More Public Reporting

Readers of this blog know that I am a fan of public reporting of performance data. I believe that data transparency helps fulfill an obligation to our patients to be honest about the care we provide, and is also a potent stimulus for improvement. There are obvious conditions that ought to be met before any sort of data – about quality, patient experience, finances or anything else – is shared in this way. The data should be meaningful (pertaining to something that patients are likely to care about), valid (the data actually measure what we say it measures), reliable (vary consistently with performance) and presented in a way that patients can easily make sense of it.

Our own efforts to report the patient satisfaction scores of Northwell Health Physician Partners physicians has been well received by our members and the press because it meets all of these criteria.

Some of the other public reporting efforts, such as recent reporting of surgical complications by Pro Publica, have been criticized for failing to meet the standards of validity and reliability, although I and others have been supportive of their efforts.

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Great Idea

Occasionally I come across something that is so profound that it illuminates how I think about a whole host of other things. The emerging science around the gut microbiome is an example. It seems like everywhere I turn there is more evidence that the variety and interactions of the bacteria in our intestines can affect everything from our mood to our risk of heart disease. It has re-ordered my thinking about health and wellness.

More recently, I read a book that has re-ordered my thinking about a lot of things, including health and wellness. The book is Connected by Nicholas Christakis and James Fowler. The central observation of the book is that we exist as social beings. We are all part of different networks of connected people, and the nature of those networks, and the people connected to us through them, have profound effects on each of us. You may have heard about some of the work that is summarized in the book, like the finding that if friends of our friends gain weight, we are more likely to do so as well, even if we don’t know those friends of friends, but that doesn’t begin to tell the story. Read the book. Or at least watch the TED talk which, when I checked, had been viewed over 1.1 million times.

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Happy New Year

I have never been a big fan of New Years Eve celebrations. Somehow the transition from December 31st of one year to January 1st of another always struck me as a poor justification for a party, and I had a hard time understanding the hoopla. As I have gotten older, however, I have come to appreciate the value of New Years as a pivot point – a chance to look back and assess the year coming to a close, and to look ahead to the one about to start. For the last couple of years I have cataloged the accomplishments of our medical group over the year ending and set out goals for the one starting, some of which I want to share.

A couple of accomplishments stand out as important markers of our continued evolution into an integrated, multi-specialty, physician-led organization. One was very “public” and easy to see and understand, and the other was internal and somewhat arcane but no less significant.

The public one was the publication of our physicians’ patient satisfaction data on our website. While the groundwork for this had been in the works as far back as the beginning of 2014, we “went live” with the program in August of 2015. Taking this step sent a powerful message that our medical group was committed to transparency of performance data and accountable for the experience of patients and their families. I believe it was also an important cultural milestone, demonstrating to our non-physician colleagues in the organization that we could – and did – take responsibility for our practice. The secondary benefits were also huge. We got lots of positive press, and our physician web-profiles now have a much higher visibility on search engines, edging out commercial rating sites such as Yelp and Healthgrades.

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Drug Prices and Costs

Drug pricing has become a hot topic. Maybe I have become sensitized to it, but it seems like there is something about the cost of pharmaceuticals everywhere I turn – in medical journals, online discussion groups and mainstream news outlets. Just this past week, the front page story in the business section of the New York Times ran a long profile of a pharmaceutical executive that centered on his company’s controversial pricing practices. The article mentioned that pricing is now generating lawsuits and potential Congressional action.

Why all the attention? I am guessing (really – just guessing) that there are a few reasons.

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Reflection on Thanksgiving

I love Thanksgiving. It is my favorite holiday – quintessentially American, and celebrated nearly universally across what are often divides of age, ethnicity, religious background, income and region. Somehow Thanksgiving always renews my love of country and faith in its future.

This year, it also got me thinking about being truly thankful for good things, large and small, that surround all of us. It is easy, of course, to get caught up in the day to day, and to focus more on the annoyances and challenges each of us faces instead of on the joy or beauty. Maybe it is even basic human nature to do so. But a recent piece in the New York Times made a pretty compelling case that gratitude is a path to happiness. Conscious efforts directed at appreciating the good make us feel better, so that we can, in a sense, train ourselves to be happier.

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Listen More

My first posting on this blog explained why I chose to name it “Auscultation.”  I wrote that I wanted to promote a conversation, and that listening was essential to doing so. I went on to write: “With an obvious nod to my being a cardiologist, I believe auscultation has long been an act that defines us as physicians and connects us in a profound way with our patients. The act of leaning in, touching the patient, listening, concentrating, and interpreting is a powerful metaphor for the entire clinical encounter: getting close to the patient and listening.”

It is therefore no wonder that I was really pleased to read “The Physical Examination and the Fifth Maneuver” by Thomas Metkus in a recent issue of the Journal of the American College of Cardiology. The piece appeared in the “fellows in training and early career page” in the Journal, which regularly features articles by trainees about their experiences, and was a mature and robust defense of the importance of developing auscultatory skills. Metkus alludes to Osler’s model of physical diagnosis, the first four maneuvers of which are inspection, percussion, palpation and auscultation. The fifth – and arguably most important – is cognition, the intellectual exercise of putting it all together.

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More Ammunition

I have never been a fan of dietary supplements. In fact, I have spent many hours trying to talk my patients out of taking nearly all of them. My reasons for doing so are based on both my conservative approach to medical therapies in general, and on my skepticism about these products in particular. A recent article in the New England Journal of Medicine gave me more ammunition to oppose their use.

Here’s what I mean by a “conservative approach” to medical therapies. I believe that there should be a good reason, backed by good evidence, to take any medication – prescribed or over the counter. Since every medication (or supplement, herb, vitamin, mineral, etc.) carries some risk of adverse side effects, and costs some money, I have never ascribed to the “it can’t hurt” school of thought. “Why not?” has never seemed to me a compelling reason to recommend or prescribe anything. There is a profound lack of reliable evidence supporting the use of the vast majority of OTC supplements that patients take.

This is of course compounded in the common scenario where people are taking multiple prescribed medications or OTC products, in which there is also a real risk of unanticipated interactions among compounds.

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No Kidding

I tend to “batch read” medical journals. I usually set aside some time on Sunday mornings, after the New York Times and before the Giants kick-off to skim the cardiology journals that I still get. This past Sunday I saw something in Circulation that caught my eye.

The title of the article was “Medication initiation burden required to comply with heart failure guideline recommendations and hospital quality measures” and it was apparently deemed important enough by the editors to have an accompanying editorial called “Rethinking the focus of heart failure quality measures.” Both were authored by luminaries in the field. The punch-line? Lots of patients admitted to the hospital with heart failure need to start one or more new medications to meet guideline recommendations and hospital heart failure quality measures. This is, of course, hard to pull off, because of the challenges associated with “managing polypharmacy” and “heart failure transitional care.”

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Improving the Evidence

All good physicians want to do the right thing. They want to recommend effective therapies to their patients that will improve outcomes or alleviate symptoms. It is widely accepted that the best way to discover new effective therapies is through the use of clinical trials. Among clinical trials, the reference standard is the randomized, double-blinded, placebo-controlled trial, which is designed to minimize bias in the selection of therapies or the interpretation of results.

I have written before about the limitations of clinical research in advancing medical practice. As I have said, it is literally impossible to study every clinically relevant question, and it is also impossible even in theory to use randomized controlled trials as the methodology for many of the questions that can be studied.

A recent article in the New York Times highlighted another challenge to the paradigm of clinical trials as the engine for improving medical practice. The piece was about a change in policy at the National Institutes of Health, being implemented by Michael Lauer, the “newly appointed deputy director for extramural research.” In the interest of full disclosure, I have known Mike for many years (we were cardiology fellows in the same program at Boston’s Beth Israel Hospital in the late 1980’s) and you would be hard-pressed to find a nicer, smarter or more upstanding guy.
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Who’s in Charge Here?

I spent a couple of hours today discussing a topic that has become increasingly important in the world in which we live, and which would have completely mystified an earlier generation of physicians. The subject was “attribution.” Simply put, how should one decide which patients “belong” to which doctors? On a more technical level, what algorithms should be employed to connect patients, or episodes of care for those patients, or specific quality measures pertaining to those patients, to particular physicians?

Here’s why this is a hot topic. CMS is moving rapidly to alternative payment models. Medicaid is transitioning to a capitated system. Commercial payers are entering into “risk” arrangements with providers. All around us, fee for service is losing sway and is being replaced by a spectrum of new ways to pay for care. In the “old world” of fee for service, whoever provided the service got the fee. There was no mystery about how the dollars should flow. In the “new world” all that changes. In many instances, payments are linked to quality measures. So, for example, physician groups or integrated health systems may be subject to penalties or earn bonuses depending on how “their” patients do. Too many readmissions? Penalty. Excellent blood pressure control? Bonus. Simple enough in theory but complicated in practice.
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