Presenting Care & Cost Data

Brian Klepper

Over the weekend, Dan Munro – see his recent provocative post on medical management and cost – dropped me most of the chart below – he had cut off everything above the main part of the graphic – which is chock full of interesting comparative information about cost and life expectancy in developed nations around the world. It was first published in the January 2010 National Geographic, but then discussed on their blog as one of many ways to present complex data.

When I first saw it, I couldn’t help but think of Edward Tufte’s classic book The Visual Display of Quantitative Information, which I discovered in my 30’s – I was developing a lot of newsletters on health industry trends at the time – and which Amazon refers to as among the “Best books of the 20th century.” An astonishingly interesting and enlightening book about how to present data.

Note that the clear winners in this chart, in terms of bang for the buck (or yen, as the case may be here), are the Japanese, who spend the least on health care to get the longest lifespan, though having an ethnically homogeneous population and a supportive social structure are two of probably many more variables that help this along.

I apologize for the size of this. It may be helpful to blow this up a bit using Control-+.

Creating Value-Based Incentives for Primary Care

Brian Klepper and David Kibbe

Posted 6/2/11 on The Health Affairs Blog

In a remarkable recent interview, Donald Berwick MD, Administrator of the Centers for Medicare and Medicaid Services (CMS), eloquently described his vision of value-based health care.

Paying for value is an incentive…The underlying idea of improvement is that American health care, historically built in fragments, often cannot achieve for patients what it really wants to achieve…Health delivery system reform refers to really reconfiguring care into much more seamless coordinated-care operations so that people, especially those with chronic illnesses, experience continuity of care over time and space.

Continue reading “Creating Value-Based Incentives for Primary Care”

Uwe on Premium Support and Vouchers

Matthew Holt

Posted 12/24/11 on The Health Care Blog

There’s a great post by Uwe Reinhardt on the NY Time Economix blog explaining the theoretical difference between premium support and voucher systems (and you thought they were the same thing!).

Unfortunately it skirts the real problem that those of us playing along at home know too well. Either a well constructed premium support (Ryan done right), or a well constructed voucher/managed competition (Enthoven) system, a mixed public/private system (Germany, Starr, Reinhardt) or even a decent Medicare for all /Single payer system (PNHP, McCanne) needs to be designed holistically to have a chance of working–especially to ensure that all people are in plans that treat them all equally.

Note that this very week HHS devolved the choice over plan benefits to the states–meaning that the very notion of Enthoven-like standard plan benefits required in a voucher system gets tossed out the window and even in the exchange plans will likely be able to alter their benefits to risk select. The sad facts of the matter are – speaking as a lefty who supports the concept of managed competition a la the Enthoven or Dutch model – that the 2009-10 debate shows that no holisitic system can emerge through our political process.

And worse, no cost containment device will be left alone by a future Congress, as this weeks extension of the now more than a decade old SGR cuts demonstrates.

So my non-cheery Christmas message is that the health care system will continue to promote over spending on the wrong types of people, and rational transformation of our 1950s designed insurance coverage and payment system will remain elusive for decades to come. What we get IF we keep the ACA will be the best we can hope for.

Meanwhile, back over at NY Times it’s great to see Uwe Reinhardt reacting to his commenters (even those not paying Princeton tuition fees!).  Kudos from a health care blogger who doesn’t engage with his commenters enough.

Matthew Holt is the Founder of The Health Care Blog and the Health 2.0 conferences.

It’s Time To Stop This [PSA] Screening Nonsense

Kenneth Lin

First published 6/21/11 on Common Sense MD

In an editorial in this month’s issue of the Journal of Family Practice, Northeast Ohio Medical University dean and family physician Jeff Susman, MD joins the rising chorus of voices urging clinicians to stop offering the PSA test to screen for prostate cancer. Dr. Susman writes:

I am going to go out on a limb here and suggest that, until we have fundamentally changed strategies for targeted case finding or early intervention (think genomic and proteomic markers), it is time to stop this screening nonsense. The facts speak for themselves: A trial of 182,000 patients finds in a post hoc analysis of a very narrow population that death can be averted in one of 723 individuals who are screened. What about the complications associated with diagnosis, work-up, and treatment? It is time for urologists and primary care physicians to tell patients that PSA screening is unlikely to benefit them. Some of you will suggest that we counsel patients about PSA testing to facilitate informed decision-making. But do we advise patients to play the lottery or try futile therapies? 

Continue reading “It’s Time To Stop This [PSA] Screening Nonsense”

Can Health Plans Explain Why They Aren’t Re-Empowering Primary Care?

Brian Klepper and David C. Kibbe

First published 10/30/2008 on The Health Care Blog

Brian’s Note: Recently I received a note from a New Jersey primary care physician who argued that, even more than Medicare, the health plans are killing primary care through extraordinarily low reimbursements. He wrote:

Through state legislation and regulatory changes over the past 10 years commercial carriers are now routinely and consistently paying less than Medicare in New Jersey.  Last year Aetna dropped to less than 65% of the local Medicare rate for a complex office visit.  This year, in my county, CIGNA dropped to 51.5% for the same office visit, and that’s when the RUC, as flawed as it is, declared that 53.5% of the full Medicare rate was what the practice overhead should be.  So now CIGNA is officially paying less than what the undervalued RBRVS system states is the cost of care.

To my mind, this type of reimbursement cannot be interpreted as anything else than an intentional effort to stifle primary care and it’s moderating influence over specialty, outpatient and inpatient excesses. While a robust literature – first by Barbara Starfield and more recently in Health Affairs – has nailed down that more primary care reduces risk and cost while improving quality, America’s health plans continue to pay primary care through volume-based reimbursement that functionally shortens office visits, increases specialty visits and diminishes our supply of primary care doctors.

David Kibbe and I asked about this problem this two and a half years ago. See below.

Sometimes a whisper is more powerful than a shout. Below is a cartoon from Modern Medicine that shows a Medical Home counseling session between a primary care physician (PCP), a specialist and the health plan. The PCP looks forlorn, while the specialist and the insurer have their backs turned, fuming. It is perfectly true.

Along with changing the way we pay for all health care and creating far greater pricing and performance transparency, we need to turn around the primary care crisis if we hope to substantively improve quality and cost.

Continue reading “Can Health Plans Explain Why They Aren’t Re-Empowering Primary Care?”

Point-Counterpoint: A Hospitalist and An Internist Argue Relative Value

Brian’s Note: Readers may know that, on this site and on Replace The RUC, I re-published the article below by the Happy Hospitalist, a physician intimate with coding and its craziness. His explanations of the system’s inconsistencies are lucid and compelling, as are his descriptions of how adhering to this system is overwhelmingly burdensome. Those of you who have read it before may want to scroll down to the content that follows and responds to it.

Then, last week, I received a long complaint from an orthopedic surgeon who appeared knowledgeable about coding, and who defended the RUC’s approach. He claimed that, properly understood, specialists make approximately the same as primary care physicians on an hourly basis. I am by no means a coding expert, but I responded that, while his argument may have some merit, the facts remain that specialists have made increasingly more over time than generalists who see many more patients. I thought there was a logical flaw in his approach.

Continue reading “Point-Counterpoint: A Hospitalist and An Internist Argue Relative Value”

In the Eyes of Medicare, You’re a 99223


First published 11/26/07 on The Happy Hospitalist.

Want to know how doctors get paid?  What is a 99223?  What does that mean? Well. It means everything. And it means nothing. It is the vast land of numbered codes, the mystery of  CPT medical coding that every physician must grasp, or at least their office staff, in order to get payed for services provided. It is how doctors get paid to remain a viable business of providing health care.  It is called coding.  I’ll repeat simply:  It is how physicians get paid.

As much as I love coding (because I’m good at it, really good at it), it is a ridiculously difficult and arbitrary. So difficult and vague that often times audits by Medicare often result in multiple different opinions by Medicare themselves, by their auditors.

Continue reading “In the Eyes of Medicare, You’re a 99223”

Really Managing Care and Costs


Originally published 3/30/2010 on The Health Care Blog.

Brian’s Note: Much of my career has been focused on medical management approaches that measurably improve health care quality and safety while driving down cost. This piece, written early last year, describes the efforts of my friend Barbara Barrett, at Langdale Industries in Valdosta, GA. I was keen to write about her accomplishments because very smart people working in small firms are seldom acknowledged by others, particularly when they live in places like Southern Georgia. This is a true success story. Enjoy!

One of my favorite health care stories is about Jerry Reeves MD, who in 2004 took the helm of a 300,000 life health plan in Las Vegas, including about 110,000 union members, and drove so much waste out of that system – without reducing benefits and while improving quality – that the union gave its members a 60 cent/hour raise. There was no magic here. It was a straightforward and rigorously managed combination of proven approaches.

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Clinical Groupware: Platforms, Not Software


Originally published 4/24/2010 on The Health Care Blog


Clinical Groupware is rapidly gaining acceptance as a term describing a new class of affordable, ergonomic, and Web-based care management tools. Since David first articulated Clinical Groupware’s conceptual framework on this blog early last year — see here and here — we’ve been discussing Clinical Groupware with a growing number of people and organizations who want to know what it is, where it’s going, and what problems it may solve, particularly for small and medium size medical practices, their patients and their institutional/corporate sponsors and networks.

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Bad Medicine: How The AMA Undermined Primary Care in America

Brian Klepper

Originally published 12/13/07 on The Health Care Blog

On Tuesday’s Wall Street Journal website, Dr. Benjamin Brewer describes physicians’ reactions to the 10.1% cut in Medicare physician payments that will take effect January 1. He argues that the onus will fall, once again, disproportionately on primary care physicians, who are already losing the struggle to keep their heads above water.

Continue reading “Bad Medicine: How The AMA Undermined Primary Care in America”

The New Science of Vascular Disease

This article, published almost two years ago on C&C, we’ll refer to these as Recycled but Relevant – is a perfect opening to our Urgent Science section.

If you agree that this kind of review article can be useful to clinicians, let us know. If you would like to write one like this about another topic, or know someone who would, let us know that as well.


Originally Published on The Health Care Blog, 1/28/09

Vascular disease and the conditions that produce arterial problems consume roughly one- third to one-half of the $2 trillion annual spend in American health care. The science and systems exist today to dramatically improve the quality and cost related to cardio-metabolic conditions but almost nothing has been done to implement these new tools since the Institute of Medicine (IOM) published “Crossing the Quality Chasm” in 2001.

Continue reading “The New Science of Vascular Disease”