This probably won’t surprise many people. But it’s useful to have some numbers on this matter.
A study by researchers from Harvard Medical School and published in the January issue of Health Affairs looked at multipayer claims data from 2014 to assess how insurers’ market power affected the rates that they could negotiate for office-based physician services.
They found that the greater market power gave insurers a big advantage. Consider that for rates for office visits paid to the same group of providers, insurers with market shares of at least 15 percent negotiated prices 21 percent lower than prices negotiated by insurers with market shares of less than 5 percent.
The Wall Street Journal reports that “{t}o make sure {medical} residents ask for help from a senior doctor, more hospitals are developing formal ‘escalation-of-care’ policies with clear guidelines on when it’s time to call one. Residents may fail to ask for help due to overconfidence, lack of knowledge or fear of seeming incompetent, studies show.”
The paper notes “Escalation-of-care guidelines are part of a broader effort to improve the way residents are trained and change a medical culture that sometimes fosters intimidation of new residents by senior physicians.”
It looks at how four Harvard Medical School-affiliated hospitals have developed new communication standards and issued residents a pocket card “listing 15 situations that require prompt notification or approval of a senior colleague, such as a patient’s transfer to the intensive-care unit.”
The study found an significant inverse association between spending and probability of a malpractice claim.
Dr. Jenna told MedPage Today:
“One of the reasons that might be the case is our research highlights the possibility that by asking doctors to reduce their spending, it may expose them to additional liability risk. It may help explain why doctors may be reluctant to reduce their utilization, because there could be a direct cost to them of doing so.”
But MedPage Today said that Jena concluded that it’s too early to say physicians should continue to spend more on their patients.
“I think that kind of reasoning would follow from our findings, but this is the first study to really answer this question. Before I would feel comfortable making that kind of conclusion, we would want to see additional evidence on the topic.”
He added: “Patients may look at spending as a reflection of how much investment the doctor made in a particular case. In cases where spending is higher, patients are relatively more reassured than in cases where spending was lower.”
Researchers found that when small practices of physicians join large hospitals, their patients pay an average of $75 more every year for such outpatient services as check-ups, although the number of appointments stays the same.
The Boston Globe reports that:
“With data from cities across the United States, the study is the first to document the cost of physician acquisitions by hospitals on a national scale.”
“Economists have known for decades that when hospitals merge, prices go up. If you’re the only shop in town, you can charge whatever you like, and insurance companies have no choice but to accept those prices. But it wasn’t clear what happens when smaller doctors’ offices join hospitals.”
“{I}f a hospital employs most of the doctors in a city, then insurance companies don’t have much choice but to accept the hospital’s prices, even if they are higher than what Medicare is willing to pay.”
“The same goes for physicians who join big hospitals. They suddenly gain the institution’s bargaining power, and can charge more.”
Physicians’ march into hospitals probably will continue because of the Affordable Care Act. That law encouraged integrating different parts of the healthcare system in the hope that it would eventually reduce costs. But some worry that providers will simply reorganize to deal lucratively with new payment models.
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.”
If they do, of course, it would obviously have huge effects on the healthcare system.
Reports reports that new experimental drugs from Eli Lilly and Co. and Biogen “have shown promise in slowing down the progression of the mind-wasting disease, attracting the attention of investors and patients.
“Those drugs are still very early in their development and could still join the scrap heap. But the field has gained a major understanding of how the brain changes with Alzheimer’s and better insight on how and when to intervene medically.”
The Lilly and Biogen drugs block beta amyloid, a protein that causes toxic brain plaques that are markers of the disease.
“‘This year is different because multiple mechanisms are being explored and there’s a tremendous revival of faith in the anti-amyloid approach,’ said Reisa Sperling, M.D., director of the Center for Alzheimer’s Research at the Harvard Medical School, told Reuters.
An officially estimated 5 million people have the disease in the United States, but some experts think that the real number is considerably higher. The Alzheimer’s Association projects that up 28 million Americans will develop the disease by 2050 and eat up 25 percent of Medicare spending by 2040.
During a recent physical, Jeff Gordon’s doctor told him that he may be pre-diabetic. It was a quick mention, mixed in with a review of blood-pressure numbers, other vital statistics like his heart rate, height and weight, and details about his prescription for cholesterol medication. Normally, Gordon, 70, a food broker who lives in Washington, D.C., would have paid it little attention.
But his physician, who recently joined MedStar Health, uses the system’s Web portal that allows him to share his office notes with patients. For Gordon, seeing the word “pre-diabetic” in writing made it difficult to ignore, and he took action.
He contacted MedStar about joining a pre-diabetes clinical study. In the course of taking the tests required to participate, the otherwise healthy septuagenarian found out his blood sugar wasn’t elevated enough to qualify.
Still, the experience of seeing the term in his doctor’s notes was a “wake-up call,” inspiring him to pay more attention to his diet and exercise. “It’s harder to ignore when it’s in your face,” he said.
This kind of note-sharing got a kick-start five years ago when researchers from Harvard Medical School joined forces with the Pennsylvania-based Geisinger Health System and Harborview Medical Center in Seattle to launch a high-profile pilot program called Open Notes. The initiative focused on encouraging healthcare providers to give patients access to doctors’ office notes and then tracked what happened when patients read them. Even before the project, some providers had independently shared notes, but since the organized effort began, interest has grown.
Now, Open Notes estimates about 5 million people see physicians who share notes as part of the initiative, said Tom Delbanco, a professor at Harvard Medical School who has been with the project since it launched. That includes doctors from more than 20 institutions across the country, consisting of major academic medical centers and health systems ranging from the Cleveland Clinic to the Veterans Health Administration to Wellspan, in Maryland and Pennsylvania. And even beyond the project’s participants, there is a trend among physicians — such as Gordon’s doctor — to move in this direction, too.
It’s part of the health system’s growing focus on patient engagement – the idea that more informed people will take better care of themselves, improving their health while lowering costs. This emphasis is driven in part by the federal health law, which links Medicare payments to how well hospitals and doctors do at getting and keeping patients healthy.
The trend is also fueled, experts suggest, by components in the health law and the earlier financial stimulus law that set out financial incentives for doctors to use electronic health records and better connect with patients online.
Advocates say that open notes could fundamentally shift the doctor-patient relationship by making it less paternalistic, putting patients in a position to catch mistakes and have more informed conversations with their physicians. But others worry the practice could curb honesty in what doctors write about their patients, or cause confusion if patients misinterpret what’s written.
What doctors write is hardly the stuff of state secrets. Some portions are technical to the point of dullness. Other portions offer clear, valuable advice.
In one note, shared by a patient who requested his name be withheld due to privacy reasons, a doctor wrote, in the context of a potential diagnosis of a hand deformity condition called Dupuytren’s contracture, that the patient’s “sensation is intact in the medial, ulnar and radial nerve distribution.” Hard to understand, yes, but still helpful to the patient for tracking the condition. Even more helpful, perhaps, is the physician’s summary of the condition: “It is very early, so we just need to monitor it.”
Some healthcare providers, though, worry patients might misuse the information – attempting to diagnose themselves or declining beneficial treatment because they misunderstand what’s written. That isn’t out of the question, said Jan Walker, a research associate at Harvard and Beth Israel Deaconess Medical Center, who also worked on the Open Notes project. “We certainly believe so far, the good far outweighs the bad,” she said.
Kenneth Burman, director of endocrinology at MedStar Washington Hospital Center, said he independently began sharing his notes with patients years ago, mailing them a private copy. When patients read their notes, he said, they can actually “understand the diagnosis and the recommendations.” Patients will look things up, he added, and occasionally correct references to things like family history, or add relevant details he might have missed.
Though he can’t document it, he said patients are generally better about following through with treatment if they get to read their notes. “It helps the patient understand the disease process and what the course of action should be,” Burman said.
How patients respond to this disclosure varies. Some use notes as helpful reminders while others use the information to challenge a physician’s recommendation and help rule out a diagnoses.
For Kent Snyder, 63, a lawyer from Portland, Ore., note-sharing was particularly helpful when he developed arthritis-like symptoms and vision trouble – part of an autoimmune condition doctors still haven’t been able to figure out.
Reading what his doctors had written, Snyder said, helped him focus conversations on “key salient issues” – for instance, correcting physicians about symptoms he’d actually experienced, which in turn allowed them to rule out potential diagnoses.
Looking at his notes, Snyder added, meant he better understood why doctors ordered certain procedures or treatments.
“It’s not just money – I don’t want to take an antibiotic unless I absolutely have to,” he said. “I don’t want to have a test if I don’t need it.”
Patients’ abilities to fix errors in their records could encourage providers to adopt note-sharing, especially if it could reduce the odds of doctor mistakes, said Steven Weinberger, CEO of the American College of Physicians, which represents internal-medicine doctors.
But while doctors and patients said they knew anecdotally of patients finding and fixing mistakes when looking at their notes, Walker said there’s no research measuring how common it is and what effect it could have on patient outcomes or satisfaction.
Some physicians worry that sharing notes could require them to change what they write so it’s easier for patients to understand, Weinberger said. Peter Elias, an Auburn, Maine-based physician, said colleagues often worry they might have to omit things for fear of confusing or upsetting patients. But, he added, sharing notes makes him have important conversations he might otherwise have skipped.
When patients see what doctors write, he said, “it makes the difficult conversations essential. You can’t skip them anymore.”
A $450,000 grant from the Commonwealth Fund is helping to develop the OurNotes platform — which extends the OpenNotes program giving patients greater access to their EHR’s.
The places involved in the new program are Beth Israel Deaconess Medical Center (BIDMC), in Boston, Geisinger Health System, in Danville, Pa., Harborview Medical Center in Seattle, Group Health Cooperative, in Seattle, and Mosaic Life Care, in St. Joseph, Mo.
“This is really building for the future. We envision the potential capability of OurNotes to range from allowing patients to, for example, add a list of topics or questions they’d like to cover during an upcoming visit, creating efficiency in that visit, to inviting patient to review and sign off on notes after a visit as way to ensure that patients and clinicians are on the same page,” the principal investigator, Jan Walker, RN, MBA, of the division of general medicine and primary care at BIDMC and assistant professor of medicine at Harvard Medical School, told Medical Economics.
Medicare is giving bonuses to a majority of hospitals that it graded on quality, but many of those rewards will be wiped out by penalties the government has issued for other shortcomings, federal data show.
As required by the 2010 health law, the government is taking performance into account when paying hospitals, one of the biggest changes in Medicare’s 50-year-history. This year 1,700 hospitals – 55 percent of those graded – earned higher payments for providing comparatively good care in the federal government’s most comprehensive review of quality. The government measured criteria such as patient satisfaction, lower death rates and how much patients cost Medicare. This incentive program, known as value-based purchasing, led to penalties for 1,360 hospitals.
When all these incentive programs are combined, the average bonus for large hospitals — those with more than 400 beds — will be nearly $213,000, while the average penalty will be about $1.2 million, according to estimates by Eric Fontana, an analyst at The Advisory Board Co. a consulting company based in Washington. For hospitals with 200 or fewer beds, the average bonus will be about $32,000 and the average penalty will be about $131,000, Fontana estimated. Twenty-eight percent of hospitals will break even or get extra money.
On top of that, Medicare this year also began docking about 200 hospitals for not making enough progress in switching over to electronic medical records. Together, more than 6 percent of Medicare payments are contingent on performance.
“You’re starting to talk about real money,” said Josh Seidman, a hospital adviser at Avalere Health, another consulting firm in Washington. “That becomes a really big driver; it really gets the attention of the chief financial officer as well as everybody else in the executive suite of the hospital.”
Among these programs, the Hospital Value-Based Purchasing initiative, now in its third year, is the only one that offers bonuses as well as penalties. It is also the only one that recognizes hospital improvement even if a hospital’s quality metrics are still subpar. The value-based purchasing bonuses and penalties were based on 26 different measures, including how consistently hospitals followed a dozen recommended medical guidelines, such as giving patients antibiotics within an hour of surgery, and how patients rated their experiences while in the hospital. Medicare also examined death rates for congestive heart failure, heart attack and pneumonia patients, as well as bloodstream infections from catheters and serious complications from surgery such as blood clots.
Adding An Efficiency Measure
Medicare this year added a measure intended to encourage hospitals to deliver care in the most efficient manner possible. Federal officials calculated what it cost to care for each hospital’s average patient, not only during the patient’s stay but also in the three days before and a month after. Often the biggest differences in medical costs between hospitals are due to what happens to patients after they leave. For instance, Medicare pays more to inpatient rehabilitation facilities than it does to skilled nursing homes, even though both treat similar kinds of patients.
“It’s your one opportunity either to make money on pay-for-performance or at least recoup some of the potential losses you have from the other programs,” said Paul Matsui, who directs data research at The Advisory Board Company.
This year, Medicare judged hospitals based on how they performed in comparison to others in the second half of 2012 and all of 2013, and how much they had improved from two years before. Medicare adds a hospital’s bonus or penalty to every Medicare reimbursement for a patient stay from last October through the end of September.
Nearly 500 more hospitals earned bonuses in the value-based purchasing program compared to last year. The biggest is going to Black River Community Medical Center in Poplar Bluff, Mo., which is getting a 2.09 percent increase, the analysis found. The largest penalty this year is assigned to the Massachusetts Eye and Ear Infirmary, a teaching hospital of Harvard Medical School, in Boston. It is losing 1.24 percent of its Medicare payments.
The Massachusetts infirmary said in a statement that it was losing only about $60,000 because most of its patients do not remain overnight in the hospital, and the penalties only apply to inpatient stays. The infirmary had so few of those cases that Medicare could not assess its performance on more than half the measures the government uses. Medicare’s program “is a poor match for what” the infirmary does, it said.
Nationally, the average bonus for hospitals under value-based purchasing was a 0.44 percent increase, while the average penalty — not including the other penalty programs — was a 0.30 percent reduction, the KHN analysis found. The actual dollar amount will depend on the mix of Medicare patients that hospitals treat through September and how much they bill Medicare. Medicare set aside 1.5 percent of its payments for the incentives, totaling about $1.4 billion.
States Most Impacted
Medicare awarded bonuses to at least three-fourths of the hospitals it evaluated in Alaska, Hawaii, Maine, Minnesota, Montana, Oregon, South Dakota and Wisconsin, the KHN analysis found. Medicare penalized more than half the hospitals it evaluated in Arizona, Arkansas, California, Connecticut, Delaware, the District of Columbia, Florida, Nevada, New Jersey, New York, North Dakota, Pennsylvania, Washington and Wyoming.
More than 1,600 hospitals were exempted from the incentives, either because they specialize in narrow types of patients, such as children or veterans, or because they are paid differently by Medicare, such as all hospitals in Maryland and “critical access hospitals” that are mostly in rural areas.
Hospitals awarded bonuses in one year of the value-based purchasing program do not necessarily do as well the next year. Out of 2,672 hospitals that have been evaluated in all three years of the program, roughly a quarter got bonuses all three years and a quarter lost money in all three years. The rest had a mix of bonuses and penalties, the KHN analysis found.
Matsui said swings were not surprising given that hospitals are getting acclimated to the programs and Medicare has added new measurements each year. “In the grand scheme of things,” he said, “we’re still in the embryonic stage of the pay for performance programs.”