Going into Drydock

I am going to take a bit of a sabbatical from this blog.  I am spending more time working with companies in the patient/provider communication space, and find my inspiration is aligning more around that subject. My husband and I contribute to a blog, “Leave a Message…”, where we share our thoughts about tips, trends, best (and worst) practices on how patients and healthcare providers interact, whether it is via phone, social media, the internet, patient portals, signal flags (just kidding)  or any other communication medium.

Healthcare is rapidly changing with tricky seas ahead. Some day, I may decide once again, to put this old boat back in the water   But til then I wish my readers smooth sailing and give a honk and a waive when you pass by.

Janet

Another example of educated patients improving their outcome…

Regular readers of my blog, knows that improved outcomes via patient adherence is an ongoing interest of mine.   Earlier this month, the New York Times had a blogpost about a program at UCSF where nurse educators worked with heart failure patients to reduce readmissions.

How the program worked was very simple.   A coordinator spends at least one hour explaining the patient’s condition to the patient and his or her family, and preparing them to manage the patient’s condition outside the hospital setting.   The coordinator asks questions about the patient’s diet and gives healthy alternatives.  They teach caregivers how look for troubling symptoms, and about the medications the patient is on.   Patients and caregivers develop an ongoing relationship with the program with emails, phone calls and home visits.  There is even coaching on how to interact with other health care providers.

While the program is not cheap, it has a great ROI.   It began with a $575,000 grant and UCSF continues to fund it.   However, since the program began three years ago, the hospital’s heart failure readmission rate has dropped by 30 percent and the hospital estimates the program has saved Medicare at least $1 million a year.

It’s another example of educated patients (and caregivers) improving the quality of their lives, and reducing the burden on our healthcare system. It’s a no brainer, and yet these programs are few and far between.   We need to figure out ways to fund and support more of these programs.   It’s in everyone’s best interest.

 

You have to give them carrots and sticks….

Hospitals are dammed if they do, dammed if they don’t.   The federal government is pushing them to reduce 30 day readmissions to lessen the Medicare spend.  However, when hospitals comply, they get bit.   An example taken from a recent post to the Bloomberg News website.

The Mount Sinai (NY) experience may be instructive. From September 2010 to May 2011, the hospital’s Medicare revenue rose only 2 percent over the previous year — in part because the number of inpatient cases fell. Why was that? One important reason was that the number of patients readmitted to the hospital within 30 days of discharge was 5 percent less than what it had been the previous year.

The post continues;

Reimbursement from Medicare is still primarily based on how many services hospitals perform rather than on how well they care for patients, so hospitals are often financially penalized for improving value and quality. The Mount Sinai program to reduce readmissions, for example, is costly for the hospital both because of the extra expense of running it and because fewer readmissions means less revenue. Ken Davis, the president and chief executive officer of Mount Sinai, says the hospital won’t be able to afford continuing the successful program if the financial incentives remain so skewed against it.

Granted the author, Peter Orszag has a political agenda with his views, having been a President Obama’s former director of the Office of Management and Budget.   However, the only reason Mt Sinai is even looking at reducing 30 day admissions is because they are no getting paid for it.  However if at the end of the day, the math doesn’t work, look for it and other hospitals to question their readmission reduction programs.

The Intersection of Cost, Quality, and Patient Satisfaction

Now that we are in the dog days of summer, I have some time to catch up on some of my backlog.  There were two items today that caught my attention.

John Goodman (the policy analyst, not the actor), has been writing in his blog about the relationship between the underlying cost of care, wait times, amenities and quality.  In an April 27 blog post he observes that when costs are transparent, and consumers have skin in the game, providers will compete on price and quality to garner business.  In a  follow up post dated June 29th , he writes about the inverse, what happens when third-party payors obscure the true cost of care.  Goodman notes that when patients do not make choices based on price, they will make choices based on time, quality or amenities.  And since quality information is the hardest to gather, patients will make use the markers that are easier to see, time to access, and amenities.  Goodman observes in markets where there is a undersupply of services, hospitals wanting to cater to patient satisfaction might not be as quick to improve quality if it means grumbling patients have to wait longer for services.  And in markets that have oversupply, many facilities go the less expensive route and compete on amenities, rather than instituting the more expensive changes that bring up quality levels. Goodman says it best “Some of the literature on hospital economics suggests that quality improvement is quite expensive, and that dollar-for-dollar amenity improvements will increase hospital revenues by more than quality improvement. This is coupled with surveys that find patients more sensitive to amenity changes than to quality changes. (Of course, this latter finding may only reflect the fact that hospitals aren’t really trying to communicate quality information.)”

A perfect intersection of what Goodman is talking about is a new service called InQuickER.  It is a website that allows patients to schedule their ER visits with participating hospitals.   My first reaction was “Are you kidding?”, but after I counted to 10, I started to smile.

The concept is brilliant.  Emergent cases are notified to go to the nearest ER. Non-emergent cases are slotted in predictable times. Patients love that they are not sitting around the ED waiting room.  Staff likes it because it allows load balancing of non-critical cases.  Participating hospitals like it as they are able to offer a low-cost perk, and differentiator.   There is a fee to use it, which looks like $4.99 for an urgent care center appointment, $9.99 for an ED appointment.

However I have to ask, if the patient is paying the true cost instead of the co-pay, would they be going to the ED for non-critical care in the first place?   Or would they go to a physician’s office (or retail clinic) instead?

Hospital Compare

So instead of doing my reading for my project management class (only 5 more weeks of school), I was on HootSuite seeing what was going on in my Twitter world.  On my business account @janetlsameh I follow 275+ folks from all over the world. In a 30 minute period I can see tweets that  range from complaints about local barrista’s to comments on macroeconomics trends.  Most of the commentators I follow touch healthcare, so the majority of  what I see falls within that realm.

Two unrelated tweets caught my eye today.  The first was from Atul Gawande linking to an blog post from the Atlantic.  The article talked about Todd Park.  For those who do not know about Todd, he is the chief technology officer of HHS, and has the idea to harness the power of  HHS data to spur innovations that improve the nation’s health and welfare.   One of the new tools that uses the HHS data, is  Hospital Compare, a website that contains detailed quality and patient satisfaction information from hospitals across the country.  The second tweet was from Mark Harmel, linking to a blog post from e-Patient Dave (Dave deBronkart) where Dave shares his experience of using Hospital Compare to choose which hospital to take his wife to when she had a foot problem.  Dave talks about how instead of automatically going to their default hospital an hour away, the deBronkarts decided to use Health Compare to choose a much closer hospital.   And it worked out fine.

e-Patient Dave’s experience shows that Todd Park’s vision is starting to work.  Granted Dave is a noted patient advocate and a VERY educated consumer of healthcare, but as more applications like Health Compare start to become accessible to consumers, it will begin to impact choices that patients make. e-Patient Dave’s case would not be a lot of revenue for the default hospital, but it impacted the relationship the deBronkarts had with it.   Instead of always going to one hospital, the deBronkarts, now have options.

Thanks to Todd Park, the data is out there. Hospital and health systems who don’t understand the impact that having the HHS data in an online patient friendly platform need to get up to speed quick.  Consumers are used to going to sites like Yelp or travel sites to see feedback on hotels, restaurants and the like.  Once they learn there is a place they can compare quality data and patient satisfaction scores for their local hospitals, they will use that to make healthcare decisions as well.

>Where you deliver affects how you deliver….

>In an article posted on the California Watch Website, Nathanael Johnson writes in depth about how the amount of C-section deliveries varies greatly from one institution to another. While some of the trends he talks about seem to point to expected non-health related influences (that nobody will cop to), including profitability, efficiency, physician and patient preferences, one unexpected trend was the decrease of C-section delivery in hospitals where healthcare professionals had regular hours.

In one section of the article, the rate of C-sections, are compared at two somewhat identical institutions. Both are non-profit hospitals on the eastern rim of the Los Angeles Basin, 22 miles apart. Both have similar patient populations with approximately 15.5 % living below the federal poverty line. And yet, between 2005 and 2007, one, Hemet Valley had a C-section rates of 28.7 percent for low-risk pregnancies, while the other, Riverside County Regional had a rate of 9 percent. A spokesperson for Hemet Valley could not discern why they had a significantly higher rate than their neighbor, but Guillermo Valenzuela, vice chairman of obstetrics at Riverside County Regional has a theory.

From the article –

Valenzuela attributes his hospital’s low rate to doctors working in shifts. Shift workers have no financial incentive to hurry a delivery along: The doctor is paid the same and can end a shift regardless of whether he or she delivers 10 babies or simply monitors the early stages of labor. The system increases accountability, he said.

By contrast, most doctors, who must be there when the baby arrives to make their fee, face a dilemma unknown to shift workers: either wait hours for a vaginal delivery or perform a C-section.

“If I come in the morning, look over the charts and see that one of the patients just had a C-section without medical indication,” Valenzuela said, “you can bet that I’m going to start asking questions.”

This trend is not an isolated incident. Kaiser Permanente hospitals use this shift-work model and generally have lower C-section rates. Dr. Tracy Flanagan, who regularly delivers babies and is director of women’s health at Kaiser Permanente Northern California, has worked under both systems and understands how the forces of time can affect a physician in private practice.

“You are sitting in labor and delivery for 12 hours and she’s barely making progress, and your family is yelling at you wondering when you are going to come home,” Flanagan said. “There’s tremendous pressure. In addition, you know that you will get paid the same or more for doing a C-section. Our medical system makes it hard to do the right thing.”

And then there was this interesting side note.

Kaiser also addresses this issue by hiring midwives, who are able to conduct births more cheaply than doctors. Midwives participate in the majority of Kaiser births.

For an in depth discussion of all influences on C-section rates – see the article

>Another reason not to like Mondays…

>In the 2010 Press Gainey Emergency Department Pulse Report, there is a lot of information regarding patient satisfaction and ED’s. However one of the more interesting pieces of information is timing of an ED visit.

From the report:

The first graph clearly shows that Monday has the lowest overall mean score for patient satisfaction with the average mean score rising steadily before reaching its pinnacle during the weekend.

The second graph drills deeper into this data by dividing scores into weekday versus weekend, as well as into six time periods throughout the day. Scores indicate that satisfaction is highest during the 7 a.m.-11 a.m. time period for both weekend and weekday. After 11 a.m., both weekend and and weekday scores decrease steadily through the 7 p.m.-11 p.m. period. At this point, the weekend scores decrease again for one more period, while the weekday scores increase slightly. From 11 p.m.-3 a.m. and 3 a.m.-7 a.m., both weekend and weekday scores increase sharply.


According to the Centers for Disease Control (http://www.cdc.gov/nchs/data/nhsr/nhsr007.pdf), in 62.9% of adult ED visits, the patient arrived after business hours. Despite this, Press Ganey consultants have noted that many organizations are staffed as if they were 9 a.m.-5 p.m., Monday through Friday operations. This could be one reason why weekdays between 3 p.m. and 3 a.m. are a weak spot.

(For a larger version of the graph and other information click here)

>Maybe I should pay more attention to those ag reports

>In a December 2009 issue of the New Yorker, Atul Gawand, a surgeon and a well known healthcare commentator, suggests that healthcare’s future could lie in agriculture’s past.

According to the article, the U.S.D.A initiated several pilot programs in the early 20th century that have gone on to modernize farming. Some the early experiments included the first demonstration farms, comparative-effectiveness research (that set about determining the most productive methods for growing plants and raising livestock), and most importantly the U.S.D.A’s efforts in providing timely data to farmers, so that they could make more rational planting decisions. Sound familiar?

From Gawand: “The government never took over agriculture, but the government didn’t leave it alone, either. It shaped a feedback loop of experiment and learning and encouragement for farmers across the country.The results were beyond what anyone could have imagined. Productivity went way up, outpacing that of other Western countries. Prices fell by half. By 1930, food absorbed just twenty-four per cent of family spending and twenty per cent of the workforce. Today, food accounts  for just eight per cent of household income and two per cent of the labor force. It is produced on no more land than was devoted to it a century ago, and with far greater variety and abundance than ever before in history”

To read the original article click here .