New Digs

Not sure if anyone is still here, but this blog has moved to http://blogs.ipro.org/ascannerbrightly/

See you there!‎ Full story...

Partners in Health

My boss - Dr Anthony Shih - is co-author of the chapter "Achieving the Vision: Payment Reform" in the recently published book "Partners in Health", available in Hardcover and Kindle.

Partners in Health: How Physicians and Hospitals can be Accountable Together (J-B Public Health/Heal

"The combination of visionary leadership, knowledge, and superb timing makes this book a winner. Health care is evolving toward collaboration and integration, and this book is essential reading for anyone wishing to change the relationships between hospitals and physicians."—Donald W. Fisher, PhD, president and CEO, the American Medical Group Association

"This book is a must-read for anyone committed to a high-performance health system. It spells out the practical steps that will move us toward an accessible, coordinated, patient-centered system of care. Its recommendations for payment and regulatory reform underscore the urgency of comprehensive health reform if the current misaligned incentives are to be changed to support those on the frontlines in providing the best care with prudent stewardship of resources."—Karen Davis, PhD, president, The Commonwealth Fund

‎ Full story...

Should Paul Levy be More Transparent?

As many of you already know, health care transparency evangelist Paul Levy, CEO of BIDMC in Boston, is having a bit of of trouble with his professional life apparently colliding with his personal life. Details are unknown, but include an inappropriate relationship with a subordinate. Mr Levy apologised to his staff via e-mail for his lapse in judgement, and little else is known.

The Boston Herald has run a few pieces about this, and sent a reporter down to Ohio where Mr Levy was speaking about health care transparency at a conference. The Herald is having a grand old time asking a transparency leader to be transparent about this particular incident, basically flogging the story as "Mr Transparency has something to hide" while Mr Levy ducks the reporter and tells everyone at the conference not to talk to the media.

So the question is probably a valid one. If you are a thought leader and public speaker on transparency in the hitherto opaque world of health care business and outcomes, shouldn't you tell us all who you're having sex with and when?

Hmm, now that I say it out loud, it doesn't sound so valid. But let's examine it a little more.

What is health care transparency, and why do so many of us give a damn about it? For me, it's a question of fair trade. I am expected to participate in an allegedly free market but I cannot know the price of goods and services before consenting to the purchase. I am expected to participate in an alleged free market but I cannot acquire adequate data to compare providers of goods and services on their quality, efficiency, or ability to render the services required.

Transparent Deck Repair

My new house has a deck that is falling apart, and I need to repair or replace it. If my deck were my appendix, I would dial a number, a dispatcher would send a contractor and his crew to my house, I would flash an insurance card that he will gladly accept. Later, I will find out that two of his staff do not actually accept my deck insurance, and I will have to pay retail for the railings. Later still I may find out that this particular deck builder has had three decks fall down after he left, but the previous owners were forbidden to tell anyone. I will call the department of housing asking why they can't tell me this, and they will say I am unable to adequately use the information without drawing potentially wrong conclusions.

Later still, I will get a bill that includes a bunch of vague billing codes but the words "wood" and "nails" will be nowhere on there. I will realise I can't afford the portions that my insurance didn't cover, and I will sell my house to pay for my deck.

Obviously, this is absurd, but it is the current state of play in health care. So that gives us the common sense reason. So why should I be in a position to demand transparency? It's a free market, right?

Wrong. Taxpayers prop up the system in a number of ways, and by dint of anyone taking public funds, we immediately expect accountability. Seeing as we're talking hospitals, let's take a look.

Most hospitals operate as non-profits, thereby evading huge property tax bills. That's money out of our public pocket. Yet many of these non-profits pay multi-million dollar executive salaries. The oft-quoted argument is that "we need to pay competitively to keep these execs out of the private sector and in our non-profit", but of course the bulk of the market is non-profit so that argument doesn't truly hold.

Then we pay taxes to reimburse these non-profits when they come across someone who (shock, horror) can't pay. The hospitals go begging at the state kitty and we pay again.

And of course, about half of all the money in health care comes directly from the government via Medicare and Medicaid payments.

So, we want accountability. We don't have it, so we demand transparency in order to hold people accountable.

Accountability is not Universal

Now, Paul Levy has done something for which he needs to be held accountable. To whom is he accountable? The Boston Herald? Me? Who?

Seems to me that while, yes, he could have made mention on his blog and twitter feed and the rest of it that something was going on, the details are not ours to know. He is accountable to the board of directors. There is talk of some severance package for the female staffer in question, and if this be the case then there is the added accountability of misuse of funds. But it is the board whose job it is to be transparent here. Transparency is not about knowing everything about everyone at all times. And those of us who preach transparency in health care have no additional requirement to confess our personal sins in the newspaper.

Over at one of my other blogs, abouthealthtransparency.org, I have received an e-mail from a business editor named Frank Quaratiello at the Boston Herald with the title "Interesting Story" and a copy of the Herald piece. I don't know Mr Quaratiello, but I assume he believes the story has something to add value to the health care transparency debate.

I will not be posting it on abouthealthtransparency.org as it is not about health transparency.

Is there a newsworthy story there? Yes, a major CEO and public figure has proven himself to have had a lapse in judgement, requiring his Board to take action. That is news. Should he resign? Maybe, that's between him and his Board. Do I or anyone else not involved with running that hospital have a right to know the who, what, when and where of the story?

Not at all.

Hot Dog Never Events

If a surgeon made a mistake on the operating table and cut off the wrong leg, are we immediately entitled to know everything he's ever done in and out of the hospital? Should we expect him to rush to update his Facebook feed "just chopped off the wrong leg, brb, chopping off the other one"? Maybe one time he put mustard on his hot dog instead of ketchup. Surely this should have bearing on his ability to perform surgery? At the least shouldn't I know he can't tell his condiments apart?

No, the transparency is in the knowledge of the event, and the efforts made to avoid it happening again. Transparency is about good, useful data that fosters better, more informed decision making.

It is my opinion, and my opinion only, that a figure with as much publicity as Mr Levy should not avoid the fact entirely on his many outlets, especially given his use of his blog as a glimpse in to his personal as well as his professional life. The modern world and its modern communications channels necessitate that we bloggers and tweeters and users of the Web cannot but give up much of our privacy, and separating personal from professional has never been harder now that we are all profiled and LinkedIn'ed.

I myself have been at the wrong end of making poor judgement in a professional setting. When your work is your play, when you are passionate about your work and your goals it can be hard to separate professional from private. Hell, most people I know who are as dedicated and hard-working as I think I am don't have time to have a personal life, and it's easy to fall into the trap of allowing your professional life to substitute for a private one at times. Been there, done that.

But I have no interest in knowing any medical provider's personal intimacies, and neither should anyone be particularly holier-than-thou when talking about Paul Levy.

I don't defend what he did, we all make mistakes and we all have to pay for them. If his Board thinks his judgement lapsed enough to warrant them losing confidence in his executive leadership, so be it. But this pious outpouring that he should be fully documenting his tribulation for all of us to benefit from his transparency is nothing but sanctimonious codswallop.

‎ Full story...

I Bet They Ain't Moving to Canada

ATLANTA, Georgia, March 19, 2010 (LifeSiteNews.com) - A new poll reveals that President Barack Obama’s health care reform may push as many as a third of the nation’s practicing doctors into shuttering their offices and getting out of the medical business entirely.

In other words, the doctor may not be in to see you shortly.

According to a survey conducted by The Medicus Firm, a nationally retained physician search firm, “nearly one-third of physicians responding to the survey indicated that they will want to leave medical practice after health reform is implemented.”

Sounds like a quick fix for bringing down the national spend. Would less doctors per capita be a good thing?

Dennis Cauchon, USA TODAY -Others worry that more physicians will drive up the cost of medical care, not make it cheaper and more accessible. Physicians will order more tests, more procedures and more drugs — without improving the nation's health, they say.

"Doctors create their own demand," says physician Don Detmer, co-chairman of an Institute of Medicine committee that, in 1996, recommended cuts in funding for medical residents. "If we produce an abundance of doctors, there's little incentive for the system to become more efficient." The Institute of Medicine is an independent group created by Congress for advice on medical issues.‎ Full story...

Field Trips are Fun! Random Op-Ed is Fun Too!

I received a link this morning to a cutesy video wherein Doctor Marshall advocates for Congress to come visit a hospital on a field trip and truly learn what's broken in health care. Obviously, a day late for me, but nonetheless it sparked a few thoughts which I've jotted down below.

Doctor John L. Marshall of Georgetown University is a very respected and highly regarded oncologist leading the charge against cancer. I'm sure the guy is a wonderful doctor, and has contributed enormously to his field.

But.

I watched the video, and those of you with a Medscape login can too, it's here: http://www.medscape.com/viewarticle/716038

After watching it, I got just a tiny bit annoyed about how simplistically the argument was made with no actual proposals, solutions or advice given, just this grumbling about congress-doesnt-know-jack-about-my-problems rhetoric I've heard time and time again. So I decided to pick apart the arguments a little, my response after the jump.

1. About not having Congressional representation: DC has three electoral votes for Presidential elections, and a delegate in the House who can vote on House committees and many other procedures, just not on the floor of the House. DC of course has no-one in the Senate, because last time I checked DC was not a state that had ratified the Constitution. Just like Puerto Rico. If you want Senate votes, stop whining and become a state. Or rejoin Maryland. In the meantime, here's a record of Congresswoman Eleanor Norton's work as DC delegate including the bills she has introduced: http://www.norton.house.gov/

I also find it oddly contradictory that someone not overly-happy with government interference in his chosen profession then implies he wants more government in the form of diluting State's rights by giving votes to a federal district. Again, with no proposed solution or desire, just a complaint that he doesn't have representation.

2. About changing or picking a health insurance plan: Elected representatives are not born that way. While they have a decent health plan as members of the House or Senate, they (assumedly) had health care insurance *before* they were elected. His argument that all Congresspersons are ignorant of the ins and outs of acquiring health care insurance is misguided. Each of these people held jobs prior to holding office, and experienced the American life and system alongside everyone else. Many of them as self-employed professionals or small business owners.

3. About being on hold waiting for someone who doesn't know what you do day-to-day to judge your performance: I believe for an elected representative they are called "constituents" and "elections".

4. About being audited on their procedures and activities: Elected representatives are under constant scrutiny, myriad rules; are subject to ethics committees; are audited by the Government Accountability Office; furthermore they are then judged by hundreds of lobby groups who pore over each representative's and senator's voting record. The accountability of your average elected official in the federal government far exceeds that of a medical doctor, and comes with the added bonus of having to do a decent job to get re-elected.

5. About getting paid for good documentation: http://clerk.house.gov/legislative/legvotes.html, http://www.senate.gov/pagelayout/legislative/, http://www.gpoaccess.gov/, http://www.fedworld.gov/, http://www.loc.gov/index.html - I would like to see how fast this or any other oncologist can pull up records for a given patient he saw ten, twenty years ago. All other shortcomings aside, you can't possibly fault the government for it's record-keeping nor it's accessibility to same.

6. About pay-for-performance: (a) the federal government has *zero* pay-for-performance affecting doctors, there are a few pilots going on but no doctor in the USA is subject to pay-for-performance involuntarily and none at all from the feds. (b) Elected representative are very much paid by performance. Don't perform? Don't get re-elected. Doctors can lose their license and simply pick up and go practice in another state. Yay freedom. (c) The only thing the feds have done is told hospitals they, and by they I mean Medicare, will no longer pay for avoidable errors. Prior to the rule, a doctor could cut off the wrong leg, bill for it, then cut off the correct leg and bill for that too. Not anymore. Boo-hoo.

7. About being told what you as a doctor are allowed to do for your patient: No insurance company tells you what you are allowed to do. They tell you what you are allowed to bill for. Correction, you can bill for whatever you want, but an insurance company tells you what they will pay you for. The most current data on health insurance denials are 2.36 percent (AHIP) and 2.65 percent to 6.8 percent (AMA). AHIP has an interest in the number being low, AMA has an interest in the number being high, so cut that down the middle however you like.

Total denials for non-covered services were 1.2 percent. The number for denials in the raw is much higher, but much of this is simply billing the wrong insurer - which counts as a technical denial but some other insurer then gets the bill and pays up - or having to resubmit and getting paid the second time. Not perfect, but not denial of service either.

8. About Congress not having a clue what is wrong with health care: Congress has 16 doctors right now, plus two dentists, three nurses, a psychologist, an optometrist, a clinical dietician, and a pharmacist which by my math (25/535) is just under five percent of Congress. Seems to me the medical community is well represented in Congress.

The implication that the legislative branch of the United States federal government is tackling this problem with too little background, understanding and general knowledge of the problem is - in my not very humble opinion - a disservice to the viewers of the video. There is plenty wrong with Congress. And plenty wrong with hospitals. But the easy target of "the government is a bunch of morons" seems a particularly poor choice for such a learned gentleman.

9. About taking a field trip to a hospital to fully understand what's broken: Hospitals are not the universe of health care, an issue I see at way too many hospitals who forget they only account for under one third of health care in the USA. Hospital care is 31% of health care expenditures in the USA. Health insurance, of course, reaches all aspects of health care.

In summary: for sure, there are plenty of things wrong in all parts of health care, including hospitals. The notion that Congress should have taken some time to explore the issue before writing and passing legislation is of course, sound. Hmm. I wonder if any of them did? Do you think any of them ever spent time in side a hospital? Hmm.

http://www.google.com/search?hl=en&safe=off&q=congressman+congresswoman+senator+visit+hospital‎ Full story...

About Health Satisfaction Two Point Oh!

The past year has seen some leaps and bounds in the way me and my team can rapidly handle publicly reportable data and get it onto Web sites. The two underpinnings of this are CLAIRE, the Claire Lightweight Agile IPRO Reporting Environment; and Pellucid, the health care transparency database system. CLAIRE is a software framework built on CakePHP that allows the dev team to grab up Pellucid data and quickly deploy Web applications. Pellucid is a MySQL data warehouse we built to house every single publicly reportable value we know of or can calculate in house. More on both of these technologies later.

So last week I initiated a test. I gave the dev team a week to come up with a complete rewrite of our Hospital Satisfaction Web site, and lo and behold they did it! You can go visit AboutHealthSatisfaction.org and review patient surveys of nearly every hospital in the US! Why are you still here? Click the link already.‎ Full story...

Good Driver Discount

Seems to me the health insurance companies go on and on about how it should be more like auto insurance, everyone needs to be in the pool. I'm in favour, generally, although I wish it were a single-payer pool, but that aside... if we are all going to be in the pool, how about some good driver discounts? If I quit smoking, I don't get my premium lowered last time I checked. For auto insurance I can take a defensive driving course and knock 10% off the bill. How about reducing my premium for attending wellness sessions?

The difference between auto insurance and health insurance is that it's not a definite that you're going to have a car accident. You are most definitely going to get old and die. If you take good measures along the way to reduce your level of sickness, shouldn't you get a discount? Insurance companies wishing to adopt my proposal can do so free of charge, but I wouldn't mind a carton of cigarettes and a bottle of scotch as a nice thank you. INCENT ME!‎ Full story...

Save MySQL

Sign The Petition.‎ Full story...

Why Not The Second Best?

'Tis the season to work all night every night for a couple of weeks. The newly updated WhyNotTheBest.org went live this weekend, with a spiffy new look and four gajillion new rows of data.

Well, truth be told it's about six million rows. But it's still a lot. WhyNotTheBest is a Web property funded by the Commonwealth Fund that is geared toward health care providers and policy makers, the basic intent being to identify the top performers for a range of measures and allow anyone to compare (benchmark) themselves against these top performers.

The new design is thanks to Digital Wave who laboured over a very functional search engine that allows any user to add as many hospitals to a comparison list as they want.

The new site contains a bunch of new data, notably the readmission and mortality rates published by CMS for several conditions, and we included average Medicare reimbursements for the same conditions.

In addition we added a whole slew of new filters, so it is now possible to create groups of hospital by Dartmouth HRR (Hospital Referral Region), by ownership, by health system and a whole lot more.

As always the data drives the user to improvement tools and intervention material that will help improve quality of care for the measures being published.

Please go check it out and comment here if you have some feedback!‎ Full story...

No Ma'am, We're Statisticians

Yes, it's true. I wanted to build the Illinois Health Care Report Card just so I could finally write a blog post laden with Blues Brother quotes. You could say I was on a mission from God. Our Lady of Blessed Web Site Acceleration don't fail us now.

Jokes aside, the IPRO eServices team has never worked this hard. Incidentally, the work allowed me to visit Chicago a few times and I have to say it is a surprisingly fun place to be, even if you can't find the Cook County Assessor's Office. We had just a few short months to get Illinois up and running, and by today's numbers I think we did a great job.

We launched early this morning and traffic started flooding in like I've never seen. Let's have a look at what's in it.

Quality

Quality data leads the tabs, and we populated it with both process and outcomes measures. We took the process of care measures from hospitalcompare.gov and rolled them up into three neat aggregate scores for Heart Attack, Heart Failure and Pneumonia. Following that are six mortality measures using AHRQ Inpatient Quality Indicators. Unfortunately due to some complex issues surrounding the measures, we couldn't risk adjust the data this quarter so the data are observed rates for now, we'll fix that for the New Year. We round off the tab with some utilisation data including the C-section rate.

Safety

For safety we published a range of Surgical Care Improvement measures, then we get the much awaited Hospital-Acquired Infection data. Illinois is out in front with collecting this data, and we had some good stories to tell, but we are looking forward to hospital-level MRSA rates next year. For now you can review central line-associated bloodstream infection rates. The last module on the safety tab shows a selection of the Patient Safety Indicators from AHRQ including accidental puncture/laceration and foreign body left after procedure.

Satisfaction

I've been vocal that patient satisfaction is the necessary final leg on the barstool of health care reporting to round out the usual quality and cost data, and I was extremely glad to include the HCAHPS data in this report. Ten measures of patient experience after an inpatient stay populate this tab.

Services

The services tab shows the number of patients, the median length of stay and the undiscounted charge for a range of procedures and conditions, depending on whether you're viewing hospitals or surgery centers.

Staffing

The final tab shows two interesting proportion measures; the first is the ratio of full time nurses compared to contract staff, the second is the proportion of registered nurses, licensed practical nurses, and certified nurse assistants. I'd like to change this up to a pie chart next quarter. Also, on this page you can see the kind of beds this facility is authorised to operate.

Next Up

We're immediately looking at the nurse staffing data to get some more granular numbers based on various service areas, we'd like to add more procedures and conditions, and maybe bring in the rest of the process data. Regardless, Illinois hosted over 10,000 visitors today so there's no shortage of interest in these data, and we look forward to growing the site over the next year. First though, whynotthebest 2.0 - it's a busy season.

It's 106 hours to Monday, we got a full tank of coffee, half a pack of cigarettes, it's dark and we're wearing sunglasses. WhyNotTheBest.org will be updated in a few weeks with the most data I've ever worked with in one fell swoop, and will feature the most flexible search engine into our millions of rows of quality performance data yet.

‎ Full story...

$1300 Nose Bleed

I received the following E-mail this morning on another blog:

"Where is Wyoming on your list. It is a state in the USA. Our local
hospital, Wyoming Medical Center here in Casper Wyoming, is so greedy
about their charges and will not tell you what they charg before
you have your visit. Emergency care for a simple nose bleed wes $1,300.00
Why are they allowed to get away with this.
How do you make the greedy companies tell you what their charges are
BEFORE you agree to have care when it is not a life or death situation. If
I had been informed how much it was going to cost I would have refused the service.
HELP"

The sender did not leave an E-mail address to reply, so I thought I'd reply here.

First things first: $1300 for a "simple nosebleed" is outrageous.

Second things first: going to the emergency room for "a simple nose bleed" is outrageous.

What to do? Call the billing department, make them an offer. But bear in mind you elected to use highly specialised services of a very expensive health care facility.

I had a lot of nose bleeds as a kid. Spontaneous ones, they would just start happening. The remedy cost less than a cent and involved tearing one tissue into two, plugging my nostrils and tilting my head back. Occasionally, I would pinch the bridge of my nose (as instructed) but it didn't really seem to do anything.

When did it become acceptable to go to the ER for a nose bleed? This is half the problem, this is what drives costs up. I don't have nearly enough information to figure out how serious the author thought the situation was, maybe it was the first time it had ever happened and he or she thought their brains were going to fall out, but I'm going to go out on a limb and say no, it was a simple nose bleed.

I feel really bad for the author that they are now stuck with a ridiculous bill. I would absolutely call the hospital and offer them $500 and a payment plan. I agree wholeheartedly that pricing needs to be more upfront. In the absence of hospitals doing this, we're working as hard as we can to publicise as many prices as we can. You can browse pricing at OutOfPocket.com where you'll notice I have a similarly-priced ER visit, for which the insurance paid less than $500.

But I would also counsel that next time you have a nosebleed, tilt your head back lean your head forward (1970s Welsh national health advice aside, apparently the thing to do is lean *forward*, thanks Kenneth!). Visiting the ER for a nosebleed is like going to the car dealer for a flat tire. They'll do pretty much the same thing as the guy on the corner, but charge you ten times as much.

As long as this country refuses to have a public option, you are consuming health care in a free market economy, with all the trappings that come with that. The ER is not your local clinic. But as long as you treat it like one, they will be happy to bill you.‎ Full story...

Is it a Bird? A Plane? No, it's Electronic Clinical Data!

Faster than a speeding bullet, the clinical data portal we launched in June has scored it's first physician! It's pretty exciting to have built it, even more so to actually see a physician using it.

The portal allows a physician - or a group of physicians - to upload clinical data relevant to a given condition, in this case Diabetes. We ask for a set of specific, discrete data, not the entire record, such as blood sugar levels, blood pressure, eye exams and the like, and then using the data from the record we score the physician(s) against an evidence-based measure set that scores the doctor on his or her performance for that condition.

So, in this case, the doctor voluntarily submits to being scored for his performance treating and managing his diabetic patients. Any eligible physician who scores well on the measure will start receiving incentive payments from participating payors and purchasers, as well as be recognised in HealthGrades.com

Pretty cool, huh?

In addition, using the same engine we also scored two batches of physicians who are using the NextGen EHR package, thereby scoring their performance directly from the data.

As EHR adoption in the United States grows I anticipate more and more data being available to more and more performance assessors like ourselves, and I look forward to the next five years. Next step? Live report cards that tell you not how a hospital did last year, but how they did YESTERDAY.

Can't wait.‎ Full story...