The Final Rule
The Importance Of Being
by Abraham Verghese
Recently a colleague asked if I would address a small, informal quarterly gathering of hospitalists. We settled on a date, and when she asked me for a title for my remarks, I offered: “Presence.”
From the pause on the other end of the line, it was clear she seemed to think there was more to follow—a subtitle perhaps, without which the word seemed to dangle.
“Just ‘presence’?”
(I’d been doodling on the paper in front of me, trying it out.)
“Yes,” I said. “Presence, period.”
On the paper, the period seemed critical. (I’m reminded of the precocious boy-narrator in an Isaac Babel story who says, “No iron can pierce the human heart as icily as a well-placed period.”) My period asked me, the reader, to stay with the word—to be present. No subtitle. Just: Presence.
The idea of “presence” had its origins for me in a parking lot not far from my office at Stanford University and near one of my favorite spots on campus, the Rodin Sculpture Garden. In walking past Auguste Rodin’s Gates of Hell, a massive pair of bronze doors inspired by Dante’s Inferno, I’m consciously or subconsciously reminded to seize the day. In the past year, I’d watched construction on a unique building in the same vicinity. The signage said it was to be the home for the modern art collection of one family, the Andersons, who were giving the collection to Stanford. From a distance, it looked like a cake box sitting on a narrower and well-lit square pedestal.
It occurred to me that the intent of the university and of the Andersons might be that the collection should not only enhance our lives as viewers but specifically enhance our lives as educators, even in fields far removed from art history. Fields such as my own of internal medicine and infectious diseases. In clinical teaching, I’ve tried when I can to link art and medicine using such iconic paintings as Luke Fildes’s The Doctor. But with modern art, with the abstract, it feels challenging to make such a connection. In truth, modern art has always felt a little intimidating to me.
One afternoon shortly after the museum opened, on my way back to my car, I impulsively decided to walk in. It was spring. I felt brave. I imagined the punchline: “Physician walks into Modern Art Museum!” After all, this isn’t a place where we routinely find ourselves, or if we do, it’s not related to work. Personally, I felt my visit was related to work and not just by proximity to my place of work: I was here in the true spirit of an educator (so I told myself) trying to climb out of what novelist Walker Percy called the ruts of specialization, the narrow chutes of professional work and our specialized language that can leave us wearing blinders to other forms of knowledge and inquiry.
The building was suffused with natural light. There were no corridors, no rooms that led into rooms, no sense of a labyrinth. Instead it was open—the cake box sans cake. I could and did stroll around the whole thing in fifteen minutes. It was much less intimidating than, say, the Louvre, where a tourist popping in for a few hours (after standing in line for a long time) can come away overwhelmed, feeling the mind has been shrunk instead of expanded. And yet the compact space (by museum standards) held a who’s who of modern art: Jackson Pollock, Mark Rothko, Willem de Kooning, Wayne Thiebaud, and many more. Iconic names. I had a vague cognitive knowledge of that kind of art but no experience. Just as I might know who RuPaul is, or 50 Cent or Amy Winehouse—but don’t ask me to hum a tune.
I was pleased with myself after my visit. Whatever fears I had (about being grilled about my knowledge by docents, or scrutinized by security guards, or finding the art to be opaque and mysterious) were unfounded. The place was inviting and friendly.
From then on, I made it a practice to stop in.
It was in the repeated visits that I began to recognize and relate to certain paintings and sculptures. If I imagined myself to be a crude but sentient probe being sent into orbit around an unknown planet, then in my loop, my antenna received different and discrete stimuli. I was surprised to find I didn’t really care for “funk” art. Even though funk art is “figurative”—featuring recognizable things such as fish and words—I wasn’t drawn to it. Not yet anyway. My reaction was the opposite: to hurry past.
But I found myself seeking out the bench in front of Pollock’s Lucifer and Rothko’s Pink and White over Red. The scientist in me recognizes my bias here: These are well-known artists, their works the jewels of the collection, and the benches strategically placed. Still, I believe it was more than that: I was also responding to the inherent appeal of these paintings, even though the words to explain why didn’t come easily.
On Thursdays I have the great privilege of making afternoon rounds with the three chief residents in internal medicine at Stanford Hospital. They often have a patient in mind for the four of us to see. These sessions are about reading the patient’s body as a text, about bettering our skills at mining the body for all it is saying. But we make all sorts of diversions, and one afternoon, in lieu of the bedside, I took them to the Anderson Collection. I made no claim to knowledge or purpose. I wasn’t the tour guide—I just walked them through a space that was new to them. In doing so, I thought of a connection to our clinical work: I drew an analogy to the phenomenon of “transference” and “countertransference” in patient care. In psychiatry, for example, patients can develop feelings for the therapist; this “transference” is often useful for patient and therapist to dissect. “Countertransference” refers to the feelings the therapist develops for the patient, feelings that range from anger to attraction. Such feelings are normal and important to recognize in oneself, primarily so as not to act on them. Walking among these paintings and observing our responses—both positive and negative—was a means of being self-aware and attentive to a variety of countertransference.
After nearly a dozen visits, alone and with others, even though I wasn’t consciously trying to relate the art to the pedagogy of medicine, I began to make connections. My tool is the medical gaze, the desire to look for pathology and connection, and it would seem there was no opportunity for that within a pigmented square of uniform color or a rectangle of haphazard paint splashes. But in me a profound and inward sort of observation was taking form.
Pollock’s piece, Lucifer, had a manic energy, a seduction—not unlike some hypomanic people I know. (We all know them; they seem more prevalent than they really are, such is their energy.) The force was confined to an elongated rectangle against a white wall. I could imagine the frenzy of an artist standing over the canvas—no easel here—throwing paint at it, using different colors, using anything but a brush (turkey basters, syringes). At times I felt I was looking into a mind—his, or maybe mine—and seeing the neurofibrillary tangle. It was not the mind depicted in the static histology slides of medical school; it was dynamic and alive, like watching thoughts emerge from a substrate of neurons, or a dream evolving. Yet there was order in the midst of that anarchy. From a distance, the random splashes of color looked mostly black and green, and only when you got close could you see thin streaks of vibrant yellow and blue and red, which were nonetheless necessary for the energy perceived from afar. My response to Lucifer was far from constant; it seemed to have a connection with how my day had gone.
As my visits accrued, I felt much like someone returning to a city over a long time span. Each visit I noticed that I had changed, and what I observed was changing, too.
At first I had studiously avoided reading anything about the art. The rationale was this: In bedside physical exam rounds with my medical students on Wednesdays and chief residents on Thursdays, I ask that if at all possible, the physician or the student who knows the patient, and is bringing us to visit, not tell us anything medical about the patient—especially the diagnosis. This isn’t so we can be clever and deduce this on our own but rather to ensure that on these rounds (which are not about management, but observation) we are not biased by a label. We can read the body as a sacred text being opened for the first time. Labels such as “cirrhosis” or “endocarditis” can blind us to what else is on display. Similarly, with the paintings, I had wanted to experience them without bias. Now that they were becoming familiar, I read about whatever work caught my fancy.
In 1956 Pollock wrote of his work:
“When I am in my painting, I’m not aware of what I’m doing. It is only after a sort of ‘get acquainted’ period that I see what I have been about. I have no fears about making changes, destroying the image, etc., because the painting has a life of its own. I try to let it come through. It is only when I lose contact with the painting that the result is a mess. Otherwise there is pure harmony, an easy give and take, and the painting comes out well.”
The italics are mine. That line resonated with me because it paralleled the dystopia that is prevalent in American health care. It’s the thing that is dragging down the experience of patients and physicians alike: the sense of losing contact. More specifically, it’s the sense that the intermediary of the electronic medical record (EMR) and fulfilling every “Lean” mandate has made us lose contact with our work. The result is a mess, with great unhappiness in the ranks.
Rothko’s Pink and White over Red is a square of a beautiful and vibrant red with a long, horizontal pink rectangular slit at the top, like the slot in the door of a speakeasy as depicted in a noir film—the opening through which the bouncer checks you out. It’s the sort of painting that when I was young and ignorant I might have been tempted to dismiss. (“Big deal, I could’ve done that.” The older me might have replied, “Yes, but you would never have thought of it.”) But having learned to sit with the painting, to be present, I viewed it differently. It seemed to represent my interior space, what I see on the back of my eyelids when I close my eyes, the image still etched with the glow of the window through which I was gazing. It is soothing. It is the womb. It is emotion. It is pre-consciousness.
In the most cursory reading of Rothko, I came across this:
“If you are only moved by color relationships, then you miss the point. I’m interested in expressing the big emotions—tragedy, ecstasy, doom.”
And:
“Art is an adventure into an unknown world, which can be explored only by those willing to take the risks.”
Forgive me if I felt he was speaking to me personally, rewarding me for being brave enough to drop in from the parking lot and engage with his work. There was also pointed instruction here. If we were to substitute the word medicine for art, his aphorism would read:
“Medicine is an adventure into an unknown world, which can be explored only by those willing to take the risks.”
Being with patients, being present and willing to engage directly in the manner they most want is a form of risk. The representation of the patient in the EMR (the iPatient, as I call it) is necessary. But being with the iPatient too long is a guaranteed way of not being present with the actual patient. It can even begin to feel safer and simpler to be present with one of the many “enchanted objects” around us—computer screens, tablets, and smartphones—than with human beings. Perhaps this is what I most want to teach at the bedside: not the causes of low sodium or the latest sepsis protocol. Or not just that (and besides, odds are you can find that online in a flash). I want to teach the art of being present. That, as Rothko says, is an adventure into a risky, unknown world.
I look back and think of patients long gone, particularly patients in the early AIDS era, who were young men for the most part at a time when I too was a young man. Was I present? They were full of the ripening of life, full of desire and longing and ambition, at a time when I too was full of those things. I wanted to “do” for them, to fix what ailed them. I wanted to be busy with them in a medical way, even though in those days we had no effective HIV medications and there was nothing we could do to change the course. I would examine them, because that was what I knew to do, and that ritual, with its laying on of hands, conveyed an important message to the patient that they would not be abandoned. The absence of any treatment also taught us physicians powerful lessons. I learned from my physician assistant, Della, a warm and caring woman who felt less of the pressure to do, and instead could just be. I remember her cajoling me to make more home visits. Once as we walked in to see a patient who was hours from exiting the world, I said, “What are we going to do here, Della?” She said: “We are going to be with him.”
As the German philosopher Martin Heidegger said, sometimes words and speech (and action, I might add) are just a way of forgetting our being or that of the person we are dealing with. I don’t think I got it then. I get it now.
Recently, while on rounds with my students, we visited with a patient whose mother was in the room. They were both so gracious, and as ill as he was, he was generous in allowing us to examine him, to focus on aspects of his illness that had little to do with management but were purely to educate the students. Once we were in the hallway, I asked the students if they had noticed anything special about the mother. They had not. And yet the mother had vitiligo, a condition that strips the skin of pigment, a patchy process at first that eventually results in no pigment anywhere for most people with the disease. While it had no bearing on the son’s condition, it was a striking observation because the son had darker skin and the mother was almost white. Had we entered as true beginners without homing in on the label “patient,” they might have seen it too.
That sense of starting with a blank slate is a feeling I relish. It has become harder to come by. Increasingly, students have a “flipped” patient experience, where a “new” patient is someone they have already met in the computer, having read all their labels before seeing them in the flesh. It is as far from the blank canvas as one can get.
My colleague Alexander Nemerov, an art historian and Stanford professor, recently gave the “First Lecture” at the university—an occasion when all thousand-plus Stanford freshmen gather in Memorial Auditorium on their first academic day to hear from a chosen faculty member. In his lecture, Nemerov spoke of Helen Keller, who at nineteen months experienced a febrile illness and subsequently lost sight, hearing, and therefore speech. She was in darkness until a remarkable teacher, Anne Sullivan, came into her world.
Nemerov described his visit to the Keller home in Alabama, and to the now-famous water pump on the property, as if visiting a shrine. There, after months of struggling to teach Keller language through signing, Sullivan had held the young girl’s hand under the flowing liquid of a hand pump and repeatedly signed out the word “water” in her palm. Suddenly, she broke through. The child understood, as Nemerov says, that the “word and the world could almost magically be the same thing.”
I resonated with the image of Keller at the pump. It seems to me that our efforts as teachers are encapsulated in that moment: Our job is to allow the student to “see” in this way, to open up their world.
What is it I want my students to see? I want them to see the signs of disease, the phenotypic manifestations of disease that get buried by the hype around genotype. I want them to see that the outline of a cigarette packet in the shirt pocket of a male patient tells us much more about the patient’s risk of sudden death than anything in his genome. So much of diagnosis is to be found in the history and the physical, which in turn guides us to order tests more judiciously. Those visits to the bedside with my students every Wednesday and Thursday—guiding hands to feel spleens and eyes to observe neck veins—are like putting their palms under the water pump, allowing them to feel and connect.
Beyond that, there is another kind of seeing that is even more important. Disease is easier to recognize than the individual with the disease, but recognition of the individual whose care is entrusted to us is vital to both parties. There are some simple rules: First, we must go to the bedside, for that is where the patient is. It’s a vital and simple step, but harder than it looks. It simply isn’t possible for the patient to feel recognized and cared for when they feel unattended; the fact that their data is getting a lot of attention in a room full of computer monitors where doctors sit does not satisfy. The gravitational forces of the hospital are always pulling us away from the patient to a screen, and it is not our doing. We are chained to the medical record, and every added keystroke adds another link in the chain. We must be unchained.
Second, when we go to the patient, it follows that we must listen, and we must examine with skill. The patient’s disease is not located on an image in the computer, nor on a histology slide, nor in numbers of body chemicals—it is located in or on their body. To touch the place that hurts, to examine the body, is to affirm the locus of their illness.
Third, one must revisit and revisit, as few things are completely revealed at the first encounter.
The crisis in health care—spiraling costs; inequities of care; the abysmal incentives for primary care; the paucity of geriatric care when our population is aging; physician depression, dissatisfaction, and attrition—offer no easy solutions. There are a few things that are timeless in medicine, unchanged since antiquity, which we can keep front and center as we bring about reform. One is the simple truth that patients want us to be more present. We as physicians want to be more present with the patient, as well, because without that contact, our professional life loses much of its meaning.
It is a one-word rallying cry for patients and physicians, the common ground we share, the one thing we should not compromise, the starting place to begin reform, the single word to put on the placard as we rally for the cause.
Presence.
Period.
Savings? Yes. But Narrow Health Networks Also Show Troubling Signs.
by Austin Frakt - NYT
You probably chafe a bit every time you learn that a certain doctor or hospital isn’t part of your insurance network. Narrowing the scope of your network helps insurers save money. They can drive hard bargains with doctors and hospitals to get lower prices and walk away from higher-priced ones.
Increasingly, insurers are offering narrow network plans. Would you enroll in one? So long as quality doesn’t suffer, consumers should welcome the lower premiums they may offer.
Researchers at the Leonard Davis Institute at Penn analyzed the relationship between network size and premiums for plans offered in the Affordable Care Act marketplaces. Plans with very narrow networks (covering care by less than 10 percent of physicians) charged 6.7 percent lower premiums than plans with much broader networks (covering care by up to 60 percent of physicians). This translates into an annual savings for an individual of between $212 and $339, depending on age and family size. For a young family of four, the savings could reach nearly $700 per year.
“Marketplace consumers are looking for value,” said Daniel Polsky, the University of Pennsylvania health economist who led the study. “That level of savings could be a very good deal for consumers, but whether these plans provide value depends on how they are achieving those savings.”
One way plans might save money could make it harder for patients to get care — so that they get less of it. Narrow network plans may do this if they don’t cover enough nearby providers, with the ones they do cover too busy to take new patients in a timely fashion. Clearly this would be especially problematic if appointments with one’s preferred primary care doctor are hard to obtain.
Are today’s narrow network plans actually doing this? Until recently, we had no data to answer this question. But two studies published earlier this year — one focused on Massachusetts, the other on California — provide some insight.
In 2012, the Massachusetts Group Insurance Commission, which provides health insurance to a lot of government employees in the state, offered most of them the chance to waive three months of employee premium contributions if they enrolled in new, narrow network plans. This premium holiday amounted to an average of $500 in savings to an enrollee. The new plans covered about half as many physicians and one-third fewer hospitals than prior, broad network plans.
The deal was offered to the 100,000 or so state employees and their dependents, but not to the nearly 20,000 enrollees who are state municipality employees. That created the natural experiment we economists love. By comparing the experiences of the two groups, the economists Jonathan Gruber and Robin McKnight teased out the effect of narrow network plans on the 10 percent of enrollees induced by the premium holiday to enroll in one.
Switchers spent a whopping 36 percent less on health care. Some of these savings can be attributed to narrow network enrollees who saw expensive specialists less. This could be because healthier enrollees who require fewer specialists were more attracted to the plans.
But savings were not entirely driven by healthier people who switched to the plans. They were also achieved by more efficient use of the health system. Narrow network enrollees used the emergency department less, particularly for conditions treatable in office settings. The per-visit cost of outpatient care also fell for narrow network enrollees, which would be expected if the plans paid lower prices. The authors did not find evidence that patients in narrow network plans used lower-quality hospitals, consistent with other work that suggests networks can be narrowed without sacrificing quality.
The savings were concentrated among enrollees who retained their primary care physician as they switched plans. And the distance that narrow network enrollees traveled for primary care visits — but not for specialists — fell. This suggests that plans that narrow their networks of costly specialists but maintain or increase their network of primary care doctors are on the right track. Not only can primary care doctors help patients select specialists and hospitals — and advise them when they’re necessary at all — but retaining primary care physician relationships is also important to many patients.
That’s why the results of a recent study of new plans offered in California are especially troubling. Simon Haeder, a West Virginia University political scientist, and colleagues at the University of Wisconsin-Madison and the University of California, Irvine, found that access to primary care physicians was relatively poor for a sample of plans offered through California’s Affordable Care Act Marketplace in 2015. Most Obamacare marketplace plans in California, as well as in other states, are narrow network plans.
Using a “secret shopper” approach, the study found that only about 30 percent of attempts for appointments with specific primary care doctors were successful. In this approach, an individual pretending to be a patient seeking an appointment called the offices of over 700 primary care doctors listed in marketplace plan directories.
In about 15 percent of cases, the doctor did not accept the caller’s plan, despite being listed in its directory. In nearly 20 percent of cases, the directory included the wrong phone number or the number was busy in two calls on consecutive days. Ten percent of doctors called were not accepting new patients. And about 30 percent of doctors called were not primary care physicians, despite being listed as such in the directory.
When callers were able to make an appointment, the average waiting time for a physical exam was about three weeks. In cases for which the caller pretended to have acute symptoms, the average time until an appointment was about one and a half weeks.
“If patients struggle to obtain primary care appointments, narrow network plans may have a rocky future,” Mr. Haeder said. Consumers revolted against managed care in the 1990s, he notes, and they could very well revolt against poorly managed and loosely regulated narrow networks.
http://www.nytimes.com/2016/10/18/upshot/savings-yes-but-narrow-health-networks-also-show-troubling-signs.html?hpw&rref=upshot&action=click&pgtype=Homepage&module=well-region®ion=bottom-well&WT.nav=bottom-well
HealthCare.gov Will Add ‘Simple Choice’ Plans in Effort to Improve Value
by Robert Pear - NYT
WASHINGTON — When the Affordable Care Act’s health insurance marketplace opens in two weeks, many consumers will have a new option for the law’s fourth open-enrollment period: standardized health plans that cover basic services without a deductible.
With many health plans on the marketplace coming with deductibles in the thousands of dollars, consumers have complained that they were getting little benefit beyond coverage for catastrophic problems. The new standardized options are meant to address that concern — to ensure that “enrollees receive some upfront value for their premium dollars,” as the Obama administration said.
“Too many people, especially people on high-deductible plans, are still struggling to afford the care they need,” Senator Sherrod Brown, Democrat of Ohio, said, praising the new effort.
But the new plans could still be costly. While the federal government specifies deductibles, co-payments and other out-of-pocket costs for the standardized options, it does not limit premiums, which in most cases are still regulated by state insurance commissioners. The administration has said it does not expect the standardized options to have a significant effect on premiums in 2017.
Federal officials say the new option will simplify shopping under the Affordable Care Act by reducing variation among plans, and consumer advocates like the idea. The standardized options will be identified on HealthCare.gov with the label “Simple Choice.”
Open enrollment begins Nov. 1 and runs through Jan. 31. People without health insurance next year face possible tax penalties that could exceed $700 a person.
“This is one more tool that will make it easier for consumers to select the right plan,” said Marjorie K. Connolly, a spokeswoman for the Department of Health and Human Services.
Sandy H. Ahn, a researcher at the Health Policy Institute of Georgetown University, said the “standardized plans will allow consumers to make more of an apples-to-apples comparison.”
Administration officials did not say how many such plans will be available, in which states they will be offered or how much they will cost. The government encouraged but did not require insurers to offer standardized options.
The standardized version of a midlevel silver plan has a $3,500 deductible, but primary care and specialty care visits, outpatient mental health services and prescription drugs are generally exempt from the deductible. In other words, consumers may face co-payments, but they do not have to meet the deductible before the insurance company starts to pay for such services.
On HealthCare.gov, the administration intends to introduce the idea of standardized options by describing Simple Choice as “the easiest way to shop for plans.”
“All Simple Choice plans in the same category (like Silver) have exactly the same core benefits, deductibles and co-payments,” states a message to be displayed on the federal website. “When viewing Simple Choice plans, you can focus on other important features that may be different: monthly premiums, additional services covered, doctor and hospital networks.”
The Obama administration is still struggling to keep the Affordable Care Act affordable for many consumers. State officials have approved rate increases of 25 percent or more for many plans in 2017, after finding that insurers lost tens of millions of dollars in the exchanges. Aetna, UnitedHealth and other insurers have pulled back from the public marketplace, leaving consumers in many states with fewer choices.
Under the standardized version of a silver plan, co-payments would be $30 for a visit to a primary care doctor, $65 for a visit to a specialist, $15 for a generic prescription drug, $50 for a preferred brand-name drug and $100 for a nonpreferred brand-name drug. Consumers may be responsible for up to 40 percent of the cost of specialty drugs, including certain high-cost medicines for cancer, rheumatoid arthritis and multiple sclerosis.
For the lowest-income families, the charges would be lower.
Federal officials said they had studied several state-run exchanges — in California, Connecticut, Massachusetts, New York, Oregon and Vermont — that provide standardized options.
Peter V. Lee, the executive director of the California exchange, said standardized options had contributed to the stability and success of the marketplace there.
“Californians seeking coverage through the marketplace can easily compare health plans, knowing that every health plan has the same cost-sharing levels and benefits,” Mr. Lee said.
Insurers generally dislike efforts to standardize health plans. Standardized options “increase the complexity of the decision-making process” by adding one more factor for consumers to consider, said America’s Health Insurance Plans, a trade group.
In a letter this month to the Obama administration, Anthem, one of the nation’s largest insurers, said, “Standardized benefit designs threaten to commoditize insurance and stifle innovation, while potentially misleading consumers.” The administration said insurers still had discretion to vary many features that would not be standardized.
Converting paper medical records to digital files a slow, difficult process
by Douglas Rooks
Asked about his interest in better medical record-keeping, Devore Culver tells a brief but vivid story. He was a young unit coordinator – part secretary, part head nurse – at Mass General when, he said, “I participated in killing a patient.”
“Everything was on paper, and there was a lot of bad information,” Culver said of the records. One day, he was talking with a nurse who carried out a physician’s order to give a diabetic patient 40 units of insulin. Not long after, an intern stopped by and told them he had already given 40 units to the patient – who died of an overdose.
“There had to be a better way,” Culver said. And he has devoted most of his subsequent career to that goal.
Since 2004 he has tackled the electronic medical records (or EMR) problem, first at Eastern Maine Medical Center in Bangor, and now with Maine HealthInfoNet, a nonprofit, state information exchange. Despite recent funding from federal sources, creating a coordinated network of digitized medical records has been daunting and progress slow. Expectations that the network would be operating and producing more coordinated care and, perhaps, lower health care costs, haven’t as yet materialized.
It turns out that the problem is nowhere as simple as transferring paper records to computers. The whole nature of health care “data” is radically different from what we normally expect computers to do, said Culver.
“This is not like banking, where you can quantify everything that’s important,” Culver said. Reducing an individual’s health care history, and prospects, to numbers isn’t easy, and there is so far little agreement even on such seemingly simple points as how to define the “normal” ranges on various medical tests.
The amount of data available, Culver said, is overwhelming. HealthInfoNet can, “every night, run information for 1.5 million people.” Yet sorting, defining and translating data into terms that can benefit providers and their patients is still very much a work in progress.
Andrew Coburn, professor of public health at the University of Southern Maine’s Muskie School, has been observing health care reform since before the Clinton Health Care Taskforce in 1993. EMR systems have required providers to spend more time entering data, which may reduce “face time” with patients. Yet he said electronic records offer so many potential benefits “there’s no going back” now.
Coburn said there can be “huge safety and quality benefits” from creating records that “capture the nuance of clinical information.” And, he said, “When a patient can go to an ER after being treated in a separately owned cancer facility, that’s a really important clinical benefit.” Yet attaining those results in a health care system that still involves thousands of separately owned providers, is likely to be elusive for some time to come.
THE DIGITAL PUSH
The notion that medical records should be digitized so they can be shared easily among a person’s health care providers was part of the American Recovery and Reinvestment Act of 2009, the “stimulus bill” that followed the nation’s financial crash a year earlier. The initiative was further refined by the Affordable Care Act in 2010.
Proponents argued that easy, but protected, access would allow for more informed, coordinated care, more engagement with patients and their families, and prevent redundant testing or dosing such as the one that doomed the patient at Mass General. The federal government mandated that health care providers should demonstrate “meaningful use” of EMR by Jan. 1, 2014. Those who didn’t by 2015 could be penalized with a 1 percent reduction in Medicare reimbursements.
The ARRA provided $19.2 billion for improving health care technology, a significant portion of which went to EMR systems – by far the largest federal commitment to date. All 50 states received money, including Maine, which received $6.6 million.
Culver said that the billions of dollars provided to states under the ARRA were a mixed blessing. The fundamental problem, he believes, was that the software programs that quickly went into use were being sold by experts in technology who knew little about health care, to health care experts who knew little about technology. Yet the grants did lay down a foundation for eventual improvement, he added.
And there have been success stories. Culver helped St. Joseph’s Hospital in Bangor reduce its readmission rate by 50 percent through better tracking of which patients would need additional support after being discharged.
In the five years Maine HealthInfoNet has been up and running, it has focused on “making data more meaningful,” Culver said – a key point since, as it turns out, doctors don’t even have a standard terminology for identifying something as simple as the sound of a patient’s cough. At this point, he said, along with Maine, only Delaware and Nebraska, and to an extent Rhode Island, have created statewide systems that meet this “value added” standard set by the federal government.
EFFICIENCY AND WORKFLOW
Dan Mingle understands the complexities of EMR. A family physician who practiced for 14 years in Norway, he grew frustrated by what he saw as the disconnected nature of his profession. Since middle school, “I had always had an aptitude for electronics,” he said, even buying one of the first Tandy computers. But his interest had been dormant until he moved to the Maine-Dartmouth Family Medicine Residency, a teaching institution that’s part of MaineGeneral in Augusta.
Maine-Dartmouth needed better electronic tools for residents, and Mingle was soon working full time on the project, eventually become chief information officer for the entire hospital.
He was able to set up medical reporting forms that could be used by all the providers in the regional hospital’s area, and the results were a major advance toward the aim of producing instantly available, standardized records that could be used by emergency room doctors and everyone else who might be treating the patient. Yet scaling up such advances to the state, regional and national levels has been daunting.
Mingle founded Mingle Analytics in 2011 in South Paris, which now has 58 employees and contracts with providers, from solo practitioners to systems with thousands of employees, in all 50 states. The company is trying to bridge the gaps between the original federal initiative and the day-to-day issues each provider faces in keeping track of patients, billing insurance companies, and trying to guide people toward better health, rather than just treating illness.
Mingle said he recommends three strategies to create a path toward successful EMR implementation: “Standardize, integrate – make sure everything works together,” and “simplify – look for ways to cut out steps.” Too much initial EMR work, in his view, tried to adapt electronic systems to existing patterns rather than figuring out how to create efficient work flows.
“Engrave them on your boardroom wall,” Mingle said of the three points. “If your policy doesn’t follow one of these rules, it’s probably not the right decision.”
3000 junior doctors walk off the job
Save
The New Zealand Herald - Tuesday, 18 October 2016
A strike has begun at 7am this morning, withdrawing the services of around 3000 resident doctors across the country.
District health board doctors who are members of the Resident Doctors Association are striking for 48 hours, from 7am today until 7am on Thursday.
The junior doctors said they were having to work 12 consecutive days with some of the shifts being up to 16 hours long, which was unsafe for patients and too tiring for them.
A spokeswoman for the country's 20 district health boards has said the 12 days comprise five week days, a weekend and the following five week days. The DHBs are willing to give two days off on week days but the junior doctors want to be paid for them, which is effectively a pay rise.
LISTEN: Tom Reynolds, Resident Doctor at Rotorua Hospital, speaks to Rachel Smalley about the strike
Rotorua Hospital has postponed more than 50 procedures today as wells as several outpatient clinics as it moves to cater for "essential emergency services" during a two-day doctors' strike.
Read more:
Bay of Plenty resident doctors were scheduled to walk off the job for 48 hours from 7am today, and 18 operations have been rescheduled.
Of the 145 resident doctors in Tauranga, about 100 were to strike along with around 3000 colleagues nationally. The action follows failed talks with district health boards over work hours and days.
Continued below.
Related Content
Northland District Health Board has lost 80 doctors, although as of last night the DHB was unable to say how many non-urgent procedures would need to be postponed.
A spokesperson for the Northland DHB there were expected to be minimal disruptions at Kaitaia, Bay of Islands and Dargaville hospitals.
More than 200 outpatient clinics and 40 surgeries have been postponed at Hawke's Bay Hospital.
Hawke's Bay Hospital chief medical officer, Dr John Gommans, said the two weeks' notice had allowed them to prepare as best they could for the strike.
Seventeen doctors at Whanganui Hospital are expected to strike.
All hospitals advise Emergency Departments will operate as normal and anyone scheduled for appointments today should phone the hospital operator to check before turning up.
As junior doctors strike, senior doctors say they've been met with a belligerent attitude from DHBs over their compensation for staffing hospitals during the strike action.
Association of Salaried Medical Specialists' Executive Director Ian Powell says senior doctors stepping in will face a stressful couple of days due to hospitals' structure during the strike.
Senior doctors want $568 an hour for any additional work, on top of their base salary.
Inpatient Drug Costs Wildly Increasing, Says Report
October 12, 2016
The EpiPen is the tip of the excessive drug price iceberg, according to a new report on how much the nation's hospitals spent on inpatient pharmaceuticals from 2013 to 2015.
The report, released on October 11 by the American Hospital Association (AHA) and the Federation of American Health Systems (FAHS), found that inpatient drug spending increased an average of 23.4% a year from fiscal 2013 to fiscal 2015, outstripping spending increases on the retail side. On a per admission basis, spending rose 38.7%.
The primary reason for the rise in spending was growth in price — in particular for old, generic drugs used regularly on the wards and in the surgical suite, according to officials who briefed reporters.
The study, involving 712 community hospitals and group purchasing organizations (GPOs) representing 1400 hospitals, set out to determine the effect of rising prices and thus identified the drugs that had the greatest impact on hospital budgets due to changes in price, not volume. Almost two dozen drugs were identified as offenders, and total spending and pricing information was aggregated across dosage/strength combinations and branded/generic versions for each.
The authors — researchers at the independent research organization NORC at the University of Chicago, Illinois — then identified the 10 drugs that had the highest total inpatient drug spending by the GPOs during 2015, and computed growth in total spending and unit price for these drugs. They also identified the 10 drugs with the largest unit price growth between 2013 and 2015.
Most participating hospitals said price increases had a moderate or severe effect on their ability to manage overall costs. One hospital, citing price increases for four common drugs ranging from 479% to 1261%, said the cost was equivalent to the salaries of 55 full-time nurses.
AHA President and CEO Rick Pollack said many drugs were becoming unaffordable to patients as well. "A drug priced beyond a patient's reach will not save anyone's life," he said.
Palpable Anger
Hospital officials who spoke with reporters were clearly angry about what they said were excessive and illogical price increases. Drug companies "have taken a path here that is absolutely unhealthy for our industry and makes zero sense," said David Vandewater, president and CEO of Ardent Health Services, a Nashville, Tennessee-based hospital and health system.
Hospitals can't keep up with the price increases because most are not paid directly for inpatient drugs. Instead, they are reimbursed using diagnosis-related group codes that bundle the drug together with other nonphysician services. Medicare's reimbursement is not keeping up, said Vandewater.
"If we use $2000 worth of drug or $20,000 worth of drug, we get paid the same amount," said Scott Knoer, chief pharmacy officer at the Cleveland Clinic in Ohio. "If you have less coming in and your costs go up, something's got to give."
Knoer said that the Cleveland Clinic is not just being hit by the cost of new and innovative drugs like Sovaldi (Gilead), the hepatitis C cure that costs $1000 a pill. It's also weathering an increasing frequency of price increases for established products. Smaller price hikes may not produce headlines, "but consistent increases can impact hospitals much more," said Knoer.
The price of Remicade (Janssen) went up 10% this year, which will result in a $3 million spending increase for that drug alone at the Cleveland Clinic, he said.
Generic Prices a Big Problem
The hospital officials said that price increases for generic drugs, in particular older, often single-source products, had risen astronomically.
In 2015, Valeant Pharmaceuticals raised the list prices for the cardiac drugs isoproterenol and nitroprusside. Isoproterenol rose from an average $278 per unit in 2013 to $1617 per unit in 2015 and nitroprusside from $102 per unit to $790 per unit, according to the report. The Cleveland Clinic said the price increases for these two drugs in 2015 were 310% and 718%, respectively, costing $5.3 million.
Another generic, the osteoporosis drug calcitonin-salmon, rose from an average $67 per unit in 2013 to $2286 per unit in 2015 — a 3263% increase for a drug that has been reported to have questionable utility and the potential to increase the risk for cancer. A Food and Drug Administration advisory committee urged the drug to be taken off the market in 2013.
Chip Kahn, president and CEO of the FAHS, said generic drugs "have seen increases which are inexplicable other than the fact that the drug companies could do it."
The price hikes reported by the hospitals echoed a Government Accountability Office (GAO) report released in September 2016.
More than 300 of the 1441 established generic drugs used by Medicare beneficiaries had at least one extraordinary price increase of 100% or more between early 2010 and early 2015, the GAO reported. The number of price increases over 100% rose steadily, with the biggest number in 2014–2015. Fifteen drugs had increases of more than 1000%, and once the price was hiked by a drug maker, it tended to stay up.
No Call for Price Controls
Although clearly frustrated, the hospital officials said they hoped that prices could be moderated by free market forces.
"We would like to see these problems solved in the marketplace by better decision making on the part of the companies that own these drugs, rather than some kind of heavy hand," said Kahn of the FAHS.
"I'm clearly not in favor of price controls," added Vandewater.
But he and the other hospital executives said they welcomed congressional intervention. Among the requests: more transparency on research and development spending, faster approval of generic drugs, increasing oversight of brand-name company maneuvers to block generic competitors, and possibly extending value-based payments to pharmaceuticals, said AHA's Pollack.
"We've got to find a way to eliminate abuses," Vandewater said. "Something's got to be done, and I believe it's got to be done quicker."
No comments:
Post a Comment