Category: Physicians

Mass Health Quality Partners releases patient experience results

published date
February 2nd, 2016 by

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Massachusetts Health Quality Partners is a national leader in reporting on patient experience in primary care. Its latest data release at healthcarecompass.org provides valuable information for patients looking for a physician and for practices seeking to understand how they perform in absolute terms and in comparison with others.

You may be familiar with the adage, “What gets measured gets done,” so it really is important what we decide to measure and to publicize. Some patient experience topics, like communication, have been measured and reported for some time. The average score is now 93.5 out of 100 –which is great, but it also means that it’s hard to improve from there and that communication may not be a great way to choose between practices.

By contrast, some of the newer categories demonstrate opportunities for –and evidence of– improvement. This is just the second year asking about behavioral health screening –an important topic since so many behavioral issues first present in primary care. Scores on that measure have risen from 53.1 to 56.5 from 2014 to 2015, while some practices have shown improvements of up to 20 points.

Self-management, a new topic this year, comes in with a score of 54.0 for adult practices and 43.6 for pediatrics. Look for that one to rise in the coming years as well. Statewide results are summarized on the MHQP website.

Most of the scores are reported as Harvey balls, with four levels of differentiation. It’s easy to compare practices against one another on specific measures, but on the other hand it’s difficult to figure out how any given practice rates overall. That’s partly because unlike commercial rating sites, MHQP is a collaborative that needs to keep the providers on board.

A shorthand way to make comparisons is with the “willingness to recommend” score that’s reported as a percentage. I asked MHQP spokesman Joe Ternullo about this measure and how to use it:

How can patients use this measure to chose a physician?

People often ask others for a recommendation when choosing a new doctor. To learn more about this, MHQP asked patients:   “Would you recommend this provider to your family and friends?”  MHQP suggests that patients look at all available information before choosing a new doctor. This is because no single rating by itself can give a clear picture about a healthcare provider’s quality of care.

Can a consumer use that measure to make a decision when the information is presented at a practice level?

Yes. A consumer should use the ratings at healthcarecompassma.org to see how his/her primary care practice fares, or to look for practices in their region that have scored particularly well.  In either case, focus on two things. First, look at the percentage of patients who said they would recommend the doctor. Don’t focus too much on minor differences, such as between practices with scores from, say, 86 to 89. Second, look at its scores for individual aspects of performance, such as communicating with patients, coordinating care, and getting timely appointments.  These measures are a guide to help patients assess certain aspects of patient care. No single measure reveals everything about the quality of care at a provider’s office.  Different practices may excel in different areas. But a low score can point out certain aspects of care that a doctor’s office needs to improve.

And as a follow-on, how do practices use that information with their own providers?

Medical care is complex, and patient experience is only one measure of quality. For example, it is important to know how well as doctor helps patients manage conditions like arthritis, diabetes, high blood pressure or high cholesterol. But patient experiences can affect those clinical measures. Many practices have used the MHQP statewide patient experience survey results to improve how they interact with their patients.

The MHQP patient experience survey is a valuable community resource that we are fortunate to have in Massachusetts. The survey is supported by leading health plans and provider organizations.

By healthcare business consultant David E. Williams, president of Health Business Group.

Evidence based defensive medicine

published date
January 15th, 2016 by

 

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Defensive medicine –when physicians provide or recommend unnecessary treatment or testing in order to reduce their chance of being sued– has always bothered me. It harms the patient, drives up costs, and can be self-serving by generating more income for the provider. I’m also skeptical about whether “defensive” medicine really reduces the chances of being sued.

So I was very interested in a Today’s Hospitalist article (Does defensive medicine work after all?) that reports the results of an intriguing study of hospital admissions in Florida. The study, conducted by a Harvard Medical School professor, revealed that physicians who were responsible for the most expensive hospitalizations also had the lowest likelihood of being sued (0.3% vs. 1.5%).

There are plenty of limitations –correlation isn’t causation, it’s based on hospital admissions only, maybe the doctors in the high and low spending groups aren’t comparable, etc. — and yet it does give one pause. Maybe doctors who order more tests and treat patients more intensively really do get sued less. Could it be that patients and families are less likely to sue if they feel that everything has been done for them?

The findings have serious implications, especially as we leave the era of fee for service medicine and enter the age of accountable care and capitation. Will it be possible to get physicians to be less defensive in the name of cost savings? Is it fair to do so? What role should the patient and family have? Do we in fact need some kind of liability reform?

Dr. Anupam Jena, lead author notes that malpractice is bother under and over-stated. Malpractice costs are routinely reported at only 3-5 percent of total costs, yet physicians also say malpractice is a major concern. My own suspicion is that there’s only a limited correlation between real malpractice and what physicians actually get sued for.

Image courtesy of stockimages at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.

 

Free market for surgery: interview with Allevion CEO Arnon Krongrad, MD

published date
January 6th, 2016 by

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Surgery can be expensive, scary, dangerous and even deadly. Yet it’s hard for patients and even for referring physicians to navigate the system. So I was intrigued when I was contacted by Dr. Arnon Krongrad , CEO of Allevion, Inc., a healthcare logistics company that markets surgery packages. The company’s Surgeo online marketplace let’s patients shop for the surgeon of their choice.

I explored the topic in depth with Dr. Krongrad in this email interview.

What are the limitations of referrals to surgeons by primary doctors?

Conventional surgeon referrals by other doctors, such as primary physicians, rely upon limited knowledge about a limited number of surgeons. For example, primary physicians tend to know a relatively small handful of surgeons for specific procedures, such as vision correction. The simple reality is that in today’s environment, when primary doctors are pressured to churn patients, type into EMRs, and speak ICD-10, they have little time to sort through choices of surgeons. They will reflexively refer to the familiar, which may or may not be optimal. Primary physicians, like the rest of us, might welcome systematic, easy access to knowledge about choice of surgeons.

It looks like your surgeons are selected based on the opinions of their peers. Are there more objective, quantitative ways to rate surgeons?

Surgeo’s purpose is to simplify access to quality care. In surgery, quality comes from the surgeon. The question, then, is how to qualify surgeons. This is an urgent question as our increasingly consumerist ecosystem demands transparency regarding cost and quality. It is a question with obvious and easy answer but a conceptual framework will help us to manage and make progress.

First of all, no, there are no objective, quantitative ways to rate surgeons. We should be clear. We are not talking here about waiting room times or adequacy of parking. We are talking here about clinical quality: blood loss, rectal perforation, positive margins, and the like. A system that has not produced an objective, quantitative way to transparently, uniformly, and broadly present cost – a much more cleanly quantifiable dimension of care – has only just begun to think about objective, quantitative ways to present surgeon quality.

As we think about surgeon quality, we should recognize that surgeons do not operate in a vacuum. Most critically, they operate on patients, who are varied, and produce outcomes that are varied. Let us use prostate cancer surgery as an example. The factors other than surgeon skill that affect various outcomes vary. For example, cure is affected by cancer grade and preservation of erections is affected by diabetes. So which outcome – cure, erections – are we looking at when we ask about surgeon quality? Once we decide, have we collected patient data in a way that would permit us to explain variation in outcomes between surgeon A and surgeon B? No, we’re just not there yet.

Secondly, formulaic objectivity, laudable as it might be, is not the only way to go. The other way is subjectivity, the argument for which was previously laid out in this article. In brief, the principle relates to the instantaneous ability of subject experts to detect artistry when they see it. It argues that surgeons know quality surgery when they see it. As one very senior surgeon who has taught surgery all around the world said it: “I can tell within a minute of skin incision if a surgeon is good.”

There are data, most notably in bariatric surgery, to show that subject expert peer credentialing correlates with objectively measured outcomes, such as hospital readmission. In other words, we think we can do well by patients and payers by applying the collective, subjective wisdom of surgeons.

Do other factors affect surgeon qualification? Any surprises?

Yes. Surgeo’s surgeons are qualified using a published, multi-factorial surgeon credentialing process that includes but is not limited to peer input. The idea is to try to get as close as possible to surgeons who know what they are doing and who exemplify the high standards of service and mission.

The additional steps have yielded some surprises. For example, Surgeo recently rejected the application of a very well known, very high volume, well published surgical specialist whose peers think highly of him. We rejected the application upon discovering what his peers did not know: that he has a history of numerous high-dollar malpractice payouts, including one incomprehensible loss at jury trial. This example relates to the opening comments: doctors do not investigate surgeon qualifications as fully as they might if given motivation and time. Surgeon qualification takes time, effort, and more than one criterion.

What do surgeons think of your approach?

Doctors generally are under siege. They are all looking for simplicity, fairness, and respect for their abilities and integrity. Surgeo delivers those and surgeons love the surgeon driven, clinically rational product design and administrative approach. The model works because it satisfies patients and providers. It has also satisfied payers, as when we used it in a previous chapter to satisfy Blue Cross and develop surgery bundles for the network.

What has been the most surprising reaction of your surgeons?

Surgeons are often paralyzed by the freedom that Surgeo offers. They have no idea how much to charge for their services because nobody has ever asked them before. Surgeo does not negotiate prices with its downstream vendors. Surgeo does not set allowed amounts or ask for discounts. This is unfamiliar to most doctors. This seems bizarre. Have you ever met a lawyer who has no idea what his hourly rate is?

What’s the history of Surgeo? What is its future?

One day, two things happened: Congress said everyone was getting healthcare and a man with cancer told me he could not get healthcare: surgery for his newly diagnosed cancer.

I tried to help him and ran into inflexibility and apathy. The solution ultimately involving sending him from Oregon, my surgical team from Florida, and a surgical robot spot purchased on eBay for 1% of retail from Colorado to an operating room in Trinidad. The exercise delivered a flat-fee surgery package at a price he could afford and worked for all involved. We then developed the model domestically and sold surgery packages to individuals and large payers. You can see a presentation of that case here.

Surgeo is a public, interactive, online face of surgery packaging and pricing software engine that was designed in-house under the direction of Kimberly Langer, our Chief Product Officer. Kim was formerly with a large payer, where she designed large enterprise claims related software. She built Surgeo to scale in a way that can work with payer EDI streams for easier network integration and for presentation to members of service choices and out-of-pocket costs. Kim also built it to accommodate our customers who want privately labeled software by which to market their own surgery packages. We’re seeing demand for that from financial and provider organizations.

You cover a variety of surgeries. Are there any surgeries that have been more popular than expected?

Penile implant surgery. We did not even think about this when we first set out. It turns out that there are huge problems related to this procedure. First of all, authentic conversation about male sexuality and erectile function is in very short supply and men with diabetes, cancer, and other conditions associated with erectile dysfunction have very few places to turn for substantive learning. Secondly, the pharmaceuticals for erectile dysfunction have taken over the airwaves and displaced much of the conversation about other, very effective treatments. We were amazed, for example, that one national network of diabetes activists, whose constituents have up to 70% prevalence of erectile dysfunction, has not discussed erectile dysfunction in 10 years!

What makes the challenges even greater is that penile implant surgery is often not covered by payers. We hear regularly from patients who thought they had what they call “really good insurance” that penile implant surgery is not covered. The way things are going, with CMS having dropped covered for vacuum erection devices, it won’t surprise us if penile implant surgery is just uniformly dropped.

We are getting sad, pleading calls from men with diabetes, obesity, cancer, and others who would like to restore their erections, relationships, marriages, and mood. These men are finding a delivery system that is broadly opaque and unhelpful. In response, we built in response is a national penile implant surgery package network. It features peer credentialed surgeons, comprehensive flat-fee packages, finance navigation, and financial protection in the event of complications. It offers plenty of choice.

The risk protected, flat-fee penile implant surgery package network is a model for efficient delivery of non-covered services. It can help payers to help direct members who do need those services.

What do you mean by financial protection in the event of complications?

Surgeo packages protect surgical patients against financial surprises by bringing in qualified surgeons. This is not a guarantee of elimination of complications but it helps. The second protection is inclusion in the flat-fee package of ancillary procedures. For example, gastric sleeve surgery includes hiatus hernia repair if it is needed: no surprise bill. In some cases, such as penile implant and laparoscopic hysterectomy, we are able to also include third-party products that take financial responsibility in the event of surgical complications. Think of it like getting collision insurance when renting a car.

What explains the variations in package prices?

We are just now starting to see a geographically distributed free market of uniformly defined surgery packages. Surgeons in Houston are looking and seeing prices in Birmingham and adjusting accordingly. So some of the variation is explained by the absence of a transparent market. Variation will probably shrink as price transparency sets in as it has on Surgeo. We see surgeons routinely not wanting to the most expensive.

Image courtesy of David Castillo Dominici at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.

Should patients choose doctors who are friends?

published date
December 10th, 2015 by
Come with me?
Can I help you?

In the social media era, it’s common to read articles discussing the blurring boundaries in the doctors/patient relationship. Usually it’s some version of, “Should a doctor accept friend requests from patients on Facebook?” or “Is it ok for doctors to Google their patients?”

The Wall Street Journal (The New Boundaries Between Doctors and Patients) explores these issues and goes on to explore what happens when patients and doctors become friendly during the course of treatment. In the midst of this there’s a throwaway paragraph:

“Some boundaries are clear. Professional medical organizations have strict rules against sex and romance with patients. Doctors are also advised not to treat family or close friends, situations that could compromise objectivity and judgment.”

I have no problem with the part about sex and romance. I also kind of understand the family issue. But the friend one is more interesting to me.

I read a few pieces that discuss this topic. (Here and here.) The typical scenario is a friend asking for medical advice in a casual setting, often on a topic that’s not related to the doctor’s specialty. I get why that’s a bad idea.

In my own case I know many practicing physicians socially, and most are in the prime of their careers: mid 40s to early 50s. A couple years ago when I was having trouble finding a new primary care doctor after mine retired, I asked physician friends who they went to. That was a little too clever on my part, since I forgot to account for the fact that physicians get treated differently than regular people when they go to the doctor’s office. No NPs for them!

But after some so-so experiences with a particular medical specialty, I decided to ask a specialist friend if he would be comfortable being my doctor. He said yes and I started seeing him. He’s a longtime friend but not an extremely close friend. I’ve been extremely satisfied with the experience. Partly because he’s an excellent doctor but also because I feel he understands me better and may even provide a little extra attention. He trusts me enough to exchange detailed emails. I’m not embarrassed to share personal medical details that I wouldn’t be comfortable with sharing someone who’s just a friend. Honestly, for me I don’t see the downside.

I did the same thing when I a needed a new dentist and that’s worked out well, too.

I hope I stay reasonably healthy and then die peacefully in my sleep when I turn 100, so I don’t have to spend a lot of time as a patient. But realistically it’s likely that I’ll be seeing more specialists as time moves along. I’m definitely planning to keep friends in mind when it comes time to find people to treat me.

Image courtesy of stockimages at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.

DocChat puts ER docs online (podcast)

published date
November 19th, 2015 by

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Dr. Steve Okhravi and his son Michael decided to do something about overuse of the emergency room. They founded DocChat to leverage telemedicine for triage and to counteract the forces of defensive medicine that send many patients to the ED that don’t belong there. Early results are strong and they are looking to scale.

I asked the Okhravi’s about their service in this podcast interview.

  1. (0:14) What unmet need are you addressing?
  2. (1:33) Are patients to blame for unnecessary visits to the ED, or do physicians deserve some of the blame?
  3. (4:26) DocChat uses emergency room physicians instead of primary care. Why?
  4. (7:00) Is DocChat appropriate for geriatric patients?
  5. (10:08) Your service is not covered by insurance. Who is the paying customer now and what do you expect in the future?
  6. (12:23) You offer a subscription service as well as charging per call. Is this the type of business where a subscription makes sense?

By healthcare business consultant David E. Williams, president of Health Business Group.