Anders Gilberg, a senior VP at the Medical Group Management Association, heard National Public Radio commentators discussing the "doc fix" on his commute to Washington, D.C., the other day.
Gilberg felt good that panelists and politicians were even talking about the issue. That's because in the nation's capital, if it's being discussed, there's a possibility that something may actually happen on Capitol Hill, he says.
Gilberg and other observers believe there is a good chance that Congress will take up the doc fix before the January 1 deadline. If the House and Senate don't act by then, it means a 27.4% cut to Medicare providers on the first day of 2012. The pain would be palpable.
Holiday adjournments may get in the way, although Democratic leaders in the U.S. House of Representatives have called on their Republican counterparts to act before December 16.
Despite politicians' talk about a doc fix, though, the problem never really gets fixed—just put off for another time.
Last year, the doc fix was continually on the ledge. Congress stalled six times and imposed "patches" on the Medicare Sustainable Growth Rate payment formula to stave off cuts that would have amounted to 20%. Since 2003, Congress has taken steps each year to override the cuts required by the formula.
"The scheduled cuts have increased from 5% in 2002 to the current level of 27%," Peter W. Carmel, MD, president of the AMA, writes in a recent blog.
"The number of older Americans whose access to care is threatened by these cuts continues to rapidly multiply as 79 million baby boomers have begun joining the ranks of Medicare patients. The cost to repeal the SGR has risen from $48 billion in 2005 to $300 billion today. And that figure keeps growing," Carmel writes.
While the physician organizations have been beating the drum for political action, Lucien W. Roberts III, MHA, FAMPE, a former medical practice administrator and vice president of a firm that consults with physicians, detects a deafening silence among rank-and-file physicians over the doc fix. Physicians "are distracted" by so many other complicated and pressing issues, such as ICD-10, he tells HealthLeaders Media.
Roberts counsels physicians to get politically active. Fiscal problems for docs are only going to get worse until the SGR is repealed, he says.
For many Americans struggling in a down economy, it's tough to sympathize with physicians simply because of their earning power. The median annual salaries for physicians range from $174,000 for family practitioners to $225,000 for surgeons, according to the Bureau of Labor Statistics. For many physicians, however, the continual hassle over the doc fix is wearying.
A baby-boomer physician, who holds a medical directorship at a healthcare facility, told me of his disgust with the health system, what he sees as misleading cuts, and the floundering of the American Medical Association in lobbying. He didn't want to be identified so he could speak freely.
"I think it was about '87 when Medicare started cutting us or certainly not giving but a token increase," he says. "That was the year I made the most and it has been downhill since. You cannot make a living seeing patients. We are regulated and cannot raise any prices."
"How can you make it when you cannot charge more but our costs go up every year?" he adds. "Remember, we are a small business, but we are totally at the whim of the government. The government jerks you around every few months and I mean every few months. They always talk big cuts so when they do smaller ones, it looks like we got a great deal."
Interestingly, there are 20 physician members of the 112th Congress, including three senators, 16 representatives, and a delegate. None of them are considered leaders of the doc fix debate, and their presence seems to have no impact on this physician issue—or others.
The AMA itself has spent much of the past two years lobbying to abolish the SGR, with so far little to show for it. Gilberg points to two House members, Rep. Allyson Schwartz, D-PA, and Rep. Phil Roe, R-TN, who are working for change. Schwartz and Roe issued a statement saying they continue to garner bipartisan support to repeal the SGR.
Generally, physician lobbying groups have failed to make true inroads to get doctors' voices heard in Washington D.C.
At best, the politicians talk about fixing the SGR but don't do anything except apply an annual band-aid. And the clock to 2012 is ticking.
Physicians are opening medicine cabinets, only to find certain drugs missing.
Increase in demand. Manufacturer shortages. Market withdrawal. Inadequate products. Unavailable raw material.
The Food and Drug Administration cites these reasons for some of the worst shortages in memory of pharmaceutical companies' ability to bring to market prescription drugs that treat life-threatening ailments ranging from cancer to serious blood disorders. As 2012 approaches, it appears the situation will get worse, despite efforts to boost supplies.
According to the White House, while a small number of drugs experience a shortage in any given year, the number of prescription drug shortages in the U.S. has nearly tripled between 2005 and 2010, with the shortages becoming more severe and frequent.
Lawrence A. Solberg Jr., MD, PhD, professor of medicine in the Department of Hematology/Oncology at the Mayo Clinic in Jacksonville, FL, says the drug shortages have been life-threatening to patients with blood-related diseases, particularly those with cancers such as leukemia, lymphoma, and myeloma.
As a result, physicians have had to choose alternative, less effective, and sometimes more toxic therapies for patients when first-line treatments were not available, says Solberg, who is chairman of the American Society of Hematology Committee on Practice. The society represents 16,000 clinicians, practitioners, and scientists who evaluate blood and blood related diseases.
"Imagine sitting there, as a patient with cancer, and your physician says, 'Sorry, We just don't have the drug right now to start your treatment.' It's a huge shock, a horrible anxiety," Solberg told HealthLeadersMedia. "And from a physician's point of view, say you are planning a treatment and have six cycles and go over six months. You may have one of the drugs right now, but how do we know three months down the road if there might be a shortage? You are partway down the treatment course and it affects that treatment course. You may be forced to use a different regimen, and perhaps the outcome in terms of cure is the same, but the toxicity profile differs."
As of August 31, 2011, there were 200 national drug shortages reported, compared to the overall total of 211 in all of 2010, according to Solberg. Some of the drug shortages have lasted for months. He says a six-month shortage of cytarabine, part of a standard therapy for certain leukemias and lymphoma, has been particularly detrimental.
He told the FDA about the case of a 50-year-old man with primary refractory diffuse large B-cell lymphoma who was receiving chemotherapy to prepare him for a bone marrow transplant. The patient received the first part of the chemotherapy and was responding well, Solberg says.
The treatment schedule called for cytarabine to be included in the second dose of chemotherapy, but because it was not available, the "physician was forced to choose an alternative therapy that was more toxic," Solberg said. "The patient was not able to receive the transplant and died from complications."
"This story is one example of several cases that have recently been described to ASH about physicians having to give patients less effective or more toxic alternatives," he told the FDA. "The increasing number of drug shortages has significantly affected the practice of hematology because the standard therapies frequently used include older, sterile injectable products that are particularly vulnerable to production, marketing, and business factors."
Another impact has been on as many as 200 clinical trials that have been interrupted by the shortages, Solberg says.
The drug shortage has become such a hot-button issue that President Barack Obama issued an executive order last month requiring the FDA to take action.
The shortages are primarily limited to generic injectables and a few key disease areas, but troublesome nevertheless, according to Murray Aitken, the institute's executive director.
In a webinar, Aitken noted that 16% of the products in short supply are oncology drugs, which may affect as many as 550,000 patients. Other affected disease areas include infections, cardiovascular disease, central nervous system, and pain. More than 80% of the products are generic and more than 80% are injectables, according to the report.
Over the last five years, White House data indicates that the demand for sterile injectable cancer treatments has increased by about 20%, without a corresponding increase in capacity. The FDA has developed a page on its website giving an overview of current drug shortages. (Healthcare professionals and patients are encouraged to notify the FDA about shortages at drugshortages@fda.hhs.gov.)
According to FDA estimates, about 42% of the 2010 drug shortages were caused by product quality issues. While ensuring safety standards is paramount, the FDA also needs to determine whether its evaluation of product quality is accurate, Solberg says.
The IMS Institute and other healthcare groups, such as the American Society of Hematology, have recommended that the FDA establish an early warning system to improve drug supply monitoring, which is being considered in legislation introduced in Congress. Lawmakers are also considering other plans, such as establishing economic incentives to produce medically necessary drugs in shortage. Some Democratic Senators are calling for hearings on the drug shortages, as well as seeking a General Accountability Office probe.
In the meantime, drug manufacturers say they are working together to examine and adjust their manufacturing schedules for "life-saving" drugs that could be susceptible to shortages.
Still, physicians and patients must be vigilant about drug shortages. Only a few weeks after Solberg was relieved to learn that cytarabine had returned to the market, he received a letter on November 21 from Janssen Products, LP, about delays in the availability of its cancer-fighting drug DOXIL.
"This suspension of manufacturing will impact the production and release of DOXIL, which remains in short supply," the pharmaceutical company wrote. "We are not able to estimate timing when DOXIL may return to market."
Unfortunately, Solberg, says, physicians like him will probably receive more letters like that from other drug manufacturers in the months ahead.
When Secretary of Health and Human Services Kathleen Sebelius issued a strategic plan for her huge federal agency last year, she cited the need for "transparency," emphasizing that President Obama was committed to "creating an unprecedented level of openness."
Initially, she demonstrated that she meant business—at least outside the walls of HHS. In 2010, Sebelius chastised health insurance industry executives for "jaw-dropping" rate increases, urged them to be more "transparent" in seeking rate hikes and reminded them they had to tell the full story about their profit margins.
Tough talk indeed.
Too bad Sebelius's shop – HHS – hasn't been very transparent when it comes to public access to a database about problem physicians.
HHS turned its back on transparency when one of its agencies, the Health Resources and Services Administration, on Sept. 1 shut down a 25-year-old database containing names of physicians who have been charged by state medical boards for improper actions. The shutdown stems from one doctor's complaint after an unflattering newspaper story.
After a subsequent flurry of counter-complaints, the agency last week reversed itself, opening the database to the public, but with major changes. HRSA imposed so many restrictions on use of the database, that journalist and consumer groups, including those representing patients, say it's virtually useless as a tool to identify bad docs.
"What they did was ill-advised, unenforceable, and probably unconstitutional," Charles Ornstein, president of the Association of Health Care Journalists, tells HealthLeaders Media, echoing a letter AHCA wrote to Sebelius protesting the action.
Physicians' groups themselves have mixed feelings about whether there should be access. While the American Medical Association states it has "long opposed" access to the database, the American Academy of Family Physicians describes itself as ambivalent about it.
Ornstein made clear that it's not only journalists who rely on the database. The information is important for healthcare systems, too, he says.
The program has been important for hospitals seeking information on doctors, especially in states where there has been inadequate public access to medical disciplinary actions, says Ornstein. "It is extremely helpful to hospitals checking out physicians and those who may be moving from one state to another," he adds.
Specifically, the issue hinges on the public use file from the National Practitioner Data Bank website, which has been consistently referred to by researchers and consumer groups to calculate trends in disciplinary actions by state medical boards. Beyond that, it has generated some provocative stories in the press nationwide about wrongdoing among doctors across the country.
The database doesn't identify doctors by name, but it gives insight into trends reflecting how state medical boards are disciplining doctors, as well as vital data about hospital sanctions and medical malpractice payouts.
The brouhaha began after a Kansas City Starreporter, culling the data bank and state court records, wrote a story about a local physician. The physician complained, and got quick action: HRSA promptly removed the public use file from its website on Sept. 1. Not only that, the agency wrote a letter warning the reporter he could be liable for $11,000 or more in civil fines for violating a confidentiality provision of the federal law.
The physician, Robert Tenny, had written six letters to HRSA before and after the Kansas City Star published the story that said he had been sued at least 16 times for malpractice and had paid out roughly $3.7 million since the early 1990s, according to the Association of Health Care Journalists.
After editorials were written objecting to the HHS database shutdown, Sen. Charles E. Grassley, (R-IA), ranking member of the Senate Judiciary Committee, criticized HRSA for "disturbing and bizarre" actions, saying the public use file had been important to weed out "bad acting healthcare practioners."
Last week, HRSA relented somewhat, reopening a public portion of the database, but imposed other restrictions. These changes make it onerous to use, says Erika Smith, chief investigator for the Senate Judiciary Committee.
Among the restrictions is a provision that bars users from matching data in the public use file with other data sources to identify physicians. If journalists and others are found to have violated the provision, they could be required to return the data and be barred from receiving it in the future.
"(HRSA) restored the website, and there is access to the database, but it is not useful in the broad sense of the law," Smith tells HealthLeaders Media. "We're displeased and the consumer groups are as displeased as we are. The database does nothing to help rein in physicians who are bad actors."
Essentially, the restrictions make the public use file unworkable, Ornstein says.
"We are particularly concerned (with) the prohibition of using the file in conjunction with other data that identifies an individual or facility. "If reporters identify doctors in their stories and also have had access to the file, would HRSA ask to see their notes, talk to their sources, confirm their facts came from other records and not the data bank?" Ornstein asked in a letter to HHS.
Those who "do not comply with the new restrictions can be asked to return the data and be barred from future access to the public use file," Ornstein says. Requiring that users return the data "is like trying to unspill milk."
One of the big mysteries in all this is how a lone Kansas City physician managed to convince someone within HHS to shut down the entire database, according to Sen. Grassley's chief investigator.
Grassley told HHS he wants a briefing on the matter, including participation "from the person who pulled the public data file after that one single physician complained. Grassley points out that the reporter identified this physician "through shoe leather reporting, not the public data file."
"One complaint shouldn't dictate public access to federal collected data for 300 million people," Grassley wrote.
After all, isn't that what "transparency" is all about?
Talk to enough physicians and hospital execs, and you will hear a term they use to refer to colleagues deviating from their peers, whether they aren't doing enough to improve patient care, are falling behind in their work, or are spending too much: outliers.
"No one wants to be an outlier," Kevin McGuire, MD, MS, chief of the orthopedic spine service at Beth Israel Deaconess Medical Center in Boston and assistant professor of orthopedic surgery at Harvard Medical School, told HealthLeaders Media.
In spine care, McGuire found a lot of outliers, surgeons wasting money by wasting medical implant devices. McGuire admits he was once an outlier too.
Here's how they got rid of the waste. Several years ago, McGuire and other physicians at Beth Israel Deaconess examined how much they used and spent, questioning why anything was discarded improperly, down to the smallest screw. They also analyzed steps that could be taken to improve implant surgeries. The hospital initiated a Lean system to improve value, reflective of the Toyota Production System management process. The medical professionals carried the process one step farther, cataloging as much as they could and precisely reviewing use of implant materials through peer-to-peer evaluations, McGuire says.
By implementing a few process changes, the spine surgeons at Beth Israel Deaconess cut in half the number of procedures that produced waste, dramatically lowering costs. Before launching a simple awareness program about this issue, the monthly cost linked to the surgical waste was about $17,680. Afterward, it dropped to $5,876.
Extrapolating from the amount of waste these physicians uncovered at their hospital, they believe that spine surgeons across the country could save more than $126 million in surgery costs for implants each year by conducting an awareness program. They presented their study to the 26th annual meeting of the North American Spine Society in Chicago last week.
"We were initially surprised at the size of the problem," says McGuire. "Most of the driver of that was implant waste. That's what drove the project forward, identification that there was a problem."
"We are the drivers of the cost; we need to be part of the solution," McGuire opines. "Physicians are responsible for ordering a significant amount of material."
Each year, more than 600,000 spinal surgeries are performed in the U.S. Medical implants require an abundance of costly equipment such as medical screws, rods, cross links, and interbody cages.
Too often, McGuire says, there is "intra-operative waste," which he and his colleagues describe as any item "wasted when it was prepared or opened during a case, but was ultimately not used or implanted and could not be subsequently used or implanted in a different patient."
What's the main driver of the cost burden? In the parlance of McGuire's study, it is simply stated as "surgeon changed mind."
In the Beth Israel Deaconess study, items improperly wasted included surgical implant devices, bone graft devices, and miscellaneous other material such as drapes, gowns, globes, sponges, sutures, and drains. A surgeon's change of mind accounted for 44% of the wasted items, and "contamination" for 27% of disposals. Other reasons for waste were "equipment failure/technical difficulties," items "opened by mistake," and "case cancellation."
"When we say 'waste,' it was something paid for, charged to the hospital, and it wasn't utilized in another patient. It was basically removed or thrown into the trash. That's waste," McGuire says. "In our environment, any of that wasted instrument is paid for by the hospital but not charged to the insurance company because it's all under the DRG [diagnosis-related group] payment system. That's why the word 'waste' is utilized."
Some level of waste is normal, "especially at level-one academic centers, since you are doing multilevel complex cases," McGuire says. "There is a significant number of older patients who have osteoporosis; you put a screw in and you engage it and tighten it down, it doesn't fit, wrong size, and so there will be an incidence of waste."
Because there are so many variations of waste, physicians weren't exactly sure how to define it properly when they began their study, McGuire says. "We realized that there was no clear definition of what constituted a wasted implant," he wrote in a blog. To get to the root of the problem, they asked surgeons, operating room personnel, industry representatives, and nurses to help them pinpoint areas of waste that should be eliminated from operating rooms.
"If a screw was placed in a patient, and removed, as long as it wasn't destroyed or significantly compromised, it can go back in the bin (and be reused). If not, I think that's a significant definition of waste," he says. "Our consensus of waste was reached by asking the people who did the work: the nurses and surgeons and clinical advisors."
In their study, researchers recorded spine procedures and incidents of intra-operative waste over a 25-month period, from October 2007 to November 2009. Although it may be hard to believe, researchers say their study represented the first extensive review of waste-related spending in spine surgery.
After reviewing wasteful actions of surgeons, Beth Israel Deaconess staff decided to make changes to improve their use of implant materials. Those steps led to significant reductions of waste, says McGuire.
Besides initiating the Lean system, and cataloging their use of implant materials, they also challenged each other, saying, "This is your waste. This is your partner's waste."
They compiled lists of who had been wasting more instruments than others, and shared that information with one another.
"I led the list for awhile and it was shocking to me," McGuire says. "We are all competitive. No one wants to be an outlier. When it was reviewed that way, it made the problem ugly, and visual."
In particular, the internal review examined the process of "surgeon changed mind," evaluating the reasons behind surgeons' choices, what was accomplished, and the impact on waste flow.
"We are the drivers of the cost, we need to be part of the solution," McGuire says. "Physicians are responsible for ordering a significant amount of material."
A few simple changes amounted to a big impact. Intra-operative waste, which had occurred in 20.2% of procedures prior to the education program, decreased to 10.3% of procedures. Before the awareness program, surgical waste represented 4.2% of the total operative spine budget. Afterward, that percentage decreased to 1.2%.
Overall, the "awareness program was successful in decreasing the cost burden associated with intra-operative waste by 66%," the report states. That was achieved by decreasing the number of implants wasted from 44% to 24% and decreasing the "surgeon changed mind" waste from 42% to 24%. The changes "proved to be and continues to be effective in making surgeons aware of the import of their choices and the costs related to surgical waste," McGuire and his colleagues wrote.
Christopher Kauffman, MD, program co-chair of the NASS annual meeting and orthopedic surgeon at the University Medical Center in Tennessee, said in a statement that the McGuire report should be a "wake-up call" for physicians, particularly spine surgeons.
Looking back, McGuire says it's important that physician leadership, in particular, prompt change. "There has to be an internal champion for medical equipment conservation." he says. "One of the physicians [must] believe that this is the right thing to do."
For two decades, Michael Barry, MD, has struggled with the question of whether men should be screened for prostate cancer. Barry hoped the U.S. Preventive Services Task Force (USPSTF) would settle the long-running debate. But when the task force issued a draft recommendation last month against screening, Barry abandoned his hope for a definitive answer—primarily based on the use of one qualifying word: "small."
Barry, president of the Foundation for Informed Medical Decision Making calls the controversy over prostate-specific antigen (PSA)–based screening and treatment of screening-detected prostate cancer an argument that "refuses to die."
Although 20 million men undergo the screening each year, the task force insists that it isn't generally necessary. In October, the USPSTF set off the latest round of debate with this conclusion from its draft report: "Prostate-specific antigen–based screening results in small or no reduction in prostate cancer–specific mortality and is associated with harms related to subsequent evaluation and treatments, some of which may be unnecessary."
For men aged 50 to 69, "the evidence is convincing that the reduction of prostate cancer mortality 10 years after screening is small to none," according to the task force. "The evidence is convincing that for men aged 70 years and older, screening has no mortality benefit."
In making its findings, the task force last month referred to two several clinical trials, and noting that neither trial some showed no decrease in overall mortality with the use of PSA-based screening through 11 years of follow-up, and that all trials showed either a "small or no benefit" in prostate cancer–specific mortality, Barry wrote last month in the New England Journal of Medicine.
It's the word "small" that gets him, Barry says.
"Who is to decide what constitutes a 'small' benefit and whether it outweighs the potential harms?" Barry he asks.
"Weighing the pros and cons to make a decision about PSA screening is an individual process, and different well-informed men will make different decisions," Barry told HealthLeaders Media. Yet the task force's recommendation "removes the patient from the equation and puts the physician in the central position of discouraging use of the test."
"Uncertainty in medicine is more common than we usually let on, and the way to address uncertainty is to allow patients the central position in decision-making," Barry says.
The public has until November 8 to comment on the proposals. The USPSTF, an independent panel composed of primary care providers, conducts scientific evidence reviews of a broad range of clinical preventive healthcare services and develops recommendations for primary care clinicians and health systems.
Indeed, prostate cancer is a significant killer of men, and the issues surrounding the screening, which is designed to catch the cancer early, pose a dilemma for physicians and patients.
Prostate cancer is the most commonly diagnosed nonskin cancer in men in the U.S. In 2010, an estimated 217,730 American men received a prostate cancer diagnosis, and an estimated 32,050 men died from the disease. The majority of deaths due to prostate cancer occur after age 75.
One of the problems with the PSA test is that it often produces false-positive results that are associated with negative psychological impacts, including a patient's persistent worry about prostate cancer, according to the task force. Men who have false-positive tests are more likely to seek or have additional tests, such as biopsies, that also trigger a host of other ailments, the task force states. "The evidence is also convincing that PSA-based screening leads to substantial overdiagnosis of prostate tumors," the report adds.
The task force's latest findings will replace a 2008 report that showed insufficient evidence to make a recommendation about PSA-based screening for men under 75. At that time, the task force recommended against screening for men 75 and older.
But Barry believes the USPSTF recommendation is too black-and-white. "What I'm espousing is the middle of the road," Barry says. "I absolutely agree that many men look at that [the report] and say that's a really small benefit for the harm of potentially doubling my risk of getting prostate cancer and all the side effects of treatment that may come with it, but I think other men would look at the same data and say, 'For me, it's worth it.' So rather than solving it with a one-size-fits-all recommendation for everyone, I like doing it on the individual level."
Many other physicians have mixed reactions to the recommendations. In a survey of "Top Doctors" conducted by U.S. News and World Report, more than 60% of internal medicine specialists said they would continue testing despite the task force recommendation.
Barry acknowledges that many physicians have a "dubious" record of decision-making for PSA testing. "We have been ordering PSA tests without discussion. We have been ordering them in very old men without anything to gain," he says.
For primary care physicians, however, serious conversations about the issue have been compromised during regular office visits, wrote Allan S. Brett, MD, and Richard J. Ablin, PhD, also in last month's New England Journal of Medicine.
"The idea that physicians could initiate truly informed discussion was wishful thinking," Brett and Ablin write, "because clinicians and patients had to consider an enormous list of probability estimates and uncertainties."
"Patients were not really making informed decisions and office-based discussion of the pros and cons of PSA testing was essentially a charade," they add.
While the controversy continues over PSA testing, that charade must cease, as Barry sees it. Physicians must take the time—or at least provide patients the proper educational tools—to help men make an informed choice about PSA screening.
Patient after patient asks for relief for sinusitis. Doctor after doctor gives them a prescription for medication—even though most infections are viral, not bacterial, needing no drugs to treat.
When prescribing statins for heart ailments or high cholesterol conditions, doctors sidestep less-expensive generic brands.
These and other wasted costs amount to nearly $6 billion, according to the National Physicians Alliance (NPA), a Washington, D.C.–based physician research group.
As the nation’s healthcare system moves toward value-based care, physicians have to step up efforts to reduce wasteful spending, which is often linked to improper patient care.
“It’s a responsibility of the professional to be decreasing costs, decreasing the amount of unnecessary care, wasted care, care that is not beneficial to patients, but adds to costs,” says Steven E. Weinberger, MD, executive vice president and CEO of the American College of Physicians.
Over the last few years, more physicians and hospitals have been adopting care checklists, not only to ensure proper procedures but also to reduce duplication of services and errors. A speaker at this week’s Medical Group Management Association in Las Vegas, for instance, urged physicians to adopt checklists to become more efficient. The Johns Hopkins Hospital in Baltimore has saved $2 million with a five-item checklist that reminds hospital personnel to first wash their hands. Weinberger says the ACP has initiated a “high-value, cost conscious care initiative” to identify areas of “overuse and misuse” to educate physicians, patients, and medical trainees. He also calls for a “national, multistakeholder initiative to reduce marginal and effective care.”
But some physician groups are taking the checklist premise one step further, focusing on procedures that should be minimized or eliminated altogether.
One of the key proponents of such lists of wasted practices is Howard Brody, MD, at the Institute for Medical Humanities at the University of Texas Medical Branch at Galveston. “The myth that physicians are innocent bystanders merely watching health care costs zoom out of control cannot be sustained,” Brody wrote last year in the New England Journal of Medicine.
Brody suggests that each specialty society appoint blue-ribbon panels to create “top five” lists of diagnostic tests or treatments that are among the most expensive and generally do not provide much benefit.
Nancy Morioka-Douglas, MD, MPH, a clinical professor of medicine/community and family medicine at the Stanford University Medical School, and a member of the NPA, agrees that doctors must take control of costs, especially needless procedures.
Referring to Brody’s plan, Morioka-Douglas seeks a “call to action” among each medical specialty to generate lists of at least the top five commonly ordered diagnostic tests or treatments that provide “care of low value to patients, specifically if it carries risk that outweighs benefits.”
The NPA convened a Good Stewardship Working Group to identify overused clinical activities across three primary care specialties, internal medicine, and family practice.
The working group homed in on seven areas of overuse, with specific cost savings in several cases:
1.Statins. Low-cost generic statins should be prescribed when initiating cholesterol-lowering treatment rather than high cost, brand-name drugs, saving $5.8 million annually.
2.Sinusitis. Antibiotics are prescribed in more than 80% of outpatient visits for acute sinusitis—accounting for 16 million physician office visits annually—but most cases are due to viral infection that will resolve on its own.
3.Imaging.Lumbar spine imaging for lower back pain before six weeks does not improve outcomes but increases costs. Back pain is the fifth most common reason for physician visits.
4. Electrocardiogram screening. Potential harms of annual ECG screening exceed potential benefits, Morioka-Douglas says. ECGs or other cardiac screening should not be performed annually for asymptomatic, low-risk patients.
5.Pap tests. They “don’t show much in women who’ve had a total hysterectomy for benign disease, and there is poor evidence for improved outcomes,” Morioka-Douglas says.
6.DEXA screening. Bone-density screening for osteoporosis is not cost-effective in younger, low-risk patients. Bone density testing in women under age 65 accounts for $527 million in annual costs.
7.Blood chemistry panels. It’s not necessary to order basic metabolic panels or urinalysis for screening in asymptomatic, healthy adults. When complete panels are performed on asymptomatic patients, only lipid screening yields significant numbers of positive results. Orders of complete blood counts for general medical examinations were associated with $40.8 million in costs.
This list is not comprehensive, Morioka-Douglas says. There could be many variations of lists, with other procedures added. “We challenge other physician groups to come up with a comparable list of goals,” she adds.
Weinberger, of the American College of Physicians, says his organization is also forming a checklist for publication soon. “We’re identifying areas of misuses and talking very much about what the National Physicians Alliance is doing,” he says.
But your organization doesn’t need to wait for a national program. Physicians can use the NPA checklist or adapt it to their own needs to ferret out waste.
As a hospital patient, I had an earache and trouble sleeping. "We'll get you some medication," the nurse said.
I looked at the capsules in my hand. Then a dose of reality hit me. I remembered I was allergic to that particular over-the-counter cold medicine. They knew that. Didn't they?
Patient-error, avoided, thanks to the patient: me.
At that moment, I was a responsible patient, an easy catch. But of course, that's not always the case, with me or any other patient. Now, healthcare leaders are trying to catch up with the idea that patients have a responsibility to take care of their own health, whether it's being on top of their medications, getting more exercise, or eating right.
But providers have a role, too. It's not hand-holding, but initiating electronic systems and other educational approaches to help patients become partners in their care.
As I report in this month's HealthLeaders Magazine, Peter Pronovost, MD, senior vice president at Johns Hopkins Medicine and the Armstrong Institute for Patient Safety and Quality in Baltimore, says health systems have a ways to go to help empower patients in the health care process. Most education that patients receive in hospitals is "completely inadequate," he says. "More and more, the private sector is working on educational tools for patients," he says.
Johns Hopkins has produced a video to encourage patient involvement, and is working on plans to make videos for patients to elaborate on their stories and needs.
Patients are the fuel that makes hospitals run, and why they exist. Patients are also a headache for the C-suite.
That is certainly reflected in the HealthLeaders Media 2011 Industry Survey, in which leaders cite patient noncompliance and lack of responsibility as the fifth-greatest driver of healthcare costs at their organizations. A quarter of respondents cited patients as among the top three cost drivers, ahead of health plan overhead, medical devices, pharmaceuticals and malpractice litigation.
The lack of communication between patients and primary care physicians when a patient is discharged from the hospital, for instance, can compromise patient safety, and lead to a return visit to the ED or hospital.
Hospitals are investing in programs to promote patient involvement in their own care, saying speed is crucial. Strictly on a health basis, more young people are facing weight issues, and more young people are facing diabetes, while others confront chronic conditions that are adding to patient care issues as well as costs.
Industry stakeholders are also under pressure to adapt behaviors to improve outcomes and contain costs, and none is more integral to the process than patients, says Susan Frampton, president of the Planetree Institute, Derby, CT, a network of hospitals that support patient-centered care.
"Everyone is focusing on patient engagement because it's going to be necessary," says Frampton. "It's the only way we can execute on the concepts of Accountable Care Organizations, or other healthcare initiatives. You can't go very far on any of that without having an engaged, empowered patient. I think the irony is we are struggling to retrofit a system that was set up to disempower patients."
For example, medical records were once sealed from patients like secret CIA documents. Even now, patients admitted to hospitals see their possessions put in little bags, and removed, "like you are in jail," Frampton says.
At the same time "we are looking at patients and families and challenging them to be better partners in their care," Frampton says. It's not going to be easy, she concedes.
To help ease transitions of care, Planetree initiated Patient-Centered Lean, a spin-off of the Lean production process for improved efficiencies that health systems have used, modeled after the Toyota system. The patient centered approach aims to involve patients and their families throughout the process of their care, from meetings with physicians and staff to evaluating care post-hospitalization, Frampton says.
The idea, as Planetree notes in planning documents, is about "improving "patient satisfaction, quality and experiences of care, and improving the caregiver workplace satisfaction and engagement."
While hospitals focus on improving patient involvement in their care, so are physicians. Ultimately, patients must become partners with their physicians and lay out a care framework.
Too many primary care physicians don't press patients to take care of themselves, says William H. Bestermann Jr., MD, medical director for medical home quality at the Holston Medical Group in Kingston, TN. Generally, "primary care physicians mean well and don't do well," Bestermann says. "If you talk to doctors and ask why they don't achieve these things they'll say, "My patients aren't compliant enough and they don't do anything I tell them."
Bestermann and other physicians at the Holston Medical Group have rearranged workdays to help patients become more involved in their care, he says. They changed visiting hours to be more flexible for patients, to get a better sense of their needs, and to learn what more they can do for themselves.
While technological improvements have helped patients, not all of them are the be-all-or-end-all to initiate patient involvement, says Roberta Schwartz, MHS, senior vice president of operations for the 864-bed Methodist Hospital, Houston, TX.
"One of the most important things is for patients to take the time to understand what is going on with their care, and recognize they have a right to get every question answered," Schwartz says.
Methodist Hospital offers free programs for weight management and diabetes that answer questions and help physicians and nurses work with patients to prepare for upcoming procedures or manage chronic conditions.
The idea, Schwartz says, is for patients to "take control" of their health.
Something went wrong a few years ago when Michelle Malizzo Ballog underwent surgery to replace a temporary stent in her liver at the University of Illinois Medical Center, Chicago, IL. Tim McDonald, MD, chief safety officer, tells me he remembers vividly the text he received from a nurse as Ballog stopped breathing: Come quick. Things going badly. Cardiac arrest.
The 39-year-old woman suffered cardiac arrest, lapsed into a coma and died several days later. Within hours, McDonald and other hospital officials, including the risk management officer, went over details of Ballog's hospital stay with her family.
McDonald had the sense that the father felt that "here we go, here's the whitewash." No, hospital officials told him, "We'll look into this." They did, McDonald says, and they found that hospital errors were to blame.
In the crucial minutes after Ballog's death, the hospital responded to stunned and questioning family members, and talked about things that went wrong. And the Malizzo family not only didn't sue the doctors, but her father, mother, and sister responded to McDonald's offer to join them on a safety review committee to prevent future medical errors.
What occurred did not turn tragedy into triumph, but served as a lesson – one step at a time – in which communication and cooperation helped detour the spiral of medical malpractice litigation.
UIMC's relationship with the Malizzos reflected "effective communication and appropriate resolution," McDonald says. "And appropriate resolution isn't always about money. That's the crux of our program."
Indeed, UIMC's communication style that was on display with the Malizzos was formed in its patient safety program that allows nurses, physicians, and administrative staff to move quickly to report, review, and effect change following patient safety errors, McDonald says.
Last year, UIMC received a $3 million federal grant for the program as a demonstration project. The program objectives, as outlined by McDonald, are to "improve patient safety and mitigate medical liability risk through improved communication with patients and family, disclosure and early (monetary) offer when patients suffer preventable harm, and learning from mistakes to prevent future harms."
When UIMC began reporting on unsafe conditions, and harmful events, staff reported about 1,500 occurrences the first year – a number that seemed "highly" inaccurate, McDonald says. However, staff "spread the word that leadership was behind this" reporting initiative. Now, there are about 8,000 such events reported annually, McDonald says.
"To some extent, we know everybody's worried about getting sued," he said. "But if you take a principled approach to harm, you can avoid a whole lot of lawsuits, and come to appropriate non-adversarial resolutions. In a whole lot of our cases, we've avoided protracted litigation that brings docs in and everything else."
McDonald says UIMC "embraces the concept of collective accountability" when appropriate and "reaches out to the family for quicker resolution before they decide to go to trial."
At least 40% of physician leaders surveyed in the HealthLeaders Media 2011 Intelligence Survey say fear of lawsuits is a major influence regarding their decisions to order tests or procedures. More than 60% of physicians age 55 and older have been sued at least once, according to the American Medical Association.
The AMA and dozens of other medical groups are pressing the Joint Congressional Committee on Deficit Reduction for a legislative package that includes a medical liability reform element. The physician groups want the committee to consider a "reasonable limit on non-economic damages" that would reduce the federal budget by $62.4 billion over the next 10 years, as the Congressional Budget Office calculates it.
While the political debate continues over medical liability, McDonald and the University of Illinois Medical Center show some improvements can be done, one step at a time, within hospital systems themselves.
After Ballog died, McDonald and his staff told the family uncomfortable details of what had happened. The Chicago Tribune reported that monitoring errors were made when she was placed under anesthesia and surgery, and that her parents were stunned that her death was caused by preventable errors that they didn't know about at first.
The hospital eased the family's concerns by being upfront. When the nurse wrote the text message, it was part of the hospital's "hotline" action plan for adverse events for which the hospital could be at fault.
"We maintained trust with (the family) and communicated throughout," McDonald says. Referring to the medical errors, "I would tell you, nobody behaved recklessly, and it was all mistakes and lapses that the entire team made which, truth be told, the institution could have been a little more on top of," he said.
As hospital officials evaluated the mistakes, the focus became being "part of the solution, instead of part of the problem," McDonald explained.
In the hours immediately following Ballog's death, UIMC made clinical changes to require an anesthesia specialist be present for procedures such as hers. McDonald says that it is difficult in a litigious climate for doctors and hospitals to embrace new systems and acknowledge that things went wrong.
"We know that liability and tort issues are up front, and you need to embrace those and understand those and move forward, where you are telling the legal system, 'we don't need no stinkin' legal system to tell us when we've not done something right,'" McDonald says. "When we know we haven't done the right thing it is incumbent upon us to fix it and be honest about it and let's cut the baloney. At the end of the day those who should worry about assets are those who behaved recklessly."
As members of the UIMC's patient safety review committee, Michelle Malizzo Ballog's father, mother, and sister drive for an hour and a half to attend meetings. They have been contributing members of the panel, McDonald says. Michelle's dad Bob Malizzo "will say things in a very respectful way like, 'wait a minute, weren't we talking about this problem a year ago, and didn't you say you would fix it?' McDonald says."It's awesome."
About one year after his daughter's death, McDonald walked in the hospital and was surprised to see Bob Mallog hooked up to a machine for a cardiac procedure.
"He told me, 'this is the place where my heart was broken,'" McDonald recalls, "'and I'mtrusting you to fix my heart.'"
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Greg Kasper, MD, FACS, chief vascular surgeon for Mercy St. Vincent Medical Center in Toledo, OH, knows an aortic aneurysm can be genetic. So when he treated a 94-year-old man for the condition, Kasper thought of the patient's brothers – a 94-year-old twin and 86-year-old "baby brother."
The siblings from Ohio reflect the impact aortic aneurysms have on elderly Americans everywhere. One million people may not realize they have the "silent killer" condition, Kasper said.
Kasper talked about the brothers after I interviewed him for a HealthLeaders Media magazine article about the increasing demand for vascular care, attributed to a growing population of aging Americans. Vascular disease covers a lot of ground, from life-threatening conditions such as aortic aneurysms or arterial blockages, to less dangerous, but painful conditions such as varicose veins.
Hospitals specializing in high-volume aortic centers focus on minimally invasive procedures and invest in new technology. Some processes are being developed within aortic centers at Mercy St. Vincent and other hospitals to provide immediate and 24/7 assistance to local hospitals and physicians for rapid diagnosis and treatment of aortic emergencies.
Patients with acute aortic syndrome face some of the most serious and lethal problems in an emergency department or physician's office, says Kasper.
"What we're seeing in Northwest Ohio, with the aging population, and the incidence of diabetes continuing to rise, there's a huge need for vascular care, and it's only increasing," Kasper said. "People in their upper 80s in years, or young 90s, they may have a vascular problem, and you have to correct it, but a lot of people don't know they have it."
An abdominal aortic aneurysm, the most common type of aortic aneurysm, occurs when the large blood vessel that supplies blood to the abdomen, pelvis, and legs becomes abnormally large or balloons outward. Risk factors include smoking, high blood pressure, high cholesterol, and genetic links. A ruptured abdominal aneurysm can be deadly, with a mortality rate of more than 50%.
Aneurysms can develop slowly over many years and often have no symptoms. If an aneurysm expands rapidly, tears open, or blood leaks along the wall of blood vessels, symptoms may develop, such as swelling of the stomach. Anyone can develop an aneurysm, but it is mostly seen in men over 60 with the key risk factors. "It's silent, until it gets to a certain size and ruptures," Kasper said.
Several years ago, the government approved an initiative that enables Medicare patients to get free ultrasound screenings that could detect potential aneurysms, Kasper says. Still, doctors and patients must communicate about the need for monitoring of patients at risk for aneurysms, he adds.
"A vast majority of aneurysms are asymptomatic and found when a test is done for another reason, and the patient comes in and has a CAT scan or ultrasound, and the radiologist looks at it," Kasper said.
The importance of timely interaction for a ruptured abdominal aortic aneurysm is reflected by mortality rates, says Michael Dalsing, MD, a vascular surgeon with Indiana University Health in Indianapolis, which also initiated a rapid response system for vascular care at IU Health.
Under the rapid response approach, the hospital can review CAT scans on a secure website before the patient is transferred from the emergency department, he says.
That allows the patient to go directly from a helicopter landing pad or triage ambulance to the operating room when appropriate. The rapid response has lowered mortality rates to 18% to 25%, from an average of 50%, he says.
"We have a Level 1 trauma center, and we have an operating room always manned and ready to go," Kasper says of Mercy St. Vincent Medical Center's rapid-response approach. "We're able to move the patient in quickly, using a stent graft and minimally invasive repair" of the aorta. Using minimally invasive endovascular treatment, coupled with the rapid-response approach, is improving outcomes, he says.
But I wonder if physicians are doing enough to get the message across that patients with the condition may susceptible to a potentially grave condition.
The 94-year-old patient, for example, didn't know what was building in his body.
He was found unconscious at home, and eventually diagnosed with an aortic aneurysm. Thanks to rapid response, he recovered at Mercy St. Vincent Medical Center, where a stent graft was placed inside the blood vessel without surgically opening it, and his life was saved.
Before the surgery, Kasper wanted to be sure the elderly patient knew about options for his care.
"I had the opportunity to talk to him, and asked him if (the aneurysm) was something he wanted fixed," Kasper recalls. "He was somebody who lived independently and played golf four days a week. He said, 'let's do it.'"
Kasper examined the man's twin brother, who showed no indication of an aortic condition, and Kasper monitored the twins' younger, 86-year-old brother, who may have a slight aneurysm. "We're keeping an eye on him," he says, and that may save his life.
A middle-aged tennis instructor swings her racket fluidly as she belts forehands and backhands. Her movements are robotic as she ambles from side to side, the result, she says, of surgery on each knee.
Another player moves stiffly at the end of a match. Before he leaves, he checks his taped knee. "It aches," he says, "and my doctor is talking about surgery, but I'm not so sure I want to do that."
Call it a Joint Commission -- and I don't mean the hospital rating agency. Players are retooling their aching joints, or thinking about it. Physicians could set up a courtside practice. Talk about net income!
The demand for replacement knees continues to boom, with Baby Boomers pushing the trend, with their aching knees, hips, and other joints. Some 50,000 knee replacement surgeries are performed each year in the U.S and are expected to increase 673% over the next decade, according to the American Academy of Orthopedics.
While middle-aged people are expected to be the largest number of patients, Generation Xers are having knee replacement surgery at an earlier age. Those with obesity, diabetes, or other ailments may also seek knee replacements.
"We are seeing a broadening of the age range of patients who are getting joint replacements," says Peggy Naas, MD, MBA, an orthopedic surgeon and vice president of physician strategies for VHA, and a panelist for the HealthLeaders Medi's Oct. 12 Webinar -- Raise Revenue, Cut Costs In Your Joint Replacement Service Line.
"We have an increased expectation on the part of the public that things will get fixed. There is the 'boomer' expectation of being forever young."
While hospitals vie for a competitive edge with increasing volumes in knee or other joint replacement surgeries, they are confronting reduced federal reimbursement rates, projected physician shortages in orthopedics, and increased expenses for implants. And the move toward multidisciplinary approaches also will call for more-affordable care and improved patient outcomes, Naas says.
Some hospitals are establishing joint replacement centers and protocols, and building special operating rooms for joint replacements. That has increased efficiency, with physicians performing as many as 8 to 12 surgeries a day, which also improves ROI.
The joint replacement centers are easing transitions for patients from the moment they enter the hospital to rehabilitation and recovery by hiring nurse navigators or joint replacement coordinators.
For a joint replacement team to be successful, it must have executive as well as physician support, says Scott Russinoff, MD, an orthopedic surgeon at Westchester Medical Center and Hudson Valley Hospital in New York and a HealthLeaders panelist on the Webinar. Joint replacement centers, if administered correctly, earn "good money for the hospital," Russinoff says. "Joint replacement centers drive more business and help patients. It's a way of putting all the pieces of the puzzle together."
While the multidisciplinary approach is often discussed, it is not easily accomplished, especially in joint replacement programs, Naas says.
To overcome turf problems, "there should be increased alliances between surgeons and hospitals" in joint replacement programs," Naas adds. "It's very attractive for bundled payments for efficient outcomes. A lot of that fits into healthcare reform." Bundling payments are designed to allow physicians and hospitals to coordinate care and reduce services of little value.
Moreover, physicians should play key roles in the decision-making process for implant purchases, Naas says. Within the hospital, a special "value-analysis team" that includes physicians should be established to have a direct relationship with sales representatives of implant device makers to negotiate cost and standardize programs for improved purchasing, Naas says.
With so many orthopedic devices in the marketplace, the government is trying to evaluate the cost and impact, especially those related to hip and knee replacements, by establishing a $12 million database, or "registry" of the products. The Agency for Healthcare Research and Quality wants to know if these devices work over the long haul, and how expensive are they.
While orthopedic devices are promoted by "surgeon enthusiasts" of particular device/procedures, AHRQ says in a planning document that "the real-world clinical performance of the devices outside of the leading centers that participate in pre-market clinical trials is difficult to evaluate."
"There are thousands of devices and device combinations in use to perform hip and knee replacement and repair procedures," AHRQ states. "The comparative effectiveness of these devices is unknown."
The American Academy of Orthopedic Surgeons has been lobbying for a federally supported national hip and knee replacement registry for years.
Naas says developing a nationwide registry of orthopedic devices will improve clinical outcomes and reduce costs. "In these registries, long-term outcomes are followed for total knee or total joint replacement," Naas says. "We don't have a national registry in the U.S. There are individual health systems that have their own registries, but there is not one specifically for this country. Other countries have them."
In the long run, "we'll find out what innovations" in orthopedic care are paying off, she says.
Joint replacement care will steadily increase with the aging population. And unlike the one tennis player who had two knee surgeries, most people with joint problems don't have surgery, says Todd Davis, vice-president of marketing and developing for Biomet, a Warsaw, IN, manufacturer of orthopedic devices.
"Many people choose not to get (joint surgery) because of the lack of knowledge, fear, or the costs" Davis says. "If these people were included in the projected increases of surgery in the population, the numbers would be off the charts."
