Uncategorized

Health Information Technology: Visioning vs. Planning

By M2|2017-10-08T11:51:55+00:00May 30th, 2017|EHRs, Health Care Trends, Health Information Technology, Hospitals, Uncategorized|

Health Information Technology: Visioning vs. Planning

A recent study in Health Affairs confirmed what health providers and their patients already know: During a typical patient, the health care professional spends more than half of his or her time staring at the computer, not talking face-to-face to the patient. As of 2015, about 96% of health care organizations have a certified electronic health records (EHRs), and by the end of 2013, 66% of physicians were using electronic prescribing. Just ten years ago, those numbers were much lower, with only 9.4% of hospitals using a basic EHR and only 7% of physicians e-prescribing. Behind the push to get hospitals and physicians using health information technology was the promise of using big data.

While there have been volumes written about this has worked well in some ways, and not so well in others, what is undeniable is that health care organizations, and the patients they serve are now digitally intertwined. It is unlikely the system will be going back to paper-only records any time soon, so are there ways to make health information technology (HIT) work better?

One point of view was recently published by Family Medicine for America’s Health (FMAHealth) which focused on what primary care physicians want from HIT. They argue, “in addition to putting up barriers to achieving the Triple Aim, the poor usability and utility is resulting in health IT contributing to the growing problem of physician burnout.”

After a one day Visioning Summit, FMAHealth put forth a vision based on the following design principles: HIT should:

“(1) foster connections among health care professionals, including the individuals and communities they serve, and the environment in which people live;

(2) accumulate and analyze data that can support these connections and address the needs of population health; and

(3) promote appropriate payment for health care.”

The vision is set forth in 1, 3, 5 and 10 year increments. For example, in one year, the group would like to see “Data visualization technologies, which make it easy for the clinician to see patterns and make insight, will emerge to support health-related decisions and actions.” In three years, technology will “provide easy ways to natively support healthy behaviors, such as improved diet and exercise…”. In seven years, the group hopes “We will effectively use technology to deliver meaningful and relevant health-related information at the right time in a way that is “frictionless” and supports bringing the joy back to the practice of medicine.”

In my opinion, HIT is capable of all kinds of things, many of which I am sure we only starting to understand. Bringing joy back to the practice of medicine might be really difficult, but FMAHealth is putting forth a vision, not necessarily a plan.

Leave the plan to the Chief Information Officers (CIOs)!

Considering all of the money, time and human resources invested in HIT, some CIOs argue that hospitals, health systems or large provider groups are essentially health care shops AND software shops. David Chou, CIO at Children’s Mercy Hospital in Kansas City, MO [check it is MO] explained, “the day you made that investment you became a software vendor.”

What are some of the ways to make this technology work better, according to these experts?

· Think like a software vendor (hint: clinicians are your customers!)

· Have a strong focus on the end user

· Use an iterative model to develop, test and get feedback from users

· If you can’t buy it, build it (don’t hesitate create a capability that works for your organization)

No matter our daily work – as policy makers, business owners, health care professionals, or patient advocates, we should all be focused on the end user, and on iterating. As the health care system continues to change, looking to some of the lessons of the fast moving and customer-focused industry of software development could be a great playbook to follow to improve HIT.

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Who should advise patients about exercise?

By M2|2017-10-08T11:52:28+00:00May 26th, 2017|Health Care Trends, Physician-patient communication, Uncategorized|

Who should advise patients about exercise?

In 2015, 20.9% of Americans exercised as recommended every week. Not sure what that recommendation is?

You’re not alone.

According to the CDC, the average American adult should try to get at least 150 minutes a week of moderate-intensity aerobic physical activity, or 75 minutes a week of vigorous-intensity aerobic physical activity, or an equivalent combination of the two. This means walking, running, biking, bowling, gardening, etc.

Less than 21% of Americans actually get this amount of exercise. And several studies show that few people know what the guidelines are, including a British study that shows only 14% of respondents even knew how much exercise they are supposed to get.

We are all busy. It is hard to know what the very latest research says.

But a new study shows the problem may run deeper.

Let’s say you have been diagnosed with cancer and are now undergoing a treatment regimen with an oncology specialist. Would it seem reasonable to ask your doctor for advice on exercise?

A study published in May in the Journal of the National Comprehensive Cancer Network says just that: “Patients want advice and support about exercise while enduring the physiological and psychological side effects of treatment. Furthermore, they prefer that the exercise recommendations come from the oncology provider.”

The gap between what the patient wanted and what the oncologist did in this small study is instructive. 95% of patients told interviewers they felt physical activity was “very important during their cancer treatment.” When focus groups and individual patients were asked, “From whom and how would you like to receive exercise information?” 80% of participants said they wanted advice from their oncologist. Ideally, the patients said, they’d like their doctor to recommend a home-based exercise program.

But more than half of providers wanted to refer patients to another health care professional for exercise recommendations.

Even discussing exercise options was difficult for oncologists, for several reasons. Time constraints, lack of knowledge of a patient’s fitness level, or what kind of program would be appropriate, cost of rehabilitation, lack of transportation, side effects of treatment (for example, fatigue) were all cited as barriers to oncologists recommending exercise programs.

In this particular study, nearly all of the cancer patients wanted their oncologists to discuss physical activity with them, but in reviewing patient-physician transcripts, the researchers found such conversations were “nonexistent.”

As with many best practices in health care, although the evidence-base supports physical activity for most cancer patients undergoing treatment, that doesn’t mean patients can get reliable information on exercise programs from their trusted heath care professionals. In part, the oncologist does not get paid for this interaction. Even if an exercise therapist or similar health care professional were able to collaborate with the oncologist, it might be difficult for the patient to either attend another doctor’s visit, or pay for such a visit. A “shared-care” clinic visit might work well if the focus is to provide health care provider focused care. But the study indicated what these cancer patients really wanted was a home exercise program.

While policymakers and others talk about “patient-centered care,” when it means moving care from a health care institution to a home setting, or asking a trusted provider to be trained in something he or she may not feel expert in, it is very hard to get the system to do what works best for the patient. Bridging the gap between the system we have and the system we want requires patients and physicians to behave differently, but it also requires payers and health systems to change their ways as well.

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Light Health Care Users: Most Americans Use Few Health Care Resources and Have Low Out-of-Pocket Spending

By M2|2017-10-09T01:49:05+00:00May 23rd, 2017|Health care spending, Health Care Trends, Insurance, Out-of-pocket spending, Uncategorized, What do we pay for and why|

Light Health Care Users: Most Americans Use Few Health Care Resources and Have Low Out-of-Pocket Spending

Every day we read news coverage focused on rapidly rising health care costs, but a seldom-reported part of the story is how very few people are responsible for those costs.

A study of health care costs from 1977 to 2014 shows that over the length of the study period, the top 1 percent of the health care using population consistently cost the system more than the bottom 75 percent. Just 1 percent of the population, in fact, accounts for nearly a third of medical spending.

The study, published in the April 2017 issue of Health Affairs, finds that “most Americans use few health care resources and have low out-of-pocket spending.”

In addition, more than 93 percent of these light spenders (those in the bottom half of the population) believe they have received “all needed care in a timely manner,” and the light spending by the majority of the population “has remained almost unchanged during the thirty-seven-year period.”

This light spending has also remained “unchanged since the inception of the Affordable Care Act (ACA),” as a Medscape article on the study notes.

These findings matter because most health care policy discussions focus on spending at the population level – in other words, on the 1 to 5% of the U.S. population that incurs significant medical costs. That isn’t how individuals think of health spending, however. Most of us think of what we as individuals, or perhaps our family, spends on health care.

Insurance, by design, must include many non-users, so to speak, in order to work. Most of us buy home insurance or car insurance and never use it. That is, we make payments to an insurer in the form of premiums, but we typically don’t have car accidents and don’t have house break-ins or fires. Similarly, most people don’t have much in the way of medical spending.

But if too many light spenders don’t buy insurance, the price of insurance increases for everyone. And in fact, that is what happens.

This chart from the April 2017 Health Affairs article shows that the highest spenders are the most likely to be on public insurance – think Medicaid for the severely disabled – and light spenders are the most likely to be uninsured – they don’t think they need it, and they probably don’t for years and years – until something catastrophic happens.

In terms of out-of-pocket spending, for light spenders in 2014 this figure was just $75 on average, which is less than the $94 (in adjusted 2014 dollars) spent in 1977, the authors find. On the other hand, high spenders averaged $1,096 in out-of-pocket costs. And 50% of light spenders had no spending at all (not including health insurance premiums, if they were insured), whereas only 6.1% of high spenders had none.

As we continue to think about how to improve or change health care insurance, delivery, and payment in the U.S., it is important to remember how few people actually interact with the health care system every year. Even for people buying health insurance, a large proportion of people spend little on actual health care services, and that has remained stable for decades.

This makes some complaints about the Affordable Care Act a little easier to understand. As the study explains, light spenders “as a group are unlikely to receive substantial short term benefits from the Affordable Care Act.”

The question is, what is insurance for? We probably shouldn’t design the entire U.S. health care system for people who don’t need care. But the subtle lines of who pays more, the sick or the well, the old or the young, are something we still need to work out.

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Hospital Consolidation as One Potential Solution to Financial Impact of ACA

By M2|2017-10-09T01:50:11+00:00May 19th, 2017|Hospitals, Insurance, Uncategorized|

Hospital Consolidation as One Potential Solution to Financial Impact of ACA

While some have looked at financial issues related to the ACA and called for its repeal, others are taking a different tack. One example is Toby Cosgrove, President and CEO of the Cleveland Clinic, one of the largest and most respected medical centers in the world.

While Dr. Cosgrove will be stepping down later this year from CEO to an advisory role at Cleveland Clinic, Cosgrove has a big idea for how to address rising health care costs in the U.S., and it is not to repeal Obamacare.

His idea? Hospital consolidation.

“We have to realize that not all hospitals can be all things to all people,” he said at an event in Washington, DC in April.

He would know; the Cleveland Clinic has been experiencing financial strain, along with many other hospitals across the country. The struggles have been attributed in part to some of the new regulations resulting from the ACA. The Cleveland Clinic recently reported a steep 70% drop in operating income, from $480.2 million in 2015 to $139.3 million in 2016.

Cosgrove said consolidation would not only improve financials, but would also increase efficiency and help decrease the burden of disease.

Looking further at ACA-related financial impacts, every sector of the health care industry is concerned about the stability of the ACA-related insurance exchanges. In mid-April, several organizations wrote a letter to the Trump administration asking for a commitment to fund cost sharing reduction (CSRs) for 2018. CSRs provide assistance to low- and modest-income consumers earning less than 250 percent of the poverty level to help reduce deductibles, co-pays and/or out-of-pocket limits.

“A critical priority is to stabilize the individual health insurance market,” the letters read. “The window is quickly closing to properly price individual insurance products for 2018.”

Signatories to the letter include not only the two main hospital associations – the American Hospital Association and the Federation of American Hospitals – but also several of the large physician, insurance, and employer groups: the American Medical Association, the American Academy of Family Physicians, America’s Health Insurance Plans, BlueCross BlueShield Association, the American Benefits Council and the U.S. Chamber of Commerce.

Without funding of the CSRs, U.S. consumers will be “dramatically impacted,” the groups say; for example, they predict there will be more limited choices for consumers; premiums will be higher for 2018 and beyond; if more people are uninsured, providers will give more uncompensated care, which will raise costs across the system; and taxpayers will pay more than they would otherwise, as premiums grow and tax credits for low-income families increase.

Regardless of the ultimate fate of Obamacare, and whether changes are made at the federal or state level, some truths about the U.S. health care delivery system remain. Technology is improving, as we explored in a recent blog post on telemedicine and knee pain treatment, for example, and the care that works best for patients is less likely to be hospital based, as we noted in this recent blog post highlighting that sometimes “less is more” when it comes to breast cancer treatment.

At this point, if one of the largest health care systems in the U.S. is arguing that fewer hospitals are needed, it is certainly time to pay attention to what true change in health care will look like.

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Who Deserves Health Care? (a.k.a. Health Care is Hard)

By M2|2017-10-09T01:51:07+00:00May 17th, 2017|Health care spending, Insurance, Uncategorized|

Who Deserves Health Care? (a.k.a. Health Care is Hard)

Congressional efforts to repeal (and replace?) Obamacare seem to be on track to continue over the summer. The American Health Care Act (AHCA) passed the House May 4, 2017, and as written will gut Medicaid, defund Planned Parenthood for one year, and allow health plans to charge older, poorer people way more than they are paying now for health insurance.

You can read all sorts of news and opinions about why the House-passed AHCA bill is problematic if the goal of the bill was either to reduce health care costs for consumers or ensure access to health insurance coverage. But you might not read this: Late in February President Trump said health care is unbelievably complex – he was right and this is why.

Health care comes down to two questions that are easy to ask, but hard to answer. First, who deserves health care? Second, who should pay for it?

Question 1: Who deserves health care?

If you think everyone deserves health care, great. Then you can just jump ahead to the second question. However, to understand the current health care debate, it is important to know that many people, including many elected officials, think only certain people deserve health care. And when they say health care, they mean health care insurance.

For those promoting a “free market” approach, they support a system in which a person who “works hard” is rewarded with health insurance coverage. That is how most people in the U.S. get health insurance now. The problem is the definition of “works hard.” In 2014, 83% of people with a full-time job who made more than about $48,000 per year (400% of the federal poverty level or FPL) were offered insurance by their employer (see chart from Kaiser Family Foundation).

So one definition of “works hard” to the proponents of “let the free market decide” is well-paid full-time workers. Indeed, employer-sponsored insurance is the basic building block of the U.S. health care system. Historians will explain that in 1940 about 9 percent of the population had health insurance. In 1943, the Internal Revenue Service (IRS) ruled an employer offering the fringe benefit of health insurance could do so tax-free. As a result, in 1953, health plan participation jumped to nearly 65% of people. The IRS giving certain kinds of health insurance tax-free status hardly seems to be “letting the free market decide,” but we digress…

Besides full-time employees, who else worked “hard” enough to deserve health insurance? The second biggest group are Medicare enrollees. About 15% of Americans receive Medicare. But again, they “deserve” it, because every worker in the U.S. pays a portion of his or her paycheck to the Medicare fund. A person receives Medicare because they earned it – he or she either worked a certain number of years during their lifetime and paid into the fund, or their spouse did.

Yes, health insurance is different from health care. Emergency rooms are required by federal law to accept emergency patients. And community health clinics provide care on a sliding scale. So technically, everyone can get health care because we have emergency rooms and free health clinics.

Question 2: Who should pay for health care?

Even if your answer to question 2 is, “We should all pay!” it doesn’t necessarily make the mechanics of everyone paying any easier. If everyone pays, how do we do it? A flat tax for every person? A tax based on income? A tax based on how much health care costs where you live?

Should sick people pay more than people who are well? Should older people pay more than younger people? Should we all pay for a basic set of benefits, even those we don’t use? For example, should men have to pay for maternity care? Should young people have to pay for prostate exams or colonoscopies? Should middle-aged people have to pay for childhood vaccines?

As mentioned previously, we all pay for health care in the system we have today because our taxes go to support free health clinics and to cover the costs of hospitals who provide emergency care that is “uncompensated.”

Which brings us to why health care is so unbelievably complex. Each of us has our own experience with the system, and whatever we don’t like, we blame on “the system.” If your premiums have gone up in the past few years, you might blame Obamacare, but it is just as likely that your employer changed your health insurance plan so they could save some money for their shareholders. On the other hand, if you couldn’t get insurance before Obamacare because you had a pre-existing condition, you might credit Obamacare for that access.

One individual’s experience of health care or health insurance is not everyone’s experience, and your experience may or may not be because of Obamacare. But every story counts. Many elected officials are hearing from constituents that Obamacare is failing them, and that may very well be true. Other constituents are saying Obamacare saved their life, and that may also be true. Having an honest conversation about all the ways Obamacare helps and hurts people, and who deserves what, would be a better way to get to policies that would work. But that would be hard.

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The Secret Sauce for Everything (Starting with Polling and Policy)

By M2|2017-10-09T01:51:40+00:00May 12th, 2017|Uncategorized|

The Secret Sauce for Everything (Starting with Polling and Policy)

A recent article in The Washington Post by Anna Greenberg and Jeremy Rosner discussed three ways people are misusing and abusing polls. While polling is not a particular interest of mine, I read the piece because it was on the way to some other article that had caught my eye. I’m glad I did because it had more relevance to my work than I would have guessed.

To read their entire argument you will have to click through, but their third point read:

“Good polling, requires good listening…The best polling has always been accompanied by directly listening to people, face to face, in their own words.”

It occurred to me this simple phrase applies to many other situations. You could substitute as follows and it would be same:

Being a “good parent requires good listening.”
Being a “good student requires good listening.”
Being a “good friend requires good listening.”
Being a “good manager requires good listening.”
Being a “good citizen requires good listening.”

You get the idea.

But it also struck me immediately how the phrase pertains to my work. What do I do for a living? I try to change people’s minds. Sometimes I am working with clients to try to change a policy. Sometimes I am helping a client sell a new service. Sometimes my job is to convince a payer to increase a client’s reimbursement for delivered services.

All of these efforts start not with gathering the evidence, or trying to prove a point, but instead with good listening.

Before I can help a client in any of these circumstances, I have to understand how the other side would benefit. And I have found the best way to do this “has always been accompanied by directly listening to people, face to face, in their own words.”

Changing people’s minds, which could also be called negotiation, is a skill that seems to be of high interest. Type “how do I negotiate…” into Google and more than 100 million results appear. In Essentials of Negotiation, a book I have been using for years, the authors advise:

“In structuring the message, you as the negotiator should emphasize the advantage the other party gains from accepting your proposal. Although this may seem obvious, it is surprising how many negotiators spend more time explaining what aspects of their offer are attractive to themselves than on identifying what aspects are likely to be attractive to the other party.”

It also seems obvious to listen, preferably face to face to people in their own words. But I guess it’s not.

Thank you, Anna Greenberg and Jeremy Rosner, for reminding us all of something so fundamentally important. Perhaps your advice will be used by more of us to negotiate for ourselves and others, and to think about how to change people’s minds.

First, listen! It works for me and my clients. It seems to work for polling. Maybe it will work for you too.

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Despite Americans’ Support for Avoiding Low-Value Health Care, One-Third Have Difficulty Understanding Benefits of Conservative Approaches; Few Favor Doctors Who Avoid Unnecessary Care

By M2|2017-10-09T01:52:43+00:00May 10th, 2017|Evidence-Based Medicine, Uncategorized|

Despite Americans’ Support for Avoiding Low-Value Health Care, One-Third Have Difficulty Understanding Benefits of Conservative Approaches; Few Favor Doctors Who Avoid Unnecessary Care

“Low-value care” is defined as expensive procedures and tests with questionable therapeutic value; examples include unnecessary screenings and antibiotics.

As much as 30% of U.S. health care spending may be unnecessary. However, one-third of Americans “have difficulty envisioning benefits from avoiding low-value care,” according to a study published in The Milbank Quarterly. This figure increases to one-half for minorities and those who are less educated.

“The public’s awareness of low-value care is incomplete, with substantial disparities related to race, ethnicity, and socioeconomic status,” the study finds. “Media messaging can help fill these gaps but, in the short run, would be enhanced by fine-tuning how low-value care is characterized. In the longer run, building robust public support for reducing low-value care may require refocusing attention away from specific tests and treatments and toward the relational benefits for patients if clinicians spent less time on testing and more time on personalized care.”

The research, conducted by Mark Schlesinger, Yale School of Public Health, and Rachel Grob, University of Wisconsin-Madison, involved a range of methods, including focus groups, intensive interviews with patients and a national survey.

Less time on low-value care means more time on personal care, right? Not so fast…

Specifically, the respondents anticipated two distinct changes: they “expected that spending less time ordering and reading tests would allow clinicians more time to talk with their patients” and that “taking a more mindful, less routinized approach to testing would encourage discussion of the benefits and limitations of each approach and greater acknowledgment of clinical uncertainty,” the authors note.

“Most Americans who anticipate benefits hope that less testing and treatment will be replaced by more interactive and personalized care. Even without media priming, many Americans would avoid common forms of low-value care like unnecessary antibiotics or excess imaging for lower back pain,” the authors say. However, “few favor clinicians who avoid these practices.”

For example, “many patients now seek specific tests or procedures or insist on quick interventions because they feel the pressure of work and home responsibilities. Clinicians find such requests difficult to refuse, even when they recognize that acquiescing will have little clinical benefit.”

These findings demonstrate that even though we are wasting nearly one-third of our health care dollars, people still are not sure they want to actively not choose “low-value care.”

Interestingly, we have seen this dynamic before (see our recent blog on “Breast Cancer: Less is More, Says Surgical Chief”); it is difficult to convince physicians and patients both that less is more.

What can we do to address this disconnect? Educating the public is a good place to start, as the authors recommend.

“To debunk the opinion that ‘more is better’ when it comes to health care, the study suggests that public education is vital to reducing spending, with an emphasis on the great risks and limited rewards of low-value procedures,” as the Association of Schools & Programs of Public Health (ASPPH) says.

But how we message this matters, the study authors emphasize: In order to maximize public education efforts on low-value care, the messages, and resulting media coverage, “must be adapted to resonate as strongly as possible with the public’s values, perceptions, and preferences about medical care,” they say.

We need to start explaining what low-value care even means. “What is needed is a message campaign that has the capacity to reach, and mobilize, the majority of Americans who currently see no advantage in reducing low-value care, particularly the third of the population that has little current understanding of what that concept even means or why it matters.”

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Physicians Missing Opportunities for Communication to Help Patients Reduce Costs, Duke Study Finds

By M2|2017-10-09T01:53:50+00:00May 3rd, 2017|Health care spending, Uncategorized|

Physicians Missing Opportunities for Communication to Help Patients Reduce Costs, Duke Study Finds

Health care providers have an important role in helping patients navigate the restrictions health plans put in place that may drive high out-of-pocket expenses. Clinicians could help patients determine whether lower price interventions might work, for example.

To help patients make health care choices that are informed by knowledge of expected costs, some experts have recommended routine physician-patient communication about out-of-pocket expenses.

However, “there is very little research assessing how often, or how well, doctors and patients discuss health care costs during clinical encounters,” Peter Ubell, Duke University, et al., note in a study published in Health Affairs.

To address this gap, the authors studied audio recorded clinical encounters, and found that “physician-patient spending conversations did not always enable patients to successfully navigate out-of-pocket expenses.”

In fact, some physician behaviors “stand in the way of helping patients make informed decisions about ways to potentially lower their out-of-pocket spending,” the authors find.

Indeed, as noted below, the authors identified a range of physician behaviors representing “missed opportunities” to address patients’ cost concerns, from dismissal of such concerns, to physicians being too quick to accept patient’s dismissals of their own concerns (for examples of actual physician/ patient conversations demonstrating some of these missed opportunities, see accompanying chart below).

Researchers reviewed 3,000 physician-patient interactions for management of breast cancer, depression, and rheumatoid arthritis.

Two broad categories of physician behaviors led to “missed opportunities to reduce out-of-pocket expenses”-

Missed opportunities to address patient’s financial concerns – For example:

Failure to recognize potential financial concern: “For patients to productively discuss out-of-pocket spending with their physicians, they need physicians to recognize that they have financial concerns. However, patients do not always state their financial concerns explicitly,” the authors say.
Distracted from patient’s financial concerns by frustration with the system: “When physicians discuss health care expenses with patients, they sometimes spend considerable time complaining about the systemic factors contributing to high out-of-pocket spending. Occasionally, voicing those frustrations seems to distract them from exploring how to reduce patients’ expenses.”
Dismissal of patient’s financial concerns: “Even when physicians pick up on and acknowledge patients’ financial concerns, they sometimes dismiss such concerns before exploring whether it is possible to reduce patients’ financial burden. For example, in one interaction, a patient explained that ‘[I] cannot take my pills, because there is now a copay.’ She mentioned that she had ‘zero income,’ to which the physician replied, ‘That’s what happens, yeah,’ without addressing her inability to pay for her medications.”
Hasty acceptance of patients’ dismissal of financial concerns: “Sometimes, patients express financial concerns to physicians, and then they, the patients, dismiss those same concerns. When physicians readily accept such dismissals, they miss out on opportunities to find out whether such concerns are legitimate.”

Limited resolution of patient’s financial concerns – For example:

Assuming “coverage” means full coverage: “Many insurance plans do not fully cover services but leave patients with copayments or coinsurance,” the authors note. “When physicians mistakenly assume that ‘coverage’ means full coverage, they might unwittingly expose patients to burdensome out-of-pocket spending.”
Assuming generic medications are affordable: “In recent years, consolidation among manufacturers has led to significant increases in the price of some generic medications,” the authors note. “Even absent such price increases, the cost of generic medications can burden those patients who are stressed to their financial limit. But physicians do not always recognize that ‘inexpensive’ generics can be unaffordable for their patients.”
Assuming copayment assistance programs and coupons resolve financial concerns: “Sometimes pharmaceutical companies create programs to help patients pay for expensive medications. These programs do not always eliminate all out-of-pocket expenses. And not all patients who seek such assistance receive it.”
Temporizing financial burden without discussion long-term solutions: “Sometimes physicians make earnest efforts to address patients’ financial concerns but focus on temporary solutions without discussing steps necessary to yield long-term financial relief. Physicians offer free samples of medications to treat patients’ problems even when such samples only delay the day when patients will face significant expenses. In some cases, in fact, the free samples are expensive drugs, and use of the free samples might distract physicians from trying less expensive alternatives first. Other times, physicians turn to short-lived drug discount cards or coupons,” the authors say.

“Many physicians want to help relieve patients of their financial burdens, to increase the likelihood that they will receive prescribed interventions and improve their overall quality of life. To achieve this goal, physicians need to recognize when their own behaviors interfere with these efforts,” Ubell, et al., say.

“For example, when patients are burdened by the expense of prescribed interventions, physicians should consider whether there are less expensive alternatives. When the best solutions are short in duration, it behooves physicians to make plans to find longer-term solutions. And when patients raise and then dismiss financial concerns, physicians should take a moment to assess whether such dismissals are warranted.”

“Many health care policies are ultimately played out ‘at the bedside,’ by influencing the way doctors and patients make medical decisions,” the authors say. “In the case of policies promoting health care consumerism, many patients are faced with important decisions about whether the benefits of health care interventions justify their financial cost.”

As this study demonstrates, patients often are ill-equipped to make medical decisions and may require additional information to do so. One way to address this issue may be to offer additional training for physicians, in order to help facilitate the conversations with patients about their financial concerns. Alternatively, physicians could consider adding a staff member who could be a resource for answering financial questions from patients.

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Chronic Knee Pain: Internet-Delivered Exercise and Pain-Coping Skills Work Well for Patients, But Will Payers Cover It?

By M2|2017-10-09T01:54:34+00:00April 27th, 2017|Chronic pain, Evidence-Based Medicine, Reimbursement, Uncategorized, What do we pay for and why|

Chronic Knee Pain: Internet-Delivered Exercise and Pain-Coping Skills Work Well for Patients, But Will Payers Cover It?

Knee pain has increased in the past 20 years, and researchers have connected this increase to aging and obesity. Perhaps more importantly, the increasing prevalence of knee pain has led to a surge in knee replacements. This highlights the growing need for effective, accessible treatments to manage chronic knee pain on a population level. In light of this need, researchers at the University of Melbourne conducted a study of Internet-delivered exercise and pain-coping skills training.

The study, published in the Annals of Internal Medicine, found that for people with chronic knee pain, Internet-delivered, physiotherapist-prescribed exercise and pain-coping skills training (PCST) provide “clinically meaningful improvements in pain and function that are sustained for at least 6 months.”

The Internet-delivered interventions included seven videoconferencing (Skype) sessions with a physiotherapist for home exercise, a PCST program and educational materials, delivered over a period of three months.

At three months, the intervention group reported “significantly more improvement in pain” compared to the control group, Kim Bennell, Centre for Health, Exercise, and Sports Medicine, University of Melbourne, at al., say.

The intervention group also showed improved physical function versus the control group and improvements were sustained at nine months.

The intervention group also reported high levels of satisfaction, and had high rates of completion; 78% accessed the educational materials, with an average of 6.3 of seven Skype physiotherapy sessions completed, and an average of 6.4 of the eight pain management modules completed.

This study sheds light on an important challenge for the U.S. health care system; chronic knee pain, is “associated with significant disability and decreased quality of life,” as noted in an accompanying editorial by Lisa Mandl, Hospital for Special Surgery/Weill Cornell Medicine.

“With the aging of the U.S. population, the medical community has braced itself for a tsunami of elderly patients with chronic knee pain – a reasonable response to the projection that almost half of U.S. adults will develop osteoarthritis in at least one knee by age 85 years,” she says. In addition, 50% of people with symptomatic knee osteoarthritis are younger than 65.

“These patients will need effective pain therapy for decades,” Mandl says. “Because osteoarthritis currently has no cure, these demographic characteristics guarantee that a large and diverse cohort of patients will be seeking treatment for chronic knee pain well into the foreseeable future. Therefore, there is a clear and pressing need to identify effective, inexpensive, and low-risk strategies to improve pain and decrease disability in these patients.

The results are also interesting given that “existing therapies have many drawbacks,” as noted in this article on the study. For example, current treatments have adverse effects or may be “cost prohibitive,” and “non-pharmacological therapies, such as physiotherapist-directed exercise and pain-coping training, may be difficult to access, especially for those in rural areas.”

“These results are encouraging and show that ‘telemedicine’ is clearly ready for prime time,” the study authors say. “An Internet-based intervention circumvents multiple issues related to access to care, making this an inexpensive and easily scalable option for people living in remote areas or any location with an inadequate supply of health care providers.”

This study is an excellent example of evidence-based medicine; the Internet-delivered intervention is a low-risk approach that is clearly preferable to knee surgery, and one that improves access for patients, particularly those in rural areas. However, the key questions are: Will U.S. insurers pay for it? And will physicians be willing to perform this service?

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Final thoughts on Service Business Model Innovation, our recently published book chapter

By M2|2017-10-09T01:55:07+00:00April 24th, 2017|Uncategorized|

Final thoughts on Service Business Model Innovation, our recently published book chapter

As we been for a few weeks, M2HCC authored a chapter entitled “Essential Characteristics of Service Business Model Innovation in Healthcare: A Case-Study Approach” in Service Business Model Innovation in Healthcare and Hospital Management published by Springer. Today we share our final thoughts on the lessons we feature in the book chapter.

Now, and increasingly in the future, a health care organization must be concerned about the quality of care a patient receives from other providers as a part of accountable care. Innovation that leads to improved performance requires focusing on the role of cooperation and trust in changing both processes and resources required to deliver value to customers.

Lessons in building trust, cooperation and leadership
The case studies clearly show trust, leadership, and cooperation are the pillars of innovation. In talking with leaders at Baylor Scott & White Health, BJC HealthCare, Massachusetts General Physician Organization, and Sutter Health and the Sutter Medical Network several common lessons emerged for successful health care service innovation.

Practical advice for health care service innovation
1. Attain commitment from leaders. A commitment from top leadership on the vision for change was a suggestion from Sutter Health. Commitment from top leadership to ensure proper resourcing was also a key component at BJC.

2. Find a way to collaborate. BJC, MGPO and Sutter all discussed collaborating on the creation of common clinical goals and provided specific examples on processes they used.

3. Build better quality measures. BJC and Sutter both discussed processes for designing meaningful projects that were clinically driven in order to improve quality.

4. Change the mentality. While changing the mentality of clinicians and staff was a common theme from all four of the case studies presented, two cases, BSWH and MGPO, specifically addressed changing the mentality in a way that focused on the external marketplace.

5. Get results. While results certainly matter to all of the organizations that served as case studies, BJC specifically explained the usefulness of getting results in helping to build trust and cooperation. BSWH used results as a way to offer transparency of price and quality to health care purchasers.

One final lesson: Innovation in health care must be “clinician-forward”
In addition to the key skills of trust, cooperation and leadership, the four case studies M2 wrote identified another condition necessary for service business model innovation in health care, that is, the need to be “clinician-forward,” which we define as reflecting or elevating the mindset and experience of health care clinicians without being exclusive of other inputs or opinions from those not specifically trained in medicine or other health care professions that diagnose and treat patients. In every case, the innovation in their health care service business model was not just about changing processes and resources, but also about achieving meaningful improvements for patients, their families and the clinicians and staff that serve them and their communities. Trust, cooperation and leadership were not just tools the organizations used, but were in fact, the very foundation of the innovative health care service business models they created.

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