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	<title>healthcare quality | American HealthScare</title>
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	<description>How the healthcare industry&#039;s scare tactics have screwed up our economy -- and our future</description>
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		<title>Primary Care Systems in the News &#8212; Do They Work?</title>
		<link>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/primary-care-systems-in-the-news-do-they-work/</link>
		
		<dc:creator><![CDATA[Richard Young MD]]></dc:creator>
		<pubDate>Sun, 28 Jan 2024 23:08:12 +0000</pubDate>
				<category><![CDATA[Blog]]></category>
		<category><![CDATA[ChenMed]]></category>
		<category><![CDATA[cost-effectiveness]]></category>
		<category><![CDATA[early detection]]></category>
		<category><![CDATA[family medicine]]></category>
		<category><![CDATA[family physicians]]></category>
		<category><![CDATA[Health Partners]]></category>
		<category><![CDATA[healthcare costs]]></category>
		<category><![CDATA[healthcare quality]]></category>
		<category><![CDATA[Iora]]></category>
		<category><![CDATA[Nuka]]></category>
		<category><![CDATA[payment reform]]></category>
		<category><![CDATA[prevention]]></category>
		<category><![CDATA[primary care]]></category>
		<guid isPermaLink="false">https://www.healthscareonline.com/?p=1469</guid>

					<description><![CDATA[<p>This is the second in a series of conversations I had with some open-minded colleagues who also deeply want to seen meaningful change in the U.S. healthcare system. The person I primarily responded to mentioned a chapter in Pursuing the Triple Aim. Here is what I wrote back to him: I was reminded how I was not super impressed with the Pursuing the Triple Aim book. Certainly, there are some good points in it, but each chapter also reads like a sales job from large healthcare systems. Rarely are these programs put to the test of peer review in the traditional medical literature. And sometimes when they are, they appear in some journals, which, in my opinion publishes too much stuff from commercial interests, such as Optum, or whoever Let’s take a look at some of the primary care programs and their claims more closely. In no particular order: The Nuka system This is one of the more transparent programs in the sense that their leaders have publicly spoken about their innovations, and their results have been published in the standard medical literature. Their leaders have talked about lots of aspects of the program: patients renamed customer-owners, inventing mini-pharmacy dispensaries for rural villages, [&#8230;]</p>
The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/primary-care-systems-in-the-news-do-they-work/">Primary Care Systems in the News — Do They Work?</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></description>
										<content:encoded><![CDATA[<p>This is the second in a series of conversations I had with some open-minded colleagues who also deeply want to seen meaningful change in the U.S. healthcare system. The person I primarily responded to mentioned a chapter in Pursuing the Triple Aim. Here is what I wrote back to him:</p>



<p>I was reminded how I was not super impressed with the <em>Pursuing the Triple Aim</em> book. Certainly, there are some good points in it, but each chapter also reads like a sales job from large healthcare systems. Rarely are these programs put to the test of peer review in the traditional medical literature. And sometimes when they are, they appear in some journals, which, in my opinion publishes too much stuff from commercial interests, such as Optum, or whoever</p>



<p>Let’s take a look at some of the primary care programs and their claims more closely. In no particular order:</p>



<p>The Nuka system</p>



<p>This is one of the more transparent programs in the sense that their leaders have publicly spoken about their innovations, and their results have been published in the standard medical literature. Their leaders have talked about lots of aspects of the program: patients renamed customer-owners, inventing mini-pharmacy dispensaries for rural villages, using lots of tribal workforce for all job descriptions, and so on. Let’s look at two publications about Nuka that appeared in the mainstream medical literature.</p>



<p><a rel="noreferrer noopener" target="_blank" href="https://www.tandfonline.com/doi/abs/10.3402/ijch.v72i0.20960%40zich20.2013.72.issue-S2">One was a time series analysis</a>&nbsp;of medical record data that looked at time periods from transition to the new system, to PCMH implementation, to early PCMH adoption, to post PCMH implementation.&nbsp;In this study, they found a decrease in hospitalizations for unintentional injury or poisoning, and asthma. The heart failure hospitalizations were about the same. Hypertension admissions increased. The study was silent on conditions such as coronary artery disease, MIs, diabetes, DKA, etc. I assume this means there was no significant difference. It would have been easy enough to measure, but I acknowledge I’m speculating about this.</p>



<p>Notice that none of these positive outcomes have anything to do with OMT or other frameworks for Syndrome X care (blood pressure, diabetes, obesity, coronary artery disease, strokes, and so on). So, what explains the decrease in poisonings and asthma? They don’t talk about any specific asthma management plan. In a&nbsp;<a rel="noreferrer noopener" target="_blank" href="https://www.annfammed.org/content/11/Suppl_1/S41.short">similar article that also mentioned a decrease in emergency visits</a>&nbsp;for asthma and unintentional injuries, they included a qualitative component. In this section, they talk about improved access to primary care as the primary driver. One of the quotes was&nbsp;<em>I think emergency department visits have gone way down because it’s so much easier to see their primary care clinician.</em>&nbsp;They also mentioned getting nurses out of the specific disease management function (diabetes nurse, asthma nurse, etc.), and better support for primary care by the leadership.</p>



<p>I wish they would have drilled down the poisoning/injury numbers more. It should have been easy to count the number of lacerations, contusions, sprains, strains, and extremity fractures before and after full PCMH implementation. In other words, were injuries and poisonings down more because community health workers counseled young men to drink less and be safer, and the young men changed their behavior? Or did the total number of incidents not change much, but the custom-owners knew that their primary care center could see them reasonably fast, and they didn’t have to go to the ER. My guess is the latter, but it’s just a guess.</p>



<p>HealthPartners</p>



<p>Harvard Business School reported on HealthPartners diabetes management program in 2003 and calculated it only saved $75 per patient. The numbers you included in your email were from 2011, but I can’t find any information in the literature to support this. The problem with the HealthPartners report in Triple Aim is there is not enough detail to support the claims. It’s left to the reader to trust the numbers. I’ll talk about this more at the end.</p>



<p>Independent Health</p>



<p>In the same HBS report, they calculated that a diabetes program in the Independent Health Association “failed to find proof of substantial short-term medical cost savings attributable to the program.”</p>



<p>IDEAL program</p>



<p><a rel="noreferrer noopener" target="_blank" href="https://journals.lww.com/jphmp/Fulltext/2003/11001/Improving_Diabetes_Care_and_Outcomes__The.7.aspx?casa_token=vS4FGu2VvCEAAAAA:Xalij0KwzGqfPxFWzZ88S2mSP0Dy96wKAxUaK3eoBhRzXKzzf3IDU5FLNQn2DhNqTLJiOVe5lqs3_XlLYz3mur-g">IDEAL was a state-wide program in Minnesota</a>&nbsp;where the Department of Health and HealthPartners collaborated in traditional QI efforts. They showed a decrease in the average A1c and LDL cholesterol levels, but did not calculate costs.</p>



<p>Iora Health/ChenMed/and so on</p>



<p>These reports are hard to parse out because they are so emmeshed in the Medicare Advantage coding game that has been highly profitable to insurance companies and private equity. I’m in the camp that believes that more of the savings/profits in Medicare Advantage have come from coding games than actual improvements in care (I think the&nbsp;<a rel="noreferrer noopener" target="_blank" href="https://www.healthaffairs.org/content/forefront/emperor-still-has-no-clothes-response-halvorson-and-crane">Gillfilan/Berwick posts about this issue</a>&nbsp;are more believable than the opposing pieces). But given this complication, let’s press on and see what we can find.</p>



<p>Harvard Business Review has reported several times about Iora Health.&nbsp;<a rel="noreferrer noopener" target="_blank" href="https://hbr.org/2017/10/the-innovation-health-care-really-needs-help-people-manage-their-own-health">Let’s look at one published in 2017.</a>&nbsp;It states, “For example, an unpublished Iora study found that inpatient hospital admissions among a cohort of 1,176 Iora Medicare enrollees over an 18-month period decreased by 50%, emergency department visits decreased by 20%, and the total medical spend declined by 12%&nbsp;— this despite the cohort being sicker than average Medicare patients.” OK, it’s unpublished, but it could be true. I’m sure their primary audience was investors, so allow me a bit of scepticism here. Another big question in my mind is the statement the “cohort being sicker than average Medicare patients.” It’s really difficult to tell if this is real or a reflection of aggressive coding within the Medicare Advantage game. Let’s keep moving.</p>



<p>In&nbsp;<a rel="noreferrer noopener" target="_blank" href="https://hbr.org/2018/07/transforming-health-care-from-the-ground-up">another HBR report on Iora</a>, there is a section that talks up the health coaches (they take the patients shopping, for example), which is in line with OMT thinking, so I won’t repeat those critiques here. Further down is a statement that is just silly, “Under its capitation system, Iora makes money only if its patients stay healthy and thus require fewer tests and procedures.” More tests are ordered when a patient is under an aggressive screen-and-treat system vs. leaving well people alone.</p>



<p>Further down is where it gets meatier. The report states, “Iora saved money by contracting specialists as consultants to the primary care practice—essentially inviting cardiologists, nephrologists, and others to join the gig economy. When Fernandopulle asked the head of endocrinology at a top hospital what percentage of endocrine clinic patients could be managed by a primary care physician with a little expert advice by phone or e-mail, the answer was an astonishing 80%. A formal study of e-consultations by PCPs across 10 specialty areas, including neurology, rheumatology, dermatology, and nephrology, confirmed that on average, primary care physicians were able to address problems in those areas for 60% of patients.” Now we’re talking.</p>



<p>For context, just in case you didn’t already know, the corridor from Washington DC to Boston is the great sucking black hole of despair for family medicine. It is the most over-specialized part of the country with the fewest family physicians who are generally highly disrespected. This is where 3 of 4 Iora pilot sites were, the other being Las Vegas, which I assume is also not the most family medicine-friendly part of the country. (And of the groups were unions, which could have had very generous benefits that needed paring). Dr. Fernandopulle was probably a combination of lucky and smart that he was in Boston and focused his early efforts on that region. This result sounds exactly like one of the classic Starfield conclusions that 50% of visits to ologists are really primary care.</p>



<p>Savings that are generated from decreasing visits to ologists makes sense to me. The lowest hanging fruit in this domain is simply to reduce the number of touches to ologist care that add no value to the patient’s journey. The higher-hanging fruit is the difference in the cultures of the ologies and family medicine that also lead to more patient-centric and less aggressive testing and treating, but this is still accomplished if a patient is steered towards primary care as the easiest and most convenient place to access care.</p>



<p>I won’t list all the other articles about Iora here, but other themes are switching more prescriptions to generic, developing its own IT system, and again, the coaches and reducing ologist visits. I’ll just say here that I accept that the coaches are part of its success, but not in the way the typical article suggests. Hosting cooking classes is not the trick, it’s being quickly accessible if the patient has a concern. The coaches serve to increase access and act as information filters for the doctors.</p>



<p>In the interest of watching my word count, I’ll just say that the reports on ChenMed and the others sound very similar to me as Iora Health, so I’ll not comment about them in more detail. I’ll make one more quick semantic comment though. All of these articles say something like, “Iora works by keeping people healthy,” which isn’t true. People with heart failure aren’t healthy, their heart doesn’t pump well. People with diabetes aren’t healthy, their ability to regulate blood sugars is broken. A better way of thinking about this is that the doctors/teams help people live as well as possible given the cards they were dealt. But they’re patients are not perfectly “healthy.”</p>



<p>Wrap Up</p>



<p>The problem with all of these reports by mostly commercial entities is that they do not provide enough transparency and detail to really prove their case. For example, no report says this, “Before we started with working with some union, they were spending $X on blood pressure, diabetes, and cholesterol medicines; related tests (blood work, stress tests, etc.); ER visits total and disease-specific to syndrome X situations (chest pain, MI, stroke, etc.); hospital visits total and disease-specific; and other related big ticket items such as heart caths and such. We then spent $Y on more drugs, tests, coaches/dieticians/counselors, primary care, and so on over the next blah-blah years. At that point in the same population (understanding that all U.S. populations are mobile), we spent $Z on roughly the same list as $X. Therefore, the net spend or savings was whatever.”</p>



<p>Within this framework, there are still some spend traps to watch out for. A group could claim that their intervention results in lower A1c levels and lower costs per diabetic. Was the before/after group the same size (and likely horribly expensively managed, like a multi-ology model) or did the coaches go out and screen a bunch of people who felt fine, found more cases of diabetes, most of them controlled on just metformin, and thereby making the dollars and outcome results&nbsp;<em>per diabetic</em>&nbsp;look better?</p>



<p>Another trap would be something like a report not using established methods for reporting cost-effectiveness results, like taking the newly detected diabetics, and projecting future costs based on an overall average spend on diabetics, not a newly diagnosed patient with very mild disease. Another trap would be cherry-picking populations that have fewer minorities, low-income patients, and patients with significant mental illness or substance abuse challenges. And of course, throw in social determinant challenges (and no, no one has invented a way to correct for these, and mathematically, I don’t think it will ever happen). Another trap would be to take a group of insured patients in a region who likely are representative of their region, show that some intervention lowered the total spend, but did not disclose that this group had an exorbitant spend before, and now have a spend that is the same as other groups (In other words, there was plenty of fat to cut out, but nothing more fundamental about care delivery changed compared to other local options).</p>



<p>What about the Medicare Advantage population? Similar situation here, with slightly different accounting. For example, if Iora or whoever claims 15% overall decrease in total spend, was it that pre-Iora the total spend was $400 PMPM, then they did their thing, then the spend was $340 PMPM (not adding inflation in this example)? Or did Iora get in there, add lots of HCC codes, which then led to a new predicted spend of $500 PMPM, and they accomplished $425 which they claimed was a 15% reduction, when in fact it was an increase in the total spend? Again, I can’t find any report that divulges this level of detail. And if there is a report that looks like this example, I’d still like to see the detail I listed in the earlier example.</p>



<p>I suspect that some of the things Iora did are substantive, real, and reduced stupid healthcare expenses. One report said their doctors/teams take care of about 400-500 Medicare patients, vs. other approaches in the HMO era where they’d assign a family doc 800 or so patients. Remember that the fundamental Barbara Starfield, MD finding that geographic places with more family physicians (not internists, by the way) enjoy better health outcomes and lower costs. In the managed care era, no one ever tried to experimentally replicate this observational finding by merely loading up an area with family physicians and see what happens. In my view, if these ratios are true, then this is kind of what Iora did.</p>



<p>Good for them, and Nuka. All I ask is that we develop a deeper understanding of WHY total cost reductions happened. Except for patients with severe cases of common chronic diseases, it had nothing to do with wellness interventions, prevention, screening, or treating chronic diseases. It has everything to do with making access to primary care be the easiest way for a patient to access the system (side thought: I wonder if there are billboards on the highways in Iora cities that say, “The wait time to be seen at Iora Clinic is 10 minutes.” The ERs seem to think it drives business to them.). It has everything to do with specifically limiting access to ologists. It has everything to do with applying the unique culture of high-value family medicine to complex patient situations, where the unique medical decision making of family medicine becomes the “right” way to deliver care.</p>



<p>I very much appreciate the members of this group who know that we need more primary care in this country to achieve better outcomes at a lower cost. But if you keep prioritizing and incentivizing the wrong features and work functions of family medicine, you’ll continue to just make it worse.</p>The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/primary-care-systems-in-the-news-do-they-work/">Primary Care Systems in the News — Do They Work?</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></content:encoded>
					
		
		
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		<title>The Cost of the Baggage of the PCMH</title>
		<link>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-cost-of-the-baggage-of-the-pcmh/</link>
					<comments>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-cost-of-the-baggage-of-the-pcmh/#comments</comments>
		
		<dc:creator><![CDATA[Richard Young MD]]></dc:creator>
		<pubDate>Tue, 27 Feb 2018 05:30:47 +0000</pubDate>
				<category><![CDATA[Blog]]></category>
		<category><![CDATA[EHR]]></category>
		<category><![CDATA[EMR]]></category>
		<category><![CDATA[family medicine]]></category>
		<category><![CDATA[family physicians]]></category>
		<category><![CDATA[healthcare costs]]></category>
		<category><![CDATA[healthcare quality]]></category>
		<category><![CDATA[outcomes]]></category>
		<category><![CDATA[patient-centered medical home]]></category>
		<category><![CDATA[PCMH]]></category>
		<category><![CDATA[population health]]></category>
		<category><![CDATA[population management]]></category>
		<category><![CDATA[TransforMed]]></category>
		<guid isPermaLink="false">http://www.healthscareonline.com/?p=1292</guid>

					<description><![CDATA[<p>First, a history lesson. Back in the mid 2000 oughts, the AAFP launched a wholly owned subsidiary called TransforMed. It was originally started to help practices implement the &#8220;new model of care&#8221; from the Future of Family Medicine Report. Soon after it was launched, the joint principles of the patient-centered medical home (PCMH) were announced, so TransforMed pivoted to help practices implement the PCMH model of care. In one of the major blunders the AAFP has committed over my career, it set up an experiment called the National Demonstration Project (NDP). An experiment was a great idea. How they carried it out was an example of supreme hubris. The enrolled 36 practices and randomized 18 of them to receive coaching on how to transform to a PCMH and the other 18 were left on their own to figure it out for themselves. Do you see the gargantuan mistake they made? Instead of testing whether or not the PCMH was a good idea in the first place, they just assumed it was great and went about testing how best to create the beast. You know where this is going. A study of the NDP practices found that there wasn&#8217;t much difference [&#8230;]</p>
The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-cost-of-the-baggage-of-the-pcmh/">The Cost of the Baggage of the PCMH</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></description>
										<content:encoded><![CDATA[<p>First, a history lesson. Back in the mid 2000 oughts, the AAFP launched a wholly owned subsidiary called TransforMed. It was originally started to help practices implement the <a href="https://www.aafp.org/fpm/2005/0500/p59.html">&#8220;new model of care&#8221;</a> from the Future of Family Medicine Report. Soon after it was launched, the joint principles of the patient-centered medical home (PCMH) were announced, so TransforMed pivoted to help practices implement the PCMH model of care.</p>
<p>In one of the major blunders the AAFP has committed over my career, it set up an experiment called the National Demonstration Project (NDP). An experiment was a great idea. How they carried it out was an example of supreme hubris. The enrolled 36 practices and randomized 18 of them to receive coaching on how to transform to a PCMH and the other 18 were left on their own to figure it out for themselves. Do you see the gargantuan mistake they made? Instead of testing whether or not the PCMH was a good idea in the first place, they just assumed it was great and went about testing how best to create the beast. You know where this is going. A <a href="http://www.annfammed.org/content/8/Suppl_1/S57.short">study of the NDP practices</a> found that there wasn&#8217;t much difference in outcomes whether the practice was coached or not, and there was practically no difference in quality (5% change in mostly meaningless metrics) and no difference in costs or patient experience in these practices over 26 months of follow up.</p>
<p>So did the AAFP accept the results of its own experiment and call a big halt to TransforMed to re-think it all?  Of course not. It was too emotionally and financially invested in it. So the PCMH patter continued unabated and in 2014 it was announced that TransforMed would &#8220;redefine (its) focus.&#8221;</p>
<p>And now comes along <a href="https://journals.lww.com/lww-medicalcare/Abstract/publishahead/The_Impact_of_a_Health_Information.98647.aspx">an article reporting the results of a Center for Medicare and Medicaid Innovations (CMMI) experiment</a> where TransforMed won the $20.8 million 3-year contract. Here are the results: <em>We estimated the program led to a 7.1% reduction in inpatient admissions and a 5.7% decrease in the outpatient emergency department visits. However, there was no evidence of statistically significant effects in outcomes in either the quality-of-care processes or spending domains.</em> Therefore, it is an exaggeration to conclude that the PMCH/HIT/Population health management/medical neighborhood did absolutely nothing. It, like some of the other PCMH experiments, made a small dent in the number of inpatient admissions and ER visits.</p>
<p>But this study is further proof that the most pressing burden of the U.S. healthcare system, its extraordinary costs, are not fixed by the PCMH or EMRs or population management. The tiny gains they realize are offset by the tremendous cost and burden of implementing their klunky systems.</p>
<p>But will the AAFP accept this latest disappointment and call for a completely new direction to support family physicians to deliver a comprehensive basket of services to their patients, free from all the e-Baggage? Don&#8217;t hold your breath.</p>The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-cost-of-the-baggage-of-the-pcmh/">The Cost of the Baggage of the PCMH</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></content:encoded>
					
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		<title>The Cost of Health Information Technology</title>
		<link>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-cost-of-health-information-technology/</link>
					<comments>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-cost-of-health-information-technology/#comments</comments>
		
		<dc:creator><![CDATA[Richard Young MD]]></dc:creator>
		<pubDate>Mon, 12 Sep 2016 02:04:26 +0000</pubDate>
				<category><![CDATA[Blog]]></category>
		<category><![CDATA[EHRs]]></category>
		<category><![CDATA[electronic health records]]></category>
		<category><![CDATA[electronic medical records]]></category>
		<category><![CDATA[EMRs]]></category>
		<category><![CDATA[healthcare costs]]></category>
		<category><![CDATA[healthcare quality]]></category>
		<category><![CDATA[healthcare safety]]></category>
		<guid isPermaLink="false">http://www.healthscareonline.com/?p=1183</guid>

					<description><![CDATA[<p>From the mid- to late-2000s, lots of pundits got into the business of shoving electronic medial records (EMRs)down doctors&#8217; throats. There were a few incentives from the Feds to help with the upfront costs, but it was a pittance of what it really costed hospitals and physician practices. And there was no consideration made for the ongoing costs of EMRs, except for cuts in already skimpy Medicare and Medicaid payments if doctors and hospitals didn&#8217;t jump on the silicon bandwagon. A recent estimate from the Medical Group Management Association  is that health IT, including hardware, software, IT support personnel, and licensing fees, costs $32,500 per physician, which is 40% higher than 2009. No payer has increased its fees to cover these costs. There are about 800,000 practicing physicians in the U.S. So (rough estimate) assuming this IT push has been going on about 10 years, and adding in the upfront costs, this means that the U.S. has spent about $250 billion on EMRs; $25 billion per year in ongoing costs. And what have we gotten as a country from this top-down mandated expense? A meta-analysis of computerized decision support EMR tools found no difference in mortality or total cost of care, [&#8230;]</p>
The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-cost-of-health-information-technology/">The Cost of Health Information Technology</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></description>
										<content:encoded><![CDATA[<p>From the mid- to late-2000s, lots of pundits got into the business of shoving electronic medial records (EMRs)down doctors&#8217; throats. There were a few incentives from the Feds to help with the upfront costs, but it was a pittance of what it really costed hospitals and physician practices. And there was no consideration made for the ongoing costs of EMRs, except for cuts in already skimpy Medicare and Medicaid payments if doctors and hospitals didn&#8217;t jump on the silicon bandwagon.</p>
<p>A<a href="http://www.mgma.com/about/mgma-press-room/press-releases/2016/healthcare-technology-costs-top-32-500-dollars-per-physician"><span style="text-decoration: underline;"> recent estimate from the Medical Group Management Association </span></a> is that health IT, including hardware, software, IT support personnel, and licensing fees, costs $32,500 per physician, which is 40% higher than 2009. No payer has increased its fees to cover these costs. There are about 800,000 practicing physicians in the U.S. So (rough estimate) assuming this IT push has been going on about 10 years, and adding in the upfront costs, this means that the U.S. has spent about $250 billion on EMRs; $25 billion per year in ongoing costs.</p>
<p>And what have we gotten as a country from this top-down mandated expense? A<a href="http://www.ncbi.nlm.nih.gov/pubmed/25322302"><span style="text-decoration: underline;"> meta-analysis of computerized decision support EMR tools</span></a> found no difference in mortality or total cost of care, and some decrease in chronic disease morbidity, though &#8220;selective outcome reporting or bias could not be excluded.&#8221; <a href="http://www.ncbi.nlm.nih.gov/pubmed/26244494"><span style="text-decoration: underline;">A qualitative study of the role of EMRs in primary care</span></a> found that EMRs can improve or worsen patient safety, especially when they &#8220;override the opportunities for face-to-face communication.&#8221;</p>
<p>I am not a Luddite. I do not have a blanket distrust of electronics. I own a recent-model smart phone. But ask yourself this: If EMRs were so great and we live in such a technophillic country, then why didn&#8217;t EMR use naturally spread like smart phones or i-pods? Why did outsiders feel the need to force us to use these klunky tools?  It&#8217;s simple. They cost a fortune, merely create extra mostly useless work for front line caregivers to do, and improve little to nothing in our ambulatory care. I wish we could put the genie back in the bottle and start all over. Hey, a guy can dream.</p>The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-cost-of-health-information-technology/">The Cost of Health Information Technology</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></content:encoded>
					
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		<title>Problems with Hospital Mortality Data</title>
		<link>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/problems-with-hospital-mortality-data/</link>
		
		<dc:creator><![CDATA[Richard Young MD]]></dc:creator>
		<pubDate>Mon, 11 Jan 2016 03:55:32 +0000</pubDate>
				<category><![CDATA[Blog]]></category>
		<category><![CDATA[DNR]]></category>
		<category><![CDATA[do-not-resuscitate]]></category>
		<category><![CDATA[healthcare quality]]></category>
		<category><![CDATA[hospitals]]></category>
		<category><![CDATA[pneumonia]]></category>
		<guid isPermaLink="false">http://www.healthscareonline.com/?p=1144</guid>

					<description><![CDATA[<p>Another recent study has exposed the limitations of the current quality indicators used by Medicare and many insurance companies. This time it&#8217;s for in-hospital patient deaths. Researchers looked at the mortality rate for patients admitted for pneumonia to 303 California hospitals. Hospitals were lumped into groups of performance using the standard quality measures. Then the figured out which patients had Do-Not-Resuscitate (DNR) orders written in their medical record physician orders section. Without accounting for DNR status, hospitals with high mortality rates had higher DNR rates. After accounting and statistically adjusting for DNR order status, the hospitals with higher DNR rates actually had lower mortality than hospitals with low DNR order rates. Only 52% of hospitals in the low-performing group stayed in that group when DNR order rates were considered. Taking care of patients continues to be more complex than the computers and big data can keep up with.</p>
The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/problems-with-hospital-mortality-data/">Problems with Hospital Mortality Data</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></description>
										<content:encoded><![CDATA[<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/26658673" target="_blank">Another recent study</a> has exposed the limitations of the current quality indicators used by Medicare and many insurance companies. This time it&#8217;s for in-hospital patient deaths.</p>
<p>Researchers looked at the mortality rate for patients admitted for pneumonia to 303 California hospitals. Hospitals were lumped into groups of performance using the standard quality measures. Then the figured out which patients had Do-Not-Resuscitate (DNR) orders written in their medical record physician orders section. Without accounting for DNR status, hospitals with high mortality rates had higher DNR rates. After accounting and statistically adjusting for DNR order status, the hospitals with higher DNR rates actually had lower mortality than hospitals with low DNR order rates.</p>
<p>Only 52% of hospitals in the low-performing group stayed in that group when DNR order rates were considered.</p>
<p>Taking care of patients continues to be more complex than the computers and big data can keep up with.</p>The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/problems-with-hospital-mortality-data/">Problems with Hospital Mortality Data</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></content:encoded>
					
		
		
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		<title>Bad Family Medicine</title>
		<link>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/bad-family-medicine/</link>
					<comments>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/bad-family-medicine/#comments</comments>
		
		<dc:creator><![CDATA[Richard Young MD]]></dc:creator>
		<pubDate>Mon, 26 Jan 2015 02:13:32 +0000</pubDate>
				<category><![CDATA[Blog]]></category>
		<category><![CDATA[family medicine]]></category>
		<category><![CDATA[family physicians]]></category>
		<category><![CDATA[healthcare quality]]></category>
		<category><![CDATA[overtesting]]></category>
		<category><![CDATA[overtreating]]></category>
		<guid isPermaLink="false">http://www.healthscareonline.com/?p=1051</guid>

					<description><![CDATA[<p>As much as I have given the ologists and other members of the dysfunctional U.S. healthcare system a hard time in previous posts, it’s only fair that I call out bad family medicine as well. I have a great example. I recently saw patient who is relatively new to the area who had seen another family physician in my community. He is 39-year-old male and his only significant potential health problem is borderline hypertension. When he came to see me he brought a bag full of about 6 medicines and was scared because he was told that he had a whole host of medical problems. Best I can tell, there were some insurance issues that caused him to seek care at my facility: private doctors not taking one of the low-pay exchange plans I suspect. He had saved a copy of the paperwork he received from the previous family physician, which included a “complete set of blood work.” It would take too long to write out all that he was subjected to, so I’ll give you the main categories of blood tests. They included panels (meaning more than one test per panel) of labs for cardiac dysfunction, cardio metabolic markers, [&#8230;]</p>
The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/bad-family-medicine/">Bad Family Medicine</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></description>
										<content:encoded><![CDATA[<p><span style="color: #000000; font-family: Calibri;">As much as I have given the ologists and other members of the dysfunctional U.S. healthcare system a hard time in previous posts, it’s only fair that I call out bad family medicine as well. I have a great example.</span></p>
<p><span style="color: #000000; font-family: Calibri;">I recently saw patient who is relatively new to the area who had seen another family physician in my community. He is 39-year-old male and his only significant potential health problem is borderline hypertension.</span></p>
<p><span style="color: #000000; font-family: Calibri;">When he came to see me he brought a bag full of about 6 medicines and was scared because he was told that he had a whole host of medical problems. Best I can tell, there were some insurance issues that caused him to seek care at my facility: private doctors not taking one of the low-pay exchange plans I suspect. He had saved a copy of the paperwork he received from the previous family physician, which included a “complete set of blood work.”</span></p>
<p><span style="color: #000000; font-family: Calibri;">It would take too long to write out all that he was subjected to, so I’ll give you the main categories of blood tests. They included panels (meaning more than one test per panel) of labs for cardiac dysfunction, cardio metabolic markers, lipids, lipoprotein particles and apolipoproteins, inflammation oxidation markers, myocardial stress/function, platelet function, lipoprotein genetics, platelet genetics, coagulation genetics, other metabolic functions, renal, sterol absorption markers, sterol synthesis markers, glycemic control (more than an A1C), insulin resistance, beta cell function, electrolytes, liver functions, male and female hormones, thyroid function (8 tests in that panel), urinalysis, CBC with differential, PSA, omega-3 fatty acids, omega-6 fatty acids, other fatty acids, and a few more that are harder to categorize.</span></p>
<p><span style="color: #000000; font-family: Calibri;">The patient’s TSH was perfectly normal, but this doctor had prescribed levothyroxine. His cholesterol was 203, LDL-cholesterol 133 and HDL 54, but she put him on a statin. His blood pressure, best I can tell, was never measured higher than the low 150s, but he was prescribed three blood pressure medicines. His pressure was way on the low side of the normal range when measured at my clinic. He also brought a list of stuff from the grocery store he was supposed to take every day such as so many teaspoons of cinnamon, cloves, and some other plants and spices.</span></p>
<p><span style="color: #000000; font-family: Calibri;">What an incredible waste. This poor guy was exposed to financial harm, psychological harm, and completely unnecessary medications. I made my best guess about the minimal regimen he would require to keep him in good stead for the next few years (one blood pressure medicine). I have not seen him back yet for follow-up.</span></p>
<p><span style="color: #000000; font-family: Calibri;">I wish there were some mechanism to report this heinous care that did not involve the state medical board. This lousy care is just as bad as when a cardiologist performed an unnecessary stent or an orthopedist does an unnecessary joint replacement. </span></p>
<p><span style="color: #000000; font-family: Calibri;">At least I have a glimmer of hope that this kind of behavior could be captured using billing data. As the pundits talk about quality of care and metrics, reforming this kind of outlier poor performance would be much more meaningful to our country’s future than the meaningless use criteria being foisted on us now.</span></p>
<p>&nbsp;</p>The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/bad-family-medicine/">Bad Family Medicine</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></content:encoded>
					
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		<title>The Cost-Effectiveness of Family Physicians &#8212; Work Up New Symptoms in Stages</title>
		<link>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-cost-effectiveness-of-family-physicians-work-up-new-symptoms-in-stages/</link>
		
		<dc:creator><![CDATA[Richard Young MD]]></dc:creator>
		<pubDate>Mon, 30 Sep 2013 02:42:36 +0000</pubDate>
				<category><![CDATA[Blog]]></category>
		<category><![CDATA[cost-effectiveness]]></category>
		<category><![CDATA[family medicine]]></category>
		<category><![CDATA[family physicians]]></category>
		<category><![CDATA[healthcare costs]]></category>
		<category><![CDATA[healthcare quality]]></category>
		<category><![CDATA[tests]]></category>
		<guid isPermaLink="false">http://www.healthscareonline.com/?p=866</guid>

					<description><![CDATA[<p>I took the longest time off from posting on this blog site that I ever have since I launched it in 2010. I had a good reason. I spent a week in England learning more about their National Health Service. I&#8217;ll share some of those experiences later. Plus, I&#8217;m working on some articles for the mainstream media. For now, I&#8217;d like to go back to the cost-effectiveness of family physicians. The next concept of how they behave different from other physicians is that they are more likely to work up new symptoms in stages. All of us know that there are perhaps 89 causes of chest pain. But if a physician sees a patient with a new symptom of chest pain, should he or she order 89 tests to cover all 89 possibilities? Family physicians clearly say that the right answer is no. Judgment should be applied based on the underlying disease probabilities of the specific patient situation. A 69-year-old smoking diabetic patient with 2 hours of crushing sub-sternal chest pain should have different tests than an 18-year-old girl with sharp right-sided chest pain that lasts for seconds and only occurs when she takes a deep breath. This is an [&#8230;]</p>
The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-cost-effectiveness-of-family-physicians-work-up-new-symptoms-in-stages/">The Cost-Effectiveness of Family Physicians — Work Up New Symptoms in Stages</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></description>
										<content:encoded><![CDATA[<p>I took the longest time off from posting on this blog site that I ever have since I launched it in 2010. I had a good reason. I spent a week in England learning more about their National Health Service. I&#8217;ll share some of those experiences later. Plus, I&#8217;m working on some articles for the mainstream media.</p>
<p>For now, I&#8217;d like to go back to the cost-effectiveness of family physicians. The next concept of how they behave different from other physicians is that they are more likely to work up new symptoms in stages.</p>
<p>All of us know that there are perhaps 89 causes of chest pain. But if a physician sees a patient with a new symptom of chest pain, should he or she order 89 tests to cover all 89 possibilities?</p>
<p>Family physicians clearly say that the right answer is no. Judgment should be applied based on the underlying disease probabilities of the specific patient situation. A 69-year-old smoking diabetic patient with 2 hours of crushing sub-sternal chest pain should have different tests than an 18-year-old girl with sharp right-sided chest pain that lasts for seconds and only occurs when she takes a deep breath.</p>
<p>This is an example of the culture of family medicine that differs from the culture of U.S. medical schools and the broader medical establishment. How many pimping sessions from some egotistical ologist in medical school revolved around the trainee not ordering enough tests to cover some extreme zebra disease? It happens a lot.</p>
<p>Perhaps our definitions of medical error need to change as well. We need to be more tolerant of what some would call the error of the delayed diagnosis. The only alternative is to order every possible test at the first opportunity. This is not only wasteful, it is harmful as well. Labeling an episode of care as resulting in a delayed diagnosis assumes that an earlier diagnosis would have changed the outcome, which is most often not the case.</p>
<p>At least most family physicians understand this. Too bad most of the other American physicians, regulators, the legal system, and the bureaucrats don&#8217;t.</p>The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-cost-effectiveness-of-family-physicians-work-up-new-symptoms-in-stages/">The Cost-Effectiveness of Family Physicians — Work Up New Symptoms in Stages</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></content:encoded>
					
		
		
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		<title>The Cost-Effectiveness of Family Physicians – Comfort with Uncertainty</title>
		<link>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-cost-effectiveness-of-family-physicians-comfort-with-uncertainty/</link>
		
		<dc:creator><![CDATA[Richard Young MD]]></dc:creator>
		<pubDate>Tue, 04 Jun 2013 04:14:44 +0000</pubDate>
				<category><![CDATA[Blog]]></category>
		<category><![CDATA[AAFP]]></category>
		<category><![CDATA[cost-effectiveness]]></category>
		<category><![CDATA[Dr. Oz]]></category>
		<category><![CDATA[family medicine]]></category>
		<category><![CDATA[family physicians]]></category>
		<category><![CDATA[healthcare costs]]></category>
		<category><![CDATA[healthcare quality]]></category>
		<category><![CDATA[medical schools]]></category>
		<category><![CDATA[Uncertainty]]></category>
		<guid isPermaLink="false">http://www.healthscareonline.com/?p=823</guid>

					<description><![CDATA[<p>This post is the 3rd in a series discussing our findings in a recently published study on the ways family physicians deliver better care at a lower cost than a multi-ologist model. Family physicians told us they are more comfortable with uncertainty than the ologists. For a little history, the Future of Family Medicine project published in 2004 identified this mental attribute as an important defining skill of family physicians (which was listed under the heading of comfort with uncertainty, which I&#8217;ll expand on in a future post). This comfort/skill/psychological ability manifests itself across the entire spectrum of family medicine. An example is reassuring a young mother that her infant with a fever will probably be fine – and ordering no tests or hospitalizations. Another is reassuring a middle-age man, who had a neck CT ordered by an ER doctor after a minor motor vehicle accident that revealed a smooth cystic mass in his thyroid gland, that he doesn’t need to worry about it (and if there is any follow up, it’s minimal and as non-invasive and inexpensive as possible), family physicians make a dozen decisions a day to not order tests or treatments that other physicians would. This doesn’t [&#8230;]</p>
The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-cost-effectiveness-of-family-physicians-comfort-with-uncertainty/">The Cost-Effectiveness of Family Physicians – Comfort with Uncertainty</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></description>
										<content:encoded><![CDATA[<p>This post is the 3rd in a series discussing our findings in a <a href="http://stfm.org/fmhub/toc.cfm?xmlFileName=fm2013/fammedvol45issue5.xml" target="_blank">recently published study</a> on the ways family physicians deliver better care at a lower cost than a multi-ologist model.</p>
<p>Family physicians told us they are more comfortable with uncertainty than the ologists. For a little history, the <a href="http://www.annfammed.org/content/2/suppl_1/S3.full" target="_blank"><span style="text-decoration: underline;">Future of Family Medicine project</span></a> published in 2004 identified this mental attribute as an important defining skill of family physicians (which was listed under the heading of comfort with uncertainty, which I&#8217;ll expand on in a future post).</p>
<p>This comfort/skill/psychological ability manifests itself across the entire spectrum of family medicine. An example is reassuring a young mother that her infant with a fever will probably be fine – and ordering no tests or hospitalizations. Another is reassuring a middle-age man, who had a neck CT ordered by an ER doctor after a minor motor vehicle accident that revealed a smooth cystic mass in his thyroid gland, that he doesn’t need to worry about it (and if there is any follow up, it’s minimal and as non-invasive and inexpensive as possible), family physicians make a dozen decisions a day to not order tests or treatments that other physicians would.</p>
<p>This doesn’t mean that family physicians are simplistic in their thinking and don’t understand that in each of these cases rare outcomes happen rarely. Rarely, a child who initially looks mildly ill worsens over the next day or so. Rarely, a smooth mass seen on imaging turns out to be cancer.</p>
<p>It’s just that family physicians also feel that overtesting and overtreating, besides causing great economic harm to society, also  harm patients. Infants indiscrimately prescribed antibiotics experience adverse effects individually, and across all patients bacterial resistance to antibiotics worsen. People who have surgery for benign-appearing masses suffer the predictable risks of surgery, including death. Movements such as the <a href="http://avoidablecare.org/" target="_blank"><span style="text-decoration: underline;">Avoiding Avoidable Care</span> </a>organization and conference have helped spread this message better than the during the fiasco of the managed care era.</p>
<p>And medical schools certainly don’t teach or value this skill. Think about how many times the presentation of a patient with a rare disease in a medical school M&amp;M conference run by one of the bigoted ologists started with a statement that “This patient was referred to us by a local MD (medical school speak for family physician) who discovered an X on one of his patients &#8212; the implication being that the &#8220;local MD&#8221; just doesn&#8217;t know enough to know what should happen next. Medical schools teach thoroughness, not judgment or prudence.</p>
<p>Medical students who have poor tolerance of uncertainty find a <span style="text-decoration: underline;"><a href="http://www.stfm.org/fmhub/fm2012/April/Maarit240.pdf" target="_blank">primary care career too challenging</a>.</span> I also believe this comfort is a huge reason mid-levels can never achieve the efficient outcomes of family physicians. They refer to ologists any patient situation that doesn&#8217;t fit one of their cookbook algorithms.</p>
<p>This family physician characteristic is so important that the AAFP should spend much more of its resources on spreading this message: that family physicians provide better care at a lower cost because they as medical decision makers are more comfortable with uncertainty than all other physicians (internists included). This is a huge undertaking. I’m asking the AAFP to make efforts to move the U.S. cultural dial to a different place than it currently is. This means the AAFP will have to fight back against the influence of Dr. Oz and the rest of the TV doctors and health beat reporters.</p>
<p>Because if the family physician is comfortable with the uncertainty that a patient with a classic migraine history doesn’t need a dose of radiation to her head – a CT scan – but she is not comfortable with the inherent uncertainty of this decision &#8212; the physician can&#8217;t be certain that the CT will find no mass &#8212; then conflict will arise between patient and physician. The family physician will  not receive a 10 on the patient satisfaction report card, which some pinhead bureaucrat will interpret as poor care.</p>
<p>And a sustainable well-supported army of U.S. family physicians will continue to only be wishful but delusional thinking. If our patients and the payers don’t support our comfort with uncertainty, we will continue to be an anemic presence in U.S. healthcare system.</p>The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-cost-effectiveness-of-family-physicians-comfort-with-uncertainty/">The Cost-Effectiveness of Family Physicians – Comfort with Uncertainty</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></content:encoded>
					
		
		
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		<title>Payers Who Cooperate to Purchase High-Value Healthcare</title>
		<link>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/payers-who-cooperate-to-purchase-high-value-healthcare/</link>
					<comments>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/payers-who-cooperate-to-purchase-high-value-healthcare/#comments</comments>
		
		<dc:creator><![CDATA[Richard Young MD]]></dc:creator>
		<pubDate>Mon, 22 Apr 2013 04:03:21 +0000</pubDate>
				<category><![CDATA[Blog]]></category>
		<category><![CDATA[healthcare costs]]></category>
		<category><![CDATA[healthcare quality]]></category>
		<category><![CDATA[healthcare reform]]></category>
		<guid isPermaLink="false">http://www.healthscareonline.com/?p=797</guid>

					<description><![CDATA[<p>Two weeks ago, I wrote about the actual lack of success Kaiser has had in reducing healthcare costs very much more than the rest of the U.S. healthcare system. This is a story about a group having a little more success. This is a post originally written by Brian Klepper, PhD on his Care and Cost blog. He is a health economist who is one of the leaders of efforts to lead the non-healthcare industries to push back against the excesses of the healthcare industry. It&#8217;s the 83% of the GDP standing up to the 17% of the GDP. Last week I visited with Gary Rost, an unassumingly knowledgeable man and the Executive Director of the Savannah Business Group (SBG), arguably one of the most effective health care coalitions in the country. Their offices are only a couple hours away from my home on the Northeast Florida coast, so it was a quick trip up. SBG was founded in 1982 as a way of mobilizing employer buying power for better care at lower cost. Its reach now extends beyond Savannah about an hour south, north into South Carolina and west from the coast. The vision described on its site is straightforward [&#8230;]</p>
The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/payers-who-cooperate-to-purchase-high-value-healthcare/">Payers Who Cooperate to Purchase High-Value Healthcare</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></description>
										<content:encoded><![CDATA[<p>Two weeks ago, I wrote about the actual lack of success Kaiser has had in reducing healthcare costs very much more than the rest of the U.S. healthcare system. This is a story about a group having a little more success.</p>
<p>This is a post originally written by Brian Klepper, PhD on his Care and Cost blog. He is a health economist who is one of the leaders of efforts to lead the non-healthcare industries to push back against the excesses of the healthcare industry. It&#8217;s the 83% of the GDP standing up to the 17% of the GDP.</p>
<p>Last week I visited with Gary Rost, an unassumingly knowledgeable man and the Executive Director of the <a href="http://www.savannahbusinessgroup.com/">Savannah Business Group (SBG)</a>, arguably one of the most effective health care coalitions in the country. Their offices are only a couple hours away from my home on the Northeast Florida coast, so it was a quick trip up.</p>
<p><b id="internal-source-marker_0.7072351495735347"><img decoding="async" alt="" src="https://lh5.googleusercontent.com/hC_UPxPpP98ZsPoMODSkNQYtNSXvunSLJaKQ5299kgDEjQl-ZaR_2uFW7x5X5ac00-MnIqBF5DqyCvWSJ0KJ143jqjWOmmL644g45PqfohJqKCfeIby21VoKvg" width="290px;" height="200px;" /></b>SBG was founded in 1982 as a way of mobilizing employer buying power for better care at lower cost. Its reach now extends beyond Savannah about an hour south, north into South Carolina and west from the coast. The vision described on its site is straightforward and easy for purchasers to appreciate:</p>
<p><em>“SBG endorses and adheres to the principles of value-based purchasing: performance measurement, transparency, public reporting, pay for performance, informed consumer choice and collective employer leadership.”</em></p>
<p>Gary arrived a decade after SBG’s founding and has led the organization for 20 years. He aggregates and analyzes the med/surg and Rx claims data of his 23 regional member companies and governmental agencies, representing more than 16,000 employees and 35,000 covered lives. More important, he has used those data to inform activities that favor performance and value, and that try to steer away from poor care. He has formed a narrow high-performance provider network that is available only to SBG members, and has required the two major health systems to compete for a sole-source arrangement with his members’ plans. He has developed favorable drug, lab and vision arrangements. He has a variety of projects underway that focus on improving quality and value in the greater Savannah marketplace.</p>
<p>To its credit, SBG’s vision is long term and bigger than its own members’ immediate interest. Mr. Rost is proud of his members’ wellness/prevention efforts and says that, in his experience, those that deploy these approaches have lower overall costs than those who don’t. His group has had a hand in developing model disease management programs for SBG’s members. And SBG takes it as an article of faith that their efforts on behalf of members should also improve the health status and lower the health cost burden of the larger Savannah community.</p>
<p><a href="http://careandcost.com/2013/04/07/when-employers-get-serious-about-managing-health-care-risk/screenshot-2013-04-06-at-3-23-19-pm/" rel="attachment wp-att-8870"><img decoding="async" alt="Screenshot 2013-04-06 at 3.23.19 PM" src="http://careandcost.files.wordpress.com/2013/04/screenshot-2013-04-06-at-3-23-19-pm.png?w=150&amp;h=96" width="150" height="96" /></a></p>
<p>Their results have been compelling. In the decade leading up to 2010, the average cost per employee of SBG’s members grew at less than half the 90 percent national rate of premium inflation, by only 44 percent (a 4.1 percent annual premium growth rate).</p>
<p>SBG’s members’ health plans outperformed those of Savannah’s non-SBG firms as well. For example, in 2010 the City of Savannah, an SBG member, spent just under $23 million for group health coverage on 3,250 employees and their families, an average cost per employee per year (PEPY) of $7,007. Chatham County, not an SBG member, came in at $12,619 PEPY, or 80 percent higher. To put that difference into perspective, assume that, all else being equal, the County handed over an additional $5.6 million per 1,000 employees to Savannah’s provider community.</p>
<p>Hard savings numbers like this are rare from business health coalitions, and beg the question, “What did SBG do differently?” One answer is that they have gone beyond merely collecting, analyzing and posting data. They have not merely hoped that their actions will encourage their members’ purchasing behaviors. Instead, SBG has become an active change agent for its members.</p>
<p>This approach has also undoubtedly transformed, to some degree, the way medicine is practiced in Savannah, though the performance numbers of non-SBG firms’ suggest that this is still only marginal. High performing physicians, hospitals and other services are identified and rewarded with preferred status. Low performing ones are, to the degree possible, bypassed. In other words, SBG’s members have used a variety of market forces to convey that they will actively seek higher value care. They insist that a community’s prosperity is tied to health value that does not place an unreasonable burden on purchasers.</p>
<p>The challenge now is to replicate what Gary and SBG have learned and make their knowledge and tactics readily available to employers and coalitions around the country. SBG has a history of sharing and would undoubtedly be amenable. The question now is whether, faced with untenable health care cost burdens, employers around the country will finally band together to begin to heal health care.</p>
<p>Market-based employer collaboratives like SBG can create successful results anywhere. Of course, bringing health care back into balance will also require that employers collaborate on policy, establishing a way to monitor and be a counterweight to the health care industry’s domination of Congress and the legislatures.</p>
<p>Following SBG’s lead – bringing employers together to act decisively in their own interests in the market and on policy – is a good place to start.</p>The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/payers-who-cooperate-to-purchase-high-value-healthcare/">Payers Who Cooperate to Purchase High-Value Healthcare</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></content:encoded>
					
					<wfw:commentRss>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/payers-who-cooperate-to-purchase-high-value-healthcare/feed/</wfw:commentRss>
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		<title>Loss of Professional Joy</title>
		<link>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/loss-of-professional-joy/</link>
		
		<dc:creator><![CDATA[Richard Young MD]]></dc:creator>
		<pubDate>Thu, 11 Apr 2013 02:38:48 +0000</pubDate>
				<category><![CDATA[Blog]]></category>
		<category><![CDATA[electronic medical records]]></category>
		<category><![CDATA[EMR]]></category>
		<category><![CDATA[EMRs]]></category>
		<category><![CDATA[family medicine]]></category>
		<category><![CDATA[family physicians]]></category>
		<category><![CDATA[healthcare quality]]></category>
		<category><![CDATA[Medicare]]></category>
		<category><![CDATA[quality improvement]]></category>
		<guid isPermaLink="false">http://www.healthscareonline.com/?p=794</guid>

					<description><![CDATA[<p>Larry Bauer, who is a leader in family medicine education in the northeast U.S., sent out a link to a piece written by teacher who complained about the over-emphasis on standardized tests in secondary education. He felt so bad about it, he quit teaching.  Here is the link: http://www.washingtonpost.com/blogs/answer-sheet/wp/2013/04/06/teachers-resignation-letter-my-profession-no-longer-exists/ Larry asked a group of family physicians what they thought about this, and if they felt this way in family medicine.  Here is how I responded: We are going through this silly meaningful use hoop-jumping now. This journey is made worse with the limitations of EMRs. Here are some of my frustrations: The bureaucrats want us to measure processes that have been proven to be essentially ineffective, i.e.  weight  loss counseling in the primary care center. Similarly, we will have to check boxes that we provided tobacco cessation counseling, which everyone knows will mostly be delivered as a quick statement, probably by an MA, that will have no impact on cessation rates (and even if it worked, it doesn’t lower healthcare costs). The diabetes quality measures can’t be directly tied to the diagnosis of diabetes in our EMR (one of the big company’s products), but must be entered separately so reports [&#8230;]</p>
The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/loss-of-professional-joy/">Loss of Professional Joy</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></description>
										<content:encoded><![CDATA[<p>Larry Bauer, who is a leader in family medicine education in the northeast U.S., sent out a link to a piece written by teacher who complained about the over-emphasis on standardized tests in secondary education. He felt so bad about it, he quit teaching.  Here is the link:</p>
<p><a href="https://www.jpshn.org/OWA/redir.aspx?C=Uapkef457Eugf8iM3cxH1P7ajTTzCdAIBm4SieOqXr2ShA8F2PL5lE7yluzdXs8MYAw015UhogU.&amp;URL=http%3a%2f%2fwww.washingtonpost.com%2fblogs%2fanswer-sheet%2fwp%2f2013%2f04%2f06%2fteachers-resignation-letter-my-profession-no-longer-exists%2f" target="_blank">http://www.washingtonpost.com/blogs/answer-sheet/wp/2013/04/06/teachers-resignation-letter-my-profession-no-longer-exists/</a></p>
<p>Larry asked a group of family physicians what they thought about this, and if they felt this way in family medicine.  Here is how I responded:</p>
<p>We are going through this silly meaningful use hoop-jumping now. This journey is made worse with the limitations of EMRs. Here are some of my frustrations:</p>
<ul>
<li>The bureaucrats want us to measure processes that have been proven to be essentially ineffective, i.e.  weight  loss counseling in the primary care center.</li>
<li>Similarly, we will have to check boxes that we provided tobacco cessation counseling, which everyone knows will mostly be delivered as a quick statement, probably by an MA, that will have no impact on cessation rates (and even if it worked, it doesn’t lower healthcare costs).</li>
<li>The diabetes quality measures can’t be directly tied to the diagnosis of diabetes in our EMR (one of the big company’s products), but must be entered separately so reports can be generated.</li>
<li>The more important outcome to measure in diabetes is blood pressure, because it reduces future events much more than the sugar level. But our EMR can’t find the blood pressure, but it can find the lab value.</li>
<li>Lots of patients have blood pressures that do not meet the ideal, and it’s nobody’s fault – the patient’s nor the doctor’s – they just have bad disease. There is now an incentive for us to dump these patients out of our practices so we look better on the scorecards, when in fact these are the very patients that relationships with family physicians result in lower costs and better care. It’s part of how we are so good at managing complexity and uncertainty.</li>
<li>The preventive reminders in our EMRs are tied to birthdays, so if a person had a test a week before the birthday, and shows up to clinic a day after her birthday, a reminder box will still pop up saying the service has not been provided.</li>
<li>Mammograms are required every year, but Medicare only pays for them every other year.</li>
<li>Eye screenings are required every year, but Medicare doesn’t pay for them.</li>
</ul>
<p>That’s enough. So yeah, I know how the teacher feels.</p>
<p>I will say that I accept that for the rest of my career, my decisions will be scrutinized by others. The problem for family medicine is that our world is complex and uncertain. Many of our decisions are made in a process of negotiations where we are balancing competing and conflicting interests. The problem is that the bureaucrats and EMRs are too simplistic to keep up with us.</p>The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/loss-of-professional-joy/">Loss of Professional Joy</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></content:encoded>
					
		
		
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		<title>Forbes Questions Patient Satisfaction Scores</title>
		<link>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/forbes-questions-patient-satisfaction-scores/</link>
		
		<dc:creator><![CDATA[Richard Young MD]]></dc:creator>
		<pubDate>Mon, 18 Mar 2013 04:01:58 +0000</pubDate>
				<category><![CDATA[Blog]]></category>
		<category><![CDATA[Forbes]]></category>
		<category><![CDATA[healthcare quality]]></category>
		<category><![CDATA[patient satisfaction]]></category>
		<guid isPermaLink="false">http://www.healthscareonline.com/?p=783</guid>

					<description><![CDATA[<p>An article in Forbes recently questioned the value of patient satisfaction scores for both pay-for-performance schemes and as markers of quality and value in general. The article effectively exposed the inordinate sway Press Ganey has on the hearts and minds of hospital administrators. Press Ganey is an influential patient satisfaction survey company many hospitals hire to appease insurance companies, government agencies, and employers. This is in spite of evidence that the most satisfied patients cost the most and are the most likely to die, according to a study from UC-Davis. A supporting anecdote in the story was of an ER with low patient satisfaction scores who started offering Vicodin &#8220;goody bags&#8221; to discharged patients to boost their ratings. American businesses who actually pay for a big chunk of U.S. healthcare want accountability in the system, which is understandable. However, they are mis-applying constructs from their markets to the healthcare industry. There&#8217;s a world of difference between satisfying a customer who ordered cupcakes or a car from dealing with a patient and family who insist that the patient be admitted to the hospital, even though there is no valid reason to do so. Congratulations to Kai Falkenberg of Forbes for pointing [&#8230;]</p>
The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/forbes-questions-patient-satisfaction-scores/">Forbes Questions Patient Satisfaction Scores</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></description>
										<content:encoded><![CDATA[<p>An<a href="http://www.forbes.com/sites/kaifalkenberg/2013/01/02/why-rating-your-doctor-is-bad-for-your-health/" target="_blank"><span style="text-decoration: underline;"> article in Forbes</span></a> recently questioned the value of patient satisfaction scores for both pay-for-performance schemes and as markers of quality and value in general.</p>
<p>The article effectively exposed the inordinate sway Press Ganey has on the hearts and minds of hospital administrators. Press Ganey is an influential patient satisfaction survey company many hospitals hire to appease insurance companies, government agencies, and employers. This is in spite of<a href="http://archinte.jamanetwork.com/article.aspx?articleid=1108766" target="_blank"><span style="text-decoration: underline;"> evidence that the most satisfied patients</span></a> cost the most and are the most likely to die, according to a study from UC-Davis.</p>
<p>A supporting anecdote in the story was of an ER with low patient satisfaction scores who started offering Vicodin &#8220;goody bags&#8221; to discharged patients to boost their ratings.</p>
<p>American businesses who actually pay for a big chunk of U.S. healthcare want accountability in the system, which is understandable. However, they are mis-applying constructs from their markets to the healthcare industry. There&#8217;s a world of difference between satisfying a customer who ordered cupcakes or a car from dealing with a patient and family who insist that the patient be admitted to the hospital, even though there is no valid reason to do so.</p>
<p>Congratulations to Kai Falkenberg of Forbes for pointing out the flaws of unfettered patient satisfaction ratings. Let&#8217;s hope Forbes&#8217; business community readers change their attitudes as a result.</p>The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/forbes-questions-patient-satisfaction-scores/">Forbes Questions Patient Satisfaction Scores</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></content:encoded>
					
		
		
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