutely safe environment. In fact, six of our hospitals have gone a year without a single case of hospital-acquired blood stream infections, or ventilator-associated pneumonia.

Larry Kellner, the CEO of Continental Airlines, can travel on any one of his airplanes without checking on the credentials of the pilots. But would you advise a family member to go to a hospital without checking its credentials or being under the care of a physician whom you know and trust? I wouldn’t.

Every single one of our hospital employees has gone through our “cultural transformation” training. They are taught new ways of doing their current jobs – based on safety training with a proven track record in the aircraft and nuclear energy industries. We also feature employees who have “good catches.” Last month’s “good catch” employee found a medication that was packaged incorrectly from the vendor. It was in the correct bin of our computerized dispensing system, the outer package was correct, but the bottle inside contained a different dose. And this medicine was going to be given to a tiny baby in our neonatal ICU. That incorrect dose could have caused terrible harm, but thanks to the alert nurse – we caught the error.

Read more »

America’s Poorest City (Detroit) Leads The US In Healthcare Quality Reform

Photo of Nancy Schlichting

Nancy Schlichting

“Detroit is the poorest city in America. But we’re not going to be victims of circumstance. We’re going to rise up and lead the country in healthcare quality and become part of the economic solution for our community. The Henry Ford hospital name must mean something when people drive up to it.”
– Nancy Schlichting, President and CEO, The Henry Ford Health System, Detroit, Michigan
I sheepishly admit to being surprised that a hospital system in Detroit was singled out for a national award for hospital quality and safety. Who would think that the poorest city in America could be a beacon of light in these dark times in healthcare? The story of Henry Ford Health System, and its female president and CEO, Nancy Schlichting, is both inspirational and motivational. I had the chance to interview Nancy at a recent award ceremony at the National Press Club where she received the 2008 National Health System Patient Safety Leadership Award.


You may enjoy our conversation via podcast, but please forgive the “tinny” sound quality. I recorded our conversation with a little hand-held digital device instead of my usual recorded phone line.

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Dr. Val: Congratulations on winning the National Health System Patient Safety Leadership Award. Has improving patient safety at your hospital been a challenge?

Schlichting: On a given day, a patient may encounter up to 50 different hospital employees. Coordinating our efforts so that the patient’s experience is consistently positive and error-free is certainly challenging.

We have 7 pillars of performance at Henry Ford, and the first is “people.” We like to say that we “have to take care of the people who are taking care of people.” We need to make sure that they have the resources they need, that the processes are in place so they can do their jobs well, and that they get their individual needs met. For example, everyone knows my email address and they can contact me at any time if they’re not getting their problems resolved. I respond to every single email. This creates a culture of openness and responsibility. They know that the person at the top cares about them.

Dr. Val: A prominent community member experienced an unfortunate lapse in communication during his hospital stay, which resulted in compromise of his care, and he eventually died in the hospital. You personally met with his wife and promised her that you’d take the necessary steps to ensure that this never happened again. Tell me more about that.

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Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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