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Demystifying Medicine One Week at a Time

Category: uncertainty (page 1 of 10)

Solid Reporting on Liquid Gold

A thousand or more cups of urine arrive most nights by express mail to Comprehensive Pain Specialists clinics. The samples are tested for narcotics and other drugs, both legal and illegal. (Heidi de Marco/KHN)

In a beautifully reported investigative piece, Fred Schulte and Elizabeth Lucas of Kaiser Health News detail the explosive growth of the urine drug testing industry in the U.S.

We’ve written about this once before (more than 4 years ago!), but the growth of the industry fueled by taxpayer dollars (Medicare payment for drug testing) appears to be continuing unabated.

In this new piece, Schulte and Lucas do an expose on an outfit called Comprehensive Pain Specialists, a physician-owned outpatient pain management practice with 54 clinics across 10 states in the southeast U.S.

Let me be clear that CPS is not being singled out for malfeasance — rather, the point of the article is that they are emblematic of a huge surge in Medicare spending for expensive urine drug tests — many of which may be unnecessary.

Ay, there’s the rub. From the piece:

     …there are virtually no national standards regarding who gets tested, for which drugs and how often. Medicare has spent tens of millions of dollars on tests to detect drugs that presented minimal abuse danger for most patients, according to arguments made by government lawyers in court cases that challenge the standing orders to test patients for drugs. Payments have surged for urine tests for street drugs such as cocaine, PCP and ecstasy, which seldom have been detected in tests done on pain patients. In fact, court records show some of those tests showed up positive just 1 percent of the time.

The other thing that has government watchdogs and other observers worried is that for many pain specialists, the lion’s share of their revenue is earned by these drug tests. Remember, reasons to order these tests are twofold:

  1. Make sure patients ARE taking the drugs that you are prescribing (therefore suggesting that said drugs are not being diverted–e.g. sold on the street).
  2. Make sure patients AREN’T taking drugs of abuse (which for many pain clinics is a violation of the clinic-patient ‘pain management contract’).

As one government attorney was quoted:

“We’re focused on the fact that many physicians are making more money on testing than treating patients,” said Jason Mehta, an assistant U.S. attorney in Jacksonville, Fla. “It is troubling to see providers test everyone for every class of drugs every time they come in.”

The excellent bar graph attached below is included with the KHN story– and clearly demonstrates the trend. What are your thoughts?

 

 

Medicine and Business: An Odd Mixture

Dr. Martin Samuels

Twitter is in the news frequently these days, because it’s a primary source of presidential communication. I like Twitter because I follow various health care practitioners and pundits and they often link to interesting articles.

I came across a link to an article (blog post, really) from Martin Samuels, Chair of Neurology at Brigham and Women’s Hospital in Boston and a Professor at Harvard Medical School. The whole post is worth a read if you’re interested in the evolution of American medical education over the 20th and 21st centuries. [The post originally appeared on The Health Care Blog.]

What really stood out to me was a long paragraph of his culled from phrases he’d overheard in various meetings with hospital leaders and business types.

Certain overtones of, well……jargon to say the least.

[I’ve broken the looong paragraph up for you for ease of reading. – ed.]

I’m afraid that if we don’t drill down on our brand equity on the front end, we’ll have to model it out on the back end to align our seemless incentives or pad our ask regarding the co-branding deliverables on the horizon.  As an FYI, this empowerment is going to require an elbow to elbow champion getting under the covers for a 360 of the eRoom to facilitate a paradigm shift in order to achieve buy-in among the stakeholders if we’re going to tip our toe into that water and get the low hanging fruit before our clients incentivize the burning platform with new metrics.

After all, you are the process owner who needs to reach out in the proper bandwidth to push back on the KOL’s or we’ll have to sunset your blue ribbon committee for not trimming the fat on the real-time escalation project.  We need to do more due diligence before we hitch our wagon to that indexed outcome measure, and let’s be careful how we message it and roll it out to the core constituency. We can model that projected gap, but we don’t want to get out ahead of our audience before sensitizing them to the moving target.

Let’s not drop the meat in the dirt but rather vet a pause point, collapse it up to a high level statement and assess the current state in order to connect the dots to achieve the ideal state and have you weigh in at the portal for service oriented architecture.  After all, at the end of the day, we’ll have more skin in the game and be in a better space if you walk the stakeholders though it so that they can leverage their halo to birddog that from 10,000 feet.

If you could create a placeholder to move the needle in the continuous quality improvement initiative, some heavy lifting might give us a report card so that there can be the accountability for a decent ROI, unless the co-branding produces a choke point so severe that the balanced score card causes a culture change, one by each.  Just between you and I, you need to parking lot that issue, take the deep dive and put the rubber to the road with a degree of commonality that will re-engineer a sea change in our SWOT analysis so that we bake it into the budget of the high level implementation group.  We have to move the ball down the field and prevent leakage.  Net-net there is value added for a win-win, rather than a zero-sum game.

You can manage the matrixed organization on the frontline and in the back office. With central discipline and local control we can achieve savings and margin, while penetrating that segment of the market.  A lot of what we have to do to reduce our trend is blocking and tackling in different spaces. Bottom line on top, if I don’t report to myself, we could really take a haircut before we can trim the fat out of the box and shift the culture beyond this pilot demonstration program.  That having been said, the PEST analysis shows that if you step up to the plate and evangelize the brand, we can be about the business of creating a placeholder of new buckets with more vertical silos so that we can finally tell whether we are on foot or on horseback.

Comparing apples to apples, it is clear that this is not a plug and play culture, so that you’ll have to hold your nose and jump in order to filter the noise and incentivize the process owners in a more granular fashion before it becomes a major mission drag.  A bread crumb has been forming so let’s put some stakes in the ground to leverage our insights as enablers of change to circle back on a more granular view, and tee up our clinical levers to mine insights from the benchmarks and beat the waste out of this process.  We will cleanse our application platform and get ready for the first wave of ambulatory e-care care go-live across the family and take advantage of the elbow-to-elbow support of the super-users and be back to 100 percent productivity by the second week.

Having said that, we traffic-lighted that report so you can optimize the outcome metrics.  If we can get the whole group on board in this arena we can try to boil the ocean with a six sigma culture change.  We mean to hit this one out of the park and get some substantive returns in the coin of our realm to avoid any mission creep.  It’s a non-starter to analyze the dashboard for crosswalking noise, so we need to slice and dice our organic growth, peel the onion and hardwire the initiative with more boots on the ground. If this could be the pause point for a new value initiative, that’s where the metal meets the road.

Let’s reach out, using our optimized tool kit to go anything north of zero and put a hard stop on this turn-key operation. If you would like to get some trend lines and traction from this piece, I can ping you a copy of my deck.

Oy vey.

Brigham Braces for Uncertain Future

If you’re interested in healthcare, health finance, and technology, consider adding STAT to your favorites. It’s a smart, online-only publication from the Boston Globe that features a great mix of seasoned health care journalism and many new voices (including an excellent first-person column).

This recent article by Ron Winslow (recently retired from 30+ years at the Wall St. Journal) is a great case in point:

Winslow adeptly takes readers though some of the tough decisions around budgeting at the august Brigham and Women’s Hospital in Boston. “The Brigham,” as it’s known, is a mecca for advanced specialty care, medical research, and a major affiliate of Harvard Medical School.

Teaching hospitals are complex economic engines, both bringing in and spending hundreds of millions (billions, in some markets) of dollars.

Such academic centers have long had a reliable flow of federal dollars through Medicare for patient care and resident training, as well as research grants though the National Institutes of Health.

But both of these resources are challenged as the federal budget for research and development grows ever more uncertain.

In addition, hospitals are under tremendous cost pressure (and deservedly so!) from insurers, who bargain to get beneficiaries better rates–and make the health care dollar stretch further.

Take a look a Winslow’s piece. If you’re at all interested in business, finance, economics, and/or health care, you will learn a lot about process in complex organizations. I’m guessing we will be seeing a lot more of this in the health care world.

Kudos to Winslow and STAT for a great investigative piece and to the Brigham for providing transparency into their finances and decision-making processes.

How Treating Cancer is All About Playing the Odds

The following is a guest post by Dr. Andrew Howard:

Like many Americans, I was sad to hear about Senator John McCain’s recent cancer diagnosis. Though I don’t always agree with his political stances, I greatly admire many things about him, including his service during the Vietnam war.

Senator McCain has a type of malignant brain tumor called a glioblastoma multiforme (also called a GBM). This is the same sort of tumor that Ted Kennedy, Beau Biden, and Ethel Merman had. Since the news about the senator’s diagnosis came out, a lot has been written about the fact that GBMs are associated with a poor prognosis. This has made me think about the term “prognosis.” In my experience, patients and their families often misunderstand how doctors think about that term.

Prognosis is all about trying to answer the question, “What’s going to happen to this person?” It’s not always easy to tell. However, early in my training, my mentors taught me that all cancer patients can be divided into two groups, which they called “curative” and “palliative.”

If a patient was palliative, that meant that there was no real chance for curing their cancer. Treatments may still be helpful for slowing the cancer’s growth and reducing symptoms. But we knew from the beginning that the cancer would eventually cause the patient’s death.

Curative patients, on the other hand, had cancers that were potentially…well, curable. The goal of their treatment was to entirely eliminate their cancer. I often imagined those patients finishing their cancer therapy and going on to live long and healthy life. Eventually, I hoped, the cancer would just be a faded, bad memory in their past.

Even in cases where the goal is curative, there is still no guarantee that treatments will cure the cancer. Instead, treatments are intended to make it as likely as possible that the patient will be cured. Curative treatments are all about playing the odds. It’s like we’re at a casino in Las Vegas, and we’re trying to maximize our chances of winning at the blackjack table. With curative treatments, we’re doing everything we can to stack the deck in our favor.

Here’s another analogy: Imagine you’re out for a walk, and your goal is to cross a busy street. You could just step blindly out into traffic, but your risk of not making it to the other side would be high. There are some simple things you can take to make it more likely that you will make it across. You could:

  • Look to your left before you start to cross
  • Look to your right before you start to cross
  • Cross at a crosswalk
  • Wait for a walk signal from a traffic light

Doing any one of those alone would increase your odds of making it across the street alive. Doing two of them would improve your odds even more. Doing all four would give you the best shot. However, even if you do all four of them, your likelihood of making it still isn’t 100 percent. A speeding truck could come out of nowhere, or you could be hit by lightning, or you could have a heart attack when you’re halfway across. Also, even if you don’t do any of them, there’s still a chance you could, by pure luck, make it across the street alive. However, no one would ever recommend you try that!

Your cancer treatments are like these things you do to improve your likelihood of making it across the street. They are each intended to improve your chances of achieving a cure. They can’t make it absolutely certain you’ll be cured. What they do is shift the odds in your favor.

I’m sure Senator McCain’s doctors will do all that they can to stack the deck in his favor. Glioblastoma is usually treated with a combination of surgery, radiation, and chemotherapy. Though the odds aren’t great, a small minority of patients do achieve full cure, and go on to live years and years after their diagnosis. I certainly hope that for Senator McCain.

Andrew Howard, MD, is an Assistant Professor of Radiation & Cellular Oncology at the University of Chicago. He has written a new book for cancer patients and their families titled So You’ve Got Cancer: A Super Patient’s Guide to Diagnosis, Treatment, and Beyond. You can find it here.

How to Age Better: Live somewhere that combats Loneliness, Helplessness, and Boredom

At GlassHospital we strive to bring you interesting ideas about improving health and health care from places far and wide:

An article in the Saskatoon (Saskatchewan) StarPhoenix features Suellen Beatty, CEO of the Sherbrooke Community Centre in Canada.

Sherbrooke is a community centre, but it also is home to more than 250 residents — the kind of place we might call a ‘nursing home’ in the U.S. I love that in Canada they’re called Community Centres. That’s what any facility or neighborhood should strive for.

Suellen Beatty rejects the idea that nursing homes are places where people go to await death. Her team’s philosophy is to make old age more fun. Sherbrooke readily acknowledges the big three elements that compound the infirmities of aging: Loneliness, helplessness, and BOREDOM.

By loading up the day with activities, by listening to their residents and families, and by hosting hundreds of volunteers who see their job as providing fun and emotional sustenance to resident and day-visitor elders, Sherbrooke attracts visitors from all over the world who marvel at its success.

It reminds me a of a piece we ran a few years ago about a pretty special elder care facility in Arizona–one that put its residents’ happiness and comfort above all else — even when it means deviating from ‘standard’ protocols of elder care like eating bland food.

Take a look at what’s going on in Saskatchewan. We can all learn.

Marching for Science

Another piece I recommend: This time from Vox, in their First Person section.

It’s an essay by someone close to me who appreciates the scientific advancements which will help her survive the breast cancer she’s just been diagnosed with.

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