Health Business Blog

My crystal ball is a little foggy so I decided to ask my Twitter followers (@HealthBizBlog) to help compile a list of health care predictions for 2011. I’ve integrated my thoughts with theirs and organized the predictions into four themes:

1. Transparency will change from buzzword to reality
2. Information technology progress will be uneven, with the biggest breakthroughs in mobile
3. A culture of patient safety will begin to take root
4. Health reform implementation will advance despite some ugly battles

Transparency will change from buzzword to reality.

The health care industry is tremendously opaque. Patients and doctors don’t know the price of medical services, while pharmaceutical and medical device makers maintain secret financial arrangements with physicians.

Much is likely to change for the better in 2011. Giovanni Colella, CEO of health care transparency company Castlight Health (@CastlightHealth) predicts, “Consumers will increase their demands for personalized information about health care cost, quality and convenience and will turn to innovative applications to address these needs.”

Bright lights will be trained on the interaction between industry and physicians. The Affordable Care Act requires pharmaceutical and device companies to report payments to physicians starting in 2013; voluntary reporting is likely to pick up next year. Beyond that, @PharmaGossip predicts, “PharmaWikiLeaks will become a force for good,” citing a recent leak about Pfizer in Nigeria as Exhibit A.

Information technology progress will be uneven, with the biggest breakthroughs in mobile.

AOL founder Steve Case (@SteveCase) tells me, “Mobile health will be a game changer in health and wellness.” I agree that mobile apps and devices present a big opportunity to prevent and manage chronic illness.

Thanks to advances in IT adoption by providers and patients, Kaiser’s Dr. Ted Eytan (@tedeytan) expresses confidence that, “The patient will finally become a customer of health care.”

Meanwhile, physicians, hospitals and vendors will continue to make slow, uneven progress on electronic health record implementation in the quest to meet Meaningful Use requirements that qualify them for federal stimulus funds. Health IT expert David Ahern (@dahern1) says, “EHR vendor consolidation will be the order of the day, especially as companies discover how difficult it will be for them to reach Stages 2 and 3 of Meaningful Use on their own.”

A culture of patient safety will begin to take root.

Beth Israel Deaconess President and CEO Paul Levy (@Paulflevy) writes, “Too many people will still be harmed in clinical settings because of a lack of focus in redesigning the work done in hospitals.”

Dennis Ferrill (@DennisFerrill), CEO of eLearning company APS offers a path forward, “We will approach a tipping point in the culture of patient safety as institutions find that significant adverse events occur under their watch, while more of their peers take concrete steps forward.  Among the observable data points supporting this movement will be an increasing tendency to mandate key protocols and safety training for nursing and physician staff as hospitals gain confidence in their duty to control quality and outcomes.”

Since the Vioxx debacle, FDA and patients have sought reassurance on patient safety, a shift that will continue in 2011, according to iCardiac Technologies CEO Mike Totterman (@mtotterman). “Regulatory cardiac safety requirements will tighten, but emerging technologies will facilitate compliance with new standards to produce better, more reliable results in clinical trials.”

Health reform will prevail despite ugly battles.

“Always an optimist, I think 2011 is the year that economic recovery takes hold,” writes Dr. Bruce Siegel (@siegelmd), CEO of the National Association of Public Hospitals. “This changes the national health care debate dramatically as the Administration’s leverage is bolstered. There are some very ugly battles ahead, especially in the state houses, but overall it’s a year of consolidation.”  To demonstrate he’s a realist, he adds, “Also, the Redskins won’t go to the Superbowl!”

I’m a little less sanguine than Dr. Siegel about the prospects for the Affordable Care Act. I expect Republicans to make moderate progress chipping away at the law, even though repeal is not in the offing. The recent one-year Sustainable Growth Rate (SGR) fix, which halted the automatic cut to Medicare reimbursement rates, was financed by snatching a little bit from PPACA insurance subsidies. Expect more gambits like that, along with objections to proposed rules, attempts to defund or delay specific provisions, and continued court challenges to the law itself.

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SeeFirst Blog hosts the second edition of the Benefits Package, a blog carnival devoted to employee benefits. Timely topic. Excellent read.

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Zynx Health is the leader in clinical order sets and decision support rules. In this podcast interview, Zynx CEO Dr. Scott Weingarten and I discuss how the rollout of the ARRA/HITECH stimulus program and the Patient Protection and Affordable Care Act are reshaping health care providers and creating new opportunities for decision support companies. We touch on the following topics:

• The connection between Accountable Care Organizations (ACOs), meaningful use, and clinical decision support
• The complexities of clinical integration among a wide variety of affiliates
• Progress that hospitals and physicians are making toward Stage 1 of meaningful use requirements
• What Zynx is doing to facilitate meaningful use and ACO development
• The degree to which order sets are evidence based (versus experience based)
• How providers calculate return on investment and clinical impact of order sets and decision support tools

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Zynx CEO Weingarten on ACOs, decision support, meaningful use [ 19:01 ] Play Now | Play in Popup | Download

Much of the legal and rhetorical challenge to the Patient Protection and Affordable Care Act revolves around the individual mandate to purchase health insurance. The idea is a good one because it expands the risk pool. Almost no one can afford to pay for health care out of pocket and more or less everyone needs health care eventually. Including everyone makes it feasible to avoid excluding people from coverage based on pre-existing conditions and even to charge them the same rates (community rating).

What’s funny about the current situation is that it’s not actually a provision President Obama favored. It was Hillary Clinton that argued for the individual mandate during the Presidential campaign while Obama rejected it. Meanwhile, some Republicans have certainly championed the idea in the past, even if they are trying to distance themselves from it now.

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Check Back in a Generation to See if the Health Law Withstands Challenge suggests the New York Times in an insightful piece, which suggests Social Security as a useful comparison. Social Security was enacted in 1935 but benefits didn’t start until 1941. During that long lag conservatives tried hard to get rid of Social Security and it took 10 years or so before it was firmly entrenched. Now of course conservatives love Social Security and other big entitlement programs they previously railed against, with Medicare being Exhibit A.

Democrats and Republicans realize the Patient Protection and Affordable Care Act (PPACA) is most vulnerable over the next few years before it is fully in effect, which is why Democrats designed it to have at least some elements kick in soon and why Republicans are mounting such a furious attack on it now.

It seems to me that history is likely to be on the side of the Democrats. Repeal isn’t going to happen with Obama in office, and if Republicans are somehow successful in having the Supreme Court declare the individual mandate unconstitutional and shave off some of the Act’s edges, what exactly are they going to do then? Health plans are going to scream bloody murder if they don’t get a bunch of healthy new customers –which the mandate is designed to deliver– and I can’t believe Republicans are going to bring back medical underwriting, i.e., exclusion from coverage based on pre-existing conditions.

If Republicans are successful in breaking the back of PPACA, they’ll have handed themselves a poisoned chalice. They have no viable alternative to PPACA, and a collapse is likely to lead to nationalized health care within a few years as employers find health insurance unaffordable and health care costs continue to bankrupt the country.

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In Today’s Hospitalist, Jeremy Graham, DO discusses implications of research he’s published about hospitalists and costs (How much is that bed on the ward? Hospitalists are clueless about patient charges). Not surprisingly, hospitalists –like almost everyone in the hospital– have no idea what anything costs. That’s no real shock, as Graham points out:

It’s often hard for hospitalists to know these charges, which are so opaque, distortional and sometimes secret. And we haven’t been trained to think in terms of costs and charges. I know I wasn’t.

Graham argues that hospitalists should learn more about charges and prices paid in order to help their patients.

Patients see physicians as their agent or representative, but we can’t do that job without at least some semblance of information about the costs and value of our services. It’s incumbent on us to actually provide that stewardship.

He also provides an example of how things might be done differently if hospitalists had that information.

I’m certainly seeing more self-pay patients, and their direct burden is getting nothing but bigger. Hospitalists, once they’re aware of the charges a patient would incur, might decide to do a cell count every other day instead of every day.

I’m generally in favor of transparency and efficiency, but I’m not 100 percent comfortable with the idea of hospitalists becoming somewhat more knowledgeable about what things cost. There are a couple reasons why:

• The whole topic area is so convoluted and arcane that it would suck up all of a hospitalist’s time to learn the information and keep on top of it. I’m not even sure it’s possible, because charges do not translate at all well into what insurers (never mind patients) actually pay. I’d rather have hospitalists use their spare time to stay on top of the clinical literature.
• I worry that hospitalists might not use the information in the right way, and in particular that they might make assumptions about patient preferences that are incorrect. In the example above, do we really want a hospitalist deciding how often to do a cell count based on perception of who’s paying and how much? I don’t.

I think it would be better to educate physicians on evidence based care including comparative effectiveness research. It could also be useful to make physicians aware of what interventions are more and less cost effective, and to provide tools to help doctors make trade-offs under different scenarios. But just providing hospitalists with more information about charges is not going to be very useful and may cause harm.

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Radiologists get awfully worked up when other specialists (like cardiologists and orthopedists) get into the lucrative advanced imaging business. In the past it really hasn’t mattered that much because there’s been plenty of imaging work to go around and the pie continued to balloon.

Now that cost control and radiation exposure are firmly on the table, the radiology community is nervous that the overall pie might stop growing or even shrink. When that happens they want to grab a bigger slice. They sure don’t want others using up the financial or radiation budget!

The latest salvo is fired by American College of Radiology researchers Jonathan Sunshine and Mythreyi Bhargavan in the December issue of Health Affairs (The Practice of Imaging Self-Referral Doesn’t Produce Much One-Stop Service). They attack (non-radiologist) physicians who refer patients for imaging tests in facilities owned or leased by the physicians themselves. Such “self-referral” is allowed by Medicare because it purportedly provides advantages to patients, including same day service.

Sunshine and Bhargavan repeat previous critiques of self-referral –including that such policies leads to a lot more use of imaging, higher costs and higher radiation doses– then hone in on their principal line of attack: that self-referral does not actually lead to same-day service, at least for CT and MRI scans.

The evidence as presented by the authors is fairly compelling, and they really go for the jugular in interpreting their findings and making policy recommendations. In particular:

• In the “study limitations” section –where authors typically explain why their results may need to be tempered in some way, these authors point out that their findings “may seriously overestimate the extent to which self-referral is truly a one-stop process.” A key reason is “abusive” practices –providers lying on their bills about the location of services. In other words, they want us to think the problem is even worse than they’ve shown!
• The authors cite profit-maximization as a motive for self-referring physicians, who claim their pricey MRI and CT  machines are used for same-day service while actually booking ahead to maximize utilization
• The authors want Medicare to limit the self-referrals to x-rays, which are low cost and low profit, and disallow it for advanced imaging such as MRI and CT
• They go even further by suggesting other self-referral exemptions not related to imaging –including physical therapy, lab tests, and durable medical equipment– should be examined, too, to see whether they also lead to overuse and other “undesirable effects” like high pricing and “cream skimming” of easy to treat, well insured patients

The authors may be completely correct in their analysis and recommendations but the results are so transparently self-serving to the ACR membership that they bear independent scrutiny.

I got my biggest chuckle out of the last suggestion (to look at areas other than imaging). The only reason that’s in there is to try to attract others to the radiologists’ side. But radiologists are famously friendless among their clinical colleagues and it will take a lot more than this suggestion to bring others around. Nice try though!

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Hospitals and physicians have been driving fairly hard on electronic health record (EHR) adoption over the past year or two, partly in response to the financial incentives for Meaningful Use of EHRs under the American Recovery and Reinvestment Act. Those incentives kick in next year and physicians who qualify in 2011 and 2012 will be in a position to collect the entire incentive payment. However, those who don’t quality until 2013 or 2014 will get less. For physicians starting in 2011 or 2012 means the potential to collect $44,000 compared with only $24,000 for those who don’t qualify until 2014. The hospital rules are a little more complicated; still the earlier they qualify the better they do.

Two new reports show that physicians and hospitals are struggling to reach Meaningful Use. That’s not necessarily a bad thing, because it means the Meaningful Use bar was set high enough so that we taxpayers are likely to see some significant improvements for our investment. But I am concerned that some providers will start to give up on EHR adoption once it looks like the incentives are out of reach. On the other hand, the drafters of the legislation thought about this, too, and implemented a penalty phase that kicks in after 2015.

Human nature being what it is, I expect we’ll see a slowdown in EHR adoption in 2012 and 2013 as the incentives appear out of reach, followed by a pickup as we get closer to 2015 and penalties loom. The picture for hospitals may look a little different as they will likely continue trying to make incremental progress. Still I think the big push will come for the laggards once they start getting slapped.

According to the first report (Survey: Top 5 reasons providers not ready for meaningful use) only about 10 percent of EHR buyers are on track for Meaningful Use adoption. Their top 5 reasons for lagging sound about right to me:

1. A lack of substantive support from their EHR vendor (93 percent);
2. Delayed implementation due to the cost of additional support from EHR vendor/consultants (89 percent);
3. A hurried selection of an EHR vendor has resulted in negative consequences (82 percent);
4. Lack available and/or trained staff to properly implement an EHR (77 percent); and
5. They are unprepared and underfunded to rectify difficult system interfaces (69 percent).

In the other report (‘Meaningful use’ readiness drops among hospital CIOs) hospitals indicated the going gets tougher the closer they get to the meaningful use qualification deadline.

“One potential reason for the drop in confidence may be due to the fact that CIOs are getting a clear view of the horizon, as many of their questions are being answered by federal agencies,” Chuck Christian, director of information systems and CIO at Good Samaritan Hospital in Vincennes, Ind., says in a CHIME press release. “Many of the clarifications are adding to the complexity of the task at hand.”

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Please consider making an end of the year gift to the Hearts & Noses Hospital Clown Troupe, using the online donation form. I’m chairman of the board and can promise that the money we raise very efficiently supports the efforts of our dedicated volunteers.

Professionally trained, volunteer clowns from the Hearts & Noses Hospital Clown Troupe have made personal, bedside visits to more than 35,000 children since our troupe’s founding in 1997. Hospitalized children often experience stress, fear, and anxiety which can become a barrier to healing. Hearts & Noses clowns are specially trained to provide relief for ill children and respite for their families. While visits are certainly entertaining, the Troupe’s clowns strive to do more. Our clowns seek to uncover the hidden spirit of joy and the creative energy that lives in the heart and soul of children− a spirit that is often dampened by the sterile and sometimes frightening clinical environment. Our clowns’ central goal is to engage, empower and give choices to hospitalized children.

After a life-changing trip to Russia with famous clown and physician Patch Adams, troupe founder Jeannie Lindheim began offering a series of seminars on hospital clowning. Lindheim, an actor, began training clowns to visit ill and disabled children at Boston area hospi-tals. She formed Jeannie Lindheim’s Hospital Clown Troupe and worked diligently to build a strong, professionally-trained group of volunteers. More than a decade later, our clowns are still all volunteers and we have helped build clown troupes throughout the world. Most recently, our troupe has trained and mentored a fledgling troupe at Baystate Medical Center in Springfield, MA as well as a small group of hospital clowns in Sao Paolo, Brazil.

Hearts & Noses Hospital Clown Troupe is the Boston area’s only professionally-trained, vol-unteer clown troupe addressing the special needs of hospitalized children. We meet young-sters when they are most powerless and most vulnerable — dealing with medical issues (acute or chronic) that force them into a hospital or institutional health care setting. Using theater arts, music, and improvisational play, our clowns engage children in interactions that lighten their spirits and take them away, for a period of time, from the hard job of get- ting well. In the process, our clowns open up the child’s will to recover, turning even the most withdrawn patient into one who is more optimistic and more receptive to the treat- ment prescribed by the medical team.
Hearts & Noses Hospital Clown Troupe partners with three Boston-area hospitals: Boston Medical Center, Spaulding Rehabilitation, and Franciscan Hospital for Children. Boston Medical Center is a private, not-for-profit, academic medical center.  Emphasizing community-based care, Boston Medical Center, with its mission to provide consistently accessible health services to all, is the largest safety net hospital in New England. We currently visit children on the Pediatrics Floor, in the Pediatric Intensive Care Unit, and in the Emergency Department.

The children we visit at Spaulding Rehabilitation Hospital are often recovering from cancer treatment, surgery, amputation, or accidents. These children are often facing weeks of painful, physical recovery work and we offer them a break from that stressful pace and the opportunity to play and have some fun. This focus on play allows children to simply be children, no matter their physical disease or disability.

Our young friends at Franciscan Hospital for Children are often medically fragile and many are on long-term care plans. Some of these children live at the hospital for months or even years; some are never able to go home. We often become part of their inner circle of friends and caregivers because we visit so regularly. We are sometimes asked to be present for a procedure such a bandage change. We distract and refocus the child on play so that the nursing staff can take care of the medical need. Franciscan is our longest- term partnership and we are a key complement to their team.
Hearts & Noses hospital clowns train for two years and work closely with artistic specialists, child development specialists as well as our Medical Director, Michael Agus, MD, Director, Medicine Intensive Care at Children’s Hospital Boston. Last year we focused our ongoing training sessions on child development topics and brought in experts to teach us how to better communicate with children who have special needs, particularly those who are on the Autism Spectrum. We are seeing more children with Autism-related disorders at all of the hospitals but especially at the long-term rehabilitation hospital. We hope to expand those trainings to other serious disabilities and special conditions. We work hard to understand the hospital environment and to be an asset. We want to encourage fun without getting in the way. We also want to be able to quickly assess a child’s needs and abilities so that we can launch right into the appropriate level of play for that child. We are hoping to incorporate new skills into our repertoire to better engage the children we visit.
Each hospital has a dedicated team of clowns. These teams work with each hospital to understand its particular patient population, the special needs of the children, and how they can be most helpful to hospital staff. We strive to train to meet the needs of the population served at each hospital. The clown team structure enables a constructive partnership with hospitals that establishes roles and continuity, creates space for reflection, and encourages creativity. Building relationships with staff is the best way for us to understand the impact we make on the children and make sure that we are a truly helpful addition on the hospital unit.

Perhaps the best way to tell you about what we do and why you should partner with Hearts & Noses Hospital Clown Troupe is to share a story of an actual clown visit. As told by one of our clowns,

We have seen a little boy, Benjamin, for years. He is 10 years old. He can’t move his hands, and is either in bed or in a reclining wheelchair. He beams every time he sees our clowns. His one foot and toes act as his hand. He makes magic tricks work by tap- ping our tricks with his foot.

Today we visit him. I play a silent clown. My partner, Poppy says, “Bloopers has lost her voice.” We look in my pockets, behind the nurse’s counter…everywhere for my voice. Benjamin says, “I will say the magic word.” He does and my voice returns. He takes cards we give him with his toes. Benjamin never wants us to leave when we visit and always says, “One more magic trick?”
We visit all the children on the floors and then talk about our visits in the lobby when we are finished seeing all of the children. I am about to leave the hospital. I look through my clown bag and realize I have left my magic box up on the floor where Benjamin lives. So I take the elevator to his floor.

Benjamin is eating lunch and beams when he sees me. I pretend I have lost my voice again. He laughs and laughs. He says the magic word; my voice returns. I see my magic box on the counter. I smile at him and wave a huge wave. As I dash down the hall leaving, he yells, “I love you!”

You can read more stories like this on our website at www.heartsandnoses.org where the contributions of our funders are gratefully acknowledged.

Hearts & Noses clowns bring joy to hospitalized children.  For more than a dozen years, our clowns have performed magic.  Even if for just a few moments, they have changed “pediatric patients” back into laughing, smiling kids.

Please give generously to support the work of Hearts & Noses Hospital Clown Troupe.  Your donation will bring joy to ill children at our partner hospitals: Boston Medical Center, Franciscan Hospital for Children and Spaulding Rehabilitation Hospital and to children at Victory Programs Portis Family Home.  It will also help to train new clowns so that we may reach as many children as possible.

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Wright on Health hosts the holiday edition of the Health Wonk Review.

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