Posts Tagged ‘Preventive care’

Dr. Ari Robicsek on Big Data & Healthcare

Wednesday, August 14th, 2013

Dr. Ari Robiszek podcast iconBig Data have become ubiquitous buzz words for the aggregation of information in data sets and the use of algorithms to define patterns. Overall, the growth of the sector is being driven by the trend towards backing up data in the proverbial cloud, online shopping (which grew 14% between 2011 and 2012 to $42.3b in sales), and all the time we spend posting content on social media. McKinsey & Company predicts a 40 percent growth annually in the data being generated. American healthcare providers currently have $300 billion invested in data, including GPS and mobile apps. With the adoption of Electronic Health Records (EHR), it is estimated that data could save providers between $300 billion and $450 billion annually (we spend about $2.6 trillion overall on healthcare).

There is no question that Big Data is a heuristic change in medicine. Through the data compiled in EHRs, it allows use of predictive modeling in order to address health issues at a population level.   For example, we are able to find out if patients are doing preventive care, taking their medication, and whether they might be at risk for chronic conditions. Population health management is a new, more proactive way to segment patients by need (both financial and clinical) and to target them for outreach. It provides a powerful tool to address hospital readmissions and hospital-based infections. For example, NorthShore University HealthSystem (NorthShore) in Evanston, Ill., aggregated 40,000 patients into a data set and analyzed 50 different pieces of data to build a predictive model. This allowed NorthShore to evaluate whether patients might be at a high risk for being carriers of particular bacteria like MRSA, a highly antibiotic-resistant strain.

There are issues going forward such as the barrier that EHRs put between the patient and the physician; in the new tech-enabled world, the doctor might spend the visit staring at the computer rather than the patient. This is a real concern. Doctors have also noted that it is harder to retrieve information in EHRs than from a paper chart. On the flip side, EHRs do provide patients with more transparency, including a portal to their lab tests, billing, scheduling, doctor notes as well as email contact with their physicians.

To listen to Dr. Ari Robicsek’s full interview on Big Data and Population Health Management, click here for the podcast.

Is It Time to Reform the Fee-for-Service Model?

Tuesday, September 25th, 2012

Despite the healthcare industry’s attempts to alter the way in which physician reimbursements are determined,  fee-for-service is still the accepted basis for payment.  Typically, physicians are reimbursed according to the number of patients they see and how many procedures and tests they order.  Policymakers have concluded that the “do more, earn more” business model is deeply flawed and one reason why Americans pay so much for healthcare.  In 2012, Americans will pay more than $8,000 per individual on healthcare.  That’s more than double the $3,400 average spent for each person in other industrialized nations.  What’s more, all that spending has not made Americans healthier.

The time may have come to find a new reimbursement model that places less of a financial burden on patients while still rewarding physicians.  An August article in the Journal of the American Medical Association notes that the fee-for-service payment is the foundation of even some emerging accountable-care organizations, including Medicare’s popular shared-savings program, say Drs. Allan Goroll of Harvard University Medical School and Stephen Schoenbaum of the Josiah Macy, Jr., Foundation.  The shared-savings program “Promotes accountability for a patient population and coordinates items and services under (Medicare) Part A and B, and encourages investment in infrastructure and redesigned care processes for high quality and efficient service delivery.”

Goroll and Schoenbaum isolate a number of reasons for why fee-for-service endures:  many physicians are risk-averse and so resist change; additionally, skepticism is a “major barrier” to reforming the payment model.  “Transitioning to a new payment system will require new modes of practice, and many physicians feel ill equipped to assume financial or performance risks individually or even collectively,” Goroll and Schoenbaum write.  “The concern is that continued reliance on fee-for-service payment for primary care as well as for specialists, with its emphasis on volume of services, threatens meaningful practice transformation and the very goals of delivery system reform.” The bottom line is that the healthcare industry must develop “robust, scientifically validated risk-adjustment models,” according to Goroll and Schoenbaum.  Payment reform could blend capitation and fee-for-service with a plan to revise the payments over time.

Change must be forced on the medical community, whether or not they are ready for it.  One provision of the Patient Protection and Affordable Care Act (ACA) requires alterations to payment and delivery systems to control costs and enhance the quality of care.  Rather than basing payment solely on the number of patients a physician sees and tests ordered, these methods promote preventive care and maintain open lines of communication between a patient’s multiple physicians.

The potential alternative reimbursement models presently being considered include:

•       Bundled payments or fixed amounts paid to healthcare providers for related services a patient needs within a given timeframe.

•       Patient-centered medical homes.  This model would restructure primary-care practices so that their focus is on preventive medicine, patient education and healthcare coordination.

•       Accountable care organizations, in which physicians and other providers share responsibility for providing cost-effective, quality care for patient groups.

When Uninsured Have Dental Pain, They Often Head to the ER

Wednesday, April 11th, 2012

Greater numbers of Americans , especially those who lack insurance coverage, are turning to the emergency room for routine dental care.  This choice frequently costs 10 times more than preventive care and offers far fewer treatment options than a dentist’s office.  The majority of these ER visits are to treat toothaches that could have been avoided with regular checkups but went untreated, often due to a shortage of dentists, particularly those who treat Medicaid patients.

The number of ER visits nationally for dental problems increased 16 percent from 2006 to 2009, and a report from the Pew Center on the States states that the trend is just getting started.

In Florida, more than 115,000 dental patients visited the ER in 2010, costing more than $88 million.  That included more than 40,000 Medicaid patients, a 40 percent increase when compared with 2008.  Many ER dental visits involve repeat patients seeking additional care.  In Minnesota, nearly 20 percent of all dental-related ER visits are return trips because emergency rooms generally are not staffed by dentists.  They are equipped to offer pain relief and medicine for infected gums but not much more.  Because many patients can’t find or afford follow-up treatment, they return to the emergency room.  “Emergency rooms are really the canary in the coal mine.  If people are showing up in the ER for dental care, then we’ve got big holes in the delivery of care,” said Shelly Gehshan, director of Pew’s children’s dental campaign.  “It’s just like pouring money down a hole.  It’s the wrong service, in the wrong setting, at the wrong time.”

For example, in 2009, 56 percent of children enrolled in Medicaid received no dental care.

Visiting ERs for dental treatment “is incredibly expensive and incredibly inefficient,” said Dr. Frank Catalanotto, a professor at the University of Florida’s College of Dentistry.  Preventive care such as regular teeth cleaning can cost $50 to $100, as opposed to $1,000 for emergency room treatment that may include painkillers for aching cavities and antibiotics from resulting infections, Catalanotto said.  Infections can be dangerous, particularly in young children, who often have fevers and suffer from dehydration from preventable dental conditions.  In Florida 200 children were hospitalized in 2006 for those types of infections.  The recession has only worsened the trend, according to Catalanotto.  When someone in the family is laid off, dental tends to take a back seat to food and other necessities.

The Wisconsin Hospital Association has estimated that 32,000 patients with dental problems visit hospital ERs every year. The fees paid to dentists by state health programs such as BadgerCare Plus are the fifth-lowest in the country, according to a report by the Pew Children’s Dental Campaign.  Raising the fees paid to dentists is not likely in the short term given the state’s budget, said Matt Crespin, associate director of the Children’s Health Alliance of Wisconsin, an affiliate of Children’s Hospital and Health System.  “That’s why some of those innovative models have to be looked at,” according to Crespin.

Pekin Hospital in central Illinois has seen a significant increase in ER patients with “very poor dental health,” said Cindy Justus, the hospital’s ER nursing director.  They include uninsured patients and drug abusers, and many are repeat patients.  “There’s just not a lot of options” for them, Justus said.  Shortages of dentists, most notably in rural areas, are part of the problem, Gehshan said.

In Illinois’ Cook County, — which includes Chicago — ER dental visits rose nearly 77,000 between 2008 and 2011.

The cause of the problem is too little financing for dental care in the healthcare system. “And when you lose adult dental coverage like California did in 2009, that creates an even bigger problem,” Gehshan said.  “We do have a safety net, and it’s not big enough,” she said.  In fact, she said, California’s dental care system can only handle about 70 percent of the need in the state, and that’s if the system were actually at full capacity.

Amazingly, 25 percent of all California children have never been to a dentist.  As a result, when those children and their parents end up in the emergency room, using time and resources that could be better spent on non-dental emergencies, that costs California’s taxpayers money, Gehshan said.

America’s Healthcare System Needs Improvement: Study

Wednesday, November 2nd, 2011

The American healthcare system is not very healthy, according to a wide-ranging new assessment of the system that covers 42 measures of healthcare delivery, the United States scored just 64 out of 100.  “Costs are up sharply, access to care deteriorated, health system efficiency remains low, disparities persisted, and health outcomes fail to keep pace with benchmarks,” concluded the 2011 National Scorecard on U.S. Health System Performance. The report was issued by the Commonwealth Fund, a nonprofit healthcare policy foundation.

There are some bright spots on the report.  For one, the number of Americans who are controlling their high blood pressure rose from 31 percent in 2008 to 50 percent in 2009.  Additionally hospitals have improved their ability to care for patients with heart attacks, pneumonia, and other common conditions.

The Commonwealth Fund report also determined that the typical U.S. infant mortality rate is 35 percent higher than the top-performing states.  Other wealthy countries still have infant mortality rates that are significantly lower than the best-performing states in the United States.  If the U.S. did as well as the top-performing country in that category — France — 91,000 fewer babies would die prematurely each year, Cathy Schoen, senior vice president at Commonwealth Fund said.  “These statistics are real,” she said.  “They are real human lives.”  Other “areas of concern” include childhood obesity, preventive care and infant mortality.

Another issue is cost, an oft-cited statistic that the U.S. spends more per person on healthcare than any other country.  According to the Commonwealth Fund report, the nation in general spends twice as much as comparable countries, but doesn’t have better care to show for it.  “We are headed toward spending $1 of every $5 of national income on healthcare,” the report’s authors said.  “We should expect a better return on this investment.”  The high cost of healthcare takes a toll on personal finances, the report said.  By 2010, 40 percent of working-age adults had medical debt or difficulties paying medical bills, an increase of 34 percent when compared with 2005.

It is important to note that the majority of the report’s data is from 2007 – 2009, prior to the passage of the Patient Protection and Affordable Care Act (ACA).  The healthcare reform law is likely to lead to improved scores on some of the categories, particularly access and affordability.  For example, 25 percent of residents in 15 states lacked health insurance.  The ACA will require that all Americans have health insurance in 2014.  It also will reduce eligibility requirements for Medicaid so more low-income people will be eligible, and provide government subsidies to others who can’t buy insurance on their own.

The report’s authors remain optimistic that the health reform law will address many of the problems highlighted in the report.  This scorecard illustrates that focused efforts to change the healthcare system for the better are working and are worth the investment,” said Maureen Bisognano, president and CEO of the Boston-based Institute for Healthcare Improvement.  “If we target areas where we fall short and learn from high-performing innovators with the United States, we should see significant progress in the future,” said Dr. David Blumenthal, commission chair and professor of medicine and healthcare policy at Massachusetts General Hospital and Harvard Medical School.

Writing in the Huffington Post, a Social Epidemiologist at Columbia University, thinks that the price Americans pay for their healthcare is too high.  “It’s well known that Americans pay more for less when it comes to healthcare than just about any other country in the world.  In 2009, we spent nearly $8,000 per person to provide medical care to just over 80 percent of our population — that compares, for example, to just under $3,500 spent per person in the U.K. to provide care for the entire population.  To add injury to insult: our counterparts across the pond get an extra year of life for their $3,500 than we do for our $8,000.

“Why do we pay more for less when it comes to our health?  Every policy wonk has his theory.  Common ones include the high cost of American medical education (which is too expensive), or that permissive tort laws in the U.S. enable lawyers to profit from the health system (which is true).  But while each of these theories, and others, explain small quirks in our health system that certainly contribute to it’s gargantuan price tag, they don’t address the fundamental issue with our health system.  And that’s that our market-driven system introduces perverse financial incentives for medical providers that don’t align with the health or wellbeing of Americans.  This leads to wasted money and lost lives.

“In our healthcare system, the fundamental billing unit is the “procedure” — doctors charge per action, diagnostic or curative, taken on the part of a patient.  While, on the surface, rewarding doctors for each step they take to make a patient better may seem fair, it has disastrous consequences for the structure of our health system.  Chief among them is our top-heavy specialty physician structure,” El-Sayed concluded.

Commonwealth Fund Tackling Better Care for Uninsured, Minorities

Tuesday, October 18th, 2011

A new strategy report issued by the Commonwealth Fund Commission on a High Performance Health System  has the goal of creating a road map to improve healthcare for the uninsured, minorities and low-income Americans.

The commission, which looks for opportunities to enhance the delivery and financing of healthcare, recommends three broad strategies for achieving that improved care in the report, Ensuring Equity:  A Post-Reform Framework to Achieve High Performance Health Care for Vulnerable Populations.  The recommendations seek to assure the safety net’s stability and stimulate higher performance; strengthen delivery systems for susceptible populations; and coordinate healthcare delivery systems with public health services and community resources.

“Our current economic situation has increased the number and proportion of people who are vulnerable, leaving even more families at risk of suffering from our healthcare system’s inequities,” said Dr. David Blumenthal, chairman of the commission, and Samuel Their, professor of medicine and professor of health care policy at Massachusetts General Hospital/Partners HealthCare System and Harvard Medical School, Boston.

According to the report, there is a significant divide between vulnerable populations and their more secure counterparts in rates of receiving recommended screening and preventive care, control of chronic diseases, and hospital admissions for conditions that may be preventable with good primary care and community health outreach.  By way of example, only four of 10 low-income adults receive all recommended screenings and preventive care, compared with six of 10 higher-income adults.  Approximately three of 10 (29 percent) uninsured adults diagnosed with diabetes do not have it under control, twice the rate of the insured (15 percent).  Black adults are hospitalized for heart failure at rates (959 per 100,000) that are more than twice the rate for Hispanic adults (466 per 100,000); that’s nearly three times the rate for white adults (349 per 100,000).

“This policy framework builds on the great strides we expect to be made for vulnerable populations once the Affordable Care Act takes full effect in 2014,” said Commonwealth Fund Executive Vice President for Programs Anthony Shih, M.D. “By addressing crucial issues like access to care, affordability, quality improvement, and better coordinated care, these recommendations seek to assure that the uninsured, those with low incomes, and racial and ethnic minorities see the full promise of health reform and experience a truly equitable healthcare system.” 

“The Affordable Care Act is a big step forward in terms of addressing the significant needs of vulnerable groups and the healthcare providers who serve them,” said Commonwealth Fund President Karen Davis. “However, the inequity in our healthcare system is significant and” as defined in the Commission’s report, “more work must be done to close that gap and assure that we have a healthcare system that provides all of us with access to high quality healthcare.”

Nine Million Americans Lost Healthcare Coverage During the Recession

Monday, April 4th, 2011

The financial crisis not only robbed nine million Americans of their jobs – but also their healthcare insurance. According to a new study by The Commonwealth Fund, only 25 percent of Americans who lost employer-sponsored healthcare coverage succeeded at finding another source.  As a result, an estimated 52 million Americans did not have healthcare coverage in 2010.  Even though the federal government provides a subsidy, just 14 percent of people who lost their jobs continued their coverage through COBRA.

According to The Commonwealth Fund Biennial Health Insurance Survey of 2010, “Using data from The Commonwealth Biennial Health Insurance Survey of 2010 and prior years, this report examines the effect of the recession on the health insurance coverage of adults between the ages of 19 and 64 and the implications for both their finances and their access to healthcare.  The survey of 3,033 adults, conducted by Princeton Survey Research Associates International from July 2010 to November 2010, finds that in the last two years a majority of men and women who lost a job that had health benefits became uninsured.  Adults who sought coverage on the individual insurance market over the past three years struggled to find plans they could afford and many were charged higher premiums, had a health condition excluded from their coverage, or were denied coverage altogether because of a pre-existing condition.  Meanwhile, Americans with health insurance had higher deductibles and consequently greater exposure to medical costs.  And millions were struggling to pay medical bills, facing cost-related barriers to getting the care they need, or skipping or delaying needed care, including prescription medications, because of the cost.”

Just 50 percent of adults aged 64 or less are current with preventive care.  Fully 49 million employed Americans spent 10 percent or more of their yearly income on out-of-pocket costs and insurance premiums, a sharp increase from the 31 million reported in 2001.  Once the Patient Protection and Affordable Care Act (ACA) goes into full effect in 2014, the situation is likely to improve dramatically.  “These reforms have enormous potential to begin solving the problems identified in this report,” said Sara Collins, vice president of The Commonwealth Fund, a private foundation that promotes a high performing healthcare system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, minority Americans, children, and the elderly.

“The report tells the story of the continuing deterioration of healthcare accessibility, efficiency, safety and affordability over the past decade,” said The Commonwealth Fund president Karen Davis. “All this despite the fact that the United States spends more than any other country on healthcare.  Most recently it has failed the millions of Americans who lost their jobs during the recession and lost health benefits as well, leaving them with no place to turn for affordable healthcare coverage.  The silver lining is that the Patient Protection and Affordable Care Act has already begun to bring relief to families,” Davis said.  “Once the new law is fully implemented, we can be confident that no future recession will have the power to strip so many Americans of their health security.”

Of those people who attempted to buy an individual plan during the study’s timeframe — 19 million individuals – or 71 percent found it difficult or impossible to locate a plan they could afford and met their needs, were denied coverage or charged extra because of a pre-existing medical condition.  Adults with family incomes of less than $22,050 for a family of four were hardest hit with 54 percent having no healthcare insurance.  An additional 41 percent of families with incomes of between $22,050 and $44,100 had no coverage.  Of higher-income families, just 13 percent lacked healthcare coverage in 2010.

Conservative groups such as the Heritage Foundation are critical of the healthcare reform law.  The Washington, D.C.-based think tank wants changes made to the healthcare system to make it less reliant on government and to have individuals “own and control their own healthcare policies.”  Additionally, Heritage believes that the healthcare law will increase government spending.  “Of course there’s some people who will benefit from the law, but just focusing on individuals with benefits is misleading,” said Brian Blase, a policy analyst in health studies.  “You have to look at the law in its totality.”