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Investment for Health Reform - Escaping the Valley of Death

By Michael D. Miller MD
April 30th, 2009

The debate about health reform has mostly focused on expanding insurance coverage and controlling costs.  However, successfully improving the US healthcare system will require some long-term quality improving investments.

The stimulus bill (ARRA) included two such investments.  The $1.1 Billion for Comparative Effectiveness Research has been widely discussed because it is important, and a very large percentage increase in the Federal Government’s spending in this area.  But the ARRA bill also included $10 Billion to increase NIH’s funding.

The significance of the increased NIH funding is twofold:  First, it will provide expansion of biomedical research related jobs.  And second, it will help the NIH increase the work it does in translational research, which should help biomedical research build a better bridge over what the Parkinson’s Action Network and others have labelled the “Valley of Death.”

Valley of Death
The Valley of Death, as described by PAN at a briefing last week hosted by FasterCures, is the work required to turn basic lab research discoveries into treatments that help people.  Some people call this “translational research,” and the NIH has been moving in this direction by funding institutional centers with Clinical and Translational Science Awards (CTSAs).  The two major activities that occur (or don’t occur readily enough), in the Valley of Death are prototype discovery and design, and preclinical development.  (See PAN’s graphic below.)

PAN Valley of Death -1

The Valley of Death is a real challenge because while these activities are vitally important for improving the quality of healthcare over the long run, the incentives for doing this work are smaller than for basic or fully applied research:  In the private sector, there may be small incentives for translational work, but in academia the incentives may actually be negative because successes in this area garner little or no professional prestige or recognition, and more importantly, generally doesn’t attract research grants, i.e. money to support the researcher’s lab and the university.

A Bridge to Better Care
Filling in - or bridging -  the Valley of Death, (feel free to pick your metaphor), is important for improving healthcare because there are so many serious conditions where current treatments are very inadequate.  For example, Parkinson’s is one of many neurodegenerative diseases where existing treatments address some of the symptoms - and often only partially or temporarily - without effecting the course of the illness.  Similarly, while significant advances have been made in treating cancer, those successes have been in select types of cancer, (with leukemia being one good example), or have made the treatments much easier for the patient.  Both of these are valuable, but it is also worth noting the recent article discussing how survival rates for cancer haven’t really increased over the last several decades.

The cure for this problem is clearly more (and better) research and development…. and the translational work that bridges the two. (Perhaps we should talk more about increasing R&T&D, rather than just R&D?) PAN’s description of how to do this is sophisticated and multifaceted.  As their illustration below shows, not only are the NIH’s CTSAs and SBIR programs important for helping institutions and individual researchers push forward with more translational work, but other parts of the solution include DoD’s Telemedicine & Advanced Technology Research Center, and private foundations and venture philanthropy.

PAN - Valley of Death -2

Increasing funding for translational work through all these sources may help build a bridge, (of fill in the Valley), but translational work will also benefit by greater coordination of efforts.  At the institutional level that is part of the role of the CTSA’s, but there could also be more coordination and emphasis of translational work at the NIH itself - which is why PAN is recommending the NIH conduct an analysis and present their own recommendations for improving the translational activities of NIH funded research programs.

Institutional researchers could also benefit by having more resources about the nuts and bolts of translational work - like how to structure research and information so that it will be readily usable for filing an IND with the FDA.  Universities already have Technology Transfer/Licensing offices that serve the dual function of licensing university generated research to private companies for commercialization and ensuring that the university receives fair compensation for the company’s use of these discoveries - which is required by the Federal Bayh-Dole Act.  Perhaps universities should also have offices that work to educate their researchers about translational activities to help them plan their research so that the information they generate will be more readily usable by those farther down the development pipeline?

This is clearly not an easy nor readily obvious task.  At the FasterCures/PAN briefing last week, someone told a story about an academic researcher who experienced a 2 year delay in moving their discovery along the development pathway because they didn’t understand the information that would be needed.

Rather than make specific recommendations about how to improve the situation for basic researchers, I’ll just note that the Bayh-Dole Act managed to get every institution receiving Federal grants to create a Technology Transfer/Licensing office.  It seems that every institution could also have a Office of Translational Research Assistance too.  How to structure the funding or financial incentives for this could be complicated, but certainly not impossible.  And given that we are spending tens of Billions of tax dollars on biomedical research, we should also be doing everything we can to make sure that the discoveries coming out of that research gets translated into better treatments for patients ASAP.  Delays because academic researchers don’t want to pitch their careers into the Valley of Death, shouldn’t be a tolerated part of the structure of our biomedical research system - which, as I’ve previously discussed, is one of the four spheres comprising our entire healthcare system.

Posted in Comparative Effectiveness, Health System Reform, Innovation, Quality of Care & Safety | 3 Comments »

Quality, Checklists, Patient Education, the TV Show ER, and Comparative Effectiveness

By Michael D. Miller MD
March 16th, 2009

In case you missed it last week, amidst all the returning stars for one of the final episodes of the TV show ER, there was a dramatic Operating Room scene where Dr. Benton (played by Eric Lasalle) is “observing” the kidney transplant of Dr. John Carter (played by Noah Wyle), because as we see, the transplant surgeon is a very coarse and roughshod individual.  The significance of the scene is that as the surgery is about to begin, Dr. Benton pulls out his  pre-surgical checklist and browbeats the transplant surgeon into going through it - during which the nurses note their concern that they don’t have reperfusion solution in the OR, so they go and get some as the surgery starts.  Since this is TV, this turns out to be crucial when the kidney develops a clot, and a delay in getting the solution could have meant the difference between success and failure of the kidney transplant.  (Note - this connection may be taking a bit of artistic/entertainment license, but the point is that delays in having needed equipment or supplies can effect the quality of care.)

While Atul Gawande has written about such checklists in the New Yorker magazine, perhaps this fictional medical TV drama will help more people understand the importance of such quality improving steps, and even encourage them to start asking their doctors and hospitals if they use these types of quality improving checklists….. And if not, why not?

Physicians’ Perspectives
The next day I was talking with a physician friend, and mentioned the episode.  I was both bemused and concerned that he said all the staff is his outpatient clinic were talking about the returning stars, and nobody had mentioned the checklist scene.  We then talked about how physicians often think the way they do things is the best, yet generally lack any data to show how well they are really doing.  We agreed that physicians have traditionally viewed checklist etc,  as “cookbook” medicine that took away their autonomy.  I pointed out that while this might be true on a very microscopic level, by systematizing what they routinely do in a way that improves outcomes, they can then focus their knowledge and skill onto the unique aspects of each patient’s needs.

This is similar to what a basic science researcher once told me about golf. (He is a near scratch golfer.)  He told me that since the game has so many variables, more of them that you can eliminate the better you will perform.  For example, always playing with the same clubs is obvious, but for the same reason you should also play with the same brand and type of ball and glove, and develop standard pregame and preshot routines.  That way, you can focus on the variables you can’t control, such as the weather, the wind, the lie of the ball, etc.  The same is true for clinical care.  By standardizing the routine and repetitive actions according to protocols that have been shown to work well, clinicians can focus on what is variable and important.  (This is also why I always keep the same set of things in one pocket: keys, chapstick, two blue pens, one red pen, and my migraine medicine. And why I always leave my keys, wallet, sunglasses, etc. at same place at home.  That way I never have to spend time looking for things I use all the time.)

Collecting and analyzing data about individual physician performance is really going to be the next significant development in health reform and quality improvement.  And it is already occurring in some places - such as within the health benefits program for Massachusetts government employees.

This data collection, analysis and reporting will be similar to what is being done for hospitals, and thus will follow the trend of taking technologies out of the hospital and using them in the outpatient world.  However, as with all healthcare data analysis. the major challenge will be in adequately adjusting for patient differences so that physician performance is based upon realistically achievable outcomes rather than the severity of the patient’s underlying illnesses.  (The limits of such risk adjustment have hindered the usefulness of hospital quality data reporting.)

Comparative Effectiveness
The recent stimulus legislation included $1.1 billion for comparative effectiveness research.  Greater federal funding in this area has raised concerns among some people in the medical research industry because this research could focus on comparing one medicine to another, or a medicine to a device, etc. without adequate risk adjustment in the research - and then be used by insurance companies and government agencies to make coverage and payment decisions.  And these concerns are legitimate because using such analysis and research for coverage decisions about medicines and devices has been done in countries such as England and Australia.

However, there is also an opportunity for comparative effectiveness research to be used to improve actual clinical practices by developing a broader array of checklists and other standardized protocols.  This is part of the promise of electronic medical records, since they can easliy incorporate such standardized guidelines into their formatting.  But from what I can tell, each brand and type of EMR/EHR has different standardizations and guidelines, and the way they display them can cause clinicians to quickly suffer from “alert fatigue,” so that eventually clinicians ignore all the suggestions and warnings - making them worse then nothing.

Aside from the technical issues of EMRs, the systemic challenge for successfully using comparative effectiveness to improve clinical care in this way is overcoming the resistance and fear of physicians. This factor almost ended the existence of the federal Agency for Healthcare Quality and Research, because its first major project, (when it was called the Agency for Health Care Policy and Research), found that surgery for low back pain was generally not indicated.  This conclusion caused such a reaction in the medical community that Congress almost stopped funding the entire agency.

Conclusions

  • Innovations that are being used in hospitals will be increasingly used in outpatient clinics and private practices.
  • These innovations will not only be technologies, such as diagnostic tests, but also methods of care, such as standardized checklists and protocols.
  • Using comparative effectiveness research to develop and validate the ability of such standardization to improve outcomes, will have greater effects on increasing quality of care and controlling costs than will research comparing different treatment options for individual diseases - even for very common and costly conditions like diabetes and CHF.  This will be true because even if such research shows which treatments are best, if clinicians aren’t following these recommendations in standardized ways, the value of this knowledge for patients and the healthcare system will be dramatically diminished.
  • Including physicians, other clinicians, and other stakeholders in the development and implementation of standardized practices will be critically important for their successful adoption and use - because as was seen in the dramatization in the ER episode, big personalities of individuals can overshadow, subvert or sidestep the proper use of standardized practices so that they may be followed in substance, but ignored in spirit.

Posted in Delivery of Healthcare, Quality of Care & Safety | 2 Comments »

Transparency & Accountability for Physicians in Health Reform

By Michael D. Miller MD
March 12th, 2009

Yesterday I had the opportunity to give Medical Grand Rounds at Caritas Carney Hospital in Boston on the topic of “Health Reform 2009 and Beyond.”  Rather than compare and contrast various national health reform proposals, I reviewed the major forces and trends that are reforming healthcare, and explained how they would likely impact different stakeholder groups - particularly physicians.

I started by discussing the major trends in cost, access and quality - noting how the first two are easier to quantify and that the debate over access to healthcare services versus insurance coverage has been resolved in favor of health insurance coverage, because only having access to free clinics and emergency rooms doesn’t enable people to get the type of healthcare that they really need.  The successor debate is what insurance needs to cover to be “adequate,” and what it means to be underinsured.

Transparency & Accountability
The heart of my talk was explaining the role of transparency and accountability in health reform at the national, state and private sector levels. (One of the earliest forms of transparency for clinicians was the National Practitioner Databank, which was created about 20 years ago to try and make it easier for the healthcare organization, insurers and government agencies to learn about adverse actions - such as malpractice suits and licensing board censures.)

“What are we getting for what we’re paying for?”
The most frequently discussed transparency initiative in healthcare is the big push for electronic health records. Information and transparency are being highly valued because as more detailed information about actual clinical and cost outcomes becomes available, it can be analyzed and used to make different parts of the healthcare system accountable for their contributions.  (Note: the apparent dramatic lack of transparency and accountability that contributed to the collapse and impairment of so many financial institutions has fueled public calls for more accountability and transparency in many parts of society - including healthcare.)

Capitation was an early attempt to place accountability for the cost outcomes of individual patients onto healthcare organizations.  However, because information connecting clinical decisions with overall costs was lacking, capitation was less than successful, and it often evolved into schemes to reduce the volume of care since that was the only measurement available related to total costs. Fortunately, accountability mechanisms have become more refined, and now include pay-for-performance, “episodes of care,  and other forms of bundling of payments.  (An example of an episode of care bundled payment would be a care group receiving a single payment amount for all the clinical services in a 30 day window for a patient receiving elective heart surgery.)

The common theme in this trend of transparency and accountability is that as costs continue to increase as a percentage of personal incomes, wages and GDP, insurance companies, private payers and employers, government agencies, and even patients are all asking, “what are we getting for what we’re paying?”

Power of the Pen
I also described for the physicians at Carney Hospital how as information systems become more sophisticated and can provide insights into the performance of smaller groups and individual physicians, more proposals and initiatives will seek to place greater accountability on the individual physicians because while physicians receive ~21% of all healthcare spending in this country, their actions influence how about 70-80% of each healthcare dollar is spent.

This concept is being translated into practice for Massachusetts state government employees, whose health benefits program has collecting and analyzing information about all the primary care physicians in the state, (and selected types of specialists), and then put them into three “quality tiers”: Excellent, Good, and Standard.  Accountability is added to this transparency because patients seeing physicians in the “higher quality” tiers pay lower insurance co-payments.

There is significant controversy around this profiling and tiering program - particularly about what data is used and how it is analyzed.  Certainly transparency and accountability are only valuable for creating positive changes when the data is valid and reliable - something I discussed with the physicians at Carney Hospital and have written about previously.  The key challenge in making this type of data valid and reliable is how adequately it is risk-adjusted in the analysis so that clinicians and providers are “graded” based upon their actual skill and work, rather than on the type of patients they see.

Medical Homes as Positive Solutions for Physicians
Another example of how the “power of the pen” concept is leading to new models for accountability in healthcare is the Medical Home.  I told the medical students, residents and attending physicians at Carney Hospital that Medical Homes might be a positive opportunity for physicians to improve the quality of care while accepting and managing more financial risk and responsibility.  Since the details of Medical Homes can be very complex, my one slide description was: “Medical Homes are arrangements where a physician (or group) is responsible for coordinating individual patient’s care across all sectors of the healthcare delivery system and ensuring that the patient receives appropriate preventive care and self-management assistance.”  Since financial compensation is often a concern for primary care physicians, I noted that payment for Medical Home services is in addition to reimbursement for traditional care services provided to patients, and it could be a flat (risk adjusted) payment per month per patient, while also including incentive payments for actually improving patients’ clinical outcomes and/or reducing the amount of healthcare spending they generated.

Challenges and Opportunities for Physicians
I concluded by noting that these changes present challenges and opportunities for physicians.  The first challenge is that if physicians don’t participate and lead in discussions about national policy issues and local delivery system reforms, then changes will be made to them rather than with them.  That is, they have the choice to “Lead or be Led.”

Such leadership also needs to be paired with collaboration - both within clinician communities and with other stakeholders such as administrators, employers, payers, government agencies and patients.  (These are two of the “lessons learned” from  Geisinger’s experience described by Paulus et. al., in their Health Affairs article last year.)  During the Grand Rounds’ Q&A it was also noted that geography and location are important factors influencing the ability of physicians and hospitals to exert leadership and promote collaboration within communities.  For example, Geisinger is the major healthcare delivery entity within a relatively contained geographic community. However, this observation illustrates the importance of multi-stakeholder collaboration, because without it, everyone is working in isolation, efforts are not coordinated, time and energy are wasted, and the outcomes provide little or no benefits to anyone.

Reviews & Outcomes
While the audience was attentive and only a few people left to answer pages, it is always hard to know how much a group benefits from this type of presentation. So I was very gratifying to receive this email review from one of the organizing physicians at the hospital:

“Thank you for the fabulous grand rounds at Caritas Carney Hospital yesterday.  You obviously put a great deal of time and thought into presenting to us; your lecture was a remarkable overview of so many issues affecting our health care system today! You have a great mind to be able to have both the comprehension to understand these concepts, and the ability to synthesize numerous trends and ideas into an integrated presentation. Two of the best compliments to you are 1) docs  stayed until the end of grand rounds and 2) our new insights inspired conversations and debates in hospital halls and offices all day long!” Mary Lou Ashur, M.D.

The last comment is precisely the outcome I was hoping to achieve, since just educating people about different proposals may not help build their understanding of the problems and possible solutions, not give them guidance for how they can get involved, etc.  And from the picture below taken after Grand Rounds, I think everyone was happy with the result - even if I do have a funny smile.

Grand Rounds - Carney Hospital -031109

Posted in Delivery of Healthcare, Economics & Financing, Health System Reform, Quality of Care & Safety | No Comments »

Controlling Health Care Costs and Improving Quality with Effective Care Coordination

By Michael D. Miller MD
February 16th, 2009

A study published by in the New England Journal of Medicine last week examining the effects of 15 different Medicare care coordination demonstrations received wide coverage by the general media.  Unfortunately, much of this focused on the study’s overall finding that these programs didn’t reduce hospitalizations or Medicare spending.  For example, the AP story’s headline, “Study finds bid to cut Medicare costs failed,” was used by many papers such as the Washington Times.

However, the actual study had much more complex, important, and useful findings, and the paper’s authors from Mathematica, (which Medicare contracted to do the analysis from this project), deserve a lot of credit for extracting meaningful information from this project.

Complexity of Medicare Care Coordination Demonstration Projects
The study was very complex and presented many analytical challenges, including:

  1. The “study” involved 15 different and diverse “care coordination” programs: 5 disease management companies, 3 community hospitals, 3 academic medical centers, 1 integrated delivery system, 1 hospice, 1 long-term care facility, and 1 retirement community
  2. Despite being called “care coordination” programs, the major intervention was nurses communicating with patients outside of the patients’ direct clinical care team
  3. Most of the programs’ care coordinators didn’t have significant interactions with the physicians treating the individual patients – although reports were provided to the physicians
  4. The primary outcomes the study looked at were hospitalizations and total Medicare costs

Given that physicians direct most clinical decisions and thus influencing overall healthcare spending, it is not surprising that third party programs were ineffective in changing clinical or cost outcomes.  With the patient’s physicians not being directly engaged in the development and implementation of these programs, nor vested – either financially or cognitively – in the success of these care coordination programs, this outcome is not surprising. This is like expecting travel agents to improve the safety and efficiency of air travel, i.e. while they can provide information to individuals they are not engaged in the operations of the airplane or airports. [OK – that’s an overly simplistic example, but I think it helps make the point.]

Positive “Findings” From the Study:
Despite the disparate structure of the programs in this study, the authors found that the more successful programs:

  1. Had greater in-person contacts with the patients – nearly 1 per month
  2. Focused their efforts on individuals with higher Medicare costs
  3. Had greater success educating patients on how to properly take their medicines
  4. “Worked closely with local hospitals, which provided the programs with timely information on patient hospitalizations and enhanced potential to manage transitions and reduce short-term readmissions”
  5. “Had frequent opportunities to interact informally with physicians”

Implications for Medical Homes
These findings reinforce the importance of focusing on the role of physicians in controlling and managing clinical care decisions – which overall account for up to 80% of all healthcare spending.  This observation is consistent with the conclusions the authors of the Care Coordination study reach in their NEJM article about their findings being able to help support the implementation and success of medical homes: “The successful interventions also may offer more detailed lessons for medical homes about how best to educate and monitor patients, the types of patients for whom they are likely to be most effective, and how to help patients overcome barriers to better self-care.”

This is a very timely and important conclusion since Medicare is getting ready to launch a Medical Home Demonstration Project in 8 states – and possibly more through legislation enacted last summer. Medicare’s Medical Home Demonstration has a greater likelihood of improving quality and lowering costs than the Care Coordination project because the Medical Home Demonstrations will directly put the responsibility for care coordination and improving patient self-management on the patients’ individual physicians – as opposed to providing an outside service for patients. In addition, similar to the two somewhat successful Care Coordination projects, the Medical Home Demonstrations will focus on Medicare patients with chronic conditions.

Implications for Overall Health Reform Efforts
The Care Coordination study’s observation that the successful programs differed from the unsuccessful ones in how they improved patients’ compliance with medications also has implications for broader health reform initiatives. It makes sense that patients with chronic conditions who aren’t receiving adequate medicinal treatments would have increased costs and hospitalizations, and thus improving compliance would reduce both. This finding, along with studies about the costs associated with medication errors, point to the value of focusing on medication compliance and proper usage in initiatives for reforming healthcare delivery.

For example, improving medication compliance might be improved by creating better written instructions for patients. An analogy might be to the checklists that help surgical teams and physicians placing central IV lines reduce errors and infections. Individualized patient “checklists” created in a standard format could help patients with chronic conditions take their medicines correctly and thus improve quality and lower costs.  And of course, these “checklists’ should also include ALL the patient’s medicines, reminders about avoiding certain OTC medicines and herbal supplements that might interfere with their prescribed medicines, and to urge them to promptly inform their physicians if they develop certain signs or symptoms related to their medical conditions.

All of this really goes back to the benefits of improving patient-clinician communications, and strengthening their joint engagement with the broader care team that includes pharmacists, nurses, specialized clinical educators, and family members as appropriate.

Strengthening Care Teams Through Better Communications
Such checklists and more standardization of care protocols – for use by clinicians as well as patients – should help foster this communications and team-base management.  However, if they are viewed by anyone in the team as cookbook medicine, or impersonal standardization – rather than guidance to protect against overlooking important actions and opportunities – then these protocols will not produce positive clinical and economic outcomes.  To encourage positive attitudes and actions about such quality improving changes, clinicians and patient advocacy leaders of all types – and at all levels – will need to be educated about the value of such shifts in clinical operations, and for them to be promoted as champions of these new paradigms for clinical care. (Group visits for patients with conditions like diabetes or congestive heart failure are an example of care delivery innovations that can increase quality and lower costs through greater efficiency and engagement of patients and their care team.)

Changing Reimbursement to Support Care Delivery Reforms
Making these changes to the clinical care delivery so that they are attractive to clinicians – both in private practice and in larger care delivery systems – will likely require altering reimbursement systems to change the financial incentives.  The Medicare Medical Home Demonstration project seeks to do this by directly paying physicians for their medical home management activities.

While this Demonstration is being implemented, a more widespread and timely change in Medicare’s physician payment system may happen this year because of the unsustainability of Medicare’s “Sustainable Growth Rate” formula.  Under the current SGR formula, Medicare payments for physician services are expected to be reduced by ~22% starting in January 2010. Deliberations to avoid this “broadsword” financial cliff may be a leverage point for making such changes – although it is unlikely that a dramatic, wholesale change will occur immediately.  It is more likely that significant changes will be phased in over several years and across geographic regions.  A gradual implementation makes sense since it provides opportunities for clinicians and Medicare enrollees to become familiar with the new payment and clinical delivery structures, it enables champions for better care delivery methods to be created, and it allows those who are more cautious to observe the changes while they are implemented for and by others.

Posted in Clinician-Patient Relationships, Delivery of Healthcare, Economics & Financing, Health System Reform, Quality of Care & Safety | 2 Comments »

Communicating Health Quality Measures

By Michael D. Miller MD
February 15th, 2009

Educating patients, (a.k.a. “consumers”), to make the “best” health care choices has been a fundamental principle in some health reforms schools, including those advocating for more high-deductible health plans.  While this concept makes sense in economic theories, it also requires belief that patients can and will make good use of the information available to them - particularly when they are ill.

Another fundamental necessity for making such consumer-directed healthcare work to improve quality and lower costs is that the information provided to people is meaningful and accurate.  A study published in the November/December 2008 issue of Health Affairs illustrates the complexity of providing accurate information.

This study was based upon the very simple question, “How easy would it be for a patient in the Boston area to find the “best” hospital by using different quality rating services?”  And the results were pretty fascinating: 5 different ratings systems designed to provide the public with quality information about individual hospitals didn’t agree on which were the best hospitals overall or even for specific conditions - even when the measure was death from a specific condition.  For example, the article notes, “Neither the observed mortality rates nor the observed/predicted rates were consistent across [rating systems for Acute Myocardial Infarction].  The hospital ranked first by HealthGrades had the second highest observed mortality; it ranked seventh according to Mass QC [a state government run information system].  Conversely, Health Grades’ seventh-ranked hospital (the only hospital ranked statistically worse than average) was ranked first by Mass QC.  This same hospital was ranked fifth in the nation by U.S. News and World Report for cardiology.”

Similarly the rating systems didn’t agree on the quality of care for heart bypass surgery:

Comparing Quality of Hospitals

Conclusions:
The study’s authors don’t just throw their hands up and profess rating systems to be complete failures.  Rather they note that transparent quality information reporting can stimulate quality improvement activities within individual institutions, and they also make three recommendations:

  1. Hospitals should embrace quality reporting and make sure that the data collected and the design of the analyses truly reflect the quality of care
  2. Patient experiences must be a meaningful part of quality of care assessments
  3. Quality rating systems must improve how they account for differences in the severity of illness of patients, (i.e. risk adjustment of the data), and for random variations

They conclude that more standardization of data collection methods, analysis and reporting may help improve the value of quality information and comparisons.  These would be positive steps towards providing individual patients with better information they could use to compare their local hospitals rather than just to rate individual hospitals against national or regional averages.

Posted in Delivery of Healthcare, Information & Communications, Miscellaneous, Quality of Care & Safety | 2 Comments »

Chronic Wellness Promotion v. Chronic Disease Management in Medical Homes

By Michael D. Miller MD
February 9th, 2009

One of the hottest health reform topics is Medical Homes: Medicare has Demonstration Project starting this year, several states have implemented, (or are implementing), medical home related initiatives, the Center for Studying Health System Change (CSHSC) released a great white paper titled “Making Medical Homes Work,” and the New York Times just had a story about how IBM is teaming up with United Healthcare to promote Medical Homes for their 11,000 employees and dependents in Arizona.

Definition of Medical Homes
One of the controversies in Medical Homes is the definition.  CSHSC and many others use the definition developed by 4 national medical societies which combines aspects of preexisting primary care and chronic care models with the goal of creating a primary care “home” that can more effectively address the needs of patients with chronic conditions.

Focus on Chronic Diseases - That’s Where the Money Is
This combination makes perfect sense since the majority of healthcare costs are used by the least well patients:  In 2003, 80% of health spending went for 20% of people in the US, and the Agency for Healthcare Research and Quality estimates that 70% of healthcare spending is for treating chronic diseases.

figure1_11.gif
[Source: Kaiser Family Foundation]

Emphasizing chronic disease management for Medical Homes reflects how most healthcare innovations, (including technologies, payment schemes, and care delivery changes), are first used in the most organized and intensive care settings -  such as hospitals - and then migrate out into primary care and preventive settings, including home use and patient self-management.  Thus Medical Homes’ focus on care coordination for chronic conditions parallels the decades old movement and growth in team-based care in hospitals.

Medical Homes and Wellness Care
Beyond improving chronic disease management, Medical Home capabilities should also help promote better wellness for all patients, i.e. the other 80% of people.  Patients wellness from better exercise, diet and other actions could be improved through Medical Homes providing more targeted counseling and self-management training.  Similarly, Medical Homes use of patient registries and reminder systems should increase compliance with vaccinations, prenatal vitamins, and reminders to follow-up on patient specific wellness interventions.

Long-Term Vision for Medical Homes
The long-term vision for Medical homes should include how they can improve clinical care for all people in a community - not just those with chronic or costly illnesses. As I work with payers, clinicians, and others about the desired characteristics of Medical Homes, this vision should help shape how payments for providing Medical Home services are structured and evolve, (e.g. PMPM for specific sets of Medical Home capabilities), and how additional compensation - such as bonuses - are constructed and modified to reward Medical Homes for achieving clinical and cost outcomes. Such a vision should also be part of our national long-term strategy for making healthcare delivery more efficient and coordinated, and transforming our delivery system’s culture to embrace the rapid adoption of change to provide greater clinical and societal value.

Posted in Clinician-Patient Relationships, Delivery of Healthcare, Quality of Care & Safety | 2 Comments »

Advancements in Understanding Head Trauma and Preventing Long-Term Problems

By Michael D. Miller MD
January 28th, 2009

When I was training to become an orthopedic surgeon, one of the senior physicians said that the two best learning sources for orthopedic surgeons were football and war.  Over the past year I’ve been talking with friends and colleagues about another connection between war and football - how minor repetitive head trauma has long-term serious consequences.

It has become clear with the increasing reports about the neurological, cognitive and personality problems military personnel have experiences after repeated minor concussive events, (often from being inside vehicles hit by IEDs), that this is a real and serious situation.  While the VA health system has taken steps to understand the consequences of repetitive minor head trauma and work to provide appropriate diagnostic and treatment methods, I have been telling people that this new understanding of neuro-trauma will have implications for football.

There have been more than a few reports about former NFL players having neurological problems after retiring; In particular, former Patriot Ted Johnson, whose problems with post-concussive syndrome was reported 2 years ago in the Boston Globe.  And just today, the Boston Globe had an article about how the brain of an 18 year old football player, (who died from nonviolent causes), showed early signs of irreversible damage from repetitive head trauma - something that had not been documented in professional football players younger than 36 years old.

War is different than football: In war, the goal is to avoid head trauma and steps can be taken to avoid it or minimize its effects through better vehicles and helmets - and by taking people out of harms way after head trauma has occured.  Conversely, in football, the contact, hits and subsequent head trauma are essential parts of the game.  While helmets have been made better and players can be taken out of the action after even minor head trauma, football can’t be played with complete cushion suits like those sumo-style outfits used in late-night and reality TV shows.  Last summer I wrote about how professional baseball teams are becoming more aware of the lasting effects of concussions on their players - but baseball isn’t inherently a contact sport.  I wish I had a good answer for football and football players.  Unfortunately I don’t think switching to flag or touch is going to make it as an alternative to full contact football. I’m a fan, but I don’t have good suggestions, and understanding the long-term consequences of repetitive minor head trauma, often makes it difficult for me to watch a football game - professional, college or high school.

Posted in Delivery of Healthcare, Public Health, Quality of Care & Safety | 1 Comment »

Quality of Care in Medical Practices - Size Does Matter

By Michael D. Miller MD
January 19th, 2009

The Journal of General Internal Medicine published a study last month that looked at primary care medical practices in Massachusetts to see how well they were able to provide the quality improving capabilities of Patient-Centered Medical Homes.  These structural capabilities represent process measures that assess the quality of care in medical practices.  However, these same measures could also help patients select their own primary care physicians.

Study Finds Larger Practices Have More Quality Related Capabilities
Not surprisingly the study found that larger practices, (and to a lesser extent those affiliated with larger networks of practices), provided more capabilities to improve the quality of patient care. The most significant difference in capabilities was seen in practices with 5 or more physicians, and these included:

  • Practice meets to discuss quality more frequently than every quarter
  • Practice regularly open to provide care on weekends
  • Use of Electronic health records that provide medication list, problem list, and electronic reminders

In addition, practices with 9 or more physicians were more likely to have specialty trained staff to assist with patient self-management, and there was an overall trend for larger practices to have reminder systems for preventive care:

Quality Improving Capabilities Increase with Practice SizeAsking Questions to Improve Quality
The questions used by the researchers in this study are clearly useful for assessing the quality relate capabilities of primary care practices, but additional research certainly it warranted to determine how well these process measures translate into actual improvements in clinical and economic outcomes. In addition, as such lists are developed and validated further, they could also be used by individuals looking for their own primary care physicians, and by patient advocacy organizations seeking to both promote quality improvement and to “grade” primary care providers.

The specific questions used in the study’s survey was:

Quality Capabilities for Primary Care Practices

One of the challenges for individuals or groups to effectively use any list of this type is that it needs to be customized because they will have different priorities and concerns. For example, the availability of translation services might be important for one family or advocacy organization, but less so for others.

Conclusion
Much has been written about using checklists to improve quality and reduce errors in hospitals - and particularly in the operating room.  But perhaps checklists could be derived from this type of Medical Home capabilities survey for use by individual patients and their advocates to assess outpatient clinical sites.   While the operating room checklist concept was based upon the airplane pre-flight checklist, maybe the checklist for assessing primary care practices could be likened to the checklist that home inspectors use to help home buyers understand the strengths and problems of a house. If individual patients and their collective advocacy groups regularly used checklists of this type, it could create a significant patient driven force for transforming the structure and operations of outpatient medical care in the United States to improve quality and control costs.

Posted in Clinician-Patient Relationships, Delivery of Healthcare, Health System Reform, Information & Communications, Quality of Care & Safety | 6 Comments »

Making Physicians Better, and Making Better Physicians

By Michael D. Miller MD
December 10th, 2008

A few recent reports point to ways for improving the quality of physician delivered care that has little to do with technology or complex interventions.  The first involves how physicians interact with patients, and the second examines the work hours for physicians in training.

Etiquette in Medicine
The first article, by Dr. Michael Kahn in the New York Times, describes six recommended actions for physician to create a good rapport with hospitalized patients. Dr. Kahn collectively calls these actions “etiquette-based medicine”:

  1. Ask permission to enter the room; wait for an answer
  2. Introduce yourself; show your ID badge
  3. Shake hands
  4. Sit down. Smile if appropriate
  5. Explain your role on the health care team
  6. Ask how the patient feels about being in the hospital

Clearly these actions are all directed towards creating a stronger person-to-person connection between the physician and the patient as a step toward improved communications - which is the foundation for developing and effectively delivering a treatment plan to and for the patient.

Physicians Getting Rest
Another challenge physicians have in this process is being awake and aware enough to actually engage in those 6 steps. (Having enough energy also would effect their ability to engage patients empathetically - something I’ve written about before.)  [Also see the previous posting about napping being better than caffeine for improving verbal and physical memory and learning.]

How much sleep physicians need to act appropriately - and avoid making errors - is the subject of a recent Institute of Medicine report, (“Resident Duty Hours: Enhancing Sleep, Supervision and Safety”), that makes new recommendations for limits to the work hours for physicians in training:

  • Duty hours should not exceed 16 hours per shift; For 30 hour shifts there should be an uninterrupted five hour break for sleep
  • Residents should have variable off-duty periods between shifts based on the timing and duration of shifts to increase residents’ opportunities for sleep each day, as well as regular days off that enable residents to recover from chronic sleep deprivation.
  • Medical moonlighting, (additional paid healthcare work), should be restricted
    [A chart comparing the current and new recommendations is available here.]

While all these changes would certainly make for more aware and awake residents, the IOM also estimates that recruiting and paying professional staff to substitute for the work hours the residents would have been (over)working, would cost about $1.7 billion.

Besides figuring out how to pay for these new staff hours, one policy question for implementing these recommendations is how to find the clinicians to actually work these hours considering there is such a shortage of non-physician clinicians.

Anther policy question these recommendations raise, is why they should they only apply to physicians in training?  Why shouldn’t they also apply to physicians who’ve finished their training and are supervising, teaching, and mentoring residents and medical students - and of course are directly responsible for patients?  While it might be argued that most physicians don’t work these long hours, for some that may not be the case - particularly in hospitals without many residents.

Considering that many quality improvements for medicine have been taken from the airline industry - such as the pre-flight/pre-surgery checklist - then why shouldn’t the limits on pilot shifts and hours also be applied to fully licensed physicians?  [I suspect that this will not make me popular with some physicians, but I wonder how they will defend their right to treat patients round-the-clock without sleep?]

Conclusions
Perhaps work hours and etiquette should be other aspects of quality improvement and patient safety that are considered as part of health reform discussions at the Federal and State levels. Certainly well-rested, empathetic physicians trained to interact with their patients with etiquette should improve the quality of healthcare by reducing errors and making physician-patient communications more effective.

How to integrate all these “innovations” into physician training and practice will be a significant challenge, because teaching such skills and promoting their use is not very exciting or technological, and it will be hard for such behaviors to be tied to economic incentives - which are often the carrot or stick for quality improvement initiatives.  Hopefully, as health reform ideas move forward and become crafted into comprehensive packages and plans, they will expand beyond direct economic incentives for improving clinical processes, to include non-economic inducements to promote quality enhancing actions and attitudes for clinicians as well as patients.

Posted in Clinician-Patient Relationships, Delivery of Healthcare, Economics & Financing, Health System Reform, Public Health, Quality of Care & Safety | 5 Comments »

Napping to Increase Productivity

By Michael D. Miller MD
December 7th, 2008

The New York Times had a great short report about a scientific study comparing a short nap to caffeine for improving a person’s memory.  The study found what many people have suspected for years - a nap is better than caffeine.

The benefits of napping are something that proponents of “power napping” have known for years. (Disclaimer: I’ve used the 20 minute power nap for years to re-energize and turn an afternoon impaired by a severe case of “the weakies” into several very productive hours.)

The study specifically found that naps were better for improving recall of a word list after both 20 minutes and 7 hours.  Naps were also better than caffeine for improving performance on a finger tapping task.  (This tested the ability to recall physically learned memories rather than the word list’s verbally related memories.)

The study also found that the caffeine group performed worse on the finger tapping test than the placebo group, and both napping and caffeine were better than placebo on a perceptual memory task of discriminating textures.

Questions Raised & Possibilities for More Research
Why caffeine is better than placebo for the perceptual task is an interesting finding?  Perhaps caffeine has some performance improving effect in peripheral nerves or nerve receptors.  This possibility could be examined by studying how caffeine effects other perceptual senses such as vibration and proprioception.

The statement from the study author in the New York Times that, “People think they’re smarter on caffeine,” points to the possibility that caffeine’s central neurological effects create false impressions of performance.  This might be another interesting avenue for research.  Particularly what does this increase in believed performance ability have on errors rates in important tasks such as flying an airplane or performing medical procedures?

Postscript: Reading this study also reminded me of a discussion I had many years ago with a corporate HR person about napping.  She had distributed information about identifying employees who had substance abuse or health problems that included “sleeping at work” as one of the warning signs.  The next day, the newspaper had an article about power-napping for productivity - which I sent to her, and she later confirmed that this was not what was meant by “sleeping at work.”

Posted in Innovation, Miscellaneous, Public Health, Quality of Care & Safety | 1 Comment »

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