Inkwell: Authors and Artists

    
Sorry for being tardy to reply. 

That NY Times article is a "must-read." It vividly illustrates the
argument for transparence. Uwe Reinhardt is present, whining about how
can we put ask "consumers" to make good choices about healthcare when
they can't find out how much something costs and is it any good? When
the obvious answer, Uwe, is: Help them. Make the insurers be more
transparent (they actually consider their payments to be trade
secrets), force the providers to post real prices. And put the
providers under "common carrier" rules. You ever notice that no matter
how many airline tickets some big corporation buys, there are no deals
where, say, Google makes all employees fly United, and in return gets
tickets at half price? That kind of discounting is illegal in "common
carrier" industries such as airlines, trucking, railways, and telecom.
There is no "wholesale" and "retail" price. You have to entice
customers in other ways, like frequent flier clubs.

You could do that in healthcare. It would force providers to establish
actual real prices — which actually help providers get better at
knowing what their cost of doing business is, and where they can
provide value in a way that helps them survive. It would force insurers
to find other ways to provide value to their customers than by using
market power on the providers to give them unreal discounts at the cost
of other customers.

It would also mean that you could do something like Kayak in
healthcare. Need a new hip? Having a baby? Some other predictable unit
of major healthcare for which you have to share some of the cost? Put
it in right here, just like you put your destination and dates in on
Kayak. And, oh, I have insurance from Company X, on plan 3b. Show me
all the places around here, how much they cost, how much that will cost
_me_, what are there quality ratings and customer scores. Okay, now
show me what I would pay if I were willing to travel somewhere else.
And so on.
  

    
> Evidence-based medicine

Jerry, you raise a number of objections to using "evidence-based
medicine." There could be errors, there could changes in opinion, it's
not flexible enough, insurance companies keep calling things
experimental when they are not.

This is another example of "anything idea is a bad idea if its done
stupidly." And mostly, I don't see this idea being done stupidly. It
arises out of the fact that when you survey medicine the way the
Dartmouth Group has been doing for two decade, you see massive
variations for no reason. One city doing six times as many back
surgeries per capita as another, or three times as many cesarean
sections, or twice as many hours on a ventilator. People objecting to
evidence-based medicine like to bring up complex cases, outliers, and
such. 

But most of this is not about complex, uncertain cases. It's mostly
about things for which there is well-established, well-studied medical
opinion. It's about, for instance, labor should not be induced before
the 39th week of pregnancy just for the convenience of the doctor or
the family, or to reduce the anxiety of the mother, because it is hard
to know when the 39th week is, and you risk bringing out a child that
is really only 36 weeks along, with incompletely formed lungs. And
there is no countervailing medical opinion. Yet early induced labor
without a medical reason is still too common.

Yes, there will be mistakes in attempting to standardize medicine, but
they will be mistakes made out in the open, and argued over and
studied over by medical scientists. In non-standardized we make massive
mistakes all the time, every day, and never even try to find out what
the right way is.

As for the insurance companies, standardizing medicine is a good
bulwark against them claiming something is experimental when it's not. 
Let the doctors, in their collective scientific wisdom, declare that
something is not experimental, but is a reasonable tool available to
the clinician — and let the insurance companies butt out and pay the
bills that they have legally contracted to pay. (Among other things, if
insurance companies can interfere in your medical treatment, they need
to be made legally liable for medical malpractice suit.)
  

    
Jane, the situation that you describe is not at all rare. In some
localities, 90% or more of all 911 calls are just such minor, repeating
problems, not life-threatening but needing attention — and the
convalescent home or assisted living place calls 911 because they have
no place else to call, and no one on staff to deal with it.

It's important to notice that each entity in this chain is getting
paid for what they are doing in one way or another. The home, the EMTs,
the hospital, the imaging center. They are paid fee-for-service, and
are not at financial risk for the continuing problem. If they were,
they might make very different decisions. 

I have talked to directors of assisted living places who have called
the local hospital and said, "Look, we have a bunch of seniors over
here who all need flu shots, and need to be seen for this and that. Who
could we talk to about setting up some kind of rounds, kind of a mass
house call, instead of loading them all up in buses or something and
taking them to the clinic." And they can't even get anyone to call them
back. 

If the local health system were in an at-risk contract for the health
of those seniors, they would do much more than call them back. They
would work with the home to have regular rounds, to have some kind of
on-call staff, some kind of ongoing tight relationship with the place —
and they would make money at it.
  

    
sigh.

I am just old enough to remember house calls. (Does France still have
house calls? I think they do.)

My DENTIST does house calls for the elderly, the incapacitated, anyone
with a condition that makes it impossible to get into the office. I do
imagine that is also rare as hen's teeth. 

And there's yet another thing that falls off the map. When someone I
know was in a care facility for psychiatric reasons, long term, not one
person there ever once suggested she see a dentist. Aside from the
toll this takes on teeth, it can take a toll on the rest of health as
well. Another argument your whole person approach is needed. Wellness,
or at least the least possible downward progress, as outcome.
  

    
"It would also mean that you could do something like Kayak in
healthcare."

Yes! That kind of change could end all the confusion and craziness,
right then and there.
  

    
Joe, is there a set of things a person like me (55, married, two
dependent children, Blue Cross-Blue Shield insured both through my job
and spouse's job) can do to make a difference in my own health care
experience? Or should I read your book first, which I ordered just
yesterday after starting to read this great discussion?
  

    
Piggybacking on something <cmarti> just wrote in his post:

"...a person like me (55, married, two dependent children, Blue
Cross-Blue Shield insured both through my job and spouse's job)"

Are there any proposals floating around to make such insurance
situations more efficient?  Here is someone who gets coverage both from
his employer and his wife's employer.  Someone is overpaying and there
is a lot of waste in something like that.  Multiply this out to all
other people who are double covered and we are talking real money.  
  

    
Great question, Chris. First thing to say: I am not an individual
healthcare or financial counselor, and I don't know your exact
situation. So these are just general observations.

Second: It's not easy. And traditionally, we
patients/consumers/individuals/families/whatever have not had many
tools, or much information. Now that's changing, and we really need to
take advantage of the differences.

You are in Illinois, right? So that's Blue Cross Blue Shield of
Illinois, owned by the customer-owned Health Care Service Corporation,
correct? I believe that the smart thing to do for the lowest cost and
the best health is to use a high-deductible health plan combined with a
strong health savings account (HSA) or health care account (HCA) —
especially one that rewards you, the employee, for doing healthy things
like getting a health risk assessment or meeting with a health
counselor. With BCBS IL you would be looking in their "Blue Edge"
programs, especially things like the "Wellness HCA". The smart thing to
do is to put especially the primary care/preventive end of health
expenditures in your own hands and then use the hell out it, really get
involved in your and your family's health.

Under some of these plans, you can spend the money any way you want as
long as it is on healthcare. In that case, if there is one available
to you in your area, you might want to consider a "direct pay" primary
care doctor. You pay them a set amount per month (examples range from
$49 per person up, significantly less for package deals with employers)
to do a package of all primary and preventive care, including
after-hours and urgent appointments. <http://www.dpcare.org> will show
you if there is one in your area.

There are increasingly programs such as Castlight that aim to tell you
the real costs of providers in your area, though these are still under
development, and the transparency is not at the Kayak-like level we
might want. Some health plans actually offer access to such information
environments to their members (I don't remember whether BCBS IL does
yet).

Then there are programs such as Dossia, which help you track your
family's health, which can be very helpful.
  

    
Another good question, David. From the system level, it's not
necessarily a big concern. In any given situation, through a
"coordination of benefits" protocol, one of the plans is deemed
primary, and pays as if there were no other coverage. Then the other
plan picks up anything that was not paid by the first plan, as long as
it's a covered expense, and they are within their annual caps, and so
and so forth. 

If the couple are paying premiums on both plans, and both plans cover
spouses and dependents, it might be worthwhile to determine whether it
makes financial sense for them to continue both plans. But you also
have to figure in catastrophic "what-ifs." As we have experienced
recently right here on the Well, what if something serious happens to
the spouse whose coverage you kept — and then they can no longer work.
Will the un-injured spouse's coverage now pick up all those expenses?
Good thing to check. Don't do it on your own, ask someone who is an
expert in your actual plan. The health plan may have such help
available, as may your employer, or you can probably hire one, the way
we hire financial counselors to help us figure out our 401Ks.
  

    
But I'm not going to let you off the hook by stopping with your
personal actions, Chris. There's another level: Energize your employer.
And your spouse's employer. Because employers actually have more
leverage and flexibility than anyone else. They really need to use that
power more aggressively, and now more than ever is the time.

There are a range of ideas in the book for how employers can save
money on healthcare while helping their employees save money and be
healthier. It's a trifecta. But most of these require the leverage of
the employer (or groups of employers). 

If I were in your shoes, seriously, I would talk the book up in the
office, then take up a collection to buy three copies, and hand-carry
them to the CEO, the CFO, and the HR director, with a hand-written note
about why you think they should read it. 

Make an appointment to talk to the HR director. I would assume, by the
way, that the HR director is not unfamiliar with at least some of the
options I talk about. What the book does is lay them out in what I hope
is a more compelling and comprehensive way that helps arm the HR
director both to come up with some realistic options for the
organization, and to have some good, well-informed talks with the CEO,
COO, and CFO.

And before long, I will have a PowerPoint available just for that
purpose, available on the websites ImagineWhatIf.com and
HealthcareBeyondReform.com.
  

    
One of the big problems I have with telling people to shop around for
the cheapest version of test x, surgery x, procedure x, is that it
results in difficult and often downright dangerous fragmentation of
information about you.  Today, insurance often dictates where lab tests
are done, and that means I often do not get test results at all; have
to waste a lot of my and the primary physician's office staff time
trying to get the results; and when I do get the results, they're in a
difficult format to integrate with the other data I have.  

If blood tests are done within a single hospital lab, for example,
they're reported in an electronic format where I can view results as a
table or a graph, to track them over time.  A graph is incredibly
useful for seeing trends and helping to know when a slightly off result
is a fluke vs a persisting 'should do something about that' issue. 
Outside results can't be entered into that system, so if I want a
graph, I have to make my own flowsheet and graph by hand on paper.  In
some places, the major outside labs now offer electronic delivery of
results so that they do come into the electronic reporting system, but
as often as not, they come in 'differently'--different rows or columns
on the flowsheet, or the outside lab may use different units so that
they can't be graphed together without converting values.

For radiology studies, as often as not, we're doing followups where
the prinicipal value of the study is change over time vs previous
imaging.  Having a one-off test that say, patient has
scarring/tumor/lumpiness/swelling here is not helpful when we already
know that, and want to know is scarring worse, tumor spreading,
lumpiness stable, swelling bigger?  Yes, patients can get and bring
their study on a CD to me (add significant time delay here), but if I
want it to be compared to the study that was done while they were
hospitalized, technically that requires a radiology consultation, which
is very difficult to get authorized.  And even for a one-off test, if
I'm looking for a subtle abnormality on a test done at my home base,
where I know the radiologists, I have a better sense of whether
"possible subtle change x" is important because it came from Doctor Y,
who is very conservative on these things.

So.....until there is better, transparent, fully
transferable/interconvertible EMR and every system can talk to every
system, and I can get all the records, seeking the cheapest provider of
thing X wherever it might be is itself is a problem.  The limited form
of that we have now--HMO patients being contracted out to various
labs, with all results being routed through their primary
physicians--is a real mess.  
  

    
Thanks for the window into the clinician's world. 

Let me pick out some pieces of that. First, when we are talking about
"shopping" in healthcare, we have to be talking about not just price,
but price and quality — and "quality" has to include not only how well
does someone perform the test or procedure, but how well-coordinated
they are with the rest of the system. And in some cases like the ones
<debunix> mentioned, part of the quality has to be that they are known
to your own doctor, so that your own doctor can properly evaluate the
report, or the progress of the case post-procedure. So part of
searching for "quality" should often be to ask your own doctor, "Whose
reports do you trust?"

But we should also notice that it is actually not cost-effective for
the health plan to insist on using the less expensive lab or
radiologist if their reports are not useful. They will have to be done
over again, or some way found around them, and besides frustrating both
the doctor and the patient, that will cost money. There is a big
monetary value to simple coordination across the system; lack of
coordination is one of the biggest sources of waste. I do believe that
as more of healthcare comes to be at risk for the _outcome_ and not
just for doing the procedure or test, we will see more organizations
find ways to really insist on seamless coordination.
  

    
Another part is, again, the lack of standardization. The book has an
appendix about how _not_ to computerize healthcare, and lack of
standardization is a big part of it. Luckily, the rules and money for
digitizing the industry were not in the reform act, but in the earlier
ARRA, the "stimulus" bill, which has not been challenged in court, and
that is proceeding apace. And the administration, under the leadership
of Todd Parks, the Chief Technology Officer of the United States, has
been very vigorous in pushing for meaningful standardized coding of
clinical data, so that they don't come in "differently." 

At the same time, there are now in the Health 2.0 world, pioneering
pieces of software that can actually translate between existing formats
seamlessly.

So there is hope and progress, I believe on the digital coordination
front.
  

    
I think what we really need are standardized patients with
standardized illnesses.  
  

    
Since we don't, <debunix>'s post clearly delineates the interesting
flip side of that. If we had standardized patients and illnesses,
reports could just be checkboxes: This patient has strep - Yes/No. The
more non-standard the case, the more we need standardized, carefully
differentiated, nuanced presentation of the data and images about the
case, because the clinician is making much finer judgments.
  

    
I have no confidence in any of the commercial systems I've been
working with being able to finally get their acts together for a
properly interconvertible & open format--when I see how hard it is for
every tiny incremental change to be addressed in those systems.  

I'm guessing that a variant of the VA network or one of the open
source efforts is eventually going to end up as the defacto standard,
but I haven't played iwth the VA system since I was a medical student
20 years ago, or seen any of the larger open source efforts in
progress.  

My dream system would not only show me all of the patient's labs and
vital signs seamlessly across all encounters and different
labs/providers/clinics, but also would let me more efficiently do the
following:  

-make a graph allowing me to plot multiple types of values over time
-to plot/correlate clinical interventions on the same time axis (with
independent perpendicular axes)

ideally, you could look plot things out, simple or complicated as you
needed, and look at the graph and *see* which interventions
(medications, fluids, procedures) took place when in relationship to
which changes in patient status (vitals signs, lab changes, symptoms
worsening or improving).  

I recently spent three hours doing this by hand for two weeks of
hospitalization on a patient where it was apparent that nearly everyone
involved in her care had made assumptions about various causes and
effects based on NOT understanding what was done where.   The data was
all there, in this case--one hospital system, everything done in
house--but very difficult to extract in a useful form.  Joe, have any
of the systems you've seen--proprietary or open source--been capable of
something like this?
  

    
Joe, my wife's employer is Blue Cross-Blue Shield of Illinois. She's
in IT, but, well, yeah.

I'll do exactly as you say with my employer because it makes a lot of
sense to me. We're a very small shop of 15 employees and the CFO is my
peer and he's also the HR person (and not all that knowledgeable about
these issues) so the book may be a godsend for everyone at the office.

I accept your challenge!

Thanks for all your other suggestions and comments, too. Great stuff.

PS - please bring on the PowerPoint slides.
  

    
> have any of the systems you've seen--proprietary or open
source--been capable of something like this [graphic capability]?

I'm not familiar enough with the systems to say. I can only say that
there are systems out there that seem to work for clinicians. The first
two places I would look would be Kaiser's system, which was put
together with the constant input of teams of doctors from all across
the system; and VistA, the free, open-source system originated in the
Veterans Administration. Like Linux, it has hundreds of developers
contributing modules to it that are freely available to all other
users. It is one of the oldest extant systems out there, and has been
constantly evolved. Many people who use it speak well of it. 
  

    
Glad you accepted the challenge, Chris. I do believe that if we are
going to change the system, people need to understand what the problems
are, and then get involved at the local level, through employers,
local governments, non-profits, health systems, and even health plans.
We have to push for real change.

And I accept the challenge of the "Help me convince my boss!" PPT. We
had a discussion last night about the right way to distribute it, and
we hope to get it out quickly.
  

    
I may be a bit scarce for the rest of today (despite the fact that the
Supreme Court decision may come down today). I am in Lincoln,
Nebraska. Already did a morning radio show, at lunch I speak to the
heads of all the top health systems and insurers in Nebraska, and in
the afternoon all the top not-for-profits. 
  

    
So keep your questions and observations coming, this is a great
discussion — and I will get back to you later today or tomorrow.
  

    

You pointed out the growing shortage of primary care doctors. One
of the results of adopting your ideas would be an increase in demand
for such people. Might this be a problem of success? How can this
issue be minimized?
  

    
Joe, at some point (no hurry) I'd be interesting in hearing your
opinions and thoughts re Kaiser. I've been a Kaiserite for close to 40
years, and love it, but I'd like to hear what you think.
  

    

Here's another story underlining one of your central premises. That the
effect is apparently not large, still, the net benefits appear to make
the effort worth while.

Behavioral Interventions Help Cut Obesity

The U.S. Preventive Services Task Force (USPSTF) has recommended
that obese adult patients receive an intense, comprehensive, and
multi-component behavioral intervention as part of weight-loss treatment.
...
The multi-component intervention "can lead to an average weight loss of
4 to 7 kg ... . These interventions also improve glucose tolerance and
other physiologic risk factors for cardiovascular disease," the task
force wrote.

The new recommendations are graded class B, meaning there is a high
certainty that the net benefit is moderate,

http://www.medpagetoday.com/PrimaryCare/Obesity/33468
  

    

(Joe, thanks for the semi-log regression analysis. Makes it look as though
US health care is absolutely topnotch and the best, far better than anyone 
else. What a fantasy! 

(The reality is that we spend far more than our economy can afford for worse 
outcomes.

(I will keep the two charts close at hand for comparison and discussion.)