The Doctor Weighs In

Brian Klepper

Regular readers will know that, last Sunday, I posted a column that pointed to HHS' schizophrenic behavior when it comes to the release of Medicare physician data. First they fight the consumer advocacy group Checkbook.org's lawsuit demanding the release of data in 4 states and DC. (The AMA's Board Chair has admitted that they lobbied HHS to appeal the court's finding that they should make the data public.) Then, a week ago last Friday, HHS announced a new program that would identify Chartered Value Exchanges (CVEs) in 14 communities - these are coalitions of employers, payers, providers and consumers - and then hand over the same physician data they've been fighting the courts to keep secret so these groups can combine them with data available from the private sector and create physician quality/cost report cards.

Apparently never a guy to let the grass grow under his feet, Mr. Leavitt then showed up last Friday in the Memphis Business Journal, calling for a "Travelocity of Health Care." The idea, he explained, is to create "a system that would give a quality grade for doctors and show how much they charge for services."

So I wondered, "Why does the HHS Secretary wander around the country calling for physician data transparency at the same time that he, as head of the nation's largest health plan, both refuses to release that data to one group and promises to release it selectively to others? Isn't this saying one thing and doing another.

Mr. Leavitt seems to be an affable, informed, talented guy who, like many of us, maintains a nice and sometimes newsy health care blog. So under his most recent post, called "Dealing with Medicare," I wrote a comment that pointed out the discrepancies I've described above and asked him to please explain them.

I was delighted to see that it made it through the moderator and was published on his site. I just checked and so far he hasn't responded. But hey, Mr. Leavitt IS a genuinely busy person, and I'm not in a hurry.

So here's a suggestion. Many of you are, like me, health care professionals and equally enthusiastic about the value that transparency can have in re-establishing our health system's stability and sustainability. Please go over to Mr. Leavitt's blog and add your own comments to this most recent post. Let him know that there are lots of us who see the "Do as I say, but not as I do" problem, and that we'd like to see him actually align his actions with his words.

Let ask nicely and see if he'll reward us with an explanation.

Laptop-attached ultrasound units that produce startlingly clear internal images for five dollars in the field. Organs that re-generate inside scaffolds.  Drugs tailored to an individual’s biology. Micro-images of cancerous cells lit up by bio-chemical markers. Decision support tools that scan the physiological values in electronic health records for patterns too complex to be detected by an unaided clinician.

The advances available from dramatic improvements in computational capabilities were a recurring theme at the Aspen Health Forum, with experts from each discipline describing where the technology was leading us. I attended two sessions featuring Star Trek clips that predicted realities now within at least theoretical reach. (Prescient and corny, audiences nodded nostalgically.) Sessions on biotechnology, imaging, electronic health records (EHRs) and the hospital of the future highlighted the power that is being leveraged to improve care.

The deeper point is that biological mechanisms are built on incredibly complex metabolic webs. The information we depend on has also become overwhelming in scope but fragmented. We’re only now beginning to have the computational power required to model, integrate and manage the many processes contained in each of these arenas. The power we access through digital analytics allows us to extend and broaden our reach.

A simple example was the argument, made long ago by David Eddy, a pioneering giant in the application of information technology to care, that the explosion of new knowledge has outrun the capacity of even the best human minds to appreciate and incorporate it. Tens of thousands of new articles are added to the medical literature every month, far more than any professional can evaluate and absorb. But information technology can store all that updated knowledge in formats available at moments of decisions, when we need it most.

Dr. Eddy described the promise of cognitive processing, in which software routines would scan and compare dozens or hundreds of physiologic measures within a patient’s health record for patterns a clinician could never identify. A quick analysis might show, for instance, that when 19 of the variables present appear in combination with the values detected, there’s a 62 percent probability of a particular condition. The tool would then describe possible next steps in the care pathway.

The horizon is receding across technologies. In a session on the future of diagnostic imaging, GE Healthcare’s Medical Director Robert Honigberg thrilled the audience by showing decade-old and new ultrasound images. He then ticked off ways that, combined with broader advances in information technology, greater macro- and micro-imaging clarity would improve our abilities to effectively address issues: screening for stroke, Alzheimers and cancer; strengthening the power of primary care physicians in rural settings; virtual identification of pathologies; global disease registries; image-guided radiation treatments; and on and on.

Finding ways to help patients, clinicians and purchasers leverage the vastness of health information for their own purposes falls into the larger realm of Health 2.0. Still in its formative stages but gathering steam quickly, this sector of health informatics could create the pricing/performance transparencies and decision support that can positively improve clinical quality and finally make health care markets work, lowering cost. But one of Health 2.0’s real appeals is its business model which, as Google has learned, leverages the utility of information to create communities and markets that have commercial value. That, in turn, makes it low cost to the end user, and therefore highly accessible.

Some developments offer more accessible (i.e., lower cost) value propositions than others. In an everyday context, those, like Health 2.0, that depend almost strictly on data analysis and reformulation into decision-support will likely be far less costly, with far greater potential for population-level impact than, say, those that involve biologics. That relationship might be reversed, though, in situations like pandemics, when the biologics are the only recourse for populations. How does one work through these dilemmas?

It is difficult to not be dazzled by these possibilities. Who wouldn’t long for progress that can replace a child’s defective heart or kidney or eye, and make a compromised life whole again? But as with virtually all progress, developments raise profound conflicts between what we want and what we can afford. In a system being crushed by cost – while the average American family’s health care costs $14,500 in 2007, one third of households make less than $35,000 – where do we invest and how should investors be rewarded? Is there a reasonable limit to the price of even great progress?

One thing was clear. The advances that have made these miracles possible will continue to accelerate and become less expensive, making the technologies that are now available but out of reach accessible as well.

So the promise is breathtaking. Only our resources, our imaginations and our judgment will limit us.

Brian Klepper is a health care analyst based in Atlantic Beach, FL. He was a Fellow at the recent Aspen Health Forum. 

Margaret Cary, MD MBA MPH

Recently a friend mentioned that her sister had just moved to Boston, was looking for a doctor and asked for a recommendation.

"Let me contact my friend. He is on the faculty at Harvard Medical School and at MIT. I bet he will know the best doctors."

Just like old times, right? When you need medical care, you ask a local doctor you trust.

His answer? "Big problem."

"There are no PCPs (primary care physicians) taking new patients at either MGH (Massachusetts General Hospital) or BWH (Boston Women’s Hospital). It is virtually impossible for someone to choose his internist anymore. Everyone's practice is closed. You can go to a practice where a junior person will be building up a panel. Those practices are either institution based, e.g., Health Care Associates at BIDMC (Beth Israel Deacon Medical Center) or private groups (e.g., _____). Can she afford a Concierge practice? She could try _____."

He concluded with, "I need one myself."

I advise friends and family to avoid doctors when possible. I never thought avoidance would be enforced en masse from the physician side.

Many people believe only uninsured people have difficulty seeing physicians. Earlier this year a Maryland boy died of a brain abscess from an infected tooth. His mother tried to get dental care but nope, no room at the inn.

Twelve-year-old Deamonte Driver died of a toothache Sunday.

A routine, $80 tooth extraction might have saved him.

If his mother had been insured.

If his family had not lost its Medicaid.

If Medicaid dentists weren't so hard to find.

If his mother hadn't been focused on getting a dentist for his brother, who had six rotted teeth. [1]

For want of a nail the shoe was lost.

For want of a shoe the horse was lost.

For want of a horse the rider was lost.

For want of a rider the battle was lost.

For want of a battle the kingdom was lost.

And all for the want of a horseshoe nail. [2]

For want of a dentist, a young boy's life was lost.

Not your problem, you think. This is an aberration. Read on.

A national health plan assigned a primary care physician to a friend living in Maryland and a partner in a District of Columbia law practice. She called to make an appointment.

"I'm sorry. The doctor is not accepting new patients."

She started calling the available physicians on the health plan's website.

One by one, she heard "I'm sorry. The doctor is not accepting new patients."

She called the health plan.

"I cannot find a physician who is taking new patients. Can you recommend someone?"

"To find doctor for you we would have to call each one, just as you have to do."

Isn't finding a doctor one way health plans justify the 30% overhead they cost the system? If that is not enough incentive, many states have laws requiring health plans to have available primary care doctors, and to give these names to their members.

Maryland's statutes read

2) A carrier shall notify each enrollee at the time of initial enrollment and renewal about how to obtain the following information on the Internet and in printed form:

(i) a list of providers on the carrier's provider panel; and

(ii) information on providers that are no longer accepting new patients.

(3) (i) Information provided in printed form under paragraphs (1) and (2) of this subsection shall be updated at least once a year.

(ii) Subject to subsection (n) of this section, information provided on the Internet under paragraphs (1) and (2) of this subsection shall be updated at least once every 15 days. [3]

What happened, Well Known National Health Plan?

What happened, Maryland?

Dr. Maggi Cary is Director of the Washington, DC office of the Institute for Medical Leadership. Click here to read her other posts. You can reach Dr. Cary at mcary@medleadership.com .

[1] http://www.washingtonpost.com/wp-dyn/content/article/2007/02/27/AR2007022702116_pf.html

[2] http://www.rhymes.org.uk/for_want_of_a_nail.htm

[3] http://mlis.state.md.us/asp/web_statutes.asp?gin&15-112

Brian Klepper

Today I’m in San Francisco for the Health 2.0 conference, billed as “User-Generated Health Care.” Organized by my pal Matthew Holt and his partner, Indu Subaiya, "Health 2.0" references "Web 2.0," social networking, applied to health care. 

The meeting will feature top executives from high and low profile IT firms that either are already dedicated to or hope to play an important role in health care, like Google, Microsoft, Yahoo, Intel, Cisco, WebMD, Revolution Health, AthenaHealth, Sermo, and many other lesser known organizations, all discussing their strategies for leveraging data in new ways to create value for all health care constituencies.

Elsewhere, I’ve referred to this as a “significant portion of market-based health care reform, with NONE of the usual suspects." What I mean by this is that, by and large, the players working in this space are NOT the people we've typically seen at important health care conferences in the past, and they may be pooh-poohed by many longstanding health care power players. That could prove an error in judgment. 

At one level, many Health 2.0 sites are about patients creating content for other patients based on their own experiences, and by doing so contributing to a larger body of knowledge about what’s important when dealing with a particular condition.

But at another level, Health 2.0 is, in a very real sense, about corporations creating information that moves the locus of power in health care away from health care corporations and to the patient. Or for that matter, to anyone who now acts as a health care decision-maker: patient, clinician, purchaser, vendor. And in that sense, this is a revolutionary development.

We'll have a lot more to report after the session, of course. But here's s guess at some of the more exciting aspects of what we might hear.

 Imagine that a large corporation could gain access to a steady flow of clinical encounter or claims data for a sizable portion of the care delivered in the US. (Claims data is more likely at this point, but clinical encounter data has more robust clinical information and has more integrity.)  Let's say it could also get hold of lab data, image data and drug data. And let's say that company could assemble the disparate data elements into meaningful individual patient records accessible by any patient who wishes to see this information. This isn't so far fetched. Organizations like Blue Cross and Blue Shield of Florida and Humana have already created similar approaches through their payer-based patient record system, Availity.

Patient records might actually be created in two levels: one for patients and one for clinicians. Privacy and security issues are paramount. Once the patient sets up an account to allow the sponsoring organization (like a Yahoo, Google or Microsoft) to create a record, then any time his/her record is accessed, the patient might be notified, and an audit trail would exist.

If the sponsoring corporation has access to continuous rivers of data, it could analyze that information, cutting it in different ways to identify

• Patients who might be prone to have serious conditions in the near future,
• Patients who have conditions that aren't receiving the proper care,
• Physicians who provide excellent quality care or maybe not such great care,
• Drugs and devices within class that perform better or worse than others in their class,
• New best practice guidelines reflecting care approaches that consistently produce better results at lower costs, and
• So on.

The company could make this information available to all users, creating both pricing/performance transparency and accountability, but also creating information that helps patients, clinicians, purchasers and vendors make better decisions.

In the long term, new, better information might help all these players make decisions that are based more than ever on data rather than speculation. But in the short term, it would almost certainly help rationalize the tremendous excess that is now destabilizing American health care, driving down cost and helping to re-establish stability and sustainability to the system.

These are just a couple issues that will be top of mind at today's meeting. I'm sure there will be more.

The innovations we'll hear about may not be here today, but they'll be realities tomorrow or the day after tomorrow. They'll portend tremendous improvements in health care, improving quality and driving down cost, not just for health care professionals, but, more importantly,  for patients.   Health care, an industry rife with excess that derives from misaligned incentives and a lack of transparency, is filled with low hanging fruit. The new tools offered by IT are just now becoming sophisticated enough to bring tremendous value while revolutionizing the way health care works. And that's why theirpromise is so compelling.

Stay tuned.

Brian Klepper is a health care analyst based in Atlantic Beach, FL.

Brian Klepper

This week TDWI is delighted to take our turn hosting Health Care Wonk Review, a collection that highlights some of health policy's best observers. The quality of these 14 posts is very high, and well worth your time.

As HWR has gained visibility and popularity, the number of submissions has risen. We couldn't publish them all, so chose the ones we thought were must-reads across industry sectors. (Apologies to those we didn't include this time.)

Before we begin, a quick announcement. Envision Solutions, LLC and Trusted.MD Network have launched the second annual global survey of healthcare bloggers.  The companies are producing this poll to shed additional light on why people blog about health-related subjects.  Click on the link to learn about and take the survey.  The study will close on October 15.

Now onto the show!

Physician Temper Tantrums. Over at Managed Care Matters, Joe Paduda picks a scab and elicits a (deliciously) minor furor. He argues that when payors use the results of claims data analysis to encourage patients to see better performing doctors, they are well within their rights as purchasers. He also notes (and I agree) that when doctors reject out-of-hand claims data as inherently flawed and inappropriate to provide quality analysis, they may not appreciate the progress in the available tools and methods, and may be simply defensive. Actually, he says "their actions look more childish than professional from here." A provocative piece.

No Docs in This Box. Retail medical clinics are popping up all over as an inexpensive alternative to a full-blown practice or the ER. Traditional providers are crying foul, but InsureBlog's Bob Vineyard suggests this is the pot calling the kettle black.

Abusing The Orphan Drug Law To Rip Off Customers. In a damning indictment of a drug company's business practices, David Williams at the Health Business Blog discusses Questcor Pharmaceuticals announcement about “a new strategy and business model for H.P. Acthar Gel(R).”

What Are The Real Savings In Medical Tourism. MedTripInfo's Michael Horowitz analyzes the probable total savings for a hip replacement obtained overseas. They're substantial.

Medical Justice League of America. The Sentinel Effect's Richard Eskow describes a new group that provides "gag order" forms to dissuade patients from reviewing their docs online, and also promises to "relentlessly" fight med mal lawsuits." The situation he relates would be hilarious if it weren't so lopsided and scary.

Make Sure Your Online SaaS Vendors Are Appliance Capable. The Healthcare IT Guy, Shahid Shah, provides sage advice on why you should not depend on "software in a cloud" without a backup plan. With big outages from Microsoft, Skype, eBay, and PayPal recently making headlines, it is wise to make sure you're protected. A fascinating and smart look at the pitfalls and realities of letting other companies be responsible for your mission-critical IT functions.

What The Lumenati Are Saying May Surprise You.  The ever-entertaining Matthew Holt is making the final dash toward hosting the Health 2.0 conference, where the discussion will focus on a significant portion of market-based reform, and the players will be none of the usual suspects. Meanwhile, back at The Health Care Blog, he ticks off some surprisingly lucid health care insights from the most unexpected sources.

Mitt Romney's Health Plan - A Foot In Each Canoe.  Over at Health Care Policy and Marketplace Review, Bob Laszewski wryly observes that conservative Presidential candidate Mitt Romney would like to have it both ways. He gloats over the Massachusetts reform he helped to engineer while assuring his political base that it wouldn't work elsewhere. (It's also not yet clear that it is going to work in Massachusetts.) It's a delightful bit of political dissonance, seen through the clarity of Bob's highly polished health policy lens.

BiPolar Diagnosis in Children: Another Epidemic? Here at The Doctor Weighs In, the erudite Dov Michaeli recounts a recent review article from the Archives of General Psychiatry. Between 1994-1995 and 2002-2003, an 8 year period, the rate of bi-polar diagnoses in children increased 40 fold! He lists a range of possible explanations for the epidemic, but settles, gloomily and cynically, on money. By explicating an immense but relatively obscure problem, he lays bare a pervasive trend that's corroding our health system. A must read!

Conflicted View on the Pitfalls of Government-Sponsored Comparative Effectiveness Research. In a withering analysis, Roy Poses at Healthcare Renewal rebuts a recent commentary by WSJ Editorial darling Scott Gottlieb. Dr. Gottlieb disparaged government-sponsored research as biased against costly drugs, while ignoring similar and more odious flaws in private sector research practices. AND Dr. Gottlieb conveniently neglects to disclose that he's associated with the biotechnology sector. Superb.

To Hell and Beyond: Dave Holland's Terrible Story. At Workers' Comp Insider, Julie Ferguson points to a particularly gruesome work-related accident by way of reminding us that these incidents are still all too common. Julie's perspective is particularly poignant, because it is also a reminder that what lies beneath the day-to-day work  of the people who write for and read this review is the vital goal of preventing and managing the suffering that is too often a part of life.

Katrina: Two Years Later Are Health Systems Better Prepared?  On the second anniversary of Hurricane Katrina, NewsHour correspondent Tom Bearden asks a coastal area provider if the health systems are now better prepared. The short answer is "No," according to the  interview excerpted by Jane Hiebert-White on Health Affairs Blog.

Cookbook Medicine Saves Lives.   A pretty good cook (I can vouch for her!) as well as a physician, The Doctor Weighs In's Pat Salber relates the substance of a July 23 article in the Archives of Internal Medicine. She describes a new heart failure guideline that improves outcomes when followed by clinicians, and details the range and depths of those improvements. She concludes with a quote from  the lead author, telling us that if these protocols were followed in hospitals across the country, they would result in 40,000 fewer deaths and 1.4 million fewer hospital days annually. Keeping in mind that this is just one condition in the vast complex of health care, it is a deeply compelling point.

Reform's Tougher Problem. I've been a bedouin lately, wandering from oasis to oasis, grateful for the chance to publish on Pat Salber's The Doctor Weighs In, Bob Laszewski's Health Care Policy and Marketplace Review, and on Matthew Holt's Health Care Blog. This post, placed on Matt's site, summarizes what I've learned working for several years on the reform problem. I now believe that meaningful change can only occur through the leadership of the non-health care business community, the one group with more power and influence than the financially conflicted health care sector. Non-health care's business leaders will pursue this effort, not because they care about health care or social justice, but because health care's impending instability will threaten the stability of their own econonic environments.

Thanks again to Health Wonk Review for letting us host, and thank you for stopping by.

Brian Klepper 

Mention a health plan to doctors or hospital administrators, and they’ll likely bend your ear about how the performance feedback data they get from the plans are wrong, how their reimbursements are based on inaccurate data, and how they think the inaccuracies are intentional.

Because they aggregate huge volumes of claims, health plans have the best patient and provider information. While many providers dismiss claims data as wholly inaccurate, these records in fact contain a wealth of useful information about patients and their care that can be teased out using the very sophisticated analytical tools that are now readily available.

These techniques permit credible evaluation of the relative performance of doctors by specialty and hospitals by service.  Virtually all analytical tools now incorporate algorithms that compensate for differences in patients' illness levels. They “severity adjust” for the doctor who claims “Of course I look bad compared to my peers! My patients are sicker!” by using markers in the claims process to estimate just how sick each patient is.

Health plans have used their ownership of large health care data sets to advantage with providers. Most providers do not have access to robust data. In contract negotiations, they are often forced to rely on the data supplied by the health plans, their adversaries. This power mismatch has characterized health plan-provider negotiations for decades, and it is a source of high enmity and distrust in a relationship that is adversarial by nature.

All this will soon change. As doctors and hospitals increasingly implement electronic patient records, health information exchanges will come into prominence as well. Of course, the best reason to exchange patient information is patient care, for clinicians to have a complete picture of the patient so they can make good diagnostic and treatment decisions. But another important reason is to develop an aggregated data source that is independent of the one provided by your adversary.

Recently I became aware of a new species of health care data tool, Context Managers, universal translators among different, typically inoperable electronic patient record systems. One example is Carefx, which provides physicians and other clinicians single sign-on Web-based access to a patient’s complete information, or at least as much of it as is represented in electronic systems that are connected to a network running the tool.

Let's say I say show up at one of my community'sl Emergency Departments. Assuming that the region’s hospitals, doctors offices, labs and diagnostic centers are on the network, the doctor can type in my name and, for the first time – Poof! – pull up all the information available about me. Physician notes, test results, medication lists and images are all displayed and available for immediate, deeper inspection.

Two immediate benefits spring from this. With more complete information, the doctor is likely to make better clinical decisions. And because previous test results are available, the necessity of repeating them is reduced. Care is better and less costly.

Though it isn’t here yet, there’s another benefit lurking around the corner. Presumably with systems like this, a patient’s record could be assembled and then redistributed to all its contributor record systems in its newly revised, more complete form. It could also be deposited into a centralized data repository, which would then allow the aggregate data to be mined to see who’s doing a good job and who isn’t, what works and what doesn’t, who needs care management and who doesn’t.

The data that emanate from patient records will be a higher order: clinical encounter data, rather than claims. Because they more directly reflect the care process and include lab values, images and other non-administrative information, they are more complete and more reliable. And most important, they’ll constitute a credible source of information to counter the data that health plans have sometimes used to dominate.

Even so, there are significant barriers to making this happen. Many hospital executives and physicians chafe against having their performance data known, particularly by competitors. But that point of view will subside as we move into a more transparent market where reimbursement is tied to performance.

All this is coming. These new tools will permit a new level of transparency, finally facilitating a much more functional health care marketplace, good news for patients and purchasers. But they will also be great for clinicians, because they’ll have vastly improved information to provide better care.

Those who prepare have the best chance for success. Those who ignore this trend or try to hold it back will...well...end up working for the others.

Brian Klepper PhD is a health care analyst and advisor. He can be reached at  904.343.2921, bklepper@gmail.com. Click here to see more of Brian's recent posts.

by Pat Salber, MD

In the early days of the clinical practice guidelines movement, doctors used to complain that it was “cookbook medicine.” As a pretty good cook, who still uses cookbooks, I say, great – when you follow the directions of experts, instead of “winging it,” you increase the odds of getting a good outcome.

So it should be not a surprise that a new study, in the July 23 issue of Archives of Internal Medicine, found that outcomes of hospitalized heart-failure patients are improved when hospital personnel follow clinical guidelines.

OPTIMIZE-HF (“Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure”) is a heart failure guidelines/quality improvement program adopted by the American Heart Association (and sponsored by drug maker GlaxoSmithKline). The program provides hospitals with tools to help improve the reliability of care, including standardized admission orders, discharge checklists, pocket cards, medical chart stickers, best-practice algorithms and critical pathways. It is currently being used by 259 hospitals across the US.

The study, led by Gregg Fonarow, MD from UCLA’s Department of Medicine, looked at data entered into an online OPTIMIZE-HF performance improvement registry. Admission, hospital, discharge care, and outcomes (death and hospital readmission rates) data on 48,612 heart failure patients were entered into the registry between March 2003 and December 2004. A subgroup of 5,791 patients were followed for an additional 60-90 days after they were discharged from the hospital.

The researchers found statistically significant improvements in three of four of the Joint Commission on Accreditation of Healthcare Organization's performance measures used to gauge the quality of heart failure care in hospitals. They included:

· Better patient discharge instructions. The rate of giving complete medical instructions to patients increased from 46.8 percent at the beginning of the study to 66.5 percent by the study's end.

· Smoking cessation counseling. Hospitals provided smoking cessation counseling to 75.6 percent of the patients at the end of the study, compared with 48.2 percent in the beginning.

· Left ventricular function assessment. Evaluating the heart's left ventricle systolic function rose from 89.3 percent to 92.1 percent.

A fourth measure, the rate of angiotensin-converting enzyme inhibitors (ACEIs) prescribed to eligible patients at discharge was 75.8% at baseline. This rate did not improve during the 2-year study.

There was a statistically significant reduction in the mean length of stay for these patients, going from 7.5 days at baseline to 6.2 days at the end of the study. In addition, were trends for reduction of in-hospital mortality, postdischarge death, and combined postdischarge death and rehospitalization, but they did not reach statistical significance.

So patients did better and hospital days were reduced (and so were costs presumably). What’s not to like? According to the lead author, Dr. Fonarow, as quoted in the Washington Post:

"If similar improvements had occurred at hospitals nationwide, this would translate to 40,000 less deaths and 1.4 million costly hospital days eliminated per year. Despite compelling scientific evidence and national guidelines for use of key life-prolonging agents and lifestyle changes, gaps exist in heart failure treatment. We hope more hospitals will adopt this validated model for enhancing heart-failure patient care."

Amen.

Brian Klepper 

Last week the New York Times reported that New York's Attorney General (AG) office threatened UnitedHealthcare (UHC) with a lawsuit if it proceeded with the September release of a physician profiling report. The details were fuzzy, but apparently the AG was responding to charges by different physician groups – the AMA and the St. Louis Metropolitan Medical Society were named  - that UHC's methodology is based purely on cost and does not consider quality. The Times piece includes this snippet:

Linda A. Lacewell, a senior lawyer in the office of Attorney General Andrew M. Cuomo, wrote in the letter that the ranking would apparently be used to steer consumers toward selected doctors. “To compound the situation,” she wrote, “we understand that employers may act on these ‘ratings’ to offer financial inducements such as lower co-payments or deductibles to promote ‘cost-effective’ doctors to their employees.”

Ms. Lacewell said patients might be steered toward doctors based on flawed data and UnitedHealthcare’s “profit motive.” She wrote, “Consumers may be encouraged to choose doctors because they are cheap rather than because they are good.”

Without more information, it is hard to know what's going on here. But UHC and the NY AG's office each have a point and each are suspect. Here's what we know:

Ingenix, a UHC subsidiary, is a health care analytics firm which owns and licenses Episode Treatment Groups (ETGs), a highly-regarded and widely-used health care patient classification system. ETGs are used by many other reputable analytical companies, like MedStat, MedAI, and ProfSoft. One would assume that UHC's analyses of physician performance in New York and elsewhere used this tool, but who knows?

On the other hand, the Ingenix tool violates what I think of as a core rule of transparency, which is that any tool used to achieve transparency must be transparent as well.  Ingenix' ETG algorithm is proprietary, which basically means that the people being evaluated can't find out exactly how the evaluation works. This invariably makes them worry that they're getting shafted.

Let's apply this problem to a real life example. I use this tool to evaluate the performance of all the doctors, by specialty, within a network. I'm going to publicly publish the results – the identification of high, average or low performing physicians – and then tie the results to payment levels.

I approach a low performing physician and show him the results, and he's aghast. “How did you arrive at THAT?” he asks. “I can't tell you,” I say. “It's a secret.”

Now take this problem of a proprietary evaluation methodology, and embed it in a profit-driven company that has been caught in disputes involving money on more than one occasion. It's not impossible to see why the AG's office is skeptical of UHC's intentions or approach.

The AG's Ms. Lacewell is concerned that the UHC analysis might steer patients to doctors based on cost rather than quality. That might be the case if UHC's analytical tool was set up that way. But unless UHC is not using their own tools, it is not likely. ETGs and other contemporary health care analytical tools provide risk-adjusted evaluations of value. That is, they hold outcomes constant and then compare cost. Or they hold cost constant and compare outcomes.

The point here is that we most certainly want to identify better and poorer performers. We want to steer patients to the better ones and give the poorer ones reasons to improve.

We have a crisis in health care in large measure because the performance of doctors, hospitals, health plans, drug companies, device companies and everyone else involved in health care has been hidden. The lack of accountability has resulted in tremendously excessive cost and a tolerance for poor and sometimes dangerous quality. Worse, the lack of transparency has created an opportunistic culture throughout health care. Professionals and companies in every health care sector gild the lily with inappropriate and wasteful products and services, because they're mostly certain that the excesses won't be detected.

Of all the things we can do to fix health care, performance transparency is the most important.  Only if we can see what has transpired – what processes have and have not been conducted, and what the outcomes have been – can we identify problems and opportunities and then begin to address them.

The New York Attorney General is right to be skeptical of the evaluative neutrality of UHC or, for that matter, any organization dedicated to profit rather than the public interest.

On the other hand, New York's AG's office should smell the coffee. To make health care and any other public function work, we need to publicly report performance information. Patients have a right to know how doctors compare within specialty and how hospitals compare within service.  They'll certainly want to go to the ones that have better track records, and the employers who pay for much of their care want to encourage them to learn which ones are best. 

The AG's office should also be skeptical of the doctors' motives.  Are the physicians against any public reporting of their performance, or just that done by for-profit entities like UHC?

To heal health care, we need transparency. But it should be provided by neutral organizations that don't have conflicts of interest, and handled to assure doctors and everyone else involved in health care that the reporting will be fair and without prejudice.

Health care is too important for patients and purchasers to not have objective information. Only if we get this accomplished properly can we say that we've taken the first steps to really fixing America's health care system.

Brian Klepper is a health care analyst based in Atlantic Beach, Florida. You can reach him at bklepper@gmail.com.

By Maggi Cary MD, MBA, MPH

Bob and Lara were my landlords, in their 60s, and lived across the nearly-two-lane road in the house they built over Adobe Canyon Creek in Sonoma County, California.

I was Bob and Lara’s doctor—not in the come-to-my-office sense, but in the I’m-the-only-medical-person-in-the-family sense.  Bob developed a Dupuytren’s contracture, which is where a finger, or fingers, is drawn down toward the palm.  The connective tissue thickens and shortens, so moving the affected finger(s) is difficult.  The treatment is surgery and I recommended one of the top plastic surgeons in town.  Another friend did Bob’s anesthesia, blocking the nerves leading to the hand, much as dentists block nerves in your mouth, with Bob awake during the operation.  I assisted with the case and we all—patient, surgeon, assistant and anesthesiologist—chattered together during the case, sharing jokes and laughing.

Bob’s hand healed well and he would often hold it up, showing the scar and proudly saying, “Maggi is my doctor.”

Lara and I were particularly close and she listened to me in good times and bad.  She saw me through each of my parent’s deaths, medical residency, my first years of medical practice, moving to Denver and a devastating break-up.  We kept in touch through telephone calls and writing.  I looked forward to each handwritten letter.  Lara had been a looker in her younger years and Bob had swept her off her feet as a handsome and cosmopolitan young man from an old New Orleans family.  

Each time I visited the Bay Area from Denver I added extra time to drive over the Golden Gate Bridge to visit them.  By the time I turned the car around in the circular driveway Lara and Bob had stepped off the porch to greet me.  Sonoma County always felt like home.  

We hugged, walked up the three stairs to the threshold and sat in the living room.  After a brief catch up, Bob drove Lara and me to the local family-owned restaurant.

Bob’s eyesight began failing from macular degeneration, a common cause of age-related blindness where the macula, or central retina, degenerates and so cannot capture images to send to the brain to interpret. Twice he nearly had a car accident as he turned onto the main highway.  Lara was getting increasingly forgetful and was anxious about becoming senile.  Their only child and his wife, Glyn and Jane, coaxed them to move into transitional housing to be near them, about 120 miles away.  Bob and Lara had lived in their house for decades and left the area and their friends reluctantly and with many tears.

I continued my tradition whenever possible, visiting Bob and Lara and staying with their son and his family.
Jane told me Lara could scarcely contain herself when she knew I was coming to visit.  She was happy from the time

I called to let her know I was coming until long after I departed.  I have often thought since then of the power in spending time with people—in just showing up.

Our roles began reversing.  Lara and Bob had always looked after me from afar and now I was looking after them, adding however I could to Glyn and Jane’s excellent caregiving.

Lara’s “forgetfulness” was early dementia.  She steadily declined from independent living in their transitional housing facility through daily assistance to needing more care than the facility could provide.  She had to move to long term care while Bob’s macular degeneration progressed to where he could no longer read.

The closest facility for Lara was two hours and three bus routes from the apartment she had shared with Bob.  Bob, virtually blind, visited her once or twice every day.  Lara often did not recognize him, yet he stayed, talking with her and holding her hand.  

Bob became ill with a chest infection and was treated as an outpatient.  After treatment he was admitted to the hospital in a confused state.

“I see spiders,” he said to Glyn as he picked at the air from his hospital bed.

Glyn told Bob’s doctors he had been a perfectly coherent, spry 88 year old before his hospital admission.   The doctors seemed indifferent.

As often happens with old people, after his acute hospitalization, Bob was transferred to a nursing home.  When he arrived the staff immediately returned him to the hospital, saying he was too sick to be in a nursing home and suggesting further evaluation and treatment.  

I flew from Denver to California to be with Bob and his family and see what I could do to sort out Bob’s medical care.  He died before I got to his bedside.

On the surface, this might seem to be just another death of an elderly man.  Often when elderly spouses are separated one will die.  As I sat with the family the day after Bob died, with his granddaughter Ann, in her final year of medical school, she and I reconstructed the details of Bob’s final days.

Bob’s physicians had started him on antibiotics a few weeks before his death.  As we listened to the course of his illness and the timing of events Ann and I began asking questions.

“Tell me again how he was acting,” I asked.

“Bob was seeing people who weren’t there and talking nonsense,” Glyn said.

I recalled the spiders.  These hallucinations sounded like liver failure, usually caused by chronic alcohol use, but also caused by certain medications with a similar effect on the liver, especially in the elderly.  Bob wasn’t a drinker.

“Was he yellow?” I asked.

“Yes, at the end.”

Another sign of liver failure.  

“Do you remember what antibiotics he was taking?” I asked.

“No.”

“Was he getting regular blood tests while on the antibiotics?”

“I don’t know.  He had blood drawn when he was in the hospital.”

Too few facts, but Ann and I looked at each other.  I mentioned medication-induced liver failure.  

Ann nodded her head and said, “That’s what I’ve been thinking.”

As near as we could tell from the limited facts it appeared the antibiotics had damaged Bob’s liver, leading to his confusion, jaundice and death.  In general, medications are processed by the liver or the kidneys before being excreted.  Some medications have well-known side effects on the organs.  Specific antibiotics are notorious for this, especially in the elderly.  The standard of care is to check the liver enzymes in the blood.  If the levels are up, it means the liver cells are being damaged.  It was not clear to me Bob’s liver enzymes had been regularly checked.

It appeared to me his physicians paid no attention to Glyn and considered Bob to be a confused old man who was grieving over separation from his wife, perhaps even thinking him an old geezer not worth saving.  

A couple of days before Bob died his physicians recognized he was jaundiced—yellow because of liver failure.  Bob was confused because of the build-up of ammonia from his liver’s inability to process it.  Bob probably died of the side effects of medications toxic to his liver.

Had Bob been cared for by clinicians who remembered to check his liver enzymes, he might have lived through his illness.  His medications could have been stopped or altered when the liver enzyme levels were elevated.  Had Bob’s care been coordinated among his many physicians, both outside and inside the hospital, I don’t believe he would have died from this event.  He would have been alive for his granddaughter’s graduation, with honors, from medical school three months later.

Failing to check liver enzymes in an elderly patient on certain medications is malpractice.  “Old” and “done for” are not synonyms. Primum non nocerum—first, do no harm.

I moved from my fourth grade dream of being a small town family practice doc to working on national health policy so I might have a tiny role in fixing the broken healthcare system.  Through all my work in clinical care, regulation, health policy, public health and business, through my journey through nearly every component of the medical industry, it came down to my friend Bob and medical error.

Dr. Cary is Director of the Washington, DC office of the Institute for Medical  Leadership.

If you’re like me, your medical records are scattered all over your home region. (In my case, that’s lovely coastal Northeast Florida.) Over the years I’ve had several doctors: primary care physicians and specialists. I’ve been a hospital patient, and I’ve had outpatient procedures at doctor-owned facilities. I’ve had workups at several diagnostic centers and labs.

The problem is that it’s health care Babel out there. No organization has my complete history because few if any of these organizations can share my medical records. Currently less than one-quarter of doctors store their patients’ information in electronic medical records that can be traded. And even if they did, the industry hasn't defined standards for records yet, so most systems can’t talk to each other. Until recently we couldn’t grab all the pieces of a patient’s record strewn throughout a region and drop them into a single medical chart.

If I landed in an emergency room tomorrow, even if the doctors knew my name, they wouldn’t be able to retrieve my records and then factor my history into their diagnoses and treatment decisions. Instead, they’d quickly order expensive batteries of tests and, with still relatively limited information, take their best shots. No matter how skilled and dedicated they are, their clinical results would be compromised by what they don’t know. The lack of full information would drive the cost up substantially as well.

The waste associated with our inability to easily pull this information together is huge, and becomes apparent when you consider how many doctors patients see, and how little coordination among them there is. Many seniors, for instance, have regular visits with a variety of doctors. A recent national study found that, annually, the average Medicare patient saw seven different doctors in four different practices. Five were specialists.

As you'd expect, sicker patients see even more doctors. About 40 percent of seniors have seven or more chronic conditions, and typically saw 11 doctors in seven practices. The sickest 25 percent went to 16 or more doctors in at least nine practices.

Probably none of these doctors currently has access to a complete patient record. Unaware of what they don’t know, they might prescribe drugs that conflict with the patient’s other drugs, They may repeat tests recently performed elsewhere. The possibilities are endless, but the results are clear. Incomplete patient information produces poorer clinical outcomes at higher cost.

The problems I’ve described affect nearly all of us; they’re not restricted to the uninsured or the poor. Only if you receive all your care through an integrated health system, like a Mayo Clinic or Kaiser Permanente, will all your records reside in a single place. Even then, getting access to that information can be difficult if you suddenly need care elsewhere, like the emergency room of another organization.

For all these reasons, a group of community-minded individuals in my home town has been working to build a regional health information exchange. The Northeast Florida Regional Health Organization, or NEFRHO (pronounced NEF-row), would be a not-for-profit community health care utility, dedicated to a single idea: facilitating better health care information that helps everybody who touches health care – patients, employers, doctors, hospitals, health plans, our city and county officials – make better health care decisions.

NEFRHO is a Regional Health Information Organization, or RHIO. There are now RHIOs under development all over the country, simply because what they're trying to accomplish makes sense. But there are enormous challenges in getting them going. One is getting the different health care leaders within a region - they have historically been adversaries - to collaborate. The other is finding a financing model that makes it sustainable. The Healthcare IT Transition Group has a great blog that tracks the progress of these efforts around the country at http://blog.hittransition.com/rhio_regional_health_information_organization/index.html.

Several very affordable tools – we got great deals from two organizations eager to show what their tools could do when implemented community-wide - would make NEFRHO effective and financially sustainable. Carefx is a commercially available tool that translates between different electronic medical record systems around the region. A doctor types in a name and, like Google, it immediately assembles all available record information about that patient. He can see a note, a medication list, an image gathered from all the systems on the network. 

Think of the impact! Doctors throughout Northeast Florida would have better patient information to make better, more cost effective treatment decisions, without duplicating recently performed tests.

Another tool would help patients make better decisions about their own care, particularly important for patients responsible for an ever larger burden of their health costs. WorldDoc is an accurate and easy-to-use Web-based diagnostic tool – its being used effectively by some very progressive health plans, like Heritage, based in Houston – that helps patients determine whether they should visit their physician and what other steps are appropriate, given their symptoms. There is a personal health record, a medical encyclopedia, a tool for evaluating lifestyle health risks, comparison tools for hospital quality and drug cost, and much more.

Like any utility, NEFHRO would be sustained by very modest dues paid by its primary funders: businesses, health care organizations and local government. That support would build on our existing health care resources to create even better care than is already available in our community, and better care than is in most other communities. Imagine how companies interested in relocating would respond, in addition to our region’s many other blessings, to demonstrably better, lower cost health care.

The trick here is that we’ve designed NEFRHO to be financially self-sustaining without government or philanthropic assistance. In large part, we hope to get leverage business’ interest in WorldDoc’s capabilities to get annual dues of $15 per employee (or $1.25 per employee per month). That would make it go. In return, though, we need to document and show the returns on investment that accrue to the community and the employers.
This project already has the support of many of our hospital and physician leaders. To make it happen, all it really needs now is vision and leadership from Northeast Florida’s business and government communities.

If you are involved in a RHIO effort in your community, post a comment describing you experience.   Let's learn from each other.

Brian Klepper, PhD

Today I saw Constance Congdon's adaptation of Moliere's 17th century play, "The Imaginary Invalid" and was rolling in the aisle with laughter.  But, as in all things humorous, there is an underlying, stinging veracity that makes you ponder, seriously, the very topics that have made you laugh.

First, some pictures, and then, the prologue to this wonderful play:

And now, back to the prologue of the play:

"We are doctors come to warn you of the phonies out to harm you, could your guru be a schmuck?  If it quacks, then it's a duck!

Your guru scoffs at your queries, and all his precious theories won't stand up to some flack?  If it ducks, then it's a quack! (Quack!)

If you are plagued by tintinitis, aggravated by bursitis, fatigue and headaches, with a rash...keep both hands upon your cash.  If someone sells you magic mud that will purify your blood, they are a lying sack.  If it ducks, then it's a quack.

Do not order things by mail that have just now gone on sale, straight to you from Tripoli, made from a secret recipe devised by monks (It's never nuns)....it might give you the runs.  There is something quite demonic in a high colonic.  Watch your purse and watch your back.  If it ducks, then it's a quack!

We're not doctors, we are actors, we refuse to be retractors.  Oh yes, verily, forsooth, we are here to tell the truth.

We PLAY doctors come to warn you of the phonies out to harm you.  Could your guru be a hack?  If it ducks, then it's a quack."

If you would like to learn more about "Growth Hormone Schemes and Scams,"  and other quackery, check out QuackWatch.org.  It is an eye opener.  Quack!

Pat Salber, MD

“Oh Lord, lead me away from temptation… but not quite yet.

St. Augustine .

The New York Times in its May 9, 2007 issue, published a front page article about oncologists prescribing excessive amounts of anemia drugs to cancer patients on chemotherapy. The statistics are enlightening: the higher the “compensation” or monetary inducements offered to the oncologist-the higher the frequency and dosage prescribed. As they say on the TV commercial, “this drug is not for everyone”.

Inappropriate prescription can actually cause harm, and recent studies showed that inappropriately high doses result in increased mortality.

Response

The American Society of Clinical Oncology distributed a letter to the members.

Complete Disclosure: I am a proud member of ASCO.

Response to the Response

· ASCO makes the same argument that professional people make when colleagues are caught with their hand in the cookie jar: most of us are conscientious, hard working people. Granted. But to turn a blind eye to the corrosive influence of pharmaceutical companies on the use of drugs is denial of the how our health care system “works” on a daily basis.

· ASCO is led by academic clinicians and researchers, whose motivation and dedication is admirable. But many of the rank and file, community practitioners, are not beyond temptation. Most so us aren’t, it’s just a question of ‘how much’. Indeed, the pharmaceutical companies spend more on ‘promotion’ and sales than they do on R&D.

· ASCO is a wonderful organization that promotes cancer research, education, and evidence-based clinical practice. I think it should keep its excellent reputation and avoid getting sullied by entangling itself in the sordid affair exposed by the New York Times.

· As an article in the New York Times of the next day ( May 10, 2007 ) showed, apparently no specialty of Medicine is immune from infectious mammon; psychiatrists are prescribing large amount of psychotropic drugs, many times inappropriately, to people who do not need them .

If the New York Times is going to continue with this series, the next specialties to come into the harsh light being shined on Medicine may be cardiology, orthopedics and radiology. The abuses in these specialties are a well-known secret in the medical community.

As the wheels are coming off our broken health care system, more revelations of waste, abuse, greed and outright criminality are bound to surface. What are we going to do about it?

Dov Michaeli MD, Ph.D

Every once in a while a medical research study is published that significantly alters clinical practice. The paper on percutaneous coronary intervention (PCI) in patients with stable coronary artery disease, published in the prestigious New England Journal of Medicine on March 26, 2007, is one such study.  The results show that PCI plus optimal medical management (lifestyle changes and drugs) are no more effective than optimal medical management alone at preventing heart attacks and death in individuals with stable coronary artery disease.

 In the NY Times’ story about the study, Steven E. Nissen, MD, President of the American College of Cardiology, describes the study as a blockbuster. And, indeed it could lead to some folks’ blocks being busted (particularly stent companies, such as Boston Scientific and the Cordis Cardiology division of Johnson and Johnson, as well as invasive cardiologists who perform these procedures).

The name of the study is COURAGE, an apt description for a study that is likely to be attacked vigorously by people who stand to lose in the high stakes arena of invasive cardiology. COURAGE stands for “Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation.”

Understanding plaque

In order to understand what these researchers were trying to determine, it is important to understand a bit about what causes heart attacks. Years ago, we used to think heart attacks were caused because one or more blood vessels supplying the heart became progressively more narrowed by atherosclerotic plaques, perhaps even closed off completely, thus, depriving the heart muscle of oxygen.

As we have learned more about the anatomy and physiology of coronary artery plaques, we have discovered that the plaques that cause h