Avatars, Computers and Robots Are Coming To Primary Care

Kent Bottles

First posted 8/19/11 on Kent Bottles Private Views

Within in five years primary care providers will begin being replaced by sociable humanoid robots, avatars, and computer programs. Within ten years you will no longer hear any complaints about medical students choosing specialty residencies over family practice because the role of the physician will be completely redefined to complement a rules based approach to the diagnosis and treatment of many diseases. This transformation is inevitable because of demographics, economics, and progress in artificial intelligence, but the academic leaders of medical education and health policy are largely ignorant and unprepared for this massive disruption.

Continue reading “Avatars, Computers and Robots Are Coming To Primary Care”

Why Medical Specialists Should Want to End the Reign of the RUC

Paul M. Fischer, MD

The old doctors know.  The practice of medicine has changed in a very basic way over the last 20 years.  Physician relationships have lost their civility and have been replaced by a level of tension that takes the fun out of collegial interactions.  I remember my first year of family medicine as the only doctor in Weeping Water, Nebraska.  My personal medical community had gone from an entire medical school campus with limitless lectures and many physicians to share in “interesting cases” to an occasional phone call with a consultant in Omaha.  These contacts became my primary source for medical education and updates for Weeping Water’s health care.  The phone calls were collegial, respectful, and focused on what was best for my patients.

Continue reading “Why Medical Specialists Should Want to End the Reign of the RUC”

The 100 Year Shift? Introduction and Overview

Vince Kuraitis and Jaan Sidorov

First posted 7/5/11 on the eCareManagement Blog

Gazing at the horizon, we foresee the potential for a tectonic realignment among physicians, hospitals and payers. Here’s a quick visual representation:

Past100

Next100

This essay is the first of a seven part series. In this first post we will capsulize our vision of this potential 100 Year Shift, answer initial FAQs, and lay out the structure for the rest of the series.

Continue reading “The 100 Year Shift? Introduction and Overview”

The Ryan Plan

Richard Young

First published 5/22/11 on American Health Scare

It’s been interesting watching the political maneuvering since Newt Gingrich criticized the plan to reduce the federal budget deficit proposed by the House Budget Committee Chair Paul Ryan of Wisconsin. After receiving push back from fellow Republicans, Gingrich spent the week backpedaling from his earlier remarks.

Many pundits have recognized Ryan for his courage to present his ideas in the first place. I also applaud the fact that he was willing to put the issue of fiscal sanity on the radar screen in a concrete way few other politicians have been willing to. This comes against the backdrop of recent estimates that a 56-year old couple will pay $140,000 in Medicare taxes per person over their work lives, but will receive $430,000 of benefits. This is unsustainable welfare.

Continue reading “The Ryan Plan”

US Physicians are Becoming Health Economists

Jane Sarasohn-Kahn

First published 4/21/11 on Health Populi

Doctors practicing in the U.S. are becoming increasingly conscious of the increasing costs of health care. Most consider themselves cost-conscious, and are considering the impact of their practice patterns — in terms of prescribing medicines, tests, and procedures — on the nation’s health bill. In fact, most physicians feel they have a responsibility to bring down health costs.

This perspective on physicians comes from the survey report, The new cost-conscious doctor: Changing America’s healthcare landscape, from Bain & Company, published in March 2011. Bain spoke with over 300 U.S. physicians to assess their perspectives on managing costs, drug and device usage, and standardized care protocols.

Continue reading “US Physicians are Becoming Health Economists”

Who Needs Intensive Primary Care?

Kenneth Lin

First published 2/24/11 on Common Sense MD

In almost every large hospital in this country, there are at least two types of patient beds: regular and intensive care. Intensive care beds are designed for the sickest of the sick – patients who require continuous monitoring, specialized respiratory or cardiovascular support, the most knowledgeable consultants, the most powerful drugs. Intensive care units (ICUs) have long been accepted as a necessary innovation in inpatient care, leading to better outcomes for patients than would have otherwise occurred if they were treated with a hospital’s “ordinary” resources.

Continue reading “Who Needs Intensive Primary Care?”

Smartphone Apps for ER Docs – Yeah!

PATRICIA SALBER

Originally published 2/7/11 on The Doctor Weighs In

Thanks to Sam Ko, MD and the California Chapter of the American College of Emergency Physicians (Cal/ACEP)  for this list of  iPhone Apps for Emergency Medicine.  The info in this post was first published  in Cal/ACEP January 2011 newsletter:  Lifeline.

I love it that ER docs are using their smart phones as reference books – it is so much better than when I was in the ER  – slinking off to the doctor’s room to look up stuff in the PDR or whatever new (or mostly old) Emergency Medicine text books happened to be on the ER book shelves.  Once I looked up stuff I couldn’t remember, I could go back to the patient and/or family and look and sound knowledgeable about the topic at hand.

Continue reading “Smartphone Apps for ER Docs – Yeah!”

Gregg Masters Interviews Brian on ACO Watch

http://www.blogtalkradio.com/BTRPlayer.swf

Gregg Masters is a long time health care manager and analyst who now, among many other things, hosts a health care talk show, ACO Watch, focused on Accountable Care Organizations and what they’ll mean in the health care marketplace, if indeed they do come to fruition in a way that can drive down cost and improve quality.

On January 19th, Greg and I spoke about ACOs, the incentives required to make them work, my skepticism that they can be effective and why, as well as the primary care medical homes that will be required at the front end of the health systems’ networks, acting as independent fiduciaries, for them to get meaningful traction in eliminating waste and promoting appropriate care.

This was done over a phone, so the quality is a little compromised. The show is right at 30 minutes, but the first few will give you a flavor.

Because Gregg is well connected and extremely knowledgeable in health care, he’s lined up a terrific list of health care experts who can speak effectively to different dimensions of ACOs. On the right sidebar, I’ve posted a button that will take you to the most recent edition of ACO Watch. I’ve been listening lately, and found the interviews short enough to be digestible and manageable, given my schedule, entertaining, and most important, useful.

Five Inevitable Trends That Will Change Physician Practices

BRIAN KLEPPER

Over at iPractice, a Sanofi-Aventis site aimed at helping physicians manage their practices, I detail several rapidly emerging trends – clinical/financial performance transparency, clinical decision support, a medical management revival, value-based benefit design and medical homes – as well as how physicians might respond.

The core thesis here is that these trends are inevitable, brought on by a system that lags far behind most industry sectors, with costs so wildly out of control that a large and rapidly growing percentage of individual and corporate purchasers have been priced out of the coverage market.

Head over and take a look. The goal is to help physicians face these trends head on so they can prepare to succeed as they take root and come to dominate the marketplace. Feel free to pose questions, and I’ll do my best to respond quickly.

Really Managing Care and Costs

BRIAN KLEPPER

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.

Continue reading “Really Managing Care and Costs”

Clinics As Health Care’s Transformational Engines

By way of full disclosure, I am Chief Development Officer of WeCare TLC, a rapidly growing onsite clinic firm, with clinics in 5 states, that produces dramatic, measurable improvements in quality and cost for its clients. I have been writing about this model – which effectively incorporates the best health care lessons from the past 25 years and places them at the front end of the care delivery system, where they can get the most traction – for several years, and have become convinced that it is both the basis of a fully-realized medical home and will drive a great deal of positive change in the system.

BRIAN KLEPPER

Originally Published in the December Issue of Medical Home News.

The recent explosion of interest in onsite clinics – not just by employers, but by health plans, hospital systems, public health programs, and others – is anything but just another health care fad. At once, clinics’ growing popularity signals purchasers’ weariness with an intransigent, self-interested health system, as well as their guarded optimism about a better way.

Today’s best clinics are single-mindedly focused on what works best for the patient and purchaser within a competitive health care marketplace. They are a return to the hard-learned care management lessons of the last several decades. They look like what experienced health care professionals would develop if they could start fresh, without the perverse incentives that drive so much of health care today. But by leveraging new tools, programs and incentives, they also create a uniquely powerful, contemporary design for managing care and cost.

Continue reading “Clinics As Health Care’s Transformational Engines”

Value Trumps Price in Onsite Clinics

by BRIAN KLEPPER

Onsite health clinics are new territory for most employers. It can be difficult to sort through the different approaches used by different vendors. Worse, in difficult economic times it’s tempting to “get in” as cheaply as possible.

But like many purchases, you may get what you pay for with clinics, especially if you scrimp. Here are three reasons to favor value over price when considering an onsite clinic vendor:

 

  • An investment. Most employers believe their health plan expenditures are high enough already. For them, a clinic represents an additional expense, and only makes sense if it can provide a return on investment that lowers overall group health and occupational health costs. Ask vendors for data and testimonials that their clinics save money and improve the quality of care.
  • Many impacts. Properly configured, clinics do far more than reduce costs for office visits, drugs and lab tests. They can positively impact the chronic diseases that consume two-thirds of a health plan’s costs. They can influence specialty and inpatient care, which the Dartmouth Atlas shows have the highest concentrations of waste. And they can affect the five major areas of occupational health — workers’ compensation primary care, disability management, human resources testing (pre-employment screens, drug screens, Department of Transportation exams), retention/recruitment and lost work time — that, together, cost two to three times as much as a group health premium.
  • Total effectiveness results from a clinic’s component medical management mechanisms. Optimizing quality and cost within the complexity of health care requires assembling an array of tools and programs, each targeted to a specific health care problem. Each approach has dedicated costs, but most also produce savings that outweigh their expenses.

For example, incentives such as free office visits, laboratory tests and free standard drugs, mostly low-cost generics, induce employees to use the clinic and help the primary care staff gain more control over the care process. Physicians cost more than nurse practitioners, but are more likely to create a fully realized medical home and have a better chance of influencing downstream care.

Clinical analysis and decision support tools help identify patients with health risks or gaps in care that deserve attention. Onsite, face-to-face disease management programs have a far better chance of influencing chronic disease costs than call center programs.

Modern clinics are a powerful innovation in an employer’s benefits arsenal. But they must be robust to be effective, integrating a variety of proven mechanisms. With those properly in place, the results can be quantifiable improvements in health care quality, cost and employee morale.

In other words, a clinic’s cost may be important. But the value — the benefit you receive for the cost — should be the reason you implement a clinic. It will certainly be how you’ll judge your investment.

 

Really Managing Care and Cost

by BRIAN KLEPPER

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 members a 60 cent/hour raise. There was no magic here. It was a straightforward and rigorously managed combination of proven approaches.

Dr. Reeves’ work betrayed the lie that tremendous health care costs are inevitable. To a large degree, the nation’s major health plans abetted this perception when they effectively stopped doing medical management in 1999. (Most have recently begun managing again in earnest.) The result was an explosion in cost – 4 times general inflation and 3.5 times workers earnings between 1999 and 2009 – that has priced a growing percentage of individual and corporate purchasers out of the health coverage market, dangerously destabilizing the health care marketplace and the larger US economy. In 2008, PriceWaterhouse Coopers published a scathing analysis suggesting that $1.2 trillion (55%) of the $2.2 trillion health care spend at that time was waste.

As the chief sponsors for most Americans’ health coverage, businesses have struggled to cope with health care cost while identifying value. Large American businesses, with tens or hundreds of thousands of employees, have recruited high profile benefits professionals – think of Jill Berger at Marriott, Ned Holland at Embarq, Peter Hayes at Hannaford Brothers or (the recently retired) Cecily Hall at Microsoft, each with terrific reputations – who, with their staffs, orchestrate sophisticated campaigns focused on the health of their employees and their families, and on the cost-effectiveness of their programming. Even so, few large firms provide comprehensive, quality benefits at a cost that remains consistently below national averages, and for years now America’s CEOs have routinely reported that their top business concern, health care, is their most unpredictable, large cost.

For mid-sized business, though, – here I’m referring to firms with 200-5,000 employees – the task is significantly more difficult. Health benefits managers in these companies have far fewer resources, typically work alone without the benefit of staff, and are often overwhelmed by the complexity of their tasks. Held accountable for their organizations’ health costs, they often default to whatever the brokers and health plans suggest.

But a few excel. For them, managing the many different issues – e.g., chronic disease, patient engagement, physician self-referrals, specialist and inpatient over-utilization, pharmacy management – is a discipline. A couple years ago, I was introduced to someone like this.

Barbara Barrett was trained as a paralegal. She is now General Manager of TLC Benefit Solutions, Inc., the benefits management arm of Valdosta, GA-based Langdale Industries, Inc., a small conglomerate of 24 firms with 1,000 employees, engaged primarily in wood products for the building construction industry, but also in car dealerships, energy and other concerns.

Valdosta is rural, which puts health benefits programs at a disadvantage. Often there is only one hospital nearby and so little cost competition. Rural Georgians also may have lifestyles that make them prone to chronic diseases, which are expensive. And so on. You get the idea.

Here’s the interesting part. Since 2000, when Barbara assumed responsibility for the management of Langdale’s employee health benefits, per employee costs have risen from $5,400/year per employee to $6,072/year per employee in 2009. That’s an average health plan cost growth of 1.31 percent per year.

I compared Langdale’s health plan cost growth to the average commercial coverage inflation rate for an employer with 200+ employees provided in the Kaiser Family Foundation/Health Research and Educational Trust (KFF/HRET) 2009 Employer Health Benefit Survey. The calculation showed that, in that nine years, Barbara’s management allowed Langdale to provide its 1,000 employees and their families with comprehensive medical, dental and drug benefits for $29 million less than the average of other firms that size. That’s a nine year savings of $29,000 per employee, or an average of $3,200 per employee per year lower than the national average. All without reducing benefits or transferring the cost burden to employees, and while quantitatively improving quality.

So how did Barbara approach the problem? Here are a few of her steps:

  • Under her leadership, Langdale set up TLC Benefit Solutions, a HIPAA-compliant firm that administers and processes Langdale’s medical, dental and drug claims. This allowed Barbara to more directly track, manage and control claim overpayments, waste and abuse.
  • The claims also gave her immediate access to quality and cost data on doctors, hospitals and other vendors. She supplements these data with external information, like Medicare cost reports for hospitals in the region. This allows her to identify physicians and hospital services that provide low or high value. She then created incentives that steer patients to high value physicians and services and away from low value ones. When complex services necessary to treat certain conditions are not available or of inadequate quality or value locally, she shops the larger region, often sending patients as far away as Atlanta, three and a half hours away.
  • She analyzes the claims data to identify which patients have chronic disease and which patients are likely to have a major acute event over the next year. Chronic patients are directed into the company’s opt-out disease management/wellness/prevention program. Acute patients are connected with a physician for immediate intervention.
  • She provides Langdale’s employees and families with confidential health advocate services that explain and encourage use of the company’s wellness, prevention and disease management programs. And she uses incentive programs to reward patients who enter these programs and meet targets.

Barbara has mounted many more initiatives in group health, but her responsibilities also extend to life, flex plan, supplemental benefits, retirement plan, workers’ compensation, liability and risk insurance. The results for Langdale in these areas include lower than average absenteeism, disability costs and turnover costs.

The point is that Ms. Barrett and Langdale have been pro-active, endlessly innovative, and aggressive about managing the process. That attitude and rigor has paid off through tremendous savings, yes, but it has also produced a desirable corporate environment that demonstrates that Langdale values its employees and the community. The employees and their families are healthier as a result, and are more productive at work. This has borne unexpected fruit. The industries Langdale is in have been hit particularly hard by the recession, and the benefits savings Barbara’s efforts generate have helped save jobs.

Barbara Barrett and many others like her on the front line are virtually unknown in health care. Most often, their achievements go unnoticed beyond the executive offices.

But they manage the health and costs of populations in a way that all groups should and could be managed.

Brian Klepper is a health care analyst.