Twelve Global Megatrends That Will Revolutionize Healthcare (Part 2)

Yesterday I presented the first 6 megatrends identified by the Harvard Business Review that will have a dramatic impact on healthcare. Today I want to finish the list. It should be noted that many of these trends have been underway for some time but in some cases have gone unnoticed.



7) Evidence based medicine. Efforts in this area have been underway for years. Many studies have identified clinical variations by provider and by areas of the country that are not adequately explained. As hospitals focus on becoming high value providers, there will be much more attention to standardized clinical pathways and addressing deviations.



8) Non MD's providing care. The new healthcare reform legislation is strongly supporting models like the medical home which change the role of the primary care physician and the specialist. The specialists are being de-emphasized with the primary care physician doing more of their role while overseeing a larger group of patients. The actual interaction with these patients will be done by physician extenders.



9) Payer's influence over treatment decisions. The old model of making treatment decisions strictly on a medical basis regardless of cost are gone. Cost of care is being factored in both directly by payers refusing to cover certain treatments and indirectly by patients opting not to pursue treatment if their out of pocket costs are too high.



10) The growing role of philanthropy. With cuts in reimbursement coming from all payers and expenses continuing to escalate, hospitals need to become increasingly resourceful. Cutting costs and growing business will carry you only so far. Many hospitals rely on the community support they can obtain from individuals and corporate sponsors. With the current economy, the source of income is also being threatened.



11) Prevention is the next big business opportunity. Prevention has always been supported as a great idea that no one wants to pay for. We realize the economic benefit down the road of an investment in prevention today but there were no sources to pay for it until the new healthcare reform legislation. Now we will see numerous entrepreneurs become socially conscientious to promote better health.



12) Medical tourism. This is also nothing new but may be more prevalent with changes occurring in health care delivery and reimbursement. Patients with money will go to where they can receive the best care possible.



These trends, some new, most not so new, are impacting our healthcare system as we enter a paradigm shift under the new reform legislation. I am reminded of the Chinese curse, "May you live in interesting times".



More on this later.



Mark Brodeur

Twelve Global Megatrends That Will Revolutionize Healthcare (Part 1)

The Harvard Business Review has identified 12 healthcare megatrends that dramatically change how the world approaches healthcare and reacts to its largely unrecognized consequences. It paints a bleak picture of what will happen to healthcare costs in the future. Because of this, the role of healthcare providers will be diminished and the role of payers will be expanded involving treatment decisions.

These 12 trends are:

1)Innovation and demand soar in emerging economies. Our appetite for new treatments and cures will not diminish simply because the current healthcare system is under funded and overtaxed. We simply will not walk away from the promises of research and development.

2) Personalized medicine and technological advances. With the advent of genomics, treatments can be tailored to individuals. This is obviously a very expensive area but will certainly be pursued by those who can afford it.

3) Aging populations overwhelm the system. The baby boomer population bulge is now hitting their golden years. This combined with the medical advances which have lengthened their lives, is causing a significant increase in healthcare cost for the elderly. This wave will be with us for some years to come.

4) Rising costs. Even with all the technological advances we have made, healthcare costs continue to go up alarmingly. There is now a strong push on hospitals to represent high value and cost efficiency. But most of this will be too little, too late.

5) Global pandemics. H1N1 was real and hit some areas of the country hard. It now seems likely that this is just the beginning of other pandemics that will follow. Our globe hopping economy now makes any localized outbreak a world threat.

6) Environmental challenges. For years we have given lip service to the environment while ignoring the impact of our pollution. Now it seems that this approach is finally catching up with us and impacting us in numerous ways. The efforts to reverse this trend will be much more serious going forward.

More on the other 6 megatrends tomorrow.

Mark Brodeur

The Real Reasons We Have A Primary Care Physician Shortage

To understand the primary care physician shortage we must first recognize that it is not just a matter of recruiting more new physicians into this specialty, but also keeping the ones we have in the field. The American College of Physicians and the American Board of Internal Medicine have found that 9% of all internists certified between 1990 and 1995 are no longer working in that specialty today. Further they found that general internists are 4 times more likely to leave the field than subspecialists. Finally they found that general internists as a group were far less satisfied with their career than subspecialists or those who switched specialties.

Why is this? What has changed for the primary care physician who for years was the backbone of our entire healthcare system? ...A lot has changed.

1) The pay is low compared to specialists. There has always been a gap between the reimbursement for primary care physicians and specialists, but this gap has continued to widen. It has now gotten out of reach. Primary care physicians earn about one half of what subspecialists make.

2) Much of the work is not reimbursed. Family doctors are primarily paid for each visit by a patient to their office. But in a particular study of physicians who see 18 patients a day in their office, they also do the following unreimbursed work: make 24 phone calls to patients and physicians; write 12 drug prescriptions; read 20 lab reports; examine 14 consultation reports from specialists; review 11 medical imaging reports; and write 17 emails to doctors and patients.

3) Increasing demands, expectations and accountability from patients and the outside public. As I have said in a previous post, the relationship between the physician and patient has changed. Patients question their physician much more and expect more from them. Meanwhile under healthcare reform the primary care physician's role is being changed to take on more of what specialists have done and expanding the number of patients they are responsible for. To achieve this they are being required to delegate a lot of the direct patient interaction to physician extenders.

Although the new healthcare legislation includes financial incentives for primary care physicians and payments for preventive health programs, I am afraid that it does not go far enough. We need to ensure that we provide a financially adequate and professionally satisfying career path for tomorrow's (and today's) primary care physicians.

More on this later.

Mark Brodeur

Three Ways To Improve Patient Medication Adherence And Reduce Admissions

One of the major causes of hospital readmission is the failure of patients to strictly follow the course of medications set out for them upon discharge. This is also a cause for many initial hospital admissions. It isn't because patients are refusing to follow the physician's orders or don't wish to be compliant. But there are other factors involved. A recent study from the New England Journal of Medicine stated that up to half of all patients fail to take their medications faithfully as prescribed thus compromising their health and costing the healthcare system $100 billion per year in preventable hospital stays. There are three steps that can be taken to address this serious issue.

1) Provide more help to patients explaining the various medications. Patients need to know what each medication is for and when it must be taken. Likewise the primary care physician must know the complete set of medications that a patient is on. A patient seeing several specialists may be getting a number of prescriptions with no one coordinating all of these. Some patients could be on as many as ten different medications which is a lot to coordinate without some outside help.

2) Discuss possible side effects of each medication. A patient could be on medications to lower cholesterol and high blood pressure, neither of which give him any symptoms. But the medications when taken correctly make him tired, so he stops taking them figuring he feels better off of the meds. Again, a thorough understand of what each drug is for will help promote compliance. But anticipating the possible side effects will also be very helpful.

3) Consider the patient's financial situation in prescribing medications. Studies have shown that an increase in copayments will reduce the likelihood that prescriptions will be filled. Patients are more likely to be compliant if their out of pocket expenses are minimized. Hopefully some of this will be alleviated on June 15 of this year for Medicare patients when they can receive $250 to help fill the "doughnut hole" in Medicare's prescription benefits.

Some effort in these three areas can not only improve patients' health, but also save some money for our overstretched system.

More on this later.

Mark Brodeur

Conflicting Studies Address Cost Awareness As Part Of Physician Training

A recent study by the Accreditation Council for Graduate Medical Education concluded that most physicians are no longer being trained just to prescribe the best course of treatment medically. They are now taught to also consider the financial implications. This is a radical change from the past.

This sudden and dramatic shift has occurred since 2007 when physicians were first asked to incorporate considerations of cost awareness and risk-benefit analysis in caring for patients. Two other studies give conflicting data on how widely this new concept has been adopted as part of medical school curriculum. One study says 60% of the schools teach this while another says only 41% do.

Some schools like Mount Sinai School of Medicine take this very seriously by having students volunteer at a student run free clinic for the uninsured. These students must collaborate with social workers to assist patients in paying for medicines. They also are exposed to the cost of drugs and commonly ordered tests. This in my opinion is an important addition to medical curriculum.

Other research suggests that Electronic Medical Records have helped expose physicians to the cost of drugs and tests that they were not exposed to before. This has resulted in a slight but perceptible change in their ordering habits. Even this slight change has resulted in an annual savings of $1.7 million in laboratory charges at Brigham and Women's Hospital.

But one last study highlights an area where there is still need for change; the practice of defensive medicine. A national survey of over 1,400 physicians found that 83% of those between the ages of 25 and 34 said that they were taught to practice defensive medicine. They were taught to protect their livelihood as well as save lives. The US is the only major country where physicians are personally financially liable for their mistakes. Also, medical liability claims make up 10% of all tort cases. Until these facts change, teaching in medical schools on this issue will remain the same, as well they should.

So we are making inroads in teaching our new physicians to practice cost effective medicine. If we could achieve some meaningful tort reform, we could go even further in this direction.

More on this later.

Mark Brodeur

Computerized Physician Order Entry May Lower Mortality

At last, a study that shows that the millions of dollars we have all been pouring into computerized health records may actually show a real benefit in terms of quality of care delivered. And what more important measure is there than mortality.

A new study at Lucile Packard Children's Hospital at Stanford University in California found that CPOE cut mortality rates by as much as 20%, which translates to 36 fewer deaths at the hospital in 18 months. That is really significant. In fact it is the lowest rate ever observed in a children's hospital according to the author.

It should be kept in mind that this is a small study and was not in a completely controlled environment. It is possible that other factors also had an influence on the dramatic drop in mortality. But even so, the impact of properly implemented CPOE can not be argued. According to the author, it was the well planned implementation that set this project apart from others that failed to show this kind of impact. There was also the investment of $50 million just on CPOE as part of a $600-700 million budget for the entire information system.

So as hospitals continue to make significant capital investments into computerized information systems to stay in compliance with all of the mandates, it is good to know that there may be some real benefits out there from a quality perspective. We all learned years ago that the preliminary promises of computerized systems saving you FTEs were not true. I would be quite satisfied though if I knew I was saving lives.

More on this later.

Mark Brodeur

Readmission Rates Are Higher For Patients Without Timely Postdischarge Followup

A recent study of heart failure patients published in the Journal of the American Medical Association had several interesting findings regarding followup care after hospital discharge. First, that patients who do not see a provider within seven days following their discharge are 15% more likely to be readmitted within 30 days. Second, that only 40% of the patients studied had this timely followup.



It is the second point that disturbs me. With our current disjointed system of care between physicians and hospitals there is often a break in the continuity of care for a patient following discharge from a hospital. Hospitals actually do better on follow up of Emergency Department patients who are not admitted. The question is "who's responsibility is it to initiate the follow up visit?" Now it seems to rely on the patient. In heart failure patients things are further complicated by the fact that a cardiologist managed the hospital care. So is it the cardiologist or the primary care physician who should follow up?



The current thinking seems to be blame the hospital by penalizing them for excessive readmission rates. This is simply not fair. While there is the possibility of premature discharge that is the cause of readmission, most are the result of poor postdischarge followup. Some readmissions are not preventable no matter what you do.



The current system is flawed and needs better continuity of care for the patient. This will require much stronger communication between all providers. But the solution to this problem is not to simply penalize hospitals thus forcing the responsibility on them. The answer lies in connecting the current patchwork of independent providers together for the sake of the patient.



More on this later.



Mark Brodeur

Pay For Performance: A Good Thing If It Is Done Right

One of the outcomes of healthcare reform is the promotion of pay for performance (P4P) systems. Essentially these reward hospitals and physicians that provide great value, that is high quality care delivered cost effectively. This is a good thing and something necessary for the future survival of our healthcare delivery system. But we can't allow healthcare providers to be incentivized for gaming the system.

A recent study out of Johns Hopkins found that physicians have more incentive to delay or even pass on treating obese patients in need of gallbladder or appendix surgery because that are statistically more likely to experience complications than their non-obese patients. And the P4P systems do not adequately adjust for case complexity of dealing with these types of patients. The social ramifications of this are that African-American and lower income patients will be disproportionately affected because they have higher rates of obesity.

This study was based on the review of 35,000 insurance claims for gallbladder patients and 6,800 claims for appendectomy patients between 2002 and 2008. Obesity is clearly the most prevalent co-morbidity that skews outcomes.

A RAND Corporation study reached a similar conclusion in a review of primary care physicians in Massachusetts. A typical physician serving the highest proportion of medically vulnerable patients, received about $7,000 less each year under a P4P model.

Any pay for performance system must adequately adjust for the complexity of medically vulnerable patients. Obesity is the most common such factor. That being said, we must also at some point hold patients accountable for life style decisions. A physician or hospital should not be penalized for treating an obese patient over a healthier one. Worse yet they should not be incentivized to pass on providing care to such patients. Any P4P system must recognize and pay additional for legitimate complicating conditions, obesity being the most common one. At the same time there should be incentives set up for patients to start living healthier. These may ultimately have to be replaced by penalties on patients who refuse to comply with basic standards. I am all for access to healthcare for everyone. But along with that comes some level of responsibility for yourself.

More on this later.

Mark Brodeur

One Quick Patient Safety Tip: Interupting Nurses Increases Chances of Medication Errors

This news should come as no surprise to any one, but perhaps the magnitude of the numbers will. A recent study published in the Archives of Internal Medicine shows a clear association between nurses being interrupted during medication administration and subsequent medication errors. As the number of distractions increase, so do the number of errors.

The study observed 98 hospital nurses during 4,271 medication administrations and found that interruptions occurred in 53% of them. That number seems very high to me particularly when you consider that only 11% of the interruptions were necessary. There are issues like monitor alarms and other critical events that must be dealt with regardless of what the nurse is doing. But the other interruptions just represent a wonderful opportunity for process improvement that will have a direct impact on patient safety.

Let's look at the consequences of these interruptions. Of those nurses who were interrupted, 74% had at least one procedural error and 25% had at least one clinical error. These rates shot up to 85% and 39% respectively when nurses were interrupted at least three times. If a nurse was interrupted four times, the patient was twice as likely to experience a medication error versus and uninterrupted nurse.

When you consider how prevalent medication errors are and the one third of them occur during administration by the nurse, it seems like an obvious area to address. This is the first study I am aware of that links medication errors and nurse interruptions. There are many critical tasks where we make sure the individual involved is not distracted; a pilot during take off or a surgeon in the OR. Let's provide our nurses with a Protected hour for medication administration.

More on this later

Mark Brodeur

Hospital Boards Are Doing Their Job On Quality Oversight

The 2009 survey by the Governance Institute shows that hospital boards have increased their focus on quality initiatives. This is good news considering some of the recent reports that have suggested that hospitals have not made the progress in quality initiatives that was expected. Chief among those was the recent Leapfrog report.

But the Governance Institute report tells a different story at the board level. The Governance Institute is a not for profit organization dedicated to educating hospital boards and assessing their effectiveness. Their most recent survey included questions related to 13 recommended board practices for quality oversight. Clearly more hospitals are adopting most or all of these practices than was the case two years ago.

Practices that have been adopted by at least 90% of the hospital boards:

1) Review quality performance using dashboards or balanced score cards at least quarterly

2) Review patient satisfaction scores at lest annually

3) Compare current quality performance to historic performance

4) Challenge medical executive committee appointments and reappointments to the medical staff

Practices that have shown significant increase in adoption:

5) Require management to set at least some quality goals on the theoretical ideal

6) Devote significant time at board meetings to quality discussions

7) Ensure that board and medical staff involvement in setting the quality agenda at least equals management input

8) Report quality and safety performance to the general public

9) Have a standing Quality/Safety Committee as one of the top four committees

Increased focus in these nine areas show that most of the hospital boards in this country get the message. With board involvement at this level, we will ultimately get the results that are necessary. My congratulation to you.

More on this later.

Mark Brodeur