The Hotspotters – Lower Costs and Better Care for Neediest Patients : The New Yorker

Atul Gawande is at it again.  This article really needs to be read by everyone in Health Care or who is interested in the Health Care debate.  And particularly anyone who dose Health Care and Statistics.  Courtesy of The New Yorker

Brenner wasn’t all that interested in costs; he was more interested in helping people who received bad health care. But in his experience the people with the highest medical costs—the people cycling in and out of the hospital—were usually the people receiving the worst care. “Emergency-room visits and hospital admissions should be considered failures of the health-care system until proven otherwise,” he told me—failures of prevention and of timely, effective care.

If he could find the people whose use of medical care was highest, he figured, he could do something to help them. If he helped them, he would also be lowering their health-care costs. And, if the stats approach to crime was right, targeting those with the highest health-care costs would help lower the entire city’s health-care costs. His calculations revealed that just one per cent of the hundred thousand people who made use of Camden’s medical facilities accounted for thirty per cent of its costs. That’s only a thousand people—about half the size of a typical family physician’s panel of patients.

Things, of course, got complicated. It would have taken months to get the approvals needed to pull names out of the data and approach people, and he was impatient to get started. So, in the spring of 2007, he held a meeting with a few social workers and emergency-room doctors from hospitals around the city. He showed them the cost statistics and use patterns of the most expensive one per cent. “These are the people I want to help you with,” he said. He asked for assistance reaching them. “Introduce me to your worst-of-the-worst patients,” he said.

They did. Then he got permission to look up the patients’ data to confirm where they were on his cost map. “For all the stupid, expensive, predictive-modelling software that the big venders sell,” he says, “you just ask the doctors, ‘Who are your most difficult patients?,’ and they can identify them.”

via Lower Costs and Better Care for Neediest Patients : The New Yorker.

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9/11 Health Bill Blocked in Senate – NYTimes.com

This just seems strategically unwise.  I assume that the Republicans think they can take the PR hit because they believe that nobody is paying attention during the holidays.   Still, it certainly is fodder for the next set of elections.

WASHINGTON — Republican senators blocked Democratic legislation on Thursday that sought to provide medical care to rescue workers and residents of New York City who became ill as a result of breathing in toxic fumes, dust and smoke from ground zero.The 9/11 health bill, a version of which was approved by the House of Representatives in September, is among a handful of initiatives that Senate Democrats had been hoping to approve this year before the close of the 111th Congress. Supporters believe this is their last real opportunity to have the bill passed.The Senate action created huge uncertainty over the future of the bill. Its proponents were working on Thursday to have the legislation inserted into a large tax-cut bill that Republicans and Democrats are trying to pass before Congress ends it current session later this month.

via 9/11 Health Bill Blocked in Senate – NYTimes.com.

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Annals of Medicine: The Cost Conundrum: Reporting & Essays: The New Yorker

One of the best articles I’ve read in a while:

Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.

via Annals of Medicine: The Cost Conundrum: Reporting & Essays: The New Yorker.

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Emergency medicine specialists in short supply – Boston.com

Link to Story

Writing in the journal Academic Emergency Medicine, lead author Dr. Carlos A. Camargo of Massachusetts General Hospital estimates that it would take until 2019 to find enough fully-trained, board-certified emergency physicians to work in the 4,828 emergency departments that are open 24 hours a day. And that best-case projection assumes that no current doctors who meet those qualifications die or leave their jobs.

The Institute of Medicine said in 2006 that ERs should ideally be staffed by doctors who had spent their residency training in emergency medicine and had later passed tests to become certified in the specialty. But only about 55 percent of doctors working in ERs meet that standard, Camargo and his co-authors write.

Does any other field have such a low percentage of physicians that are not board certified in the field of practice?  I know some of this has to do with the recent certification process, but that is pushing nearly 20 years now, and grandfathering options were available for those who were practicing before that.  What makes this worse, these calculations were done under the rosiest of scenarios where the doctors do not burn out and leave the field… good luck with that.

I’m not sure there is an easy solution to this problem.  I don’t think anyone is (or shoud be) suggesting we lower the standard of being qualified as an emergency medicine specialist.  There are already over 1000 residents trained a year, and at some point you run out of quality facilities to train residents (getting the right amount of volume with broad, well-rounded training isn’t possible just anywhere).  Decreasing the meteoric rise in ER visits in the past decade will also help a whole lot.

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NYT: China and Pollution

As China Roars, Pollution Reaches Deadly Extremes

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Law of Unintended Consequences

One of the hardest things to try to explain to people when discussing various kinds of institutional or governmental policy is the law of unintended consequences. It basically says the policy can have effects that are very different than what one expects. History is full of examples, yet people continue to believe that the idea/policy is smart enough to prevent thousands or millions of people from figuring out a way to mess it up while imaginatively trying to better their lives. It shouldn’t scare someone from trying to change things, but steps need to be taken to measure the change in order to ensure that what was intended to happen is indeed happening.

Glen Whitman, an associate professor of economics at California State University, Northridge, wrote a very nice article on this topic, linked here. It is worth a read, as it explains an idea which can be difficult to explain in a nice, accessible way.

The article is also saved after the break for archival purposes.

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Google VP on the state of Medical Informatics

Adam Bosworth, VP of Google recently has posted a few items on their blog regarding health care and the poor information transfer withiin the field.  I can only imagine that Health Informatics must seem truly backwards when one comes from a place like Google.

His first post is here:
http://googleblog.blogspot.com/2006/11/health-care-information-matters.html

And there is a second post, including a link to a transcript of a keynote address regarding this very issue.

http://googleblog.blogspot.com/2006/12/thoughts-on-health-care-continued.html

There are a number of obstacles to overcome, and the technical limitations are only a part of them. The bigger problem is that people working in the field are so fearful of litigation from a privacy breach, especially when it gets released to the “net.”  Some of this is because people are afraid of increased insurance rates, and many of these concerns are legitimate because information is just SO easy to duplicate a million times over once it is digitized.

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NYT: New Nerve Test, a Moneymaker, Divides Doctors

Another article from the New York Times.

A product sold by Neurometrix, called NC-stat, is the topic of an article today’s New York Times, in particular the way it shows the problems with how doctors are reimbursed for the care that they provide.

Also provided here, is a link from Medgadget, and their review of how the NC-stat device works.

The interest for me, however has less to do with the device itself, but the following paragraph near then end of the piece:

For physicians, who might be able to bill only $80 or so for a routine 30-minute office visit, Neurometrix’s promise of a profit as high as $250 for 15 minutes, is compelling. So was a customer-referral program in which physicians could receive hundreds of dollars in free products for steering other doctors to Neurometrix.

….

For some health policy analysts, the popularity of such procedures illustrates why primary care doctors should be paid more for basic office visits and less for money-making procedures. Earning $250 from a diagnostic test “is obviously out of line with what physicians can earn from office visits,” said Paul Ginsburg, the president of the Center for Studying Health System Change, a Washington research group.

The reality is that doctors are simply not paid very much for spending time with patients, particularly in comparison to doing some fancy procedure.  The Medicare payments system that prices things based on the amount of resources it uses encourages people to use resources.  It seems obvious, but if one creates an incentive, one shouldn’t be surprised if people take it.  In this case, one shouldn’t be surprised if the entire medical industry is geared toward using more resources.

In fact, the expert doctor who can accurately diagnose people quickly is actually paid less, because, well, they’re too fast.

Anyway, the complete article is below.

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NEJM: Kellermann: Crisis in the Emergency Department

Arthur L Kellermann is a role-model to many of us who have earned or aspire to MD-MPH degrees. Having met him, he speaks with uncommon insight and wisdom. He has written a valuable editorial in the New England Journal of Medicine this week regarding the rising problem of crowding in the Emergency Department, particularly regarding disaster capacity. The Journal has been good enough to offer the editorial for free on their website.

When crowding reaches dangerous levels, hospitals often divert inbound ambulances to other facilities. In 2003, diversions occurred more than half a million times — an average of once per minute.³ Diversion may provide a brief respite for a beleaguered staff, but it prolongs ambulance transport times and disrupts established patterns of care. It also creates ripple effects that can compromise access to care throughout a city. Because crowding is rarely limited to a single hospital, one facility’s decision to divert ambulances can prompt others to follow suit. When that happens, a city may experience the health care equivalent of a “rolling blackout.” Everyone’s access to care is affected — the insured and uninsured alike.⁴

The complete article can be found here.

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NYT: Heart Procedure Is Off the Charts in an Ohio City

An article in the New York Times presents a microcosm to a phenomenon that occurs throughout medicine.  In Public Health school we call this “small area variation,” and it drives insurers completely nuts.

When it comes to treating blocked arteries, there are no definitive studies showing which approach most benefits patients in the long term. And some local insurers agree that the Elyria hospital provides high-quality care.

But there is little doubt that hundreds of Elyria patients each year are getting angioplasties that they would not be getting if they lived elsewhere in Ohio — or in any other part of the country for that matter — at a cost of millions of dollars a year to Medicare, the federal insurance program for the elderly. Elsewhere in the state, some of the sickest of these patients might have received bypass surgery, while many others might have simply been treated with drugs. Or, for those whose conditions were not diagnosed or were not deemed serious enough, there might have been no treatment at all. .

Experts know that changing the financial incentives can change the way medicine is practiced.

A major problem, as cited above, is that often times medical technology and approaches change so fast that it is very difficult to have definitive studies.  At the same time, many doctors are not comfortable with the fiscally conservative approach which demands that the cheapest method be used unless a more expensive option is proven to be more effective.  The truth is that many other industry have practices that don’t demand clear undisputed evidence, and medical practice will often not advance without it.

Still, small-area variation clearly is evidence that a problem exists.  Both groups of doctors can’t be right, and extreme variation like this only make it obvious the degree to which we simply don’t know.

complete story below

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