Carrots for Doctors
By BILL KELLER
WITH its ambitious proposal to pay doctors in public hospitals based on the quality of their work — not the number of tests they order, pills they prescribe or procedures they perform — New York City has hopped aboard the biggest bandwagon in health care. Pay for performance, or P4P in the jargon, is embraced by right and left. It has long been the favorite egghead prescription for our absurdly overpriced, underperforming health care system. The logic seems unassailable: Reward quality, and you will get quality. Stop rewarding waste, and you will get less waste. QED! P4P!
If only it worked.
For if you spend a little time with the P4P skeptics — a data-bearing minority among physicians and health economists — you will come away full of doubts. In practice, pay for performance does little to improve outcomes or to control costs. But if you look hard enough at why this common-sense approach doesn’t deliver, you find some clues to what might.
The New York plan would give hospitals bonuses to distribute to their doctors based on such indicators as patient satisfaction, speeding the flow of cases through the system and administering specific therapies. It is an attempt to get ahead of the federal law we all know as Obamacare, which includes rewards for hospitals that peg pay to a list of quality metrics. I’ve said before that I consider Obamacare an important leap forward, mainly for extending the basic safety net to millions of Americans. And there are aspects of the law, notably the Medicare Independent Payment Advisory Board, that may help bring down costs, if Congress can resist the temptation to interfere. But the pay-for-performance provisions are a triumph of theory over experience.
More Using Electronics to Track Their Health
Carrots for Doctors
By BILL KELLER
WITH its ambitious proposal to pay doctors in public hospitals based on the quality of their work — not the number of tests they order, pills they prescribe or procedures they perform — New York City has hopped aboard the biggest bandwagon in health care. Pay for performance, or P4P in the jargon, is embraced by right and left. It has long been the favorite egghead prescription for our absurdly overpriced, underperforming health care system. The logic seems unassailable: Reward quality, and you will get quality. Stop rewarding waste, and you will get less waste. QED! P4P!
If only it worked.
For if you spend a little time with the P4P skeptics — a data-bearing minority among physicians and health economists — you will come away full of doubts. In practice, pay for performance does little to improve outcomes or to control costs. But if you look hard enough at why this common-sense approach doesn’t deliver, you find some clues to what might.
The New York plan would give hospitals bonuses to distribute to their doctors based on such indicators as patient satisfaction, speeding the flow of cases through the system and administering specific therapies. It is an attempt to get ahead of the federal law we all know as Obamacare, which includes rewards for hospitals that peg pay to a list of quality metrics. I’ve said before that I consider Obamacare an important leap forward, mainly for extending the basic safety net to millions of Americans. And there are aspects of the law, notably the Medicare Independent Payment Advisory Board, that may help bring down costs, if Congress can resist the temptation to interfere. But the pay-for-performance provisions are a triumph of theory over experience.
More Using Electronics to Track Their Health
By MILT FREUDENHEIM
Whether they have chronic ailments like diabetes or just want to watch their weight, Americans are increasingly tracking their health using smartphone applications and other devices that collect personal data automatically, according to health industry researchers.
“The explosion of mobile devices means that more Americans have an opportunity to start tracking health data in an organized way,” said Susannah Fox, an associate director of the Pew Research Center’s Internet and American Life Project, which was to release the national study on Monday. Many of the people surveyed said the experience had changed their overall approach to health.
More than 500 companies were making or developing self-management tools by last fall, up 35 percent from January 2012, said Matthew Holt, co-chairman of Health 2.0, a market intelligence project that keeps a database of health technology companies. Nearly 13,000 health and fitness apps are now available, he said.
The Pew study said 21 percent of people who track their health use some form of technology.
They are people like Steven Jonas of Portland, Ore., who uses an electronic monitor to check his heart rate when he feels stressed. Then he breathes deeply for a few minutes and watches the monitor on his laptop as his heart slows down.
“It’s incredibly effective in a weird way,” he said.
Mr. Jonas said he also used electronic means to track his mood, weight, mental sharpness, sleep and memory.
Dr. Peter A. Margolis is a principal investigator at the Collaborative Chronic Care Network Project, which tests new ways to diagnose and treat diseases. He has connected 20 young patients who have Crohn’s disease with tracking software developed by a team led by Ian Eslick, a doctoral candidate at the Media Lab at the Massachusetts Institute of Technology.
Aging in Brain Found to Hurt Sleep Needed for Memory
By BENEDICT CAREY
Scientists have known for decades that the ability to remember newly learned information declines with age, but it was not clear why. A new study may provide part of the answer.
The report, posted online on Sunday by the journal Nature Neuroscience, suggests that structural brain changes occurring naturally over time interfere with sleep quality, which in turn blunts the ability to store memories for the long term.
Previous research had found that the prefrontal cortex, the brain region behind the forehead, tends to lose volume with age, and that part of this region helps sustain quality sleep, which is critical to consolidating new memories. But the new experiment, led by researchers at the University of California, Berkeley, is the first to directly link structural changes with sleep-related memory problems.
The findings suggest that one way to slow memory decline in aging adults is to improve sleep, specifically the so-called slow-wave phase, which constitutes about a quarter of a normal night’s slumber.
Doctors cannot reverse structural changes that occur with age any more than they can turn back time. But at least two groups are experimenting with electrical stimulation as a way to improve deep sleep in older people. By placing electrodes on the scalp, scientists can run a low current across the prefrontal area, essentially mimicking the shape of clean, high-quality slow waves.
The result: improved memory, at least in some studies. “There are also a number of other ways you can improve sleep, including exercise,” said Ken Paller, a professor of psychology and the director of the cognitive neuroscience program at Northwestern University, who was not involved in the research.
Tips to make sure doctors don’t tune you out
I always admire doctors who can write books criticizing their own profession, including any shortcomings they may have as practitioners, in an effort to improve patient care. In their new book, When Doctors Don’t Listen, Brigham and Women’s Hospital emergency room physicians Leana Wen and Joshua Kosowsky reveal what patients have long suspected: Doctors often tune out a patient’s story when seeking a diagnosis and simply clue in on specific symptoms, which may lead them to over-test and over-treat.
When patients utter the words “chest pain,” doctors may kick into immediate action, giving patients an aspirin to chew, an EKG to monitor their heart’s electrical activity, blood tests, and X-rays, and possibly keeping them overnight in the hospital to confirm or rule out a heart attack.
All too often, patients with muscle strains or heartburn are admitted to the Brigham and elsewhere for a two-day heart work-up — despite having no initial signs of a heart attack. That’s because doctors were following a standard diagnostic protocol for evaluating chest pain — instead of listening to their patients to determine whether something more common was likely to blame.
Today’s doctors, Wen and Kosowsky contend, have failed to practice the art of listening to gain a context in which to place a patient’s symptoms. Wen, who is completing her residency training, admitted that she, at first, stuck to this form of cookbook medicine — ticking off a checklist of symptoms in her head as a patient spoke — in an effort to become an efficient doctor.
Kosowsky, vice chair and clinical director of Brigham’s emergency medical department, called it a “failure in the way doctors are being trained to think,” a result of too much reliance on high-tech imaging tests and blood tests to measure biomarkers that weren’t around a generation ago.“It’s about finding a balance,” he said in an interview. “Neither Leana nor I would say to throw all guidelines out the window, and doctors are well intentioned when they follow these protocols,” Kosowsky said, “but they’ve taken on an oversized role.”
Keeping Blood Pressure in Check
By JANE E. BRODY
Since the start of the 21st century, Americans have made great progress in controlling high blood pressure, though it remains a leading cause of heart attacks, strokes, congestive heart failure and kidney disease.
Now 48 percent of the more than 76 million adults with hypertension have it under control, up from 29 percent in 2000.
But that means more than half, including many receiving treatment, have blood pressure that remains too high to be healthy. (A normal blood pressure is lower than 120 over 80.) With a plethora of drugs available to normalize blood pressure, why are so many people still at increased risk of disease, disability and premature death? Hypertension experts offer a few common, and correctable, reasons:
¶ About 20 percent of affected adults don't know they have high blood pressure, perhaps because they never or rarely see a doctor who checks their pressure.
¶ Of the 80 percent who are aware of their condition, some don't appreciate how serious it can be and fail to get treated, even when their doctors say they should.
¶ Some who have been treated develop bothersome side effects, causing them to abandon therapy or to use it haphazardly.
¶ Many others do little to change lifestyle factors, like obesity, lack of exercise and a high-salt diet, that can make hypertension harder to control.
Dr. Samuel J. Mann, a hypertension specialist and professor of clinical medicine at Weill-Cornell Medical College, adds another factor that may be the most important. Of the 71 percent of people with hypertension who are currently being treated, too many are taking the wrong drugs or the wrong dosages of the right ones.
An Oil Boom Takes a Toll on Health Care
By JOHN ELIGON
WATFORD CITY, N.D. — The patients come with burns from hot water, with hands and fingers crushed by steel tongs, with injuries from chains that have whipsawed them off their feet. Ambulances carry mangled, bloodied bodies from accidents on roads packed with trucks and heavy-footed drivers.
The furious pace of oil exploration that has made North Dakota one of the healthiest economies in the country has had the opposite effect on the region’s health care providers. Swamped by uninsured laborers flocking to dangerous jobs, medical facilities in the area are sinking under skyrocketing debt, a flood of gruesome injuries and bloated business costs from the inflated economy.
The problems have been acute at McKenzie County Hospital here. Largely because of unpaid bills, the hospital’s debt has climbed more than 2,000 percent over the past four years to $1.2 million, according to Daniel Kelly, the hospital’s chief executive. Just three years ago, Mr. Kelly added, the hospital averaged 100 emergency room visits per month; last year, that average shot up to 400.
Over all, ambulance calls in the region increased by about 59 percent from 2006 to 2011, according to Thomas R. Nehring, the director of emergency medical services for the North Dakota Health Department. The number of traumatic injuries reported in the oil patch increased 200 percent from 2007 through the first half of last year, he said.
The 12 medical facilities in western North Dakota saw their combined debt rise by 46 percent over the course of the 2011 and 2012 fiscal years, according to Darrold Bertsch, the president of the state’s Rural Health Association.
Hospitals cannot simply refuse to treat people or raise their rates. Expenses at those 12 facilities increased by 15 percent, Mr. Bertsch added, and nine of them experienced operating losses. Costs are rising to hire and retain service staff members, as hospitals compete with fast food restaurants that pay wages of about $20 an hour.
“Plain and simple, those kinds of things are not sustainable,” he said.
Many of the new patients are transient men without health insurance or a permanent address in the area. In one of the biggest drivers of the hospital debt, patients give inaccurate contact information; when the time comes to collect payment, the patients cannot be found. McKenzie County Hospital has invested in new software that will help verify the information patients give on the spot
The fight to defend Britain’s National Health Service
28 January 2013
Britain’s National Health Service (NHS) is suffering death by a thousand cuts and faces wholesale privatisation.
The Conservative-Liberal Democrat coalition has demanded a £20 billion cut by 2015 from an overall budget of £108 billion—a reduction that is impossible without slashing essential life-saving services.
So far, only £6 billion in cuts have been made—mostly one-off savings. Much worse is to follow. But staff levels are already being cut by as much as 20 percent and new labour contracts are being imposed with lower wages and higher workloads.
Accident and Emergency departments (over 30 nationally), children’s units and other wards and facilities are closing—justified by claims that services and medical procedures can be better provided in specialised units. There are no guarantees that such specialised units will not be swamped by demand, or that lives will not be lost due to the distances involved. Yet the medical director of the NHS, Sir Bruce Keogh, dismisses broad opposition to these changes as pressure to “inhibit excellence” and “perpetuate mediocrity.”
The Health and Social Care Act allows private companies to provide health care under the auspices of the NHS and comes in to effect in April 2013. However, this will only escalate a process already underway. The NHS is being bled dry by innumerable private corporations that are fleecing the taxpayer while care is either rationed or denied outright to the chronically ill and the most vulnerable members of society.
On November 13, 2011, Circle Health became the first private corporation to run an NHS hospital. In October 2012, a Freedom of Information request found that in one week alone contracts were signed taking more than 400 community services out of the NHS, including ambulance services, diagnostic testing, podiatry and adult hearing.
Doctors warned that the NHS was being “atomised”, with over 100 health care firms now providing basic care under Any Qualified Provider rules. Some private companies already earn up to £200 million a year each from NHS-funded work.
Sixty NHS Trusts face being declared bankrupt in the next four years, threatening hospitals with “rationalisation” or closure. To fend off this threat, trusts must cut budgets and ration or deny treatments declared to be “of limited clinical value”. Nearly one in five hip replacements and hernia repairs are already handled by private companies. Soon they will have to be paid for.
Cold hard cash is a major factor in the drive to first gut and then privatise the NHS. It will open up massive revenue streams for private medicine, which previously made up just 8 percent of the health sector and was for decades almost entirely parasitic—a form of glorified queue-jumping for the better-off, using NHS taxpayer-funded facilities and doctors trained at public expense.
The NHS is hated by the ruling class as a symbol of everything they were forced to grant the working class in Britain in the post-war period—the “cradle to grave” welfare reforms—in order to placate demands for social change.
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