Inkwell: Authors and Artists
Joe Flower (bbear) Sat 23 Jun 12 22:10
Sorry for being tardy to reply. That NY Times article is a "must-read." It vividly illustrates the argument for transparence. Uwe Reinhardt is present, whining about how can we put ask "consumers" to make good choices about healthcare when they can't find out how much something costs and is it any good? When the obvious answer, Uwe, is: Help them. Make the insurers be more transparent (they actually consider their payments to be trade secrets), force the providers to post real prices. And put the providers under "common carrier" rules. You ever notice that no matter how many airline tickets some big corporation buys, there are no deals where, say, Google makes all employees fly United, and in return gets tickets at half price? That kind of discounting is illegal in "common carrier" industries such as airlines, trucking, railways, and telecom. There is no "wholesale" and "retail" price. You have to entice customers in other ways, like frequent flier clubs. You could do that in healthcare. It would force providers to establish actual real prices which actually help providers get better at knowing what their cost of doing business is, and where they can provide value in a way that helps them survive. It would force insurers to find other ways to provide value to their customers than by using market power on the providers to give them unreal discounts at the cost of other customers. It would also mean that you could do something like Kayak in healthcare. Need a new hip? Having a baby? Some other predictable unit of major healthcare for which you have to share some of the cost? Put it in right here, just like you put your destination and dates in on Kayak. And, oh, I have insurance from Company X, on plan 3b. Show me all the places around here, how much they cost, how much that will cost _me_, what are there quality ratings and customer scores. Okay, now show me what I would pay if I were willing to travel somewhere else. And so on.
Joe Flower (bbear) Sat 23 Jun 12 22:28
> Evidence-based medicine Jerry, you raise a number of objections to using "evidence-based medicine." There could be errors, there could changes in opinion, it's not flexible enough, insurance companies keep calling things experimental when they are not. This is another example of "anything idea is a bad idea if its done stupidly." And mostly, I don't see this idea being done stupidly. It arises out of the fact that when you survey medicine the way the Dartmouth Group has been doing for two decade, you see massive variations for no reason. One city doing six times as many back surgeries per capita as another, or three times as many cesarean sections, or twice as many hours on a ventilator. People objecting to evidence-based medicine like to bring up complex cases, outliers, and such. But most of this is not about complex, uncertain cases. It's mostly about things for which there is well-established, well-studied medical opinion. It's about, for instance, labor should not be induced before the 39th week of pregnancy just for the convenience of the doctor or the family, or to reduce the anxiety of the mother, because it is hard to know when the 39th week is, and you risk bringing out a child that is really only 36 weeks along, with incompletely formed lungs. And there is no countervailing medical opinion. Yet early induced labor without a medical reason is still too common. Yes, there will be mistakes in attempting to standardize medicine, but they will be mistakes made out in the open, and argued over and studied over by medical scientists. In non-standardized we make massive mistakes all the time, every day, and never even try to find out what the right way is. As for the insurance companies, standardizing medicine is a good bulwark against them claiming something is experimental when it's not. Let the doctors, in their collective scientific wisdom, declare that something is not experimental, but is a reasonable tool available to the clinician and let the insurance companies butt out and pay the bills that they have legally contracted to pay. (Among other things, if insurance companies can interfere in your medical treatment, they need to be made legally liable for medical malpractice suit.)
Joe Flower (bbear) Sat 23 Jun 12 22:37
Jane, the situation that you describe is not at all rare. In some localities, 90% or more of all 911 calls are just such minor, repeating problems, not life-threatening but needing attention and the convalescent home or assisted living place calls 911 because they have no place else to call, and no one on staff to deal with it. It's important to notice that each entity in this chain is getting paid for what they are doing in one way or another. The home, the EMTs, the hospital, the imaging center. They are paid fee-for-service, and are not at financial risk for the continuing problem. If they were, they might make very different decisions. I have talked to directors of assisted living places who have called the local hospital and said, "Look, we have a bunch of seniors over here who all need flu shots, and need to be seen for this and that. Who could we talk to about setting up some kind of rounds, kind of a mass house call, instead of loading them all up in buses or something and taking them to the clinic." And they can't even get anyone to call them back. If the local health system were in an at-risk contract for the health of those seniors, they would do much more than call them back. They would work with the home to have regular rounds, to have some kind of on-call staff, some kind of ongoing tight relationship with the place and they would make money at it.
Jane Hirshfield (jh) Sat 23 Jun 12 23:06
sigh. I am just old enough to remember house calls. (Does France still have house calls? I think they do.) My DENTIST does house calls for the elderly, the incapacitated, anyone with a condition that makes it impossible to get into the office. I do imagine that is also rare as hen's teeth. And there's yet another thing that falls off the map. When someone I know was in a care facility for psychiatric reasons, long term, not one person there ever once suggested she see a dentist. Aside from the toll this takes on teeth, it can take a toll on the rest of health as well. Another argument your whole person approach is needed. Wellness, or at least the least possible downward progress, as outcome.
Chris Marti (cmarti) Sun 24 Jun 12 07:30
"It would also mean that you could do something like Kayak in healthcare." Yes! That kind of change could end all the confusion and craziness, right then and there.
Chris Marti (cmarti) Sun 24 Jun 12 07:35
Joe, is there a set of things a person like me (55, married, two dependent children, Blue Cross-Blue Shield insured both through my job and spouse's job) can do to make a difference in my own health care experience? Or should I read your book first, which I ordered just yesterday after starting to read this great discussion?
David Wilson (dlwilson) Sun 24 Jun 12 08:20
Piggybacking on something <cmarti> just wrote in his post: "...a person like me (55, married, two dependent children, Blue Cross-Blue Shield insured both through my job and spouse's job)" Are there any proposals floating around to make such insurance situations more efficient? Here is someone who gets coverage both from his employer and his wife's employer. Someone is overpaying and there is a lot of waste in something like that. Multiply this out to all other people who are double covered and we are talking real money.
Joe Flower (bbear) Sun 24 Jun 12 08:27
Great question, Chris. First thing to say: I am not an individual healthcare or financial counselor, and I don't know your exact situation. So these are just general observations. Second: It's not easy. And traditionally, we patients/consumers/individuals/families/whatever have not had many tools, or much information. Now that's changing, and we really need to take advantage of the differences. You are in Illinois, right? So that's Blue Cross Blue Shield of Illinois, owned by the customer-owned Health Care Service Corporation, correct? I believe that the smart thing to do for the lowest cost and the best health is to use a high-deductible health plan combined with a strong health savings account (HSA) or health care account (HCA) especially one that rewards you, the employee, for doing healthy things like getting a health risk assessment or meeting with a health counselor. With BCBS IL you would be looking in their "Blue Edge" programs, especially things like the "Wellness HCA". The smart thing to do is to put especially the primary care/preventive end of health expenditures in your own hands and then use the hell out it, really get involved in your and your family's health. Under some of these plans, you can spend the money any way you want as long as it is on healthcare. In that case, if there is one available to you in your area, you might want to consider a "direct pay" primary care doctor. You pay them a set amount per month (examples range from $49 per person up, significantly less for package deals with employers) to do a package of all primary and preventive care, including after-hours and urgent appointments. <http://www.dpcare.org> will show you if there is one in your area. There are increasingly programs such as Castlight that aim to tell you the real costs of providers in your area, though these are still under development, and the transparency is not at the Kayak-like level we might want. Some health plans actually offer access to such information environments to their members (I don't remember whether BCBS IL does yet). Then there are programs such as Dossia, which help you track your family's health, which can be very helpful.
Joe Flower (bbear) Sun 24 Jun 12 08:48
Another good question, David. From the system level, it's not necessarily a big concern. In any given situation, through a "coordination of benefits" protocol, one of the plans is deemed primary, and pays as if there were no other coverage. Then the other plan picks up anything that was not paid by the first plan, as long as it's a covered expense, and they are within their annual caps, and so and so forth. If the couple are paying premiums on both plans, and both plans cover spouses and dependents, it might be worthwhile to determine whether it makes financial sense for them to continue both plans. But you also have to figure in catastrophic "what-ifs." As we have experienced recently right here on the Well, what if something serious happens to the spouse whose coverage you kept and then they can no longer work. Will the un-injured spouse's coverage now pick up all those expenses? Good thing to check. Don't do it on your own, ask someone who is an expert in your actual plan. The health plan may have such help available, as may your employer, or you can probably hire one, the way we hire financial counselors to help us figure out our 401Ks.
Joe Flower (bbear) Sun 24 Jun 12 08:57
But I'm not going to let you off the hook by stopping with your personal actions, Chris. There's another level: Energize your employer. And your spouse's employer. Because employers actually have more leverage and flexibility than anyone else. They really need to use that power more aggressively, and now more than ever is the time. There are a range of ideas in the book for how employers can save money on healthcare while helping their employees save money and be healthier. It's a trifecta. But most of these require the leverage of the employer (or groups of employers). If I were in your shoes, seriously, I would talk the book up in the office, then take up a collection to buy three copies, and hand-carry them to the CEO, the CFO, and the HR director, with a hand-written note about why you think they should read it. Make an appointment to talk to the HR director. I would assume, by the way, that the HR director is not unfamiliar with at least some of the options I talk about. What the book does is lay them out in what I hope is a more compelling and comprehensive way that helps arm the HR director both to come up with some realistic options for the organization, and to have some good, well-informed talks with the CEO, COO, and CFO. And before long, I will have a PowerPoint available just for that purpose, available on the websites ImagineWhatIf.com and HealthcareBeyondReform.com.
paralyzed by a question like that (debunix) Sun 24 Jun 12 09:43
One of the big problems I have with telling people to shop around for the cheapest version of test x, surgery x, procedure x, is that it results in difficult and often downright dangerous fragmentation of information about you. Today, insurance often dictates where lab tests are done, and that means I often do not get test results at all; have to waste a lot of my and the primary physician's office staff time trying to get the results; and when I do get the results, they're in a difficult format to integrate with the other data I have. If blood tests are done within a single hospital lab, for example, they're reported in an electronic format where I can view results as a table or a graph, to track them over time. A graph is incredibly useful for seeing trends and helping to know when a slightly off result is a fluke vs a persisting 'should do something about that' issue. Outside results can't be entered into that system, so if I want a graph, I have to make my own flowsheet and graph by hand on paper. In some places, the major outside labs now offer electronic delivery of results so that they do come into the electronic reporting system, but as often as not, they come in 'differently'--different rows or columns on the flowsheet, or the outside lab may use different units so that they can't be graphed together without converting values. For radiology studies, as often as not, we're doing followups where the prinicipal value of the study is change over time vs previous imaging. Having a one-off test that say, patient has scarring/tumor/lumpiness/swelling here is not helpful when we already know that, and want to know is scarring worse, tumor spreading, lumpiness stable, swelling bigger? Yes, patients can get and bring their study on a CD to me (add significant time delay here), but if I want it to be compared to the study that was done while they were hospitalized, technically that requires a radiology consultation, which is very difficult to get authorized. And even for a one-off test, if I'm looking for a subtle abnormality on a test done at my home base, where I know the radiologists, I have a better sense of whether "possible subtle change x" is important because it came from Doctor Y, who is very conservative on these things. So.....until there is better, transparent, fully transferable/interconvertible EMR and every system can talk to every system, and I can get all the records, seeking the cheapest provider of thing X wherever it might be is itself is a problem. The limited form of that we have now--HMO patients being contracted out to various labs, with all results being routed through their primary physicians--is a real mess.
Joe Flower (bbear) Sun 24 Jun 12 12:38
Thanks for the window into the clinician's world. Let me pick out some pieces of that. First, when we are talking about "shopping" in healthcare, we have to be talking about not just price, but price and quality and "quality" has to include not only how well does someone perform the test or procedure, but how well-coordinated they are with the rest of the system. And in some cases like the ones <debunix> mentioned, part of the quality has to be that they are known to your own doctor, so that your own doctor can properly evaluate the report, or the progress of the case post-procedure. So part of searching for "quality" should often be to ask your own doctor, "Whose reports do you trust?" But we should also notice that it is actually not cost-effective for the health plan to insist on using the less expensive lab or radiologist if their reports are not useful. They will have to be done over again, or some way found around them, and besides frustrating both the doctor and the patient, that will cost money. There is a big monetary value to simple coordination across the system; lack of coordination is one of the biggest sources of waste. I do believe that as more of healthcare comes to be at risk for the _outcome_ and not just for doing the procedure or test, we will see more organizations find ways to really insist on seamless coordination.
Joe Flower (bbear) Sun 24 Jun 12 12:39
Another part is, again, the lack of standardization. The book has an appendix about how _not_ to computerize healthcare, and lack of standardization is a big part of it. Luckily, the rules and money for digitizing the industry were not in the reform act, but in the earlier ARRA, the "stimulus" bill, which has not been challenged in court, and that is proceeding apace. And the administration, under the leadership of Todd Parks, the Chief Technology Officer of the United States, has been very vigorous in pushing for meaningful standardized coding of clinical data, so that they don't come in "differently." At the same time, there are now in the Health 2.0 world, pioneering pieces of software that can actually translate between existing formats seamlessly. So there is hope and progress, I believe on the digital coordination front.
Mark McDonough (mcdee) Sun 24 Jun 12 12:43
I think what we really need are standardized patients with standardized illnesses.
Joe Flower (bbear) Sun 24 Jun 12 12:55
Since we don't, <debunix>'s post clearly delineates the interesting flip side of that. If we had standardized patients and illnesses, reports could just be checkboxes: This patient has strep - Yes/No. The more non-standard the case, the more we need standardized, carefully differentiated, nuanced presentation of the data and images about the case, because the clinician is making much finer judgments.
paralyzed by a question like that (debunix) Sun 24 Jun 12 13:50
I have no confidence in any of the commercial systems I've been working with being able to finally get their acts together for a properly interconvertible & open format--when I see how hard it is for every tiny incremental change to be addressed in those systems. I'm guessing that a variant of the VA network or one of the open source efforts is eventually going to end up as the defacto standard, but I haven't played iwth the VA system since I was a medical student 20 years ago, or seen any of the larger open source efforts in progress. My dream system would not only show me all of the patient's labs and vital signs seamlessly across all encounters and different labs/providers/clinics, but also would let me more efficiently do the following: -make a graph allowing me to plot multiple types of values over time -to plot/correlate clinical interventions on the same time axis (with independent perpendicular axes) ideally, you could look plot things out, simple or complicated as you needed, and look at the graph and *see* which interventions (medications, fluids, procedures) took place when in relationship to which changes in patient status (vitals signs, lab changes, symptoms worsening or improving). I recently spent three hours doing this by hand for two weeks of hospitalization on a patient where it was apparent that nearly everyone involved in her care had made assumptions about various causes and effects based on NOT understanding what was done where. The data was all there, in this case--one hospital system, everything done in house--but very difficult to extract in a useful form. Joe, have any of the systems you've seen--proprietary or open source--been capable of something like this?
Chris Marti (cmarti) Sun 24 Jun 12 13:59
Joe, my wife's employer is Blue Cross-Blue Shield of Illinois. She's in IT, but, well, yeah. I'll do exactly as you say with my employer because it makes a lot of sense to me. We're a very small shop of 15 employees and the CFO is my peer and he's also the HR person (and not all that knowledgeable about these issues) so the book may be a godsend for everyone at the office. I accept your challenge! Thanks for all your other suggestions and comments, too. Great stuff. PS - please bring on the PowerPoint slides.
Joe Flower (bbear) Mon 25 Jun 12 06:43
> have any of the systems you've seen--proprietary or open source--been capable of something like this [graphic capability]? I'm not familiar enough with the systems to say. I can only say that there are systems out there that seem to work for clinicians. The first two places I would look would be Kaiser's system, which was put together with the constant input of teams of doctors from all across the system; and VistA, the free, open-source system originated in the Veterans Administration. Like Linux, it has hundreds of developers contributing modules to it that are freely available to all other users. It is one of the oldest extant systems out there, and has been constantly evolved. Many people who use it speak well of it.
Joe Flower (bbear) Mon 25 Jun 12 06:47
Glad you accepted the challenge, Chris. I do believe that if we are going to change the system, people need to understand what the problems are, and then get involved at the local level, through employers, local governments, non-profits, health systems, and even health plans. We have to push for real change. And I accept the challenge of the "Help me convince my boss!" PPT. We had a discussion last night about the right way to distribute it, and we hope to get it out quickly.
Joe Flower (bbear) Mon 25 Jun 12 06:48
I may be a bit scarce for the rest of today (despite the fact that the Supreme Court decision may come down today). I am in Lincoln, Nebraska. Already did a morning radio show, at lunch I speak to the heads of all the top health systems and insurers in Nebraska, and in the afternoon all the top not-for-profits.
Joe Flower (bbear) Mon 25 Jun 12 06:50
So keep your questions and observations coming, this is a great discussion and I will get back to you later today or tomorrow.
descend into a fractal hell of meta-truthiness (jmcarlin) Mon 25 Jun 12 10:40
You pointed out the growing shortage of primary care doctors. One of the results of adopting your ideas would be an increase in demand for such people. Might this be a problem of success? How can this issue be minimized?
Eric Rawlins (woodman) Mon 25 Jun 12 15:22
Joe, at some point (no hurry) I'd be interesting in hearing your opinions and thoughts re Kaiser. I've been a Kaiserite for close to 40 years, and love it, but I'd like to hear what you think.
descend into a fractal hell of meta-truthiness (jmcarlin) Mon 25 Jun 12 16:01
Here's another story underlining one of your central premises. That the effect is apparently not large, still, the net benefits appear to make the effort worth while. Behavioral Interventions Help Cut Obesity The U.S. Preventive Services Task Force (USPSTF) has recommended that obese adult patients receive an intense, comprehensive, and multi-component behavioral intervention as part of weight-loss treatment. ... The multi-component intervention "can lead to an average weight loss of 4 to 7 kg ... . These interventions also improve glucose tolerance and other physiologic risk factors for cardiovascular disease," the task force wrote. The new recommendations are graded class B, meaning there is a high certainty that the net benefit is moderate, http://www.medpagetoday.com/PrimaryCare/Obesity/33468
. (wickett) Mon 25 Jun 12 16:47
(Joe, thanks for the semi-log regression analysis. Makes it look as though US health care is absolutely topnotch and the best, far better than anyone else. What a fantasy! (The reality is that we spend far more than our economy can afford for worse outcomes. (I will keep the two charts close at hand for comparison and discussion.)
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