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Bitcoin sister technology and healthcare

 

bitcoin

Bitcoin ATM at a Las Vegas casino.

This link explains how a sister technology of bitcoin could change the future of healthcare. It’s a computer code called blockchain — the purportedly unbreakable security backbone of all bitcoin transactions.

“It helps to think about a blockchain kind of like a global computer,” Micah Winkelspecht, founder and CEO of Gem, a blockchain technology company, told Becker’s Hospital Review. “It’s a giant machine that allows us to interoperate with each other and to do that in a very trusted way. Economists call it the global trust machine — a giant network of connected computers all operating together to come to a consensus on what is true.”

Mr. Winkelspecht told the news service that every time   that patients see their physicians, they create wakes of digital activity that ripple through the care continuum, from the pharmacists who fill prescriptions to the pharmaceutical firms from which they order drugs.

“What the blockchain allows us to do is create a new type of fabric for the underlying infrastructure of the entire healthcare industry. It would allow all parties — from insurers to providers — to connect in real-time and share information essentially instantly, without having to pass paper or even data back and forth.”

 

 

 

 

 

 


Curadux CEO looks at overtreatment and undertreatment

We were pleased to read this essay in Modern Healthcare by David L. Brown, M.D., chief executive and co-founder of Curadux, a healthcare decision-support firm that’s partnering with Cambridge Management Group in some projects.

Americans dealing with advanced illness are at risk of overtreatment and undertreatment of their conditions because powerful and silent incentives are often driving their healthcare, rather than their own unique values and goals. After 38 years of practicing medicine inside the world’s elite healthcare institutions, and as a survivor of my own advanced illness, this is my foremost concern for current and future generations of patients and their families.

For those serving inside modern medical institutions, these risks are well known. As one caregiver recently told the Institute of Medicine, “When you take the time to find out what’s most important to patients and families, they make very reasonable choices. The challenge is that our healthcare system does not encourage these conversations, our professional providers frequently do not have the time or training, and treatment measures default to those that are health system centered.”

Healthcare is not always patient-centered because our third-party payer system disrupts the normal buyer-seller relationship we often take for granted. In healthcare, for reasons of public policy, the consumer isn’t always the paying customer for the services they consume, which distorts incentive structures throughout healthcare (and not always for the patient’s benefit).

Overtreatment — treatment that is unnecessary or futile for improving a person’s quality of life—is the dominant problem today. It may cause unwanted, invasive and expensive care, as well as unnecessarily prolonged and painful deaths. Health systems are subtly incentivized to overtreat patients because they generate more revenue based on the volume of services provided. Physicians are incentivized to recommend more services because they want to minimize perceived risks to patients and their own legal liability. Without clear guidance to the contrary, physicians default to treating a condition, often no matter how futile or painful for the patient.

Undertreatment — the lack of necessary treatment for improving a person’s quality of life — is the emerging problem. Policymakers are seeking ways to control healthcare costs as governments bear more financial responsibility for healthcare due to an aging population, the expansion of government programs, and increased consumption of healthcare by individuals. Since policymakers can’t change demographics and since a policy decision has been made to expand programs and subsidies, the primary option left for policymakers is to limit consumption of services.

Like most service industries, healthcare providers have traditionally been paid fees for the services they provide. Healthcare is unique, however, because the third-party payer system eliminates the natural market mechanism for limiting consumer demand and optimizing the quality and quantity of services around the perceived value to the consumer. At present, without a meaningful limit on consumer demand, providers act in their self-interest and deliver higher volume of services, which generates more revenue and increases costs.

To control costs, whether wise or unwise, policymakers opted against moving toward a market-based model whereby consumers assume more responsibility for healthcare and, instead, expanded the current system. They are now testing an artificial mechanism for controlling demand by simply capping payments to providers through population-health concepts. While this may reduce costs, it creates the risk that providers may discourage healthcare services for people who may legitimately benefit from them.

To permanently realign healthcare incentives around the individual would require overhauling the entire system so market forces could naturally optimize consumption. This is unlikely because of legitimate public policy issues and the practical difficulty of overhauling established commercial, financial, and regulatory frameworks in a polarized political environment.

Today, patients must educate themselves and stay actively involved in aligning their values and goals with their healthcare decisions. Primary-care physicians traditionally led this process through end-of-life conversations, but as clinical production pressures and demands have increased, physicians have less time to thoroughly discuss and analyze each patient’s unique values and goals. Instead, physicians now often rely more on other staff to perform this function. While these staff can be useful, the rich expertise provided by experienced physicians is often lost. True patient-centered care for patients and families facing an advanced illness is clearly ready for further innovation.

Dr. David L. Brown has practiced medicine for 38 years. He recently retired as chairman of the Anesthesiology Institute at the Cleveland Clinic. He has also led the anesthesiology departments at the University of Texas M.D. Anderson Cancer Center, University of Iowa Hospital and Clinics, and Virginia Mason Medical Center, as well as serving as professor of anesthesiology at the Mayo Clinic. 

 


Physicians told to embrace ambiguity

foogyroad

A new book, Nonsense: The Power of Not Knowing,  by Jamie Holmes, proposes that physicians would do well to make themselves more comfortable with ambiguity.

“Psychologists have shown that there is a fundamental tension between the ubiquity of ambiguity and our natural preference for definite answers. Misunderstanding that tension and putting too much faith in tests to resolve ambiguity, it turns out, is one cause of medical overtesting,” reads an essay in Slate adapted from the book.

His remarks add to  other studies that support the idea that we need more gray thinking in medicine.

Mr. Holmes has written that rather than placing  such confidence in scans, tests and imaging, physicians should shift  more of their focus to talking with and observing closely the patients  themselves — in all their full personhoods.

“New ways of seeing aren’t necessarily clearer ways of seeing, and sometimes, the illusion of knowing is more dangerous than not knowing at all,” he wrote.


Baltimore medical center at cutting edge of primary care

 

harborplace

The USS Constellation near Baltimore’s Harborplace.

Greater Baltimore Medical Center seems to be  setting the standard for providing quality primary  care during industry upheaval, reports The Baltimore Sun.

Its “comprehensive medical teams that include physicians, nurses, advanced practitioners, nurse care managers and care coordinators are available for extended hours on weekdays and weekends and are always connected to up-to-the-minute patient data through an electronic health record system,” the paper reports.

“Because the offices are interconnected, a patient can go to any of its sites, regardless of where their regular primary-care physician is located. The patient’s test results and other critical information are also available through any of the locations….”

“What’s more, all offices are recognized as Level 3 patient-centered medical homes by the National Committee for Quality Assurance, the highest designation available. And through a Web-based tool known as myGBMC, patients have 24-hour online access to their electronic health records. Using myGBMC, patients can also securely request prescription refills, look up test results, communicate electronically with their caregivers and request referrals to see specialists.”

 

 


Medicare experiment looks like ‘faux managed care’

roulette

By JORDAN RAU and  JENNY GOLD for Kaiser Health News

A high-profile Medicare experiment pushing doctors and hospitals to join together to operate more efficiently has yet to save the government money, with nearly half of the groups costing more than the government estimated their patients would normally cost, federal records show. Providers don’t want to gamble on taking a  financial risk in the program.

The Centers for Medicare & Medicaid Services offers the lure of bonuses to healthcare practitioners who band together as Accountable Care Organizations, or ACOs, to take care of patients. The financial incentives are intended to encourage these physicians, hospitals, nursing homes and other institutions to keep patients healthy rather than primarily treat illnesses, which is what Medicare payments traditionally have rewarded. ACOs that save a substantial amount get to keep a share of the savings as a bonus.

The Obama administration touts ACOs as one of the most promising reforms in the 2010 federal healthcare law. The administration set a goal that by the end of 2018, half of Medicare spending currently based on the volume of procedures a doctor or hospital performs will instead be linked to quality and frugality. But so far the ACO program generally has been a one-way street, with most doctors and hospitals happy to accept bonuses while declining to be on the hook for a share of any excessive costs run up by their patients.

Last year, Medicare paid $60 billion to 353 ACOs to take care of nearly 6 million Medicare beneficiaries. Some ACOs made significant strides in reducing use of hospitals and other costly resources. But patients at 45 percent of groups cost Medicare more than the government had projected based on their patients’ historic costs, records show. After paying bonuses to the strong performers, the ACO program resulted in a net loss of nearly $3 million to the Medicare trust fund, government records show.

“It’s turning out to be tougher to transform care and realign delivery than people had expected,” said Eric Cragun, an analyst with The Advisory Board Company, a consulting group based in Washington.

Medicare officials said most ACOs are still in their infancy, and that performances will improve with experience and ultimately save significant sums for Medicare while improving care for beneficiaries. “In the long run we’re shooting to achieve those goals,” Sean Cavanaugh, CMS’s deputy administrator, said in an interview.

Nonetheless, the results are short of what Medicare projected in 2011 as it launched the program. Those estimates anticipated the government would save between $10 million and $320 million during 2014.

‘Bearing Risk Is A Big Leap’

The ACO program’s bottom line has been hurt by the reluctance of most ACOs to accept financial responsibility for their patients. Only 7 percent of ACOs opted last year for a high-risk/high-reward deal in which they had the potential to earn larger bonuses but would have to reimburse the government should their patients instead cost Medicare more than expected.

The rest of the ACOs opted to avoid the potential of financial punishment even though it meant their potential bonuses would be smaller. The risk aversion proved so widespread that Medicare has given ACOs up to six years to participate without fear of penalties, instead of phasing out that option.

“Many of these ACOs are newly formed groups of doctors and hospitals, and bearing risk is a big leap,” Cavanaugh said.

Last year, 196 ACOs saved Medicare money, while 157 ACOs cost more than expected. Medicare ultimately did not realize any savings because it paid out bonuses to 97 ACOs, but only three of the costly ACOs had to repay Medicare for losses their patients incurred.

In Oregon, North Bend Medical Center ACO patients cost Medicare $9 million. Spending for those patients was 12 percent more than projected, the largest gap of any ACO. In Los Angeles, the government spent $20 million, or 11 percent, more than expected for ACO patients at Cedars-Sinai Medical Care Foundation. That was the largest amount in dollars. Both ACOs had chosen to be exempt from financial penalties.

North Bend dropped out of the program earlier this year.

Cedars-Sinai said its ACO patients ended up more expensive than other previous patients because the hospital added new physician practices specializing in cancer and heart disease, which are among the most costly conditions to treat. Cedars said last Thursday that it unintentionally failed to include those patients in the comparisons it sent to Medicare and was now revising its calculations.

Even some of the ACOs that saved the most money have yet to accept financial risk. Costs for patients at Winchester Community ACO in Massachusetts were 16 percent less than Medicare estimated. The ACO earned a bonus of $5 million. Catharine Robertson, an executive with Winchester Hospital, said their cost-saving initiatives were created when the ACO was formed. One team at the ACO identified patients as high risk of getting sick and sought to intercede before they ended up requiring hospitalization.

“We’re absolutely thrilled with our success the last few years, but the reality is there’s a lot to learn about population-based management,” she said.

The largest bonus in dollars, $23 million, went to Memorial Hermann Accountable Care Organization in Houston, which was 11 percent below Medicare’s cost expectations. Christopher Lloyd, the CEO of Memorial Hermann’s ACO, credited its success to a decade’s worth of changes that improved cooperation among physicians and the hospital, as well as the creation of systems to share medical details of patients.

“The ACO when we formed it in 2012 was just an extension of what we were already doing,” Lloyd said. He said committed ACOs could make the same improvements in three to four years. “What took us 10 years to build does not take 10 years to replicate,” he said. Still, Memorial Hermann, like Winchester, is not yet accepting risk.

Difficulties In Implementing The Program

To wring overall savings for Medicare, the government faces a bind, analysts said. If Medicare makes the potential of repayments mandatory, many existing ACOs may drop out of the program and new ones are less likely to join. If the majority of ACOs continue to risk no financial repercussions, they have less incentive to save the government money. And without showing savings, it will be hard for Medicare to expand the program.

Clif Gaus, president of the National Association of ACOs, said Medicare should be making it easier for ACOs to earn bonuses as they assemble their operations. “Any start-up company, I don’t care who they are, never makes profits in the early years,” Gaus said. “Starting a healthcare delivery system is just as hard, if not harder, than starting a Facebook or an Amazon.”

Because Medicare sets its expectations based on national spending averages, “it’s really hard to save money in some parts of the country,” said David Muhlestein, an executive at the consulting firm Leavitt Partners based in Salt Lake City. “We’ve talked to ACOs that have joined the program, started to make changes and decided that it’s really too much work right now.”

Sharp Healthcare, a well-regarded five-hospital system in San Diego, dropped out of the program last year after concluding it might not be able to avoid penalties. In a financial statement, Sharp said that because Medicare’s assessments are “based on national financial trend factors that are not adjusted for specific conditions that an ACO is facing in a particular region (e.g., San Diego), the model was financially detrimental to Sharp ACO.”

Jeff Goldsmith, a health-industry analyst and professor at the University of Virginia who is a longtime ACO critic, said the ACO model is flawed. Consumers do not actively opt to participate in the ACOs and do not share in any savings, so they lack financial incentives to help keep costs down, he said. ACOs also have limited leverage to control the costs incurred by highly paid specialists such as surgeons and cardiologists. Patients in ACOS can still go to any doctor who accepts Medicare’s regular method of paying, in which they receive a set fee based on the nature of the service without regard to its outcome.

“Faux managed care is actually harder to do than real managed care,” Goldsmith said. The ACO program, he said, “has a bad enough reputation in the provider community that is not going to grow sufficiently to replace regular Medicare.”

The Obama administration is more optimistic. The administration said patients are benefiting with better care, as most quality measures Medicare is using to track ACO performance improved between 2013 and 2014.

CMS’ actuaries believe the ACOs are performing better than they appear when compared to the historical benchmarks that the health law established, which CMS has been using. The actuaries employed an alternative method in a report issued last spring, comparing Medicare spending trends in places with ACOs and those without, and concluded that, overall, ACOs were saving money.

Still, ACOs’ appetite for taking risk remains small. The number of ACOs opting for the largest potential bonuses and penalties has shrunk from 32 at the start of the program to 19. Rob Lazerow, an Advisory Board consultant, said, “In a world where ACOs are still optional, CMS still has to make it attractive for providers to want to participate.”


In the end, these patients must manage own care

 

A look at how it works when patients with multiple chronic illnesses must take charge of managing their own care:

As a Wall Street Journal article notes: “Managing those people’s health care is often difficult. Integrated health systems, such as Kaiser Permanente and Mayo Clinic, aim to ensure that treatment for one condition doesn’t interfere with care the patient is receiving for other diseases. Often, however, the responsibility of coordinating treatments falls on the patients themselves.”

Trying to avoid serious complications from taking different medications and dealing with the fact that too  often physicians of a patient with multiple chronic illnesses don’t talk with each other about the patient’s case are among the biggest challenges.

Maybe it will help that the U.S. Department of Health and Human Services (HHS) has issued a curriculum for training healthcare professionals and others in caring for patients with multiple chronic conditions.

HHS has taken other steps to help patients with multiple chronic conditions. The Centers for Medicare and Medicaid Services,  a HHS agency, now reimburse providers for time spent coordinating chronically ill patients’ care  outside of regular office visits.

Obviously, many experts hope that electronic health records will increasingly help  physicians keep track of their chronically ill patients.

One recommendation is that patients create  their own  medical records by, for example, keeping  updated lists of medicines that  they are taking  and bringing  them to all visits to physicians.

 

 


NPs do well vs. physicians in diagnostics study

 

physical

A comparison of the diagnostic abilities of physicians and nurse practitioners in New Zealand found that  the latter were almost as good in diagnosis as the doctors in a complex inpatient case of a seriously ill man.

The correct diagnosis was made by 61.9 percent of physicians and 54.7 percent of NPs. The correct problem was identified by 56.3 percent of physicians and 53.3 percent of NPs. The correct actions were identified by 34.4 percent of the physicians and 35.8 percent of the NPs.

The study concluded that NP diagnostic reasoning in a complex-case scenario compared favorably with that of physicians.

Such studies, of course, give more firepower to U.S. hospital C-suites seeking to use more NPs and fewer physicians because the former, while well paid, aren’t anywhere nearly as well compensated as physicians. The latter are by far the highest paid doctors in the world.


A fresh look at physician employment by hospitals

 

doctor

“The Doctor,” by Luke Fildes 

With health-insurance companies and hospital systems getting fewer and bigger, more physicians are seeking to work in hospitals, which have more price-power than  do  physician groups.

Paul Keckley, of Navigant Healthcare, takes a fresh look at physician employment by hospitals. He poses some big questions and at least implies some answers.

“Here’s the challenge for hospitals: employing physicians is not a slam dunk, even if the market is benign about shared risk arrangements with payers. Physicians want clinical autonomy whether employed or not. Physicians want the technologies and tools that are required to ply their trade and they expect them to help, not hinder their work. Physicians want to be heard on matters of consequence to the entire organization, not just clinical issues de jour. Physicians want to be  ‘in the room,’not outside looking in. Physicians want to be compensated for their experience and aptitude, not just their production. And they want to be aligned with a winning organization that’s recognized for quality and well-positioned long term.”

“In tandem with the Healthcare Financial Management Association, we gathered impressions from the administrators of 44 hospital-sponsored group practices to see how their marriage with the hospital is working. They’re losing sleep over three concerns:

Operations: “We worry about how to operate the group efficiently as payments shift from volume to value, margins shrink, and costs for information technology and labor increase. It’s a tough job, and it’s a different job than running the hospital.”

Compensation: “We worry about how to compensate doctors as the change from production to performance accelerates. Doctors like to ‘eat what they kill’ and they expect to get paid well. Something’s gotta give.”

Recruitment: “We worry about how we will recruit new physicians to join the group and sustain its growth.”    

 

 

 


The eyes have it: The growing role of optometrists

optom

In another sign of the increasing role of non-physician clinicians, Modern Healthcare reports, “o}ptometrists are working more closely with physicians and insurers to identify patients’ chronic conditions and make sure those patients receive appropriate medical care. They want to demonstrate that they have the training and skills to do more than just fit people for glasses and contact lenses.”
An example: “The Charlotte, N.C.-based Carolinas HealthCare System is working with Vision Source, a Kingwood, Texas-based network of 3,800 independent optometrists, to boost its performance in serving diabetes patients and raise its diabetes-care quality score.”
“Three white papers done at UnitedHealthcare found that eye-care professionals were effective in identifying patients with diabetes, high cholesterol, hypertension, juvenile rheumatoid arthritis and multiple sclerosis. ”

Addressing the crisis of physician burnout

 

suicide

“The Suicide,” by Edouard Manet.

Arnold R. Eiser, M.D., discusses physician burnout and that doctors have a considerably higher suicide rate does than the general population.

He ends his essay, a blog on  The Philadelphia Inquirer Web site, with:

”I think it is fair to say that there a crisis in medical practice in the United States. We need to examine the cultural and social causes of this crisis if we are to maintain high professional standards for the medical profession.  No patient wants a clinician taking care of them who is burned out, depressed, or suicidal.  However, if we just focus on individuals and their psychological shortcomings, we will miss the big picture of factors afflicting postmodern healthcare.

”As a start we need to teach physicians-in-training how to deal better with stress. Mindfulness training including meditation, case discussions of stressful practice situations, and other positive psychology practices need to be part of the curriculum of medical schools and should also be made available to practicing physicians. We also need to re-examine the current best practices in medicine to take into account their psychological impact on clinicians. Reevaluating the usual way of doing business in medicine is not just important for clinicians. It is also essential for the good of their patients and of society too.”


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