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Questioning a Health Care Sacred Cow

If you’ve worked in U.S. health care for any length of time, you’ve no doubt lived through a period of impending ‘inspection’ by the Joint Commission at your hospital or health care organization. Stress levels amongst all staff inevitably rise in the runup.

Everyone needs to look sharp, have their protocols down, and most importantly, where to find organizational policy information if it’s not available by quick memory retrieval.

One of the 800 lb. gorillas of the U.S. health care world, the JC (as it’s known) audits, inspects and accredits nearly twenty-one thousand U.S. health care enterprises.

I was always under the impression that the JC had a complete monopoly in its market–that is, if your health care organization wanted to be accredited (the vital ‘seal of approval’ for your organization’s public relations and safety standards, but also key for reimbursement through CMS) than you had to play ball with them.

In 2012, one of the hospitals at which I worked decided to go in a different direction, choosing instead to work with the accrediting agency DNV, which has its origins in the world of Norwegian shipping. For real. As in, ocean liners need a ton of regulation and safety standards so that they don’t run into each other and sink. We’re always comparing health care to airlines, right? Maybe it’s not such a big stretch after all.

Like most of my physician colleagues who’d lived through years of JC audits, we were a bit flabbergasted: “You mean the JC actually has competition?” As it turns out, the JC only controls a mere 80% of the market. Turns out it’s only a 785 lb. gorilla.

Even though this whole issue is a little bit “inside baseball,” I wrote an essay about it for NPR. My reasoning was that there’s always value in questioning monolithic conformity. And I had been really surprised to learn that there was actually competition to the JC.

Now comes a study in BMJ, led by Harvard researcher Ashish Jha. The study compared more than 4000 U.S. hospitals and the outcomes generated for 15 common medical conditions and six common surgical conditions between the years 2014-2017 in a Medicare population data set of more than four million patients.

What did the study find?

Interestingly, there was no statistical difference in 30-day mortality or readmission rates in the patients that were seen at JC-accredited hospitals vs. those at hospitals accredited by ‘other independent organizations.’ There was a slight but not statistically significant benefit in mortality and readmission rates for JC-accreditation vs. hospitals reviewed and accredited by state survey agencies.

The study raises the reasonable question: if there aren’t patient outcome differences in hospitals accredited by JC vs. those accredited by either state review (government) or other independent agencies (other privates), then should the JC enjoy such a massive industry dominance?

After all–many health care leaders cite the JC’s regulatory and inspection processes as burdensome, and argue that the whole preparation game and citation-fixing business is expensive and distracting from the core hospital mission: taking care of people.

Other JC critics cite the fact that the organization is less than optimally transparent, electing to keep its inspection reports private, despite the fact that many health care enterprises flagged for violations are able to stay accredited.

Congress has even begun an investigation into possible lax oversight.

Apparently Jha’s work has struck a chord, as there was some notable media coverage about the BMJ piece. For one, the Wall Street Journal ran a story about it, which it kept in front of its paywall, while noting that hospitals pay on average $18,000 for an inspection and annual fees of up to $37,000 to the Commission.

Cardiologist and prolific blogger John Mandrola also wrote an opinion piece titled “Joint Commission Accreditation: Mission Not Accomplished.” In his piece, Mandrola compares JC accreditation to medications or surgery that fail to live up to evidence-based standards and subsequently fall out of practice. He concludes, “If the JC’s brand of accreditation can’t show benefit, than it too needs to be de-adopted.”

Having learned that there’s an emerging marketplace of agencies equipped to inspect hospitals and health care enterprises it seems there’s an opportunity here: Perhaps the agency offering the greatest value in terms of cost, reporting, and public accountability will triumph against a behemoth that seems too complacent and entrenched in its ways.

Does Medical Marketing Work?

20140929-dollars-for-docs-300x200_1You bet it does.

In the ‘old days,’ doctors were taken on junkets to sunny destinations and indoctrinated with the latest and greatest in brand name medications. The trips were paid for by the pharmaceutical firms that manufactured these drugs.

Trips like this started to become unseemly, and the public began demanding more transparency in the relationships their doctors had with drug companies. A database was created to keep track of the monies flowing to docs from drug companies.

Docs can still get a meal (as long as it’s ‘educational,’ i.e. there’s a lecture along with it) and the traditional branded pens and pads of paper for the office. Sometimes drug reps (the sales people for the pharma firms, known in the trade as ‘detailers’) bring by bagels or doughnuts to woo the staff and steal a few minutes to tell us about their latest product.

The big money comes to the select few who become ‘thought leaders,’ i.e. spokespeople on behalf of certain drugs. This can range from five to six figures. Per year.

Docs have always been a little defensive about having these relationships explored or highlighted. “No drug company influences the way I prescribe,” is a common sentiment.

“I prescribe the best products that are on the market,” is another retort — not hard to defend, as the brand name drugs create the perception (at least) of being the best.

Conventional wisdom has always held that drug companies wouldn’t spend the billions that they do on marketing if it wasn’t beneficial. Proof of that has been hard to come by, though, as there wasn’t a way to clearly demonstrate a relationship between drug company payments and the rate of prescribing brand name (i.e. heavily marketed, more expensive) drugs.

Now there is.

In a beautifully conceived and executed investigative report, the non-profit news source ProPublica has linked the pharma payment database with the Medicare Part D (which since 2003 has paid for prescription drugs for seniors) database.

You know what?

There’s a perfectly linear correlation: Docs that receive payments (in one database) prescribe more brand name drugs (from the other database).

Nothing about this is illegal. There’s no doubt that some of the doctors receiving payments genuinely believe the brand-name products they prescribe are better. It’s just that no one can claim with a straight face any longer that payments to doctors don’t influence the way we prescribe.

(Mind you, the drug companies have known this all along, but have kept this information private as ‘proprietary’ information. Trade secrets, you know.)

If you like this kind of reporting, you can listen to a story about the investigation here:

Costs of Care

Getty Images

Getty Images

Ever received a bill for a health service that troubles you? Does it seem too much?

Is it hard to understand what you owe from what insurance pays? Does it seem like the share you pay always goes up?

Medical costs are a universe unto themselves. How doctors and medical facilities (hospitals, radiology practices, etc.) come up with their charges seem to lack any rational basis.

Famously, in his article that became a book, author Steven Brill challenged the CEO of a big health insurance company to explain his ‘explanation of benefits’ (the bill-like statement you get that is NOT A BILL), and the CEO couldn’t do it. Here Brill recounts the story in an interview with Minnesota Public Radio. Context — Brill had a big operation for an abdominal aortic aneurysm, so he decides to use himself as a test case:

After I got home, about 2 or 3 days later, I received in the mail 36 different explanations of benefits from my insurance company, in 36 different first class envelopes, which tells you something about how inefficient the system is.

As I started to open them, I thought to myself: I’m the world’s leading expert on hospital bills and insurance bills, this is going to be fun. When I opened the third envelope, it said the following. This is an explanation of benefits from United Healthcare, which is headquartered in Minnesota: Amount billed: $0; amount paid by insurance: $0; amount you owe: $154.20. I looked at it and I looked at it. If nothing was billed, how could I owe $154.20? I turned it over, I tried to decode it, I couldn’t figure it out.

As it happened, before I went into the hospital, I had scheduled an interview with the CEO of United Health out in Minnesota … So as soon as I was able to travel, I went out to Minnesota and I did the interview. … And then at the end, I reached into my pocket and took out that explanation of benefits and handed it to him. I said: “I’m wondering if you could just help me understand this, I’m having trouble figuring out what this means. How could I be billed $154 if nothing was billed?”

He looked at it and he looked at it, he turned it over, he looked at the coding, and finally looked up and said to me: “I could sit here all day and I could not explain that to you. I have no idea what it means. I don’t know why they sent it to you.”

I said, “Aren’t you they?

That explanation of benefits is the single most common form that consumers receive in what is by far the largest industry in the United State: The healthcare industry. Tens of millions of those explanations of benefits go out from United Healthcare every year, and the head of the company can’t even understand what it means, so how are the rest of us supposed to understand what it means?

As an entree to discuss the issue of health costs in the U.S., and people’s disparate reactions to them, I share with you the story of Mrs. Sutton, a patient of mine who had a somewhat atypical reaction to the cost of her colonoscopy — even though she owed nothing out of pocket. I also want to emphasize how poorly doctors do in helping patients anticipate their costs of care. Reliable pricing information is hard for us to come by, too — as some commenters note. But some new companies (apps, of course) are trying to tackle this issue head-on.

Click on the box below to read it. Feel free to add your own story to the mix.

Evidence shows that in spite of mutual doctor-patient desire to discuss drug costs, we docs usually shirk the duty, writes Dr. John Henning Schumann.

Posted by NPR on Saturday, January 16, 2016

Thanks for reading.

The Inflection Point(s) of Aging

A new column of mine has been posted on NPR’s website about “de-prescribing,” the art of pruning medications from older adults that take too many of them, a condition we refer to as polypharmacy.

Katherine Streeter for NPR

Katherine Streeter for NPR

It’s well-known that being on too many medications can lead to more side effects and drug-drug interactions, so anything medical professionals can do to minimize such negative outcomes is welcome. Thus we revert to our Hippocratic doctrine: First, do no harm.

Contrast that with the competing ethical imperative toward beneficence — to do good for patients. Medical science teaches us that many (though far from all) of the medications we prescribe for chronic illnesses (e.g. cardiovascular conditions) lead to fewer ‘events’ (think heart attacks & strokes), which prolong lives.

As a result, doctors wind up prescribing a lot of stuff — and decades of medical practice and now guidelines and quality metrics push us to do this even further.

One area I’d like to see science help us is in identifying “The Inflection Point of Aging,” which I define as the point in a person’s life when we can pare down ‘aggressive’ treatment of chronic conditions because it becomes counterproductive: when taking the “medically proper” action is likely to cause more harm than good.

This whole notion arises out of recent discourse: As I recently blogged, the SPRINT Trial, which was stopped early because it showed that treating blood pressure even more aggressively than we’d previously thought leads to fewer bad ‘events.’ How low, I wonder, is too low?

Also, an article in the Atlantic by medical pundit Ezekiel Emanuel titled “Why I Hope to Die at 75” emphasized this idea.

Emanuel is a known iconoclast, but I appreciate his efforts to stir up dialogue and get us talking about important issues that we are otherwise reluctant to discuss. In this case, I think his editors at the Atlantic did him a disservice, because the provocative headline of the article caused a furor and detracted from his real message, which was simply this: There comes a point where undergoing standard medical practices no longer makes sense. That point is different for everybody and is dependent on a person’s values as much as their physiology. Emanuel never said he wants to die at 75, merely that he plans to stop seeking medical interventions at that age — two very different ideas.

If you click over to the NPR column, you can see that anecdotally, we care for patients for whom physiology does change — and it therefore doesn’t make sense to keep doing the same things over and over. It’s trite to say it (and you’d be amazed at how challenging it can be to fight medical inertia), but we must think about each patient individually and truly weigh the risks and benefits of adhering to population-based norms and recommendations when goals and bodies change.

Doctor, Don’t Treat Thyself. Or Family Members.

The day I started medical school, I called home to tell my parents about it. My mother, a hypochondriac, didn’t want to hear about the class schedule or the amount of work.

“I have a new rash I need you to take a look at,” she told me.

What did she think? That after one day, I’d suddenly been imparted all the knowledge I’d need to treat her? (As you’ll see later, I would come to wish that had happened.)

Silly Mom. As if I’d been admitted to some special club.

This comes up more often than you might think in medical practice. The ethics are fairly clear — it’s not illegal to treat family members or friends, but it’s unethical because those friends and family members cannot exercise their full autonomy when making medical decisions.

Just published on NPR’s Shots blog is a column I wrote about our experience caring for our daughter during this past winter’s flu season, and a couple of stories of familial ethical challenges from other doctors. Please click over and take a look. Thanks to Katherine Streeter for great collage art.

Gotta get me one of those “Dad” hats, but I’m not much into argyle.

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