Maestro Muti Gets Pacemaker

Feeling poorly in October, 2010, the Chicago Symphony Orchestra's Maestro Riccardo Muti traveled to the World Health Organization's #2 country for health care delivery, Italy, to be evaluated for "abdominal discomfort" and was diagnosed with "extreme exhaustion" while costs of care are held to a minimum:

After a series of medical tests at San Raffaele Hospital, it was determined that Maestro Muti is suffering from extreme exhaustion as a result of prolonged physical stress. In this case, as often happens, the exhaustion manifested itself in abdominal pain and other physical symptoms. His physicians believe that he was able to work through his symptoms in his first two weeks, given all of the heightened excitement, but, that as time wore on, it became increasingly more difficult to do so.

Maestro Muti’s medical doctors have prescribed one month of complete rest, which he has begun at his home in Italy. The Maestro reports that he is feeling “not perfect, but relieved” to know it was not something more serious as first indicated by his symptoms.

Later, he returns to the United States just before the great #SNOMG, collapses at rehersal in Chicago, has facial fractures and receives America's finest: a permanent pacemaker, courtesy of the good ol' 37th WHO-ranked U. S. of A.

While hindsight is always 20:20, you can bet his workup and treatments were thorough, timely, and quite expensive here in the United States.

Suddenly, though, #37 doesn't sound so bad, does it?

-Wes

Achieving Linearity in a Non-Linear World

Harlan Krumholz, cardiologist and professor of Medicine at Yale University, wants better doctor ratings:

For most patients, the decision of where to seek care comes down to a recommendation based on hearsay. Good reputation plays a role, but unfortunately studies show that just because you have a famous name doesn't mean that you're good.

Even doctors don't know what to do. I broke my collarbone in a bicycle accident a few years ago and had no good way of selecting a surgeon. I picked someone based on advice from colleagues, but neither they nor I had any way of knowing what his past results for this operation — or any operation — had been.

Our health care system has a grasp of the astronomical amounts spent on care, but we have little information about the overall results that we achieve. We lack a trustworthy source of information in most areas of medicine to guide this most critical choice. We don't have a Consumer Reports for doctors and hospitals — at least not yet. For-profit ranking systems, such as the 100-best-doctors-in-your-area feature found in glossy magazines or online, often do not fully reveal their methods or submit their measures to independent peer review. Patients almost always have to make blind choices about where to receive elective care.

The paucity of information about medical performance not only makes it hard for patients to choose care. It also impairs our ability to improve care. If we in the medical profession could measure results, we could weed out bad practices and nurture the good ones — and save more money and lives than we could with virtually any breakthrough procedure or medication we are likely to see in the near future.

I completely agree that even doctors can't figure out who to go to when problems arise. But to suggest this is a simple, resolvable issue that can be posted online misses the point. The issue is not just how many complications a doctor has, but how many procedures has that individual done in their lifetime, what is their diagnostic acumen, interpersonal skills, eye-hand coordination, fund of knowledge based not only on standardized tests, but clinical experience. Are these things simply quantifiable? Furthermore, none of these measures disclose a doctor's availability clinically, or their personality and compatibility with a particular patient. You can have the world's expert in anything, but his clinic is full, then whom do you go to?

Presently, board certification, years of experience, and legal history might be quantifiable entities to use to roughly assess doctors' capabilities. TO some, low complications might be most important, to others, an affable personality. But to suggest that this will EVER be a simple assessment that can be placed online seems ill-conceived since we're attempting to make linear a non-linear algorithm.

To me, it's still better to ask a good nurse you trust whom to see. They've not let me down yet.

-Wes

Could Hospital Rankings Hurt Patients?

There's now evidence hospital ranking schemes might adversely affect some patients:

"Recent studies in Massachusetts and nationally suggest that cardiologists may be turning away more high-risk patients as an unintended consequence of public reporting, Resnic said. In a paper published in the Journal of the American College of Cardiology last month, Resnic and his coauthors reported that in 2005, the proportion of patients undergoing angioplasty in Massachusetts for cardiogenic shock - a life-threatening condition caused by poor heart function - dropped to 1.3 percent, from 2.3 percent in 2003, the year the state began publicly reporting angioplasty death rates. Since then, the rate has been level, he said."

-Wes

Seeing Stars

Seems the star-rating system used by CMS to rank nursing homes has some rough edges:

Many nursing home officials—and consumer advocates—assail the star system for rating the facilities.

Administrators say the ratings are too simplistic. Advocates fear some five-star homes are overrated and may give consumers false comfort.

Wendy Meltzer of Illinois Citizens for Better Care said she thinks the star ratings "are going to kill people."

Self-reported data might be part of the problem, as are lack of electronic medical records...

Oh, wait, electronic medical records? Why might nursing homes, with our sickest and oldest patients, need those? (Taking tongue out of cheek now...)

-Wes

From Five Stars to One

How does Healthgrades rate hospitals?

An article on one hospital's fall from grace from a 5-star ranking to a one-star ranking cites two possible methods Healthgrades, the "industry standard" company that rates hospitals, obtains their data. On one side, we hear this from their spokesperson, Todd Van Fossen:

"To arrive at its ratings, Fossen said, Health Grades used Medicaid and Medicare data from 2004 through 2007."

But what kind of Medicare data? It's interesting to note that rating hospitals makes money (and plenty of it) for Healthgrades. In fact, Healthgrades is projected to make $10.42 million in Quarter 3 of this year. So does it come at any surprise that Decatur Generals' Dr. James Gilmore was less than pleased about their sudden drop in their CV surgery's status from five-star to one-star, stating that Healthgrades used a financial means of rating hospital surgical programs, claiming:

"Speaking before the program shut down, Gilmore said Health Grades uses billing data instead of clinical data to arrive at its ratings and that its primary responsibility is to its stockholders."

Could this be true? Given the lag time required to process Medicare claims data, we are left to wonder, do they use billing data or clinical data to "grade" hospitals? Could financial conflict of interests be swaying rankings?

-Wes

Olympics Fever

Boy, the marketing departments are into the Olympic Spirit! I mean, Triple Gold?

It was quite a feat:

To receive Triple Gold recognition, Aurora St. Luke's Medical Center had to meet 85 percent of performance measures, in all three categories, for two or more years.

Just think of the manpower, the cost, the countless hours devoted to non-patient care to assemble this crown.

All for a spot on PRNewswire that's picked up by Marketwatch.

It makes you wonder where our money goes, doesn't it?

-Wes

The Patients Who Cry Wolf

If you want to find out how a hospital of emergency room works, do you send in "secret shoppers?"

"As a matter of ethics, you always have to justify why you would need to deceive someone," said Nancy Berlinger, deputy director and a research associate at The Hastings Center, a bioethics research institute in Garrison, N.Y.

Questions have also been raised about how far these undercover patients should go, because they could be exposed to procedures and medications that carry real risks.

Earlier this year, an Essex County, N.J., hospital had some of its own employees pose as secret shoppers to see whether nurses were reading back physician medication orders over the phone to ensure accuracy. Protocol also called for the nurses to record the encounter in the patient's chart

A spokesman for the hospital said employees from doctors to technicians were tapped to secretly observe the nurses, then record whether they complied with the rule.

"We discovered there was very high compliance, although it wasn't 100 percent. In those instances where the person was not complying, we just contacted them and informed them we really needed them to do this," spokesman Richard Wells said, adding that no punitive action was taken.

In a time where ER's are overcrowded, resources are in short supply, doctors and nurses are pushed to their limits, and patients' care is compromised by this fraudulent activity, this monitoring practice should be outlawed.

-Wes

The $1.9 Million Shout-Out

Yep, the cost of a one-day ad campaign by the Centers for Medicaid and Medicare Services to promote their hospital rankings:

Officials there are spending $1.9 million for a one-day advertising blitz in 58 local markets, including Chicago, urging consumers to compare the quality of care at medical institutions.

I wonder why they have to advertise? Aren't people using these rankings? I mean, they're so helpful and save money, no?

-Wes

Physician Profiling

It's official. Doctors are being discriminated against.

We're being profiled.

By our own AMA.

Buffalo (NY) physician Nancy Nielsen of the AMA, worked with New York Attorney General Andrew Cuomo to develop the model to profile doctors.

But in a remarkable display of double-speak, we find:

"The AMA commends Independent Health for voluntarily joining the ongoing shift in the health insurance industry's stance on physician profiling," Nielsen said. "Although Independent Health does not profile physicians, its agreement with the Attorney General indicates that a primary commitment to quality improvement already exists within the company."

Wow.

So the AMA commends Independent Health for joining the physician profiling although Independent Health does not profile doctors.

And the AMA commends them for this behavior.

From the Wall Street Journal:

Over the next year, the rankings will become more transparent and thorough under agreements reached in recent months between several of the biggest health insurers and New York Attorney General Andrew Cuomo. Aetna, Cigna, UnitedHealthcare and WellPoint have said they'll apply the agreed-upon approach to their ratings nationwide.

The insurers have agreed to rate quality as well as cost and to use independently accepted criteria -- which might include, for example, measures from the not-for-profit National Committee for Quality Assurance -- instead of just claims data to rate physicians. They also will adjust for risk so that, for example, a doctor is not
penalized for handling more complex cases that may result in higher costs and more
deaths.

Additionally, doctors will be able to review the data and appeal the decisions.

Now I touched on this before, but since it now seems that the National Committee for Quality Assurance (NCQA) from Washington DC "might" be developing the ranking criteria, I thought I would see who will be doing this important task.

Here are some of the positions the NCQA needs filled right now (according to their website). I've included my comments about each one in italics:

Assistant Director
The Assistant Director (Focus on Health Promotions & Disease Management) will manage and coordinate measure and program development and implementation activities (e.g. MAP/ expert panel meetings), including establishing goals and strategies and generating new ideas.

In other words, this person has no idea what he's to do, but "wellness" strategies and removing sick people from the insurance rosters will help future rationing strategies for healthcare.

Assistant Vice President, Product Development
The Assistant Vice President will provide NCQA leadership in California with its large number of NCQA customers and significant managed care market; to do so by working with a variety of organizations to make NCQA evaluation tools relevant to them; and to identify business opportunities for NCQA and be responsible for carrying them out This involves establishing California relationships; understanding the environment in California, understanding NCQA products and capabilities and directing California-based and headquarters-based NCQA resources.

California doctors, you're screwed. It seems your managed care market is particularly perplexing since the "environment" is less than tasteful to "organizations" like insurers and government. Therefore, doctors will be really ranked there. Oh, and what "relationships" are they talking about that need to get "established," any way? Glad I work in Illinois.

Chief Information Officer
The Chief Information Officer (CIO) is responsible for providing data & technology vision, and strategic direction, for developing and implementing information technology (IT) initiatives and information products that support NCQA's mission. The major purpose for this role is to lead the creation of a significant data strategy, which will support performance measurement within the health care system.

You see, the data strategy still needs some work. And the data systems to update the voluminous quality data points aren't ready quite yet, so the updates to the ranking websites will not be in real-time. That will take the hire of ten more IT specialists to implement. Estimated date of completion: 2062.

Manager, Data Collections
The Data Collections Manager will oversee and manage HEDIS data submission operations and staffing (3+ staff positions), including non-survey HEDIS data and survey HEDIS data (CAHPS, HOS, etc.).

There are never enough people to measure the data. Never mind they have no idea what it all means. Rest assured the data, however, will be transparent as they'll publish it quickly.

Manager, Information Products
The Manager, Information Products will lead day-to-day management of Health Plan Report Card redesign project, including planning, analysis, testing, implementation, and training for immediate and longer term development phases.

Once they have the data, they plan to sell it as their "product," I guess.

Policy Analyst
The Policy Analyst will analyze questions, research content; prepare accurate written responses to questions for customers and for discussion at internal meetings and serve as an internal resource to organizations.

Hmm. Which "organizations" exactly will this person serve as a resource to? Doesn't sound like they're a resource to patients. Could it be the insurance agencies? CMS?

Policy Analyst (HEDIS)
The Policy Analyst (HEDIS) prepares standard written responses to customers through the Policy Clarification Support system. This person serves as an internal resource to organization.

Everyone needs, wants, and understands a "Policy Clarification Support" system that explains what all the verbiage means and supports other organizations like the insurance industry.

Policy Manager
The Policy Manager will serve as product and content experts for assigned accreditation and certification products. This person will provide direct support and clarification on complex questions regarding Standards and Guidelines and associated HEDIS measures.

So much policy, so little time. A "Manager" is certainly needed here, especially for all those "Standards and Guidelines!"

Senior Health Care Analyst
The Senior Health Care Analyst will establish goals and strategy; manage and coordinate measure development process in assigned areas, including prioritization of measures and issues, assessment of measures, and development of specifications; develop pilot testing strategy and implementation of measures.

What are these guys goals and strategy? I thought they were ranking doctors. How hard can this be? I mean "prioritization of measures and issues?" You mean, not all measures are created equal? How are the measures "prioritized," by coin toss?

Senior Health Care Analyst (Focus on RRU & CMS)
The Senior Health Care Analyst will establish goals and strategy; manage and coordinate measure development process in assigned areas, including prioritization of measures and issues, assessment of measures, and development of specifications; develop pilot testing strategy and implementation of measures.

Just like the last guy, only more, since he reports to our Government.

VP, Product Development
The Vice President is responsible for leading the product Development Department in execution of opportunities or organization growth, while keeping NCQA in the forefront of the quality movement in health care. He/she will have primary responsibility for evolving NCQA evaluation products to advance our mission.

In other words, the sales of the quality assurance "Product" will assure the maintenance of the NCQA's remarkable budget and bureaucracy.

Incredible display, eh? So many people hell-bent on physician profiling and "transparency."

All supported by the AMA in concert with the insurance industry.

But in the end, Even the AMA's own believe we'd be better off ignoring the rankings and listening to friends and nurses:

But "at the end of the day most of us rely on friends, family and word of mouth" to choose a doctor, says Alwyn Cassil, a spokeswoman for the Center for Studying Health System Change, a research group in Washington. She recommends asking a trusted pediatrician, internist or family physician for a referral to a specialist. If you don't have a doctor, ask friends and family for recommendations.

Hospital nurses also are a great resource. "They know who is nice, and they know who is good," says Dr. Nielsen of the AMA.

Funny how the nurses never seemed to mention Dr. Nielsen.

-Wes

Leapfrog's Best Hospitals

Although I'm not a real fan of rating systems for hospitals, it seems congrats are in order for Evanston Hospital for their inclusion as one of the Leapfrog Group's 41 best hospitals in the US:

The 2007 Top Hospitals list is based on 1,285 hospitals that responded to the Leapfrog Hospital Quality and Safety Survey as of August 31. Top Hospitals fully meet Leapfrog’s standard for ICU Physician Staffing (IPS) and the Safe Practices Score (SPS) and either of the following: (1) Two or more of the eight Evidence Based Hospital Referral (EBHR) areas; or, (2) Computerized Physician Order Entry plus one of the eight EBHR areas. Thirty–three hospitals meet these criteria. Top Children’s Hospitals fully meet the standard for IPS, SPS and the EBHR Neonatal ICU standard for high-risk and complicated newborns. Eight children’s hospitals meet these criteria.

I may whine, rant, and complain from time to time, but all told, the admin folks do a pretty good job here.

-Wes

Reference: The Leapfrog Group's methodology.

Food for Thought

I recently ate dinner and paid my tab at a local restaurant.

I looked at the amount: $53.61

Tell me, was it a good meal?

What, you’re having trouble telling what the quality of the meal was from how much I paid? What's that you asked? Oh, you want to know how many people were dining? Why that's not important! Just tell me: was it a quality meal?

Impossible to tell, right?

Now imagine your "Checkbook" just won the jackpot and got its hands on a database of 4 billion or so Medicare payment amounts and the names of the doctors that received them.

Tell me, which of these doctors are the good, er, quality, doctors?

Come on, people. You have the DATA! What the heck's wrong with you? There it is, black and white. Surely you'd send your wife or child to the doctor with the most receivables from Medicare, right?

Oh, no? What's the matter? Having trouble making the connection between Medicare payments received and the quality of a physician?

Me, too.

-Wes

Health Care Quality Rankings Be Damned

Today pharmacy rankings produced by J.D. Power were posted on the Wall Street Journal Health Blog. It seems that even pharmacies are not immune to such rankings. The J.D. Powers’ ranking system is different that those created by individuals close to a particular industry and offers a glimpse into the minds of health care consumers. Issues like convenience, communication, economy and responsiveness to the consumer’s needs are paramount.

But remarkably I don’t use any of the pharmacies listed. I use my local pharmacist who lets me have a credit account, will deliver the drugs to my door (and those of many seniors in our area), and knows me (and my family members) by name. My needs must be different than those of the J.D. Powers survey respondents.

Not to be dissuaded, I decided to perused other rankings by J.D. Powers, particularly their Distinguished Hospitals ranking. It was interesting to note the dramatic difference in J.D. Powers “Distinguished Hospitals” for service excellence compared it the US News and World Report’s list of Best Hospitals. How remarkably different they are! Not a single university hospital exists on the J.D. Power list, but many university hospitals are on the US News and World Report’s list.

So which is better? Where should you receive your care?

It depends, doesn’t it? When we or a loved one is sick and hospitalized, we want the “best” care possible. But the best might be very different from one patient to another. For the young patient suddenly afflicted with a serious cancer, “best” might be the hospital center with the widest experience treating that form of tumor. For the aging senior who has been in and out of hospitals repetitively, “best” might be the center that makes accessibility and attentiveness to their daily needs most important (its amazing what free valet parking to do for a local center’s rankings).

But despite all of these rankings used as powerful marketing aides, the one thing that never waivers is this: the quality of the health care providers - the doctors, nurses, and technical staff (yes, even pharmacists) - is what really matters. Doctors that are not afraid to refer to others with more expertise, encourage second opinions, and look you in the eye as they speak are critical to me. Sure, the physical plant and information technology help, but if you can’t see your doctor quickly, talk to a real human being, and get the answers to your questions and support for your concerns in a timely and professional manner, you’ll take your health care business elsewhere - rankings be damned.

And you know what?

That’s the way it should be.

-Wes