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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Leadership Development

One of the things that I am most proud of about the North Shore–LIJ Health System is our institutional commitment to leadership training. There are lots of examples, but the best I know of are the “high potentials program” for administrators and the “leadership development program” for physicians. Both accept a fraction of nominated individuals, and provide a variety of support services, classroom training and mentorship to participants. Not surprisingly, the programs get rave reviews and the graduates are sprinkled in leadership roles throughout the organization.

I was recently asked to address a group of about 50 participants from both programs as part of a series called “executive forums,” in which a senior executive tells his “personal leadership story” and does a Q&A with the attendees. Sounds good except – because of some crossed lines of communication – I didn’t realize that was the expectation until I had little or no time to prepare. As it turned out, I am glad I didn’t have more time.
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Guide for the Perplexed

It is clear that the way that health care gets paid for in the United States is undergoing rapid change. What is not at all clear, at least not to me, is exactly what the payment model will look like in the future, or how far off that future is. Although everybody agrees with Yogi’s assessment that “it’s tough to make predictions, especially about the future,” this exercise seems particularly challenging because of the wide variety of “alternative payment models,” likelihood that they will co-exist, and the prevalence of regional differences.

It is because of this complexity that I found a recent paper in the Annals of Internal Medicine to be helpful. It is a simple “field guide” to different payment models that starts with distinguishing the “unit of payment” (e.g., per unit of time, per episode of care, per beneficiary, etc.) and then uses these to review efforts at payment reform over time.

I found this helpful in keeping all of these things straight in my head, and I liked the way it started from “first principles.” I think it is worth the read.

What do you think?

Live, from NY…

Back in June, I wrote that “I support the public reporting of validated survey data from real patients” and I am now proud to report that our Medical Group is actually doing it.

Last week we went live with patient satisfaction scores and patient comments on our “find-a-doc” website. Here’s how it works. We contract with a nationally recognized company to send surveys to patients who have seen one of our physicians for an outpatient visit. If we have the patient’s email address, we have the survey sent electronically; if not, it is mailed to a random sample. The survey asks patients about a wide variety of issues associated with the visit, and includes 10 questions specifically about the interaction with the physician. Patients are also asked to add a comment.

We then post the average score that each of our physicians has received, along with a breakdown of the score by individual question, as well as the comments. More details are available here, but a few are worth mentioning.

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The Future of Medical Practice

I had the opportunity last week to talk and learn about the future of office-based medical practice. The occasion was my participation in a panel discussion sponsored by a manufacturer of equipment for medical offices. A professional facilitator conducted a day-long interactive interview of 6 panelists, strategically selected from non-competing health care markets across the country. We talked about what was going on nationally, regionally and in our own organizations in order to provide a context for the sponsor’s strategic planning.

Much of what we talked about centered on the transition from “volume to value,” the catch-phrase for the movement away from fee-for-service to some form of quality-based payment system. The content of the discussion reminded me of the saying that “the future is already here, it’s just not distributed evenly yet.” Physician leaders from west-coast organizations described a landscape of capitated payments and “accountable care” that we talk a lot about but have not yet lived in a significant way. A representative of an institution in Boston spoke of a more highly consolidated provider community. Those stories were interesting, but not entirely novel. Here are a few things that were:

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This is a Very Bad Idea

I was stunned when I saw this headline in the New York Times last week: “Court sides against FDA in ‘off-label’ drug promotion case.” In case you missed it, here is the lede:

The maker of a prescription fish-oil pill won an early victory Friday against the Food and Drug Administration over its right to publicize unapproved uses of its drug.

The gist of the story is that the pharmaceutical company successfully claimed that restricting its ability to promote off-label use with (in the words of the court) “truthful and non-misleading information” violated its First Amendment right to free speech.

Let me be clear here. I am all for maintaining the longstanding prerogative that physicians and other licensed prescribers have to prescribe approved medications for unapproved indications.  That’s not what this is about.

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Right Call; Wrong Reason

There were several news stories last week that reported that Pfizer had abandoned its efforts to have its Lipitor brand of atorvastatin made available over the counter, without a prescription. I was never a big fan of OTC statins (more on that later) but I was struck by the reason that Pfizer put out:

The study did not meet its primary objectives of demonstrating patient compliance with the direction to check their low-density lipoprotein cholesterol (LDL-C) level and, after checking their LDL-C level, take appropriate action based on their test results. 

Left unstated (and unclear) in this is exactly what the appropriate action was supposed to be. I guess they were implying that patients were supposed to check how they responded to the drug and then figure out if they should keep taking it, change the dose or seek professional advice about next steps.
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Good Enough?

There are a few themes that permeate this blog – the impact of new technology on medical practice, evidence-based care, health care financing, and a patient-centered approach to care delivery. The recent dust-up over the release of surgeon-specific outcome data touches almost all of them.

ProPublica, a not-for-profit organization devoted to investigative “journalism in the public interest” got the ball rolling last week with the publication of their “surgeon scorecard.” They compiled 5 years of Medicare data (2009-2013) on 8 generally elective surgical procedures: Knee and hip replacement, laparoscopic cholecystectomy, lumbar spinal fusion (broken out by anterior and posterior approach), “complete” prostatectomy, TURP and cervical spinal fusion. For each one, they identified a list of principal diagnosis codes associated with a hospital re-admission within 30 days of the surgery that could reasonably be interpreted as complications of the index surgery. For example, if a patient had undergone knee replacement and was admitted within 30 days with a principal diagnosis of “infection due to prosthesis” then that “counted” as a complication of surgery. Details of the methodology were provided online. The complication rates were adjusted by patient age, gender, and a few other variables, and their user-friendly tool allows for easy look-up of complication rates by surgeon or hospital.

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Talking About Death

A few recent experiences have me thinking about death.

The first was hearing a story on the radio about how physicians “manage” their deaths. The gist of it was that physicians are more likely to die at home without aggressive life-extending interventions than the general public. The implication was that more people would have a “better” death, more in accord with their own wishes, if frank discussions about end of life care were more common.

I didn’t think too much about the story, which registered only a “no kidding” in my mind when I heard it, until I thought about it in the context of two deaths that touched me this past week.

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Rethinking a No-Brainer

What does someone having a heart attack look like? I think the New York Times captured what many of us probably have in mind, when they published this picture as part of a recent series on advances in cardiovascular care:

Nash_Blog_ImageMark Makela for The New York Times. Retrieved from http://www.nytimes.com/2015/06/21/health/saving-heart-attack-victims-stat.html

Here is the iconic middle-aged guy, in extremis, pointing to his chest, with a team of health care professionals at the bedside. There are also signs of initial management – he has ECG electrodes on his chest, an IV in his left arm, what looks like monitor/defibrillator pads on his right chest and below his left arm and, of course, an oxygen mask.

What is wrong with this picture?
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