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The bottom line of reducing clinical variation

September 6, 2016by Robert Whitcomb in Uncategorized tagged , , , , , , , , , , , ,

bottomline

Donna Hopkins, R.N., vice president for  the healthcare-consulting firm Novia Strategies, led a Becker’s Hospital Review seminar on reducing clinical variation to improve hospitals’ bottom line. As Becker’s noted: “Clinical variation involves the overuse, underuse, different use and waste of healthcare practices and services with varying outcomes.”

“Reducing clinical variations means creating uniform clinical guidelines and order sets, reducing tests and procedures, eliminating care gaps and delivering true interdisciplinary care,” said Ms. Hopkins.

The panel’s participants discussed successes in clinical variation.

Here are  some highlights:

Steven Goldstein, CEO of Strong Memorial Hospital, in Rochester, N.Y., said reducing clinical variation within clinical redesign efforts is, in Becker’s paraphrase, “imperative for staying viable under risk-based payment models, and CMS’S goal to link 50 percent of Medicare payments to value-based reimbursement models by 2018 has fueled the sense of urgency around such efforts.”

Patrice M. Weiss, M.D., CMO, of Roanoke, Va.-based Carilion Clinic,  said that after the American College of Obstetricians and Gynecologists recommended in 2013  refraining from inducing elective deliveries before 39 weeks of gestation, Dr. Weiss pushed to eliminate them at Carilion altogether.

“We quickly became one of the lowest early induction rate hospitals,” she said, noting that her hospital’s rate was less than 1 percent. “Then we received a letter from the state of Virginia that said a different Carilion hospital had a 17 percent early induction rate.”

Becker’s reported: “Dr. Weiss said she realized then that reducing clinical variation means hospital executives must know the differences in practices between hospitals, even within one system.”

Shelly Hunter, CFO of Mercy Hospital Joplin (Mo.),  noted:

“If you have wide variation, you have less predictability in your finances, which leads to lower operating performance.”

She  continued, in Becker’s paraphrase: “With standardized care, there are better outcomes for patients, fewer complications, lower rates of readmission and higher performance on other quality-based metrics that are tied to reimbursement. Importantly, as hospitals zero in on eliminating waste and duplicative services, standardized clinical pathways help reduce over-utilization of tests and labs. On the other hand, with high clinical variation and erratic utilization, it’s much more difficult to accurately predict costs.”

“In addition to quality-based metrics, patient satisfaction scores measured by HCAHPS affect federal reimbursement to hospitals. Clinical variation has the potential to derail patient satisfaction because lack of standardized care can lead to medical errors, complications, increased length of stay and readmissions, among other issues.”

“It is absolutely key that physicians are on board and engaged” with clinical variation reduction efforts, said Dr. Weiss.  She added (Becker’s paraphrase): “Achieving systemwide physician engagement requires identifying and naming physician champions to serve as leaders. A strong physician champion is clinically active, highly respected by their peers, enthusiastic about effecting positive change and a strong communicator. While hospital administrators might be inclined to turn to department chairs or the most productive physicians to serve as physician champions, these factors alone don’t mean a provider will be a successful leader.”

 

Nancy Lakier, R.N., CEO of Novia, said that physicians are, in varying degrees, scientists. and so will want to see data before they change.  “When physicians look at solid risk-adjusted data, and they don’t feel that they are being told what to do but rather being supported with data, we find they very quickly use this information to improve the care they provide for their patients,” she said.

To read the whole story on the Webinar, please hit this link.

 

Who pays the bill for a medical mistake?

November 10, 2015by Robert Whitcomb in Uncategorized tagged , , , , , , , , , ,

By SHEFALI LUTHRA

For Kaiser Health News

When Charles Thompson of Greenville, S.C., checked into the hospital one July morning in 2011, he expected a standard colonoscopy. He never anticipated how wrong things would go.

Partway through, a doctor emerged from the operating room to tell Thompson’s wife, Ann, that there had been complications: His colon may have been punctured. He needed emergency surgery.

Thompson, now 61, almost died on the operating table after experiencing cardiac distress. His right coronary artery required multiple stents. He also relies on a pacemaker. “He’s not the same as before,” said Ann Thompson, 62. “Our whole lifestyle changed — now all we do is sit at home and go to church. And that’s because he’s scared of dying.”

When things like this happen, questions arise: Who’s responsible? If treatment makes things worse — meaning that a patient needs more care than expected — who pays?

It depends.

Despite provisions in the Affordable Care Act that put added emphasis on quality of care, entering the hospital still carries risk. Whether because of mistakes, infections or plain bad luck, those who go in don’t always come out better. More than 400,000 Americans die annually in part because of avoidable medical errors, according to a 2013 estimate published in the Journal of Patient Safety.

In 2008, the most recent year studied, medical errors cost the country $19.5 billion, most of which was spent on extra care and medication, according to another report. If a problem such as Thompson’s stemmed from negligence, a malpractice lawsuit may be an option. But lawyers who collect only when there’s a settlement or a victory may not take on a case unless it’s exceptionally clear that the doctor or hospital was at fault.

That creates a Catch-22, said John Goldberg, a professor at Harvard Law School and an expert in tort law. “We’ll never know if something has happened because of malpractice,” he said, “because it’s not financially viable to bring a lawsuit.”

That leaves the patient responsible for extra costs. Ann and Charles Thompson maintain that he experienced an avoidable error. The hospital denied wrongdoing, she said, but the physician’s notes indicated  that they had been advised of the risks of the procedure, including injury to the colon.

The Thompsons tried pursuing a lawsuit but couldn’t find a lawyer who would take the case. The hospital and the doctor declined to comment, with the hospital citing patient privacy laws. Because of his heart problem, which led to the loss of his specialized driver’s license, Thompson lost his truckdriving job. He lost the health insurance he had through his job, depriving him of help in paying for follow-up care.

The couple paid close to $600,000 out of pocket, depleting their life savings. They struggled to pay other bills until Thompson was awarded disability benefits, his wife said. “You would expect if [health-care providers] make the mistake, they would make you whole,” said Leah Binder, president of the Leapfrog Group, a nonprofit organization that grades hospitals on their record of preventing errors, injuries, accidents and infections. “But that is not what happens. In health care, you pay and you pay and you pay.”

There’s no single rule for how hospitals handle the cost of care when patients have bad outcomes and fault is disputed, said Nancy Foster, vice president for quality and patient safety at the American Hospital Association. Some hospitals have rules requiring that a patient be told right away if something happened that shouldn’t have and, to the best of the institution’s knowledge, why.

Typically, those rules stipulate that if the hospital finds that it erred, the necessary follow-up care is free. Hospitals may not have an obvious financial interest in admitting guilt, though research suggests that patients are less likely to sue when hospitals are transparent about medical mishaps.

“If the [need for further] care was preventable, we’re waiving bills,” said David Mayer, vice president of quality and safety for MedStar Health, which operates 10 hospitals in the Baltimore/Washington area.

Virginia’s Inova Health System has a similar policy, said spokeswoman Tracy Connell. Most hospitals don’t have such rules, said Julia Hallisy, a patient-safety advocate from California.

That may change: A number of professional and safety groups are urging more hospitals to adopt them. Supporters include the American College of Obstetricians and Gynecologists, the American Medical Association, Leapfrog, the National Quality Forum and the Joint Commission, which accredits many health-care organizations. The federal Agency for Healthcare Research and Quality is also on board.

But even when they tell patients that something went wrong, hospitals may say it was unavoidable. Then, patients often pay for the consequences, directly or through their insurance. Determining error can be straightforward, Mayer said, in such instances as misdiagnosis or operating on the patient’s left leg when his problem was with his right leg.

Other times, providers follow correct procedures but things go wrong. Then, hospitals can deny culpability. “Some things happen, and it’s hard to tell if it could truly have been avoided,” Binder said. If hospitals don’t agree to pay for unexpected care, employers might push them to do so because absorbing such costs might eat into the firm’s profits.

On average, a privately insured patient cost about $39,000 more — $56,000 vs. $17,000 — in hospital bills when surgery led to complications than when it did not, according to a 2013 study in the Journal of the American Medical Association.

People with employer-based insurance — 147 million Americans this year — who have experienced complications or otherwise gotten worse while in the hospital should contact their benefits offices, especially if they can show hospital error, Binder said. If that doesn’t pan out, insurance plans may step in.

When insurers add hospitals to their networks, they sometimes stipulate how to handle certain errors. For some mistakes, the hospital may provide necessary follow-up care for free, part of a “bundled payment,” said Clare Krusing, a spokeswoman for America’s Health Insurance Plans, a trade group. For that to apply, complications must clearly stem from bad treatment. In other situations, patients can complain through the insurer, which should work with the hospital to determine who’s responsible.

Patients, Krusing said, shouldn’t pay for what’s out of their control. And if the hospital doesn’t provide financial assistance, insurance should cover these unexpected expenses once the patient has met his or her deductible.

“Patients don’t normally think about these issues — and who would? They don’t think of any of these issues until they’re right in the middle of it,” patient-safety advocate Hallisy said. “At that moment, they’re completely shocked and overwhelmed to think that this is how this works.”

 

Why your physician probably won’t ‘friend’ you

August 26, 2015by Robert Whitcomb in Uncategorized tagged , , , , , , , , , , , ,

friends

By SHEFALI LUTHRA, for Kaiser Health News

Physicians’ practices are increasingly trying to reach their patients online. But don’t expect your doctor to “friend” you on Facebook – at least, not just yet.

Physicians generally draw a line: Public professional pages – focused on medicine, similar to those other businesses offer – are catching on. Some might email with patients. But doctors aren’t ready to share vacation photos and other more intimate details with patients, or even to advise them on medication or treatment options via private chats. They’re hesitant to blur the lines between personal lives and professional work and nervous about the privacy issues that could arise in discussing specific medical concerns on most Internet platforms.

Some of that may eventually change. One group, the American College of Obstetricians and Gynecologists, broke new ground this year in its latest social-media guidelines. It declined to advise members against becoming Facebook friends, instead leaving it to physicians to decide.

“If the physician or health care provider trusts the relationships enough … we didn’t feel like it was appropriate to really try to outlaw that,” said Nathaniel DeNicola, M.D., an ob-gyn and clinical associate at the University of Pennsylvania, who helped write the ACOG guidelines.

But even the use of these professional pages raises questions: How secure are these forums for talking about often sensitive health information? When does using one complicate the doctor-patient relationship? Where should boundaries be drawn?

For patients, connecting with a physician’s office or group practice on Facebook can be a simple way to keep up with basic health news. It’s not unlike following a favorite sports team, your child’s middle school or the local grocery store.

One Texas-based obstetrics and gynecology practice, for instance, uses a public Facebook page to share tips about pregnancy and childcare, with posts ranging from suggestions on how to stay cool in the summer to new research on effective exercise for post-birth weight gain. Practices have also been known to share healthy recipes, medical research news, and scheduling details for the flu shot season..

“I have people come up to me and say, ‘I follow you on Facebook — thank you for posting this particular article. It helped me and my husband and my family,’” said Lisa Shaver,  M.D., a primary-care physician based in Portland, Ore.

But unless they’re already friends, she won’t add patients to her personal account — where, she said, she posts less health information and more cat videos.

Historically, professional groups including the American College of Physicians and American Academy of Family Physicians have advised against communicating through personal Facebook pages. The American Medical Association notes that social media can be a valuable way to spread health information, but urged doctors in its 2010 guidelines  to separate their personal and professional online identities to “maintain professional boundaries.”

Finding ways to use Facebook and other forms of social media to connect with patients — even if it may just be through professional pages — fits a trend in which patients seek more equal footing with their doctors, said Zack Berger,  M.D., an assistant professor of medicine at the Johns Hopkins School of Medicine who studies patient-doctor relationships and social media. It also follows what James Colbert, M.D., a hospitalist at Massachusetts-based Newton Wellesley (Mass.) Hospital, described as the growing consumer approach to medicine — including the notion that patients should be able to reach their physicians at all hours. Colbert is also an instructor at Harvard Medical School who researches how patients want to fit social technology into their health care.

Email can be particularly convenient method, though it isn’t without concerns. Eva Schweber, 44, emails her doctor from a personal account and sends messages through an online portal — a more digitally secure system that is being adopted by a growing number of practices. The portal, she said, is for discussing complex, specific information. She’ll email her doctor from her personal email for less private concerns: scheduling, filling prescriptions and asking if certain symptoms might warrant a check-up.

“The unsecure email is easier, in that I can do it from my phone, my tablet, whatever,” said Schweber, of Portland, Ore.

In a recent study published in the Journal of General Internal Medicine, almost 20 percent of patient respondents reported trying to contact doctors through Facebook, and almost 40 percent through email. “Patients want to communicate with doctors [in whatever way] is convenient,” said Joy Lee, a postdoctoral research fellow at the Johns Hopkins Bloomberg School of Public Health, and the study’s lead author.

Doctors don’t yet seem to share that enthusiasm, Colbert said.

Meanwhile, security questions persist.

Social-networking platforms aren’t usually digitally encrypted, increasing the odds they could get hacked or shared with third parties. The same worries hold true for other, casual forms of online communication such as email and text-messaging.

That means doctors who discuss specific health concerns with patients through those could break the Health Insurance Portability and Accountability Act, the patient privacy law.

“Those concerns are always going to be there,” said David Fleming, past president of the American College of Physicians. “How private is it when we share, when we talk to people? … Once I’ve written it or once I’ve emailed it, it’s gone, and I have no control.”

But because HIPAA was written before email and social media’s ascent, it may not address patient preferences or behavior, Colbert said. With more patients becoming comfortable using personal accounts for health needs, he said, the law perhaps deserves another look.

“Should we allow patients to be able to share or send messages without going through these privacy safeguards if they’re willing to do so? Or do we say that that’s not safe and even if patients don’t care about privacy we need to protect them,” he said. “That’s an open question.”

That public nature is a real worry for such patients as Katie Cardenas, 45, who lives in Garner, N.C. She doesn’t think that Facebook is secure enough for personal medical details. For sensitive information, she’ll usually send messages through a patient portal, the more secure website her doctor’s practice has set up.

Doctors could address that, several said, by using social media in other ways. These include maintaining active Twitter presences and professional Facebook pages for less-tailored health tips. That way, patients can get useful information and a sense of their doctors as people, but privacy stays intact and physicians maintain distance.

At the Minnesota-based St. Cloud Medical Group, patients can follow a public page. Doctors who are part of the practice post updates with safety tips and seasonal health reminders, or use the page to coordinate and publicize small projects, such as a week-long initiative geared to reducing children’s screen time.

Julie Anderson, a family physician who is also part of the practice, sees the value in this option, but doesn’t personally befriend patients on Facebook. Beyond patient privacy, she said, she fears blurring her personal and professional lives, or patients using that access to seek extra care when she’s off the clock.

“I’ve known colleagues that have friended somebody and have had inappropriate questions asked online, in terms of kind of abusing service,” she said. “Or abusing that … Facebook friendship, where they’re asking medical advice and you’re not even their physician.”

Gimlet eye on fetal-ultrasound-scan boom

July 19, 2015by Robert Whitcomb in Uncategorized tagged , , , , ,

fetus

Is this another medical profit center that needs considerably more limits?

The Wall Street Journal reports that “women have been getting fetal ultrasound scans at sharply higher rates than before, and parents have turned the images of their unborn into fixtures of social media.”

“In 2014, usage in the U.S. of the most common fetal-ultrasound procedures averaged 5.2 per delivery, up 92% from 2004, according to an analysis of data compiled for The Wall Street Journal by FAIR Health Inc., a nonprofit aggregator of insurance claims. Some women report getting scans at every doctor visit during pregnancy.

“But medical experts are now warning that frequent scans in low-risk pregnancies aren’t medically justified. A joint statement in May 2014 from several medical societies, including the American College of Obstetricians and Gynecologists, calls for one or two ultrasounds in low-risk, complication-free pregnancies.”

More problematically:

“Some animal experiments have suggested ill effects of ultrasound on embryos of mice and chickens. And multiple fetal ultrasounds can raise false alarms, including overestimation of fetal size that can lead to potentially unnecessary caesarean deliveries. ‘Increased use of prenatal ultrasound scanning may be contributing to the rising CD [caesarean delivery] rate,’ said a 2012 paper in the American Journal of Obstetrics and Gynecology.”

 

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