Health Business Blog

Rich Noffsinger is CEO of Anvita Health, a leading clinical decision support and health care analytics company. I spoke to Rich a little more than a year ago when the company was known as SafeMed and was launching its partnership with Google Health and completing a pilot in radiology at Beth Israel in Boston.  This time we spoke about the impact of the Federal stimulus package, prospects for health care reform, and how payers and providers are making use of Anvita’s solutions.

You can listen to the audio or read the transcript.

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David Williams interviews Rich Noffsinger of Anvita Health Play Now | Play in Popup | Download

From MedPage Today (Psoriasis Patients’ Brains Filter Disgusted Looks)

The brains of patients with psoriasis are less responsive to expressions of disgust on other people’s faces, a neurological device that may help them cope with the social stigma of the disease, a new study found.

This is a pretty good trick.

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Regular readers know I have a thing against excessive medical imaging. Imaging can be a great tool but CT and PET scans expose patients to high levels of radiation. Repeated tests lead to cumulative exposure that exceeds the dose of nuclear power plant workers and can even approach and surpass the level of Hiroshima and Nagasaki survivors.

Writing in the New England Journal of Medicine (Elements of Danger — The Case of Medical Imaging) Michael S. Lauer MD cautions against over-reliance on medical imaging. There’s little evidence (outside of mammography) that the potential dangers of imaging outweigh the benefits. Often imaging results lead to the use of non-evidence based interventions, and there’s little to suggest patients are better off.

The dangers are real, however. Lauer cites another source indicating that 2 percent of cancers may be attributable to CT scans. Use of CT has continued to escalate, so that number may even be low.

One of the under-appreciated values of personal health records (PHRs) is that they can be used to help a patient determine their cumulative radiation dose. Scans are usually considered in isolation –making it easier for physicians and patients to discount the radiation impact of a single scan. But seeing the cumulative impact may give pause.

I hope so.

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In normal industries when someone makes a mistake it has negative financial consequences. When a factory damages a widget during the manufacturing process, the company can’t sell the final product and has to absorb the labor, material and capital costs of the wasted efforts. To survive in a competitive industry factories focus on increasing first-pass yield, reducing scrap, and pursuing initiatives such as six sigma to virtually eliminate defects. Factories with low yields and high defect rates go out of business. That’s capitalism and it works.

Health care is a lot different. If a hospital or physician makes an error, they can typically bill for the work involved in making that error. Not only that –they can also bill for the work involved in correcting the mistake or mitigating the damage! Unlike sub-par factories, hospitals with low yields and high defects can be just as profitable or more profitable than hospitals that perform much better. And thanks to the complexity of health care and lack of solid measurement and reporting, such performance may be obscured from the general public and even from hospital management itself.

Medicare started trying to change this situation over the last couple of years, announcing it would stop paying for “never events” –big mistakes that everyone agrees should never happen. Examples include wrong-side surgery and wrong-patient surgery. These are quite rare so the financial impact on a hospital wouldn’t be great. However it set the precedent. Private payers such as Aetna followed along and these policies are now fairly common.

I’m glad to see that Aetna is now taking the next step: forcing providers to lose all the revenue associated with caring for the affected patients for the three most egregious kinds of errors. Aetna is also making the providers take a number of reporting steps when such events occur. Those requirements may get more attention but I don’t think they matter that much.

It will be interesting to see where things go from here. How many patients will be affected? Will Aetna expand the policy beyond the most serious events?

The true test of Aetna’s policy and others like it will be whether it causes the financial performance of high and low performing hospitals to diverge. If so that will be a good thing: the introduction of tried and true market forces to health care, driving quality up and costs down.

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It took me a few paragraphs to figure out what GOP chairman Michael Steele was getting at in Protecting Our Seniors, his Op-Ed in yesterday’s Washington Post. Near the top he says:

Republicans want reform that should, first, do no harm, especially to our seniors. That is why Republicans support a Seniors’ Health Care Bill of Rights, which we are introducing today, to ensure that our greatest generation will receive access to quality health care. We also believe that any health-care reform should be fully paid for, but not funded on the backs of our nation’s senior citizens.

It sounds sensible –especially the “first, do no harm” allusion to Hippocrates– but what does he mean exactly? It turns out the whole article is an exercise in subtle fear-mongering with phrases such as:

• “government-run health-care system”
• “prohibit government from getting between seniors and their doctors”
• “government-run health-care experiment”
• “government boards”
• “outlaw any effort to ration health care based on age”
• “protect our veterans”

It’s obvious that Steele is trying to kill health care reform and preserve the status quo while pretending to be in favor of reform. Senior citizens are the group most in favor of the status quo, and with good reason. There is universal, government sponsored health care for old folks (i.e., Medicare), which is funded by a regressive tax on wage earners.

Everyone who works –including folks who don’t have health insurance– pays 1.65 percent of their income as a Medicare tax. Their employer pays an equal amount. This money goes to fund Medicare –a program open to anyone who meets the age or disability criteria regardless of income or wealth. But it’s actually worse than that because almost half of Medicare is paid for out of general taxation. And to make things even worse, dual-eligible patients (eligible for Medicare and Medicaid) suck down a big portion of the Medicaid budget for nursing home costs that I believe should be counted as part of  Medicare costs.

Meanwhile, under Republican leadership, Medicare got even more generous: adding an outpatient drug benefit and the expensive Medicare Advantage plans.

Steele asserts that seniors should be exempt from any changes, but why shouldn’t we consider inter-generational equity? He argues that seniors are our “greatest generation,” which I assume is a reference to WWII veterans. But it’s baby boomers who are starting to retire now so whatever merit that argument had is losing out.

Let’s face it: seniors receive an inordinate share of government health care spending. That’s why Steele thinks he can get them on his side.

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In addition to my consulting work and writing the Health Business Blog, I’m chairman of the board of Advanced Practice Strategies, a medical risk management firm that provides litigation support for malpractice defense and an eLearning curriculum focused on enhancing patient safety. Here’s the Advanced Practice Strategies case of the month.

For previous examples see Fetal assessment and response,  Stroke after lung surgery and Coronary artery disease vs. medication administration.

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Recent revelations of pharma companies arranging for the publication of ghost-written articles aren’t surprising to Health Business Blog readers –it’s something I’ve been writing about for years. It is interesting though, how the media tend to place the blame squarely on the drug companies for such activities. And to be sure it is hard to give Glaxo a pass when they use a name like CASSPER to refer to their initiative to boost Paxil!

But there is plenty of blame to go around, and one view is that the drug companies were treating the medical profession and journal publishers the way they deserve to be treated.

Here’s how it worked:

• Pharma company salespeople approached doctors to offer help in writing and publishing articles favorable to their product
• Pharma hired ghostwriters to compose articles based on their own outline
• Doctor signed off on the article and submitted it for publication
• Journal sent article for peer review
• Journal accepted article and published it
• Pharma bought reprints and circulated to physicians for marketing purposes

Clearly there is something fishy about what pharma’s doing here, and without them funding the enterprise it wouldn’t occur. Nonetheless, doctors shouldn’t be putting their names on ghostwritten articles, peer reviewers should be finding problems with the articles and rejecting them or calling for revisions, and journals shouldn’t publish such stuff.

Journals that published these articles have the most to answer for in my opinion. Keep in mind that the pharmaceutical industry is a major reason these journals thrive in the first place. After all, pharma companies:

• Write many of the articles (ghost-aided or not)
• Buy the majority of advertising
• Purchase subscriptions
• Purchase reprints –sometimes hundreds of thousands of copies of a single article as was the case with an infamous Vioxx reprint

Frankly I’m surprised medical journals have been able to retain so much prestige.

If anything the situation reminds me of the scandal involving bias on the part of equity analysts. A lot of individual investors took what they said at face value, even though the fix was in. Readers of journals may be making the same mistake.

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Welcome to the Health Wonk Review on the Health Business Blog. No doubt about it, it’s a good time to be a wonk. With health care reform on the front burner, there’s no shortage of things to write and talk about. And when was the last time you saw people go berserk at town hall meetings over notions from our wonky little world? Let’s savor it, folks!

Health reform

No surprise, this was the big theme for submissions this time around. We’ve got a healthy mix of viewpoints and topics here.

Mad Kane’s Political Madness leads with a limerick, the first poetic submission I’ve received for any blog carnival.

If reform can’t be fought using facts,
Simply give civil discourse the ax.
Block discussion with mobs
Packed with morons like Dobbs.
That’s the path of Republican hacks.

Insureblog says the success of Medicare Advantage Plans demonstrates that “private plans are beating Medicare fair and square.” But The Incidental Economist points out that Medicare Advantage’s Private Fee Fer Service Plans (PFFS) are paid well above the average for traditional Medicare Fee for Service. His analysis show that “implementing payment parity… would nearly wipe out PFFS plans, reducing their participation by 85%.”

The Sentinel Effect tells us co-op’s are a cop-out –not a realistic alternative to a public plan. Colorado Health Insurance Insider says co-ops aren’t needed anyway, because there’s plenty of competition in the private market, at least in Colorado.

Robert Wood Johnson Foundation presents a users’ guide to health reform. Key assertion: if we improve efficiency in health care we can avoid cost/coverage tradeoffs. Healthcare Technology News lets us know what’s in the latest legislation.

HealthBlawg sets out the role of prevention and comparative effectiveness research in health reform.

Managed Care Matters presents the top ten misconceptions about health reform. Reason #2: “A public plan would crush private insurers and we’d all end up covered by the public plan.”

Healthcare Economist raps Sarah Palin for claiming health reform will bring in government rationing –when health care is rationed already.  Covert Rationing observes that “given the behavior of our elected representatives, Sarah and the right-wing mobs may not be as crazy as we think”. Robot Heart is terrified of –and sickened by– conservatives like Peggy Noonan. Robot says they “manipulate… people by giving them blatantly false information.” (To Noonan’s credit, she was right when she was caught on a live mic saying McCain’s nomination of Palin meant “It’s over” for his campaign.)

Medicaid First Aid notes that even states are entering the misinformation fray on health reform.

The Lewin Report says stories of industry leaders being “mugged” by the health care reform process are exaggerated, and that his field, cardiology is likely to be an attractive profession for a long time to come.

The e-CareManagement blog wants us to think about “meaningful use” as something more than a set of technical criteria: i.e., as a “powerful unifying force across the health system.” Disease Management Care Blog would love to see disease management and the medical home make their way into health reform, but he’s not holding his breath.

Get Fatty

Now that smokers have been driven into submission, it must be time for the obese to take a beating. Who’s next I wonder?

How To Live a Longer Life says of the obese, “They mooch the system and run up the cost for everybody.”

Workers’ Comp Insider reports on Cleveland Clinic head Tony Cosgrove’s support for a Fat Tax and his desire to stop hiring obese workers.

Health Access Blog uses the Mad Men TV show to show how far we’ve come in public health since the 60s: less smoking, less drinking, less drunk driving, more seat belt use. He wonders what our generation will look like to the next.

Brain spasm

Brain fitness is an emerging trend but just can’t compete with health reform for share of blog.

Sharp Brains says brain fitness needs to overcome several issues to advance, including increasing public awareness and improving definitions and standards.

Green Rising talks about Ray Kurzweil’s plans to live beyond 120. Good luck!

Questionable practices

And of course a Health Wonk Review just wouldn’t be complete without a gaze into the sleazy side of health care.

Health Care Renewal thinks hospital Group Purchasing Organizations (GPOs) are acting more like Group Kickback Organizations. Actually, he’s written about it as far back as 2005 but now investigators are taking an interest.

Boston Health News once saw some ghosts (writers that is), and lived to tell the tale. Others may not fare so well.

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Thanks for reading! The Lucidicus Project (In Defense of Individual Rights and Capitalism in Medicine) hosts next time around.

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My good friend Dr. Giovanni Colella, CEO of Ventana is quoted in Tackling the Mystery of How Much It Costs in today’s New York Times. (Too bad they referred to his company as Ventura –perhaps the writer or editor was unconsciously channeling Governor Jesse.)

Colella’s company is helping employees and employers understand what they’re paying for medical services. That’s information that should be routinely available but rarely is. Lack of transparency is one reason medical prices are sky high. As an illustration, Ventana adviser Dr. Alan Garber –a health economist at Stanford and one of the sharpest guys I’ve met– describes how even he got tripped up in out-of-network charges when his wife was in the hospital. (An out-of-network anesthesiologist provided services, even though the hospital itself was in-network.)

The article begins in typical fashion, highlighting the oddity of medical pricing.

You go to a restaurant, peruse the menu, take your waiter’s suggestions, and order a meal. But there is something odd: the menu has no prices and you have no idea what you will be required to pay until a few weeks later when the bill arrives in the mail.

That, it turns out, is analogous to what goes on in health care, where fees are hidden at the time of service. Making matters even worse, patients often are seeking care when they are frightened and vulnerable, in no position to ask about prices or to haggle.

That’s a pretty good description but it’s not extreme enough. In health care there often is no equivalent of a menu to “peruse.” The doctor or other provider tells you what you’re getting and that’s it. If you’re lucky you can go home and browse the Internet for alternatives.

It’s not just that the patient doesn’t feel comfortable enough to “ask about prices or to haggle.” Often the physician or hospital has no idea of the price. And when they send out a bill based on “charges” they know that the true price paid by an insurance company is only a fraction of that. Only an uninsured/underinsured patient with the means to do so pays charges.

Much of the article focuses on the high fees charged when patients go out of network: often double, triple or quadruple the in-network charges. I’m sympathetic to the idea that these fees should be regulated. In the meantime patients should try negotiating the fees –ahead of time or once they’re billed—on their own or by hiring a company to do so.

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Well it looks like the scaremongers have succeeded in removing provisions for voluntary end-of-life counseling from the pending health care reform legislation. (Although their broader goal: killing health care reform, remains elusive.) That means you may be on your own to figure things out. Luckily the Wall Street Journal has a good piece today on Advance Directives (Preparing for the Final Hours).

“Everybody knows they’re going to die, but it’s really scary to think about how,” says Audrey Seeley, a registered nurse in the stroke unit at Inova Hospital in Falls Church, Va., who sees many patients who are suddenly seriously incapacitated. “A lot of people say, ‘If I get to that point, I don’t care what happens to me.’ But your family does.”

Indeed, advance directives are as much for the living as for the dying. Without specific instructions, family members may have to decide whether you would want to be kept alive artificially, what level of disability you’d be willing to live with and how to let you die if you had no hope of recovery.

Advance directives are a tricky business. No one knows what sort of end-of-life situation they’ll find themselves in or whether their wishes will be taken into account at all. And end-of-life isn’t always so easy to define except in retrospect. When someone’s told they have six months to live it’s often off the mark.

It seems straightforward to say  –as the nurse quoted above does– that, “If I get to that point, I don’t care what happens to me.” But I don’t even think people can say that with confidence. When you’re healthy and strong, it seems like it would be much better to die than to sit around partially-demented, incontinent and in pain. But when you actually get to that point, you may look at things differently: that extra few months with your family –or even alone in your thoughts– may be worth the trouble. By that time you may not be able to express yourself so well.

Some people set out general principles. Others take the path of leaving everything up to a loved one. Other people leave strict instructions that they want every measure taken. Sometimes that’s for religious reasons and sometimes it’s because they don’t trust their relatives or doctors.

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