Health Business Blog

CNN Money has an interesting piece (How to get help in a hurry in the ER) on tactics to reduce one’s wait in the emergency room. The author describes the experience of a house guest who had an allergic reaction, then asks four ER physicians what they would do to get a loved one seen faster.

The suggestions include:

• Telling the triage nurse the patient’s condition is worsening or that the patient has “an emergency medical condition that should be evaluated right away”
• Drop the name of a hospital big shot (that’s what the house guest does and what one of the ER docs recommends)
• Page the patient advocate or hospital administrator

I’m not that comfortable with these suggestions. In particular, if everyone acted this way it would make things much, much worse than they already are. The first suggestion is especially troublesome if it means exaggerating the patient’s condition. On the other hand, I know the helpless feeling of being in an emergency room and not feeling like your making any progress moving toward the front of the line. Some of the comments on the CNN article are from triage nurses who basically say, “trust us,” but I’m not really buying that either.

In my experience, the best option is to try to avoid going to the emergency room unless it can’t be avoided. If possible, that means going to see one’s own doctor or meeting him or her at the hospital. Not every doctor can or will do it, and it won’t always work, but it’s worth a try. Although I’m not a big fan of concierge medicine, this is the type of situation where it could be worth it for the patient.

In some communities –though not where I live– urgent care clinics or MinuteClinics are a realistic alternative and a better experience. Finally, some hospitals’ emergency rooms are less busy than others. Sometimes those are found in community hospitals rather than big academic medical centers. If it’s going to be a 3 or 4 hour wait, driving an extra 15 or 20 minutes for a better experience can easily be worth it.

When I visited Singapore, some hospitals were putting video cameras in their emergency room waiting areas so people could see for themselves what the crowding was like before coming in.

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Edwin Leap hosts this week’s Grand Rounds, which he’s focused on all those medical residents who’ll start work tomorrow.

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In most  industries, strong companies expand and take market share from their less able competitors. The results are generally good for the expanding companies and for consumers, who typically get better and/or cheaper service and more players competing for their business. There are lots of examples:

• Southwest Airlines vs. legacy carriers like US Airways
• Home Depot vs. regional players such as Grossman’s and Hechinger’s. More recently Lowe’s against Home Depot itself
• Microsoft vs. IBM. More recently Google vs. Microsoft
• Walmart vs. Kmart
• Toyota vs. GM

Now it’s certainly also the case that at least in the retail examples, players like Home Depot and Walmart had a negative impact on smaller, mom and pop players. Yet some of the smaller players have survived and even thrived under pressure from the big guys, by providing better, more convenient service and understanding their local markets better. At least consumers have voted with their pocketbooks and made decisions that were in their own interests.

Healthcare services, though, are a different story. In Neighborhood rivals; Boston hospitals’ suburban expansion sets up a showdown between dueling outpatient centers the Boston Globe reports that academic medical centers (mainly Partners Healthcare) are expanding into the suburbs and how that is harming various parties. The article quotes a number of parties complaining: community physicians, community hospitals, local officials, and state legislators. The only people presenting a sympathetic view of Partners are Partners itself –and me.

David Williams, a consultant who has studied suburban expansion of teaching hospitals, said that Partners is drawing controversy mainly because it’s the most successful hospital system and able to afford more expansion in the midst of a deep recession. Founded by Mass. General and Brigham and Women’s Hospital in 1994, Partners has grown to eight hospitals backed by an endowment of more than $4 billion.

“They believe – and with some justification behind it – that they are a premier academically based system. It’s part of their mission to reach a broader audience,’’ said Williams, who wrote a report on teaching hospital expansion for the Massachusetts Medical Society. Partners, he said, is doing “what most people would do in their shoes.’’

I’ll be the first to point out that healthcare is not the same as the industry examples I provide. In particular: third-parties including the government foot much of the bill, Partners is more expensive than community players without necessarily having higher service or quality, and healthcare is a “service” people don’t always choose to have. Supply of anything –including healthcare– tends to induce more demand, and since that demand is paid for by employers and the public it will drive our already high per capita costs up even more.

And yet, I’d still like to see some of the same principles apply in this argument as they do in my examples. In particular, I’d like to see community hospitals do a better job competing on cost, quality, local knowledge, community mission and convenience so that the public can enjoy some advantages of competition.

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Small practices worry they’ll have trouble benefiting from federal stimulus money, but it looks like they aren’t being forgotten. From iHealthBeat:

On Wednesday, National Coordinator for Health IT David Blumenthal said the federal government would pay special attention to individual physicians and small group practices as it works to implement the health IT provisions of the federal economic stimulus package, CongressDaily reports.

Blumenthal testified before the House Small Business Regulations and Healthcare Subcommittee along with pediatricians, optometrists and other health care providers concerned about being left out of federal health IT incentive programs.

Most physicians still practice in groups of 4 or fewer, so obviously this is an important segment to take into consideration. However, it’s reasonable to ask whether we should seek to preserve these small practices and why. After all, maybe they should go the way of the dodo bird, and just merge into larger organizations.

There are arguments for physicians to practice in larger groups, and this has led to an ongoing consolidation of practices. For example:

• Larger practices can spread administrative overhead  and capital costs over a broader base of activities
• Larger practices are better positioned to negotiate with payers
• Larger practices can provide more timely access to providers –by balancing capacity across more people
• Larger practices can produce enough data to do internal quality improvement programs
• Larger practices make it possible for physicians to take vacations and generally have a more reasonable lifestyle

However, there are also some downsides of larger practices. In particular they can be impersonal for patients –kind of like a factory.

Personally I prefer to see physicians who are solo practitioners or practice in small groups, especially those that don’t try to get me to see mid-level providers.

What I’d really like to see occur is for physicians to figure out how to lower the minimum efficient scale of their practices, so that small practices can provide a broader scope of activities, such as medical homes, and not get left behind in the information age. This can be done through the deployment of information tools that are geared to smaller practices, the intelligent use of outsourcing, and collaboration with larger groups for negotiating power and specialized services.

The management consulting field is one where new technology and business practices have lowered the minimum efficient scale. When I started in consulting more than 20 years ago we needed an office of at least 30 people to make it worthwhile. A “real” office needed a library (preferably with a librarian for advanced searches), report production department, phone system, copying machine and so on. But now with the Internet and associated services it’s quite possible to achieve better results with just a few consulting staff and no dedicated administrative personnel. In fact, smaller firms tend to have more reliable service providers (for things like email and file servers) than the big firms that do things in house in a more costly, less flexible manner.

Physicians should strive for something similar and ONCHIT should support them.

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In The truth about generic drugs Fortune magazine reports on its interview with Jacqueline Kosecoff, who runs the pharmacy benefit management (PBM) unit of United Health, called Prescription Solutions. This PBM, like others, wants to drive generic utilization since it’s more profitable for the PBM and less costly for their employer and health plan customers. Prescription Solutions just released a survey, which is designed to push generics.

The findings reveal that Americans don’t really understand that there is a huge cost difference between brand and generic medications. That’s an interesting finding that I would not necessarily have expected.

But there’s another key finding that’s also interesting:

Nearly one-third of Americans do not know or believe that generics have the same active ingredients and effectiveness as brand name drugs.

I’m definitely a supporter of generics from a public policy standpoint. The price differential is so great that we really need to be using generics. And when I need a prescription I allow the pharmacist to substitute a generic.

However, in this case it’s possible that public’s hunch may be equally on target as the expert’s view. I’ve done consulting work for the manufacturing operations of big pharma companies. I’ve toured their facilities and have also toured those of generics manufacturers. I’ve seen that big pharma often struggles to meet its specs, even when it has plenty of resources to apply. If that means scrapping product that isn’t quite right they’ll do it.

Meanwhile there’s a reason Wal-Mart can sell generics for $4. And the reason is that generic manufacturers focus ruthlessly on cost, whereas big pharma is much more focused on security of supply and is less worried about manufacturing cost.

I’m not saying that all products made by big pharma are high quality and those made by generic companies are low quality, but I do worry about quality when there is such an imperative for generic companies to keep costs as low as possible. And while the public’s view may not be based on firsthand experience –and is counter to what the experts say00 it doesn’t mean it’s wrong.

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For the latest collection of health policy posts, check out the Health Wonk Review at Healthcare Economist.

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From where I sit, the most exciting aspect of the healthcare reform debate is the discussion around a public plan that would compete with private plans. So I was interested to read that Senate Finance Committee members Olympia Snow (R-ME) and Charles Schumer (D-NY) appear to be negotiating a compromise bipartisan agreement that would establish a public plan –but do so in a way that would be less frightening for private insurance companies.

According to Citi:

Private insurers would bid state-to-state on a standardized benefit package (similar to the Federal Employees Health Benefits Plan or FEHB). Only if private plans aren’t deemed “affordable” (even after a re-bid opportunity) would a “safety net” public plan option (run by either Health and Human Services or a new government entity) step in to provide coverage. Current expectations are for these plans to be up and running by 2013.

This proposal is analogous to some of the health plan regulation language in the health plan Obama campaigned on. In that plan, Obama advocated regulating medical loss ratios in states where there was insufficient competition among plans.

I don’t know whether the compromise will succeed but it seems like a reasonable way to give something to everyone.

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Back in the 80s and early 90s people with HIV infection didn’t have a great prognosis, and not many folks thought there was much of a chance for them. But as USA Today reports (A generation born with HIV/AIDS defies the odds) some kids born during that time are thriving, thanks to the advent of antiretroviral therapies.

[B]abies who were born with HIV/AIDS in the 1980s have defied initial expectations.

With advances in medicine, the babies born with what was once thought of as a sure-fatal virus have danced at their high school proms, walked on stage to receive their diplomas and even experienced the birth of their children.

The story brought back memories of a situation I witnessed in 1995 on a flight between Raleigh Durham and Boston. There was a stir in the back of the plane because people were refusing to sit near a little girl who was traveling  alone. I didn’t hear exactly what was going on but am almost sure she had AIDS. Finally a man in first class with an open seat next to him (remember those days?) told the flight attendant to have her sit with him. She came up there hugging her teddy bear and slept through the whole flight.

This was well past the time that it had become clear that the HIV virus couldn’t be passed through casual contact, yet this little girl had to endure the ostracism along with the disease itself. I felt terrible for her.

I hope she’s one of those whose grown up and in good health. If she’s lucky maybe she’ll even live to see a cure.

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“No news is good news.” If you hear that from your doctor, don’t take it at face value. A study (Frequency of Failure to Inform Patients of Clinically Significant Outpatient Test Results) in today’s Archives of Internal Medicine reports that about one in fourteen cases of abnormal test results are not reported to patients. The authors found no significant difference between practices with and without electronic medical records. The worst performers were practices with a hybrid paper/electronic system. Some physicians closed the loop 100 percent of the time, some as little as 74 percent.

I’m not an Archives subscriber so I had to make do with reading press releases from the California Healthcare Foundation, JAMA (publisher of the Archives), and Weill Cornell Medical College. From the Cornell release:

“Failure to report abnormal test results can lead to serious, even lethal consequences for the patient,” says Dr. Casalino. “The good news is that physicians who use a simple set of systematic processes to deal with test results can greatly lessen their error rates.”

The study suggests that five simple, common-sense processes are useful for dealing with test results: (1) all test results are routed to the responsible physician; (2) the physician signs off on all results; (3) the practice informs patients of all results, normal and abnormal, at least in general terms; (4) the practice documents that the patient has been informed; and (5) patients are told to call after a certain time interval if they have not been notified.

The finding that EHR use makes no difference in the aggregate isn’t surprising, and points to the need for better systems and better implementation of the systems and adjustments to workflow. It also highlights the value of patient portals. For example, I get my care at Beth Israel Deaconess Medical Center in Boston and can log in to the PatientSite portal and easily look up my lab results. My doctor happens to be good at reporting my results, but if for some reason he slipped up or the results were delayed I could easily send him a note electronically and ask him what’s going on.

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With Fiat now in control of Chrysler, CEO Sergio Marchionne is moving in and taking charge (Wall St. Journal: Fiat CEO Sets New Tone at Chrysler). Marchionne is situating himself with the engineers rather than taking the usual spot in the executive suite, and he’s told staffers to expect to come to work seven days a week “for the forseeable future.” It may seem a bit galling to Americans to have a Southern European arrive to straighten out a capitalist enterprise and to instill a new work ethic, but Marchionne doesn’t really fit that stereotype.

He does fit another one, however:

Running Chrysler also may force Mr. Marchionne to make another change. A heavy smoker, he is used to lighting up regularly at work. But Michigan law restricts smoking in the workplace.

A few years ago I was working with an Italian cardiac technology company and was somewhat shocked when I visited their offices and met a group of chain-smoking cardiologists. I asked the owner of the company –also an Italian cardiologist, but a non-smoker– about how this could be. He told me cardiologists in Italy were known as big smokers, but that oncologists and pathologists were even more so. His explanation was they were fatalistic after so much exposure to death. I have no idea if his observations are borne out by the statistics, but it’s something that made a deep impression.

Restrictions on public smoking in Italy have been implemented since that time, and I understand they’ve made an impact.

In any case, here’s where Chrysler has something to give back.

No word in the paper on whether a bottle of wine at lunch is now ok in Auburn Hills, MI, though.

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