Trapped

Hard to be a physician... slightly harder in Massachusetts

From the Massachusetts Health Council:

DOCS SEE WORSENING ENVIRONMENT IN MASS.

Doctors say practicing in Massachusetts, where elected officials often tout gains under the 2006 universal health care access law, has become a tougher challenge. According to a Massachusetts Medical Society analysis released Tuesday, physicians face a growing burden from liability insurance rates, increasing use of emergency departments by patients, an aging physician workforce, and increasing costs associated with maintaining their practices. The society's latest Physician Practice Environment Index declined slightly, “representing a continued deterioration of the practice environment for physicians in Massachusetts.” The society identified liability insurance reform as the best step to take to improve the practicing environment, noting “defensive medicine” efforts aimed at preventing lawsuits come with a cost of $1.4 billion per year. Society officials say the index results conflicted with national surveys showing an improved climate for physicians. The report also concluded visits to the emergency department were up 3.5 percent in 2009 and that Massachusetts residents are using emergency departments at a rate 40 percent greater than in the nation. “A strong practice environment is essential to maintain a strong physician workforce, and both together mean better care for our patients,” society president Alice Coombs said in a statement. This becomes even more critical with universal coverage, given the added pressures that it puts on physicians, especially those in primary care specialties. The continued viability of physician practices should be a cause for concern about our state’s health care delivery.” The index has declined in 16 of the 18 years that it has been assembled.

There's nothing particularly new in this report (though the mention that Massachusetts residents are 40 percent more likely to use an emergency room than in other parts of the nation is alarming... and curious) which states that it's getting harder to practice medicine in Massachusetts.  We've been hearing that for a long time given the complexities and burdens of expanding payer requirements, much publicized malpractice woes, shortages of key staff, declining incomes, etc.  It is interesting to note that leading indicators for the U.S. and for Massachusetts seem to be moving in opposite directions.  Across the country, doctors are a bit happier.  In Massachusetts, a bit less so.

This coming decade will be marked by new advances in "physician extender" strategies.  Advance practice nurses will be given greater responsibility (for example, being able to order ancillary services, including home health care), primary care will continue to shift toward nurse practitioners and physician assistants, highly skilled technicians will assume tasks formerly completed by physicians, and the general public will become more accustomed to seeing physicians later on in the care process.  The debate will shift from whether this is a good or bad thing to how best to implement the changes.

Organizations such as the Massachusetts Medical Society will increasingly need to determine whether to support and lead this movement... or whether to buck it and defend the historical role medicine has played.

The Pendulum Giveth, the Pendulum Taketh...

I was an HMO executive at the time and remember well sitting in that darkened movie theater.  The Helen Hunt character said, clear-as-day, "______ HMO, ______ pieces of ____!  Think of the spiciest, nastiest words you can and insert them into that sentence and you'll understand how tobacco company executives feel.  The movie, "As Good As It Gets", contained a single mom's struggle to obtain adequate health care services for her ill son.  The pretext was a vehicle only as it helped spark the relationship between Hunt's character and the one played by Jack Nicholson.  The underlying merits of the health care coverage/access issue at stake was preposterous, but that didn't matter to the movie audience who erupted into wild applause at Hunt's three-bad-words-in-one-sentence commentary.  You know a backlash is in full swing when an audience vigorously claps in the middle of a mainstream movie at an insult lobbied by one of the characters.

The heart of the matter is that, back then, the health maintenance organization movement was continuing along its predestined path to control health care costs by selectively restricting access to providers and services.  As a general rule, in order to cut waste you need to direct care to the most efficient providers and you must eliminate duplicative and unnecessary services.  Some view that as rationing.  Helen Hunt's character clearly did.

So the HMO industry responded.  Networks were opened up, benefits were expanded, and the industry witnessed the return of fee-for-service medicine.  Pay-for-performance and bonus structures based on quality outcomes were introduced as a mechanism for inducing responsible behavior among providers.  Sticks gave way to carrots.

But the pendulum is clearly coming back the other way now.

Last week, the Massachusetts legislature advanced a bill requiring small group insurers to offer restricted networks to spur premium savings.  Yes, requiring smaller provider networks.  That means limiting choice.  What would Helen Hunt say?

And today, The Boston Globe reports that insurers, emboldened by the public scrutiny of the Partners system, reports from the Attorney General's office about payment discrepancies that are not tied to performance and quality, and a more activist legislature when it comes to health care costs, are reaching out to providers seeking payment cuts.  We have already seen benefits packages being stripped and the reimbursement cutting will not only narrow choices, but prompt closed network models of care delivery.

It will be interesting watching this unfold.  Interesting until the next backlash...

Are all home care agencies the same - part 3?

It's a great challenge that many of us face: keeping straight all of our prescription medications.  For the home bound, who are often frail and elderly, this challenge is even greater... and more important as mistakes can have troubling consequences.  Home health clinicians actively assist and teach their patients how to manage this vital task.  As a result, all Medicare certified agencies track the measurable progress their patients make in this regard.  The above graph shows how the Visiting Nurse Association of Boston (dark blue line) fares compared to Massachusetts (green line) and U.S. (red line) averages.  As indicated, and dramatically so, our patients improve at a substantially higher rate than do patients of other agencies.  Again, this is compelling evidence that not all home health agencies are the same!

They're watching....

I have one of these in my wallet.  Often, I'm glad I do because I can buy one package of Thomas' English Muffins and get a second package free.  Or the four for a dollar cans of Polar Seltzer becomes five for a dollar with the simple swipe of the card across an infrared beam reader.  It's quite nice of Stop & Shop to do this for me.

But alas, I clearly understand that the company is watching my every move and that niceness has nothing to do with it.  They are analyzing my buying patterns not only for valuable market research purposes, but also so that they know precisely how to target me.  It's no accident that when my receipt is spit out of the automated register, it's accompanied by coupons for english muffins and seltzer water.

There's nothing new here.  Marketers have been assessing our shopping habbits and buying patterns for decades, but newer technologies have brought the practice to even higher levels of sophistication.  Google's entire business model is predicated on intricate and automated means of understanding what we do when we're on-line, what we search for and what we type when we're in places like their gmail program.  I once typed to a friend in a gmail message that I had passed through a town named Spoon River and the very next day I received an "exclusive" email offer on a new set of silverware.  Coincidence?  Maybe.

Over the weekend, The Wall Street Journal addressed the reach of similar technologies into the delivery of health care.  Selected excerpts from the article, by Anne Kadet:

Whether a patient comes in for a gall-bladder operation or to have a baby, the routine remains the same for staff at Sharp HealthCare hospitals in San Diego. The front desk checks insurance records to make sure the bills get paid on time. Nurses take vitals and tag their charges with a bar-coded wristband. And behind the scenes, fund-raisers scan the assets of each patient -- to find out whether they're "megarich," "wealthy" or merely "comfortable."

While the folks checking in don't know it, the nonprofit hospital chain is hunting for prospective donors. Armed with powerful data-mining software, staffers screen admissions records to find wealthy patients who've shown prior interest in the hospital. Those who make the cut may enjoy a bedside visit from a "patient-relations director" who offers perks like free parking passes for visitors.

Medical institutions have been particularly aggressive about prospect research. Some use software to screen admissions lists; some even train doctors to identify new prospects. Once a patient is scouted as a VIP, the perks roll in. At the Hospital of the University of Pennsylvania, some 1,200 donors and volunteers can get priority for appointments with specialists. At San Diego's Sharp HealthCare, major donors receive a card with staffers' pager numbers.
 
Some people question whether these practices should be overlapping with medical care. Arthur Caplan, a bioethicist at the University of Pennsylvania School of Medicine, says it's hard to justify "golden runways" that whisk donors past waiting lists. During treatment and recovery, he adds, patients may feel too vulnerable to refuse a solicitation.

Hospitals say grateful patients are their only natural donor constituency. Paul Mischler, the Pennsylvania hospital's senior executive director of development, says the donor relationship "can be a natural, rewarding part of the healing process."

The key question pertains to the ethics of not-for-profit health care organizations utilizing sophisticated technologies and techniquess to "hunt for prospective donors" and "screen admissions lists".  What about providing perks (e.g., faster appointment times) for patients with means?  And training physicians to screen patients for donor prospecting purposes?

It strikes me that the mere deployment of sophisticated tools to facilitate more effective fundraising performance for often cash-strapped, mission oriented health care organizations is not a bad thing.  It can drive efficiencies and aid in supporitng needed programs and services.

But the latter scenarios, such as offering differential care for those who are better prospects but who do not pay for the higher end services and asking clinical staff to do prospecting, crosses over the line.

“One person’s waste is another person’s income....’’

Great piece in today's Boston Globe by columnist, Joanna Weiss.  Harkens back to a few themes from my own post here, particularly her comments regarding the impact of the profit motive on driving health care costs upward.

The full article:

By Joanna Weiss

Globe Columnist / May 18, 2010

Another axiom: Eventually, something will happen to your family.

Take, for example, my own elderly relative, who recently spent time in the hospital. Everyone wanted him to recover at home, but we knew that would require nursing care. And his care coordinator in the hospital had strange, bad news: If he went to a residential nursing home, Medicare would foot the bill. But if he wanted an at-home nurse, at substantially less cost, Medicare would only cover a few hours of care, a few days a week.

To anyone with a smidge of common sense, that sounds absurd. But when I relayed the story to Dr. Brent James, he wasn’t surprised. As chief quality officer at Intermountain Healthcare, a network of hospitals and providers in Utah, he’s an expert in Medicare’s one-size-fits-all solutions and perverse incentives. More than a decade ago, his hospitals put a reform in place, involving the timing of antibiotics, that helped patients recover more quickly and completely. But the hospitals were losing millions of dollars, and the billing records solved the mystery. If a patient got pneumonia and went on a ventilator, the reimbursement from Medicare was $800 more than the treatment itself. If that same patient didn’t get pneumonia, the billing codes changed, and the payment for his briefer, simpler hospital stay was $800 less than the cost.

As Congress turns to the must-do task of cutting Medicare costs — and considers Cambridge-based health care innovator Donald Berwick to lead the effort — it’s worth reminding ourselves what Berwick surely knows. It’s not just that many of Medicare’s problems are well-known. So are many of the solutions.

James has already implemented many of them at Intermountain, which is known as a national model for sensible management. Among them are “global payments,’’ which opponents have managed to demonize as rationing of care. As James explained it to me, it’s a far-less-nefarious way to create the the right incentives in a system that now often has the wrong ones.

In the case of my elderly relative, Medicare would give his hospital a set amount of money to coordinate and spend. Any money left over would be profit. If the payment fell short of the cost of his care, the hospital would eat the loss.

In theory, that could give doctors and nurses a reason to provide him with less care. Careful monitoring of quality would have to go hand in hand with global payments. But this change could also encourage steps known to reduce the length and cost of illnesses. Washing hands more often to reduce the spread of infection. Coordinating better among hospital divisions. Offering better access to the home-based nursing care that would cost a lot less.

“Over 50 percent of expenditures on a patient on health care are technically waste,’’ James told me. But “one person’s waste is another person’s income is a major political contribution.’’

In other words, he says, the probable downside isn’t so much that patients would get less care, but that some providers would get less autonomy, and oftentimes, less money. That’s the heart of the resistance to some other reforms, such as competitive pricing for Medicare, which would provide payments based on bids instead of uniform rates. Insurers would bid for Medicare business by promising to hold care costs within limits.

According to some health care and economics experts — including Roger Feldman and Bryan Dowd at the University of Minnesota and Bob Coulam at Simmons College, who wrote a recent paper on the subject — competitive pricing would shave 8 percent off the annual Medicare budget. That amounts to $50 billion to $60 billion every year. And yet, every time that reform has been proposed, providers have revolted, and Congress has blocked it in a very bipartisan way.

Now we have a looming crisis, a foreseeable future when the Medicare Part A trust fund will go bankrupt, or when Medicare costs will start to overwhelm the federal budget. There will come a point when ignoring the problem won’t be feasible anymore. Maybe it will happen too late to help some of my own relatives. But when it does happen, there’s some small comfort in knowing that solutions are out there — just waiting for action, a little bit of courage, and a will to change.

Joanna Weiss can be reached at weiss@globe.com

Frantic

Are all home care agencies the same - part 2?

Homebound patients often have a difficult time moving around, walking, getting in and out of bed.  Organizations such as the Visiting Nurse Association of Boston strive, through skilled nursing and physical therapy services, to improve the ambulation of patients.  As the above graph indicates, such organizations have improved in this regard over the past few years.  As also indicated, the VNA of Boston performs at a level steadily above National and Massachusetts averages.

Looking Up Now

Shed

The Meadow

When the Sky is the Subject