Health Business Blog

Rationing is a very dirty word in America, evoking grim images of wartime Great Britain and –in the health care context– withholding of needed care from patients based on cost. But cut back on costs we must, and with magical thinking about the deficit becoming every more popular, we’ll have to find other ways to convince folks to do it.

Patient safety is a promising guise under which to achieve cutbacks, especially in costly areas where the dangers are real. The new radiation protection bill signed into law in California yesterday is a great example. From AuntMinnie (Calif. governor signs medical radiation bill into law):

The bill requires that radiation dose be recorded on the scanned image and in a patient’s health records, and that radiation overdoses be reported to patients, treating physicians, and the state Department of Public Health (DPH).

The law is clearly focused on overdoses, but once patients realize how much radiation they’re being exposed to –especially by repeated CT scans– many will start cutting back on what they request or accept. Over time, perhaps this attitude will spread to other areas of medicine such as surgical procedures and prescription drugs, where the risks are not always recognized today.

The federal government has done a great job whipping people into a sustained frenzy about airport security. All the time I hear people say they’ll put up with whatever hassles it takes at the airport in the name of security, and it almost seems the greater the hassle, the more satisfied people are to be subjected to it. I don’t admire this approach in airport security, but if the same zeal were devoted to patient safety (with the idea of reducing health care costs) I think it could succeed.

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The Boston Globe has a lengthy front page story on Charlie Baker today, focusing on his decision as CEO of Harvard Pilgrim to pull out of the Rhode Island market (To Baker, R.I. pullout was right move). It’s a pretty thorough and balanced piece and definitely worth a read if you’re a Massachusetts voter trying to decide who our next Governor should be.

In December 1999, an ailing Harvard Pilgrim Health Care pulled out of Rhode Island with two months’ notice, shuttering the company’s three health centers there and forcing 1,200 physicians and other employees to search for new jobs. Thousands of patients suddenly had to find new doctors, and about 128,000 subscribers scrambled for other health insurance.

The Ocean State accounted for about 10 percent of Harvard Pilgrim’s customers but 45 percent of its losses, and to save the company, new chief executive Charles D. Baker essentially cut off its Rhode Island leg.

Personally, I think the withdrawal from Rhode Island was necessary and a good, decisive move by Baker, even if it caused pain there. The alternative would have been a lot more pain in Harvard Pilgrim’s home market of Massachusetts if the company collapsed.

Baker didn’t initiate the move into Rhode Island but he did do a good job of unwinding a number of bad decisions including that one.

If I remember correctly, Harvard and its competitor, Tufts Health Plan had both expanded into neighboring states including Rhode Island, New Hampshire and Maine and both ended up pulling out of those markets after big losses.

So in the end it was less about Charlier Baker and more about what anyone competent would have had to do to respond to the circumstances.

I’m undecided on the Governor’s race, but I do think Baker’s health plan leadership experience is a plus.

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Yesterday I expressed satisfaction that California was likely to veer off the Idiocracy path, by making drinking water available in cafeterias. Now a MedPage Today article (Teens May Mistake Sports Drinks as Good for Them) makes me realize the Idiocracy trend is pretty powerful.

Teens with otherwise healthy lifestyles often consume sports drinks and sugary fruit-flavored beverages in large quantities — perhaps because they mistakenly believe these products are good for them, researchers suggested.

“The most likely explanation for these findings is that FSBs [flavored and sports beverages] have been successfully marketed as beverages consistent with a healthy lifestyle, to set them apart from sodas,” [Nalini] Ranjit and colleagues concluded.

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In the movie Idiocracy, a very average soldier named Joe is sealed in a time capsule. When he wakes up 500 years later the world has continued down its path toward idiocy and has basically fallen apart. On a relative basis, the guy is now a genius, and he begins trying to make things right. What’s so funny about the movie is that it represents an almost believable extrapolation of the path we’re headed on today.

Among the big things Joe finds upon his arrival in the future is that water isn’t being used much anymore. Crops are dying because they are being irrigated with Gatorade (or something similar). And of course no one thinks of actually drinking water.

Here’s an audio recording of a scene from Joe’s visit to the doctor’s office:

Joe: “Uh, excuse me. I think this might be Gatorade or something. I was just looking for some regular water.”
Doctor in Waiting Room (Joseph Cheatham): “Water?”
Joe: “Yeah.”
Doctor in Waiting Room: “You mean like in the toilet? What for?”
Joe: “You know, just to drink.”
Doctor in Waiting Room: “(laughing)”

Anyway, apparently this situation is not that far off reality of today’s California.From the LA Times (Bill seeks to add free water to school menus):

In many California school cafeterias, there’s no free water to drink. Surprised?

“Everyone I talked to says, ‘You’re kidding,’ ” said state Sen. Mark Leno (D- San Francisco).

“As we all know, young people are constantly bombarded by advertisements and pressure from their peers to consume junk beverages that are high in calories and sugar. Yet many students do not have access to free, fresh drinking water at lunchtime,” Leno said in material promoting his bill.

“You just don’t imagine in our country in 2010 that there isn’t free water to drink while you are having a meal. But there isn’t,” said Kenneth Hecht, executive director of California Food Policy Advocates, an Oakland-based organization that supported the legislation.

Luckily thanks to Leno and others, it seems we may veer from the Idiocracy path. It seems kids actually do like to drink cold water if it’s offered to them.

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Lighthouse Learning, a new, independent producer of continuing medical education (CME) may have made a bigger splash than it wanted last week on the front page of the Boston Globe. The author devoted much of the article to Lighthouse’s rejection of pharmaceutical industry funding, which got a bunch of folks in the industry riled up.

In my recent discussion with Lighthouse’s CEO, Jon Leibowitz, he clarified the company’s position on industry funding and presented a broader view of how the company plans to operate and differentiate itself. Excerpts from our interview are published below.

David Williams: What was the motivation to set up Lighthouse Learning?

Jon Leibowitz: We think there is an opportunity to do things differently; to create a fully independent provider of medical education for physicians. We span 12 specialty areas and focus on the needs of both specialists and generalists. We believe education can be shared between specialists and generalists to achieve an outcome of better communications and better delivery of care to patients.

Williams:    I haven’t heard so much about the generalists and specialists being educated together.  Is it an approach of one of your physician leaders or how did you come to that as a positioning?

Leibowitz:    Actually Dr. Martin Samuels is a keen believer in the need for breaking down the barriers and silos that exist between specialists and generalists.  He can cite many examples of how there could be much better efficiencies, more effective medicine if neurologists and primary care physicians were educated with similar approaches in terms of diagnosis and treatment and were able to work in greater sync with one another.

Williams: You have decided not to seek pharma industry funding. But do you believe it is possible for industry-funded CME companies to be pristine, assuming they follow the various guidelines that are in place?

Leibowitz: The ACCME has put together very strong standards and guidelines for organizations that work with industry and receive commercial support. Those standards begin at the planning stage with identification of needs and creation of education. They continue all the way through the process, including conducting outcomes studies to assess the impact of the education on physician knowledge, competency and performance.

I believe that organizations that follow the guidelines in practice and in spirit can develop very high quality continuing medical education for learners.

Williams: You are planning to be in 12 different areas, but are there specific areas of focus at the outset?

Leibowitz: Our curriculum development model begins with our 12 curriculum directors, each of whom oversees the development of curricula within the respective specialty areas. So we are not approaching this in a linear fashion at all but instead pursuing a pretty aggressive build-out simultaneously across the 12 specialty areas.

Williams:    What activities will the company undertake?

Leibowitz:    We develop content.  We do not put on meetings and we’re not going to become a publishing company.  Our business requires that we partner with organizations that license our content and provide the distribution means to the physician learner.  Our model is platform independent, thus allowing us to partner with organizations that put on live meetings, with established health care and medical websites that reach out to physicians, and publishers who also access the same marketplace.
Williams:    Who will your customers be?
Leibowitz:    At this point our efforts are  targeted at the sale of curricula to medical societies, insurance companies, professional meetings companies, health care organizations and other entities that seek to provide educational content. It’s difficult however at this point to anticipate how each of these categories will play out in terms of prominence going forward.

Williams:    Considering what you said earlier –that it is possible for industry-funded players to produce high quality CME–do you anticipate having industry support at some point down the line even if that’s not your initial focus?
Leibowitz:    We will not have any direct ties to industry down the line.  We believe this is one of the important differentiating factors for Lighthouse Learning.

Williams:    How is the CME market changing?  Certainly there has been a substantial reduction in industry support for CME over the last several years.  Do you see a shift going on in the marketplace?  How does Lighthouse fit in?

Leibowitz:    Our perspective is that the demand side of the picture hasn’t changed one bit.  States continue to maintain their same requirements in connection with number of hours required of physicians for continuing medical education.  We believe that based on that continued and level demand, there is an opportunity for multiple approaches to CME, whether supported by industry or not.

I do believe, however, that all stakeholders in this equation: physician learners, pharmaceutical grant committees, engaged faculty, all have greater expectations for quality of content and desire a very clear separation between content and any sort of commercial influence.

Williams:    How is the company financed?

Leibowitz:  It’s a bootstrap approach with a lot of self funding by the founders.

Williams: What else would you like to share?

Leibowitz:    We believe what sets us apart are our independence, the quality of our physician leadership, and a unique approach to educate specialists together with generalists, with the ultimate outcome of better communication, great effectiveness, and better patient care.

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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 (APS), a medical risk management firm that provides litigation support for malpractice defense and an eLearning curriculum focused on enhancing patient safety.

To learn more contact: Timothy Croke, Director of Demonstrative Evidence Group. tcroke@aps-web.com or 617-357-0553 ext. 6664.

Here’s the Advanced Practice Strategies case of the month.

Judgment for the Defense
Internal Hernia Following
Laparoscopic Right Colectomy

The plaintiff underwent a laparoscopic right colectomy to remove a recurrent sessile neoplastic lesion that was not amenable to safe colonoscopic removal due to its size and configuration. The operation was uneventful, and the postoperative recovery was also initially without incident. Worsening clinical findings, however, resulted in further evaluation, including a CT scan. The radiologic findings, coupled with the patient’s clinical condition, necessitated a return to the operating room. Exploration revealed an internal hernia along with an anastomotic leak and associated abscess—known complications of the original procedure. The defendant resected the previous ileocolic anastomosis and created a new ileocolic anastomosis.  The patient’s postoperative recovery was long and complicated, involving two subsequent major procedures and several minor procedures, but ultimately he recovered fully.

PLAINTIFF’S CLAIM:

The plaintiff believed the defendant failed to follow standard of care by not closing the mesenteric defect between the terminal ileum and the transverse colon.  Plaintiff’s lawyers argued that the defect allowed an internal hernia to occur, resulting in an anastomotic leak and subsequent complications.  The plaintiff maintained that failure to close the mesenteric defect was the “sole cause” of his difficult and complicated recovery from the laparoscopic right colectomy.

DEFENSE’S ARGUMENT:

Resection of the plaintiff’s neoplastic disease created a defect in the mesentery of the bowel. Defense experts testified that the standard of care does not require routine closure of the mesentery after performing a right colectomy.  They also testified that an anastomotic leak is  known to be a serious possible complication of this type of surgery.  Furthermore, during the original procedure, the defendant followed standard practice for minimizing the risk of an anastomotic leak, using proven, safe techniques to perform the anastomosis to ensure there was no tension between the two segments of intestine and that each margin was healthy and viable.

___________________________________________________________________

VISUAL STRATEGY:

Collaborating with the defendant and his attorney, APS created illustrations to help convey his recollection of events to the jury.

APS started with an illustration of the normal anatomy of the abdomen and an illustration clarifying the anatomy of the mesentery and colon.

Another diagram illustrated the laparoscopic port positions.

An additional illustration detailed the relevant surgical anatomy and, specifically, the right colon and mesentery removed during the right colectomy.

The anastomosis created between the ileum and colon following excision of the specimen was depicted on another illustration board.

The last board showed the internal hernia that the defendant believed led to the anastomotic leak.

This series of illustrations helped the defense successfully convey the following key points to the jury:

• The surgery was done correctly and followed the standard of care.
• Anastomotic leaks are a known risk of these procedures.
• Although its occurrence in this case was unfortunate, the anastomotic leak was recognized and corrected promptly and appropriately.

RESULT:

The jury found in favor of the defense.

“We received a defense verdict on the case and the illustrations were very helpful in the process.  Thank you for all of your assistance.”

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The latest Cavalcade of Risk blog carnival is posted at Chatswood Consulting. Fine reading!

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Some of the first significant elements of the Patient Protection and Affordable Care Act (PPACA) go into effect today, and a number of articles provide details of the changes. (Kaiser Health News has a good roundup.) Among the most significant: the ability for children to remain on parents’ policies up to the age of 26, and the ban on annual and lifetime caps on payments. Down the road some other popular provisions will come into play including a ban on medical underwriting (which means sicker people pay more) and a ban on excluding people due to pre-existing conditions.

When reform passed my expectation was that there would be grousing for a while but that as popular provisions kicked in health care reform would become more popular, if not by the mid-term elections then at least by 2012. There appears to be a lot of popular momentum against PPACA right now, fed by Republicans, tea partiers, and –to some extent– by health plans that are trying to blame big premium increases on PPACA.

Opponents appear hellbent on repeal and may get their way, at least in part, depending on how the elections turn out.

But once the public learns about what repeal means they won’t be all that happy, because the provisions described above are likely to prove popular. It will be hard to argue for a return to the days when people are denied coverage or pay more due to pre-existing conditions, or when people find their premiums skyrocketing or coverage dropped once they get sick.

Opponents know they need to act fast to knock out health reform before its benefits are widely felt. They need a big win in November to make that happen, which is why the upcoming elections are going to be fought so hard.

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M/C Holding CEO Frank Britt does his best to defend Continuing Medical Education (CME) that’s sponsored by the pharmaceutical industry. Responding to a recent Boston Globe article (For physicians, another option on education) about a new CME company that aims for independence from industry influence, Britt argues in a letter that rigorous standards ensure that industry-funded CME programs produced by companies like his are unbiased. Further, he points to evidence that indicates that CME is good for physicians and patients.

Over the last three years, 45 percent of US primary care physicians have participated in an [M/C Holding] offering. They do so year after year because it meets their clinical and education needs with full and complete disclosure of funding for them to discern and evaluate.

Britt is walking a fine line here. CME used to report into the marketing function at pharmaceutical companies and those companies participated actively in developing and reviewing the courses. Thanks to reforms, that’s no longer the case.

What, then is the motivation for pharmaceutical companies to continue sponsoring CME? A lot of companies agree with Britt and have cut off funding as a result.

But clearly those companies that still provide funding hope to gain a return on their investment. It could be as simple as gratitude from physicians for providing the sponsorships, but I doubt it.  In reality they are probably still hoping to influence physicians to prescribe their drugs. This can be done by the choice of topic, a bias toward presenting cases where drugs are used, and other subtle techniques. Companies like M/C know where their bread is buttered even if there’s little direct client influence on courses.

Britt chose his words carefully when he said doctors can “discern and evaluate” the funding behind these courses. In my experience few physicians can do so effectively. If they did, more physicians would likely obtain their CME elsewhere.

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Kaiser Family Foundation just issued a useful brief on the uninsured (Five Facts About the Uninsured), which is a good, data-driven summary about the roughly 50 million people in that category in the US as of 2009.

The facts are as folllows:

1. 90 percent of the uninsured are in low or moderate income families, i.e., making less than 400% of the Federal Poverty Level of $22,050 for a family of four.
2. >75 percent of uninsured people are part of a working family. Either their employer doesn’t offer insurance or the employee contribution is considered too high.
3. Medicaid is a key gap filler, picking up some of the slack as private coverage declined during the recession, especially with additional funds paid to the states through ARRA. However, Medicaid’s eligibility rules mean not all low-income adults are eligible.
4. About 25 percent of uninsured adults skip care they need because it’s too costly. They are less likely than those with insurance to get preventive care and services for major illnesses.
5. Medical bills are a big burden and often land the uninsured in big debt that they can’t escape. Exacerbating the problem: hospitals and doctors often charge the uninsured more than what they charge insurance companies.

The report doesn’t break a lot of new ground but it is a helpful summary for policymakers.

It would be interesting to understand how issues #4 and #5 are affecting people with insurance. My sense on #4 is that even insured patients are deterred by high co-payment, co-insurance, etc. from getting some care they need and that the problem is getting worse. And on #5 it’s surprisingly easy to run up bills in the thousands of dollars or beyond and also to lose health insurance during an illness.

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