Good deed turns into good business

Marketplace reports on a doctor in Seattle who is offering his recently laid-off patients care at a reduced cost:

It became clear to Rosenfield the economy was affecting his practice. So he sent out letters to his patients and introduced a new payment plan for those who lost their health insurance. They don’t get billed. But they pay upfront, usually between $40 to $60 for each visit, depending on their financial situation.

In the process he has stumbled upon something interesting:

Rosenfield was bracing to take a financial hit. But it’s actually saving him money. It’s reduced the amount of paperwork he has to file. And since patients pay him directly, he spends less time chasing after insurance companies for reimbursements.

Don’t write about your physician interaction online, ok? Dumb.

Some physicians are upset because anonymous patients are leaving (reckless? sniping?) comments on review sites like Angie’s List and Zagat’s.  Welcome to the internet.

The response?  They’re asking patient’s to sign what amounts to a gag order (waiver form) according to this Associated Press article.  Welcome to medicine.

Dumb. Really dumb.  Dumb, dumb, dumb.

Why?  One of the sites that allows anonymous comments is going to create a “Wall of Shame” for physicians who use waivers.  A lawyer says the waivers likely will not produce successful results in a lawsuit anyway.  And if a patient really wants to share negative anonymous comments online, they will (despite a signed waiver).  It’s a snowball effect with bad outcomes.

What should a physician do?  Two possibilities:

  1. Change behavior so patients don’t have bad things to say.  Yes, there will be the occasional patient who is unhappy about everything.  They may even post a negative review online.  But when there are multiple patients saying the same things, it may be time to look inward.
  2. Embrace the long tail.  Ask all patients to review physician services.  Give them a business card (or an Angies’s form, pdf) or a list of reviewing sites to enable them to brag about how great the service is.  Get on the ratings sites and professionally respond to criticisms.  Build a page on Squidoo.  Write a blog.  Build a website. 

    Here’s the best advice, it’s from Seth and is especially pertinent:

    Google never forgets.

    Of course, you don’t have to be a drunk, a thief or a bitter failure for this to backfire. Everything you do now ends up in your permanent record. The best plan is to overload Google with a long tail of good stuff and to always act as if you’re on Candid Camera, because you are.

The cure for panic is action

Bruce Sterling in his less than concise critique (it was originally a speech, via Boing Boing) of Web 2.0 at Webstock likens the 2.0 movement to the current perils of the financial world and literally says “The way we ran the world was wrong.”  But the speech touches much more than Web 2.0.  Here’s the pertinent health care quote:

The American health system is a market failure — and most other people’s health systems don’t make much commercial sense.

And now that the world’s problems (plentifully laid out in the speech) are coming to a head, change is coming:

I’ve never seen so much panic around me, but panic is the last thing on my mind. My mood is eager impatience. I want to see our best, most creative, best-intentioned people in world society directly attacking our worst problems. I’m bored with the deceit. I’m tired of obscurantism and cover-ups. I’m disgusted with cynical spin and the culture war for profit. I’m up to here with phony baloney market fundamentalism. I despise a prostituted society where we put a dollar sign in front of our eyes so we could run straight into the ditch.

The cure for panic is action. Coherent action is great; for a scatterbrained web society, that may be a bit much to ask. Well, any action is better than whining. We can do better.

I’m not gonna tell you what to do. I’m an artist, I’m not running for office and I don’t want any of your money. Just talk among yourselves. Grow up to the size of your challenges. Bang out some code, build some platforms you don’t have to duct-tape any more, make more opportunities than you can grab for your little selves, and let’s get after living real lives.

Opportunity arises in difficult situations and that opportunity is most definitely upon us.  The world needs an abundance of selfless problem solvers, health care too.  “The cure for panic is action.”

Health care is information

An interesting thought from Google’s chief information evangelist Vint Cerf at

On the health-care side, health care is information. Diagnosis, treatment, patient history, knowledge of pharmaceuticals and surgical procedures — it’s all information. Our own personal medical records represent incredibly important information to each of us because it can be crucial in helping to diagnose or treat a medical condition. It might be needed in a hurry should there be a need for emergency treatment, especially at a hospital you have never been to before.

Health care is information.  Given today’s technological affordances health care does a poor (understatement?) of putting that (quickly approaching) limitless information to use.  Plenty of opportunity as health care continues efforts (some much faster than others) to fuse that information with action.

The Opportunity of the Challenge

Challenging times hold great opportunity.

The Health Care Blog has Amanda Goltz’s review of last week’s Institute for Healthcare Improvement‘s National Forum on Quality Improvement in Health Care.  Among her criticisms is a lack of provider participation in Health 2.0:

The fact that the session billed “Geeky Trends for Experts” is just a basic overview of tools that other industries have been using for a decade tells us something about health care. Patients are the exception here, as they are well-organized on the Web and growing, but as long as hospitals, physician groups, insurers, quality officers and safety improvement organizations remain so behind the curve, patients’ ability to leverage the Internet to manage their health will be limited.

It’s great that one patient with COPD can talk to another about her shared condition, but what about asymmetrical and timely communication with her doctor about a new medication? Or what about instantaneous notification to her case manager’s PDA if she is away from home and goes to the ED? Integration of values collected through her home health monitoring system into her EMR? Daily podcasts on managing fluids?  A “dealing with your HMO” wiki?

I know all of this is in the works, but we need to do more to create physician and hospital leadership in this area (italics mine). “Build it and they will come” will work with patients seeking advice or shared experiences; it won’t work with overworked, overwhelmed physicians or hospital administrators just trying to keep the hospital financially sound, clean, safe, and in line with mandates to report thousands of metrics to CMS, TJC, Leapfrog, etc.

Very. Well. Put.

How much is that going to cost, Doc?

The Milwaukee Journal Sentinal:

What’s the cost of surgery for a spinal fusion of the lower back in southeastern Wisconsin?

It can range from $25,000 to more than $50,000.

The price depends on the hospital and the doctors. And that’s just for patients covered by one insurer — Anthem Blue Cross and Blue Shield. It would differ for other health insurers.

The wide disparity in prices explains why businesses and consumers contend that more information on what hospitals and doctors charge is needed to lower costs and make the health care system work better.

Seconded.  But there’s a problem:

Yet the effort to provide consumers with meaningful information on prices is proving to be a lot slower and more complicated than expected.

Transparent pricing is an important bit of information patients could use in selecting providers and choosing where to seek medical care.  But as the article states, it’s not always an easy task for a patient to find such information.  Hospitals have an opportunity to make that easier.

Two health systems in Sioux Falls, South Dakota, post prices.  Sanford Health posts price averages for the top 25 diagnoses at its main hospital prominently on its website.  The table displays information in four categories: minimum, median, average, and maximum charges along with specifics about charge, length of stay, out of pocket cost with coverage, and out of pocket cost without coverage.

Competitor Avera also posts price information, although it is more difficult to find and doesn’t provide as much information.

Here’s a comparison on strokes: Sanford, Avera.

There’s obviously still room for improvement.  But it’s a great start.  Price transparency helps us toward what really matters: competition on value.

As covered previously, at least one health system is working hard on making prices transparent amongst a group of competitors.

Encouraging Patient Involvement

The Chicago Tribune brings us this story:

Four years ago, when Edward Lawton was admitted to a New York hospital for surgery, he came prepared.

He brought his own case of sterile gloves and asked nurses to use them after washing their hands with soap and water.

He asked for a blood pressure cuff to stay at his bedside so it wouldn’t come in contact with other patients.

And he requested that newspapers not be delivered to his room because “newsprint is dirty” and he wanted to avoid the potential for contamination.

Lawton had reason to be careful: He had acquired several painful, debilitating hospital-based infections during a surgery nearly six years before.

The empowered patient. It’s the type of patient that hospitals want. Hospitals want them because they participate in health care. They are double checkers. And they improve outcomes.

The traditional caveat:

It helps if doctors and nurses are receptive and if they talk to patients and families in terms that they can understand. Rush-Copley Medical Center asks them to do just that each morning in the intensive care unit, when doctors, care managers, nurses and families meet at patients’ bedsides.

Caveat or not, if patients are asking the questions, answers are sure to ensue. Getting them to ask the questions is the difficult part:

Earlier this year, a study of 80 surgery patients in London reported that patients found it much easier to ask factual questions—”how long will I be in the hospital?”—than challenging questions such as “have you washed your hands?”

This reluctance could stem from the aura of authority that surrounds doctors, the authors speculated. The study was published in the British journal Quality and Safety in Health Care.

In December, a separate study of 856 adults in Pennsylvania discovered that 91 percent were willing to ask doctors or nurses to explain something they didn’t understand. But only 25 percent were prepared to ask providers whether they had washed their hands before an examination.

Participatory health care–when the vast majority of patients feel empowered to ask questions–is a change our health care system needs.

PS: it’s coming.

PSS: I’m late to the party.

What are we measuring?

So it has become apparent (to me) that our methods of measuring return on investment in health care are flawed.

Prevention’s savings are debatable. The NEJM: “Whether any preventive measure saves money or is a reasonable investment despite adding to costs depends entirely on the particular intervention and the specific population in question.” PLoS: “Although effective obesity prevention leads to a decrease in costs of obesity-related diseases, this decrease is offset by cost increases due to diseases unrelated to obesity in life-years gained.”

OK, but what about the individual lives saved? How about the extra years of quality living?

Value of care assessments at hospitals are numerous and have a long way to go.  Consumer Reports is trying something new according to Comarow on Quality:

Unlike the magazine’s trademark tables with little filled-in colored circles showing how well hospitals perform various procedures or deliver types of care, these rankings show how aggressively or conservatively—longer or shorter stays, more or fewer tests and specialist visits—patients are treated at a hospital relative to all other hospitals. The rankings are based on Medicare patients in the last two years of their lives who had been hospitalized any number of times during that period for any of nine chronic conditions—heart failure, dementia, and coronary artery disease are three. Adjustments were made to compensate for some patients being sicker than others.

Kaiser: “Health information technology by itself is unlikely to produce the significant cost savings projected by economic analysts and policymakers, according to a Congressional Budget Office analysis.”

OK, but what about reduced medical errors or the existence of continuity of care? Health Populi writes:

The ROI-rationale for the widespread adoption of health IT in the U.S. is a macro, national one. It’s a public health calculation that’s been mired in commercial/private health arithmetic. The denominator of these wrong-headed ROI calculations has been wrong-chosen: it’s been the individual physician practice, or the hospital, or the single health plan. The denominator is the public’s health.

As we begin to make decisions that will change our health care system, our measurement of the impact of those changes will have to evolve as well.

Non-profit status questioned

A recent court ruling in Minnesota has sent shock waves through the non-profit world recently according to this New York Times article:

Authorities from the local tax assessor to members of Congress are increasingly challenging the tax-exempt status of nonprofit institutions — ranging from small group homes to wealthy universities — questioning whether they deserve special treatment.

If you recall (or not), the non-profit status of hospitals has been questioned in the past two (or so) years.  So this is definitely something to pay attention to.  The discussion continues.

As local and state governments endure tough budgetary environments calls for such measures may gain momentum.

Good excerpt:

“The nonprofit sector is being pressed to be more business-like and to find new ways to fill the gaps between what government will pay and what services cost, but then assessors want to treat us like businesses, which pay taxes,” said Jan Malcolm, chief executive of the Courage Center in Minneapolis and a former state health commissioner.

And this:

“We need to figure out what we mean by ‘purely public charity’ because, frankly, we can’t afford as a state to lose nonprofits providing these kinds of services,” said State Representative Paul Marquart, chairman of the property tax subcommittee. “But it isn’t going to be easy.”

Paul Levy provides a defense of the non-profit status here:

But, I think the actual question is more interesting and subtle: What do people hope to achieve by threatening to take away the tax-exempt status of current non-profits? If their goal is not actually to take away the tax exemption, then they are seeking to have these organizations do more of what they feel is appropriate in the way of public service.

An interesting discussion in the comments ensues.

Forcing the Transparency Conversation

If not by carrot, then definitely with a stick.

CMS placed advertisements in 58 newspapers on Wednesday publicizing area hospital satisfaction rates found on the Hospital Compare website.  The ads reported the results of two questions: “The percentage of patients who always got help when they needed it. And the percentage of patients who got antibiotics one hour before surgery.”

Interesting approach.  Especially as web use increases and newspaper readership declines.  Maybe they are looking to reach a different audience.  But as an example of generational difference: I’m willing to bet more hospitals were concerned when they heard their results would be published in a newspaper than just on the website.

PS, the first patient satisfaction survey were not required.  So not hospitals reported.

More coverage: Comarow on Quality, Health Blog, USA Today