Blog Home

Archive for the 'Physicians' Category




The Strategic Challenge Of Electronic Health Records


December 16th, 2014

Despite a 2005 prediction that electronic health records (EHRs) would save $81 billion, RAND Corporation just validated clinicians’ complaints in a report describing EHRs as “a unique and vexing challenge to physician professional satisfaction.” The American Medical Association also published EHR “usability priorities” – strong evidence that current EHRs don’t support doctors in practicing medicine.

In a world of Apple-typified simplicity, why is it so hard to get the right EHR? Because, unlike Apple, EHR designers haven’t started with the question of how value can be created for users of the technology. Technology isn’t the problem. The challenge is in articulating clinicians’ information needs and meeting them by making the right tradeoffs between corporate and business unit strategies.

EHRs can, and should, provide relevant information when and where clinicians need it, recognizing that care is not a commodity and that different care processes have different information needs. User interfaces must anticipate clinicians’ needs rather than require individual user design. EHRs need to eliminate low-information pop-ups and alarms and instead provide alerts and reminders that are both timely and relevant. They must be designed with assiduous attention to data entry requirements, replacing blind mandates with thoughtful assignment of the task and the timing.

In this post I look at how rethinking the design of EHRs can better balance the different strategic needs within care delivery organizations.

Read the rest of this entry »

New Health Policy Brief: Physician Compare


December 16th, 2014

A new policy brief from Health Affairs and the Robert Wood Johnson Foundation (RWJF) looks at the evolution and current development plans for Physician Compare, a website mandated by the Affordable Care Act (ACA). A simple version of the site first launched in 2010.

Since then the Centers for Medicare and Medicaid Services (CMS) has slowly been adding limited sets of data listing the various physician groups participating in a number of Medicare quality improvement initiatives. In 2015 the site will expand to include more recent and extensive information about physician performance and quality of care, in a format that’s similar to the other ACA-generated websites — Hospital Compare, Nursing Home Compare, Home Health Compare, and Dialysis Facility Compare.

These sites, which encompass tens of thousands of facilities nationwide, are credited with advancing accountability and motivating improvements in care and quality. They are also faulted as poorly organized and inadequately audited when the data are submitted by facilities.

Read the rest of this entry »

Why I Oppose Payment Reform


December 12th, 2014

I recently gave the keynote address at the New York State Health Foundation Conference “Payment Reform: Expanding the Playing Field.” This blog post is adapted from those remarks (you can watch the half-hour speech beginning around the eight-minute mark).

I had my epiphany shortly after I announced my departure from the National Academy for State Health Policy (NASHP) about nine months ago. In an effort to help find my successor, I contacted some executive search firms. One firm quoted what they referred to as the “market price.” When I pressed them to tell me how much effort this price represented, they declined to do so. Ultimately, I recommended that NASHP contract with a search firm that charged by the hour.

It was then that I realized that, given the choice between capitation (a fixed fee for the outcome I desired) and fee-for-service (an hourly rate with no accountability for the outcome), I, as a purchaser, chose fee-for-service. Only a hypocrite would go around talking about the importance of payment reform, while secretly conducting business the old way!

Having given the matter some further thought, I present my five reasons for opposing payment reform:

Read the rest of this entry »

Preparing US Hospitals To Safely Manage Ebola Virus-Infected Patients: At What Cost?


December 11th, 2014

Since Ebola first reached US shores this summer, hospitals nationwide have attempted to prepare. National guidance has been helpful, but no such guidance can deal with the fastidious attention to every minute and mundane aspect of caring for a patient with Ebola virus infection that could place a healthcare worker at risk if a breach occurs. Simulation training has helped to uncover defects and to assess our capacity to mitigate those defects.

Additionally, innumerable hours of countless healthcare workers, hospital administrators, infection control staff, facilities and environmental services providers, communications specialists, security personnel and others have been brought to bear focused on the task at hand. Despite this effort, in the 30 years since becoming a physician, I have never witnessed a greater, more palpable level of stress and anxiety among my peers.

Read the rest of this entry »

The Accidental Administrative Law Of Policymaking In The Medicare Program


December 11th, 2014

Editor’s note: This post is part of a series of several posts stemming from presentations given at “The Law of Medicare and Medicaid at Fifty,” a conference held at Yale Law School on November 6 and 7.

When Congress establishes a new regulatory program, it lodges the program in a regulatory agency or executive department. A regulatory agency generally has presidentially appointed commissioners with staggered terms and expert staff. This design provides insulation from politics and facilitates applying technical expertise to regulatory problems. Also, administrative agencies make rules and policy and have the powers of investigation, adjudication, and sanction to enforce compliance. Administrative law, an essential instrument of democracy, regulates the operation and procedures of government agencies.

The Social Security Amendments of 1965 established Medicare in the Social Security Administration (SSA). Medicare initially contained two parts, hospital insurance for hospital and related services and supplementary medical insurance for physician and other outpatient services. Pursuant to contract, Medicare contractors handle claims and pay providers as well as adjudicate appeals and make program policy.

This post chronicles the development administrative law, policymaking, and regulation in the Medicare program. It describes how the program evolved a revolutionary collaborative model of regulation that could provide a useful guide for other programs.

Read the rest of this entry »

Should Doctors Deny Ebola Patients CPR?


December 11th, 2014

The first time I did CPR, coagulated blood spurted onto my new white coat from a wound in the patient’s chest. Another time a patient’s urine soaked through the knees of my pants as I knelt at his side.

Even in the best of conditions, cardiopulmonary resuscitation (CPR) is a spit-smeared, bloody business that can expose health care workers to all kinds of body fluids. Like all health care workers, I put on gloves and a game face and accept such things as part of patient care.

The 2014 Ebola outbreak changes all that. Hospitals all around the world are now training staff in personal protective equipment (PPE) use and convening rapid response teams. A key part of this process involves grappling with how dangerous it will be to perform CPR on patients with Ebola.

Fully 70 percent of those stricken with Ebola in 2014 have died. That means in countries like the United States where we attempt CPR routinely to save dying patients, health care workers will be called to resuscitate Ebola patients.

From placement of an artificial airway to the administration of chest compressions and beyond, each step in CPR can expose health care workers to body fluids containing as many as a million viral particles in each drop and well-proven to transmit Ebola. In contradistinction to the bowling alley and subway exposures that have drawn so much media attention, health care workers performing CPR on Ebola patients will truly be in the direct line of viral fire.

Read the rest of this entry »

California’s Proposition 46 And The Uncertain Future Of Medical Malpractice Liability Reform


December 10th, 2014

On November 4, 2014, Californians voted against Proposition 46, an unprecedented statewide ballot initiative that would have, among other things, raised the $250,000 cap on noneconomic damages to $1.1 million and indexed it to the rate of inflation in future years. The margin was significant — 67 percent voted against it.

For nearly 40 years, noneconomic damages, which entail payments to patients for pain and suffering resulting from medical malpractice (as opposed to economic damages such as lost wages and medical costs), have been at the forefront of debates over the U.S. medical liability system. Currently, 22 states have caps on noneconomic damages of varying sizes in place. If it had passed, the ballot initiative would have raised the cap on noneconomic damages in California from among the most restrictive to the least restrictive among all states with caps.

Opponents of Proposition 46, and supporters of malpractice reform more generally, argued that raising the noneconomic damages cap would have increased malpractice awards and subsequently malpractice premiums, which would be passed on to patients and insurers as higher costs.

Read the rest of this entry »

The Health Care Holy Grail?


December 9th, 2014

A friend practicing internal medicine in Massachusetts is a pillar of his community, a beloved physician — and he is miserable.

“The practice of medicine has deteriorated to that point where many of my colleagues would like to get out,” he told us. “I certainly would. Medicine now is about production lines, insurance company power, regulations. It is one fire drill after another throughout the day, day after day with a bureaucrat peering over your shoulder all the while.”

In countless conversations in recent years we have found that these sentiments are as common as they are troubling. Imagine going through the rigors of medical school and training and then looking back and regretting your career choice? Burnout is sweeping physician ranks throughout the country.

Read the rest of this entry »

From The National Coordinator For Health IT: The Federal Strategy For Collecting, Sharing, And Using Electronic Health Information


December 8th, 2014

Making our nation’s health and wellness infrastructure interoperable is a top priority for the Administration, and government plays a vital role in advancing this effort. Federal agencies are purchasers, regulators, and users of health information technology (health IT), as they set policy and insure, pay for care, or provide direct patient care for millions of Americans. They also contribute toward protecting and promoting community health, fund health and human services, invest in infrastructure, as well as develop and implement policies and regulations to advance science and support research.

The Office of the National Coordinator for Health IT (ONC) has a responsibility to coordinate across the federal partners to achieve a shared set of priorities and approach to health IT.  To that end, today we released the draft Federal Health IT Strategic Plan 2015-2020, and we are seeking feedback on the federal health IT strategy.  This Strategic Plan represents the collective priorities of federal agencies for modernizing our health ecosystem; however, we need your input. We will accept public comment through February 6, 2015. Please offer your insights on how we can improve our strategy and ensure that it reflects our nation’s most important needs.

A collection of 35-plus federal departments and agencies collaborated to develop the draft Federal Health IT Strategic Plan: 2015-2020, identifying key federal health IT priorities for the next six years (Exhibit 1). The landscape has dramatically changed since the last federal health IT strategyWhen we released that Plan, the HITECH Act implementation was in its infancy. Since then, there has been remarkable growth in health IT adoption. Additionally, the Affordable Care Act implementation has begun to shift care delivery and reimbursement from fee-for-service to value-based care.

Read the rest of this entry »

Transforming Rural Health Care: High-Quality, Sustainable Access To Specialty Care


December 5th, 2014

Editor’s note: This post is also authored by Kate Samuels, a project manager at Brookings. It is informed by a case study, the fourth  in a series made possible through the Merkin Initiative on Physician Payment Reform and Clinical Leadership, a special project to develop clinician leadership in health care delivery and financing reform. The case study will be presented on Monday, December 8 using a “MEDTalk” format featuring live story-telling and knowledge-sharing from patients, providers, and policymakers.

Health care for patients in rural communities across the United States remains a unique challenge.  Despite many programs aimed at improving access to physicians and hospitals, access to health care providers remains limited.  While 19.3 percent of Americans live in a rural area, only about 10 percent of physicians practice in rural areas.  Similarly, 65 percent of all Health Professional Shortage Areas are in rural areas.  Rural residents often face long travel distances to see a specialist after what can be months waiting for an appointment.

Even in areas where rural primary care providers (PCPs) remain committed and engaged in the community, often having been raised and educated there, these providers often lack close connections to specialists who tend to be based in larger, urban academic medical centers (AMC).  The result is a worsening gap in specialty care access, in turn leading to a deteriorative effect on rural provider morale and retention.

Read the rest of this entry »

The Council On Graduate Medical Education (COGME)—Not Yet Ready For End-Of-Life Care


December 4th, 2014

In November, 1985, twenty-nine years ago, members of the first session of the 99th Congress addressed growing concern and controversy regarding Graduate Medical Education (GME). Although Medicare had financed GME for the previous twenty years, Congress began to recognize that our rapidly evolving health care system could require significant changes in the composition of our physician workforce, and that these changes could impact the appropriate governance and funding of GME.

In this setting, the Council on Graduate Medical Education (COGME) was conceived and underwent rapid gestation, with its birth achieved via enactment of authorizing legislation in 1986. Its charter charged the Secretary of Health and Human Services (HHS), under Title VII of the Public Health Service Act, with responsibility for taking national leadership in the development of policies related to GME, and in the research, development, and analysis of such policies that impact on the health workforce needs of the nation. COGME was instructed to provide advice and make policy recommendations to the Secretary and committees of the House and Senate within their jurisdiction.

Contrary to a sunset provision in the legislation, COGME still survives. While continuing to function on very limited support, it recently issued a noteworthy report entitled “Improving Value in Graduate Medical Education” in 2013. COGME presently is preparing its 22nd Report, which addresses the need for change in GME due to changes in the U.S. health care system and focuses on opportunities to improve training through more effective targeting of public resources.

Read the rest of this entry »

Health Affairs Web First: National Health Spending In 2013 Continued Pattern Of Low Growth


December 3rd, 2014

A new analysis from the Office of the Actuary at the Centers for Medicare and Medicaid Services (CMS) estimates that in 2013 health care spending in the United States grew at a rate of 3.6 percent in 2013 to $2.9 trillion, or $9,255 per person. The increase was slower than the 4.1 percent growth in 2012 and continued a pattern of low growth that has held relatively steady at between 3.6 percent and 4.1 percent annual growth for five consecutive years.

The continued low growth in health spending is consistent with the modest overall economic growth since the end of the recent severe recession and with the long-standing relationship between economic growth and health spending—particularly several years after the end of economic recessions, when health spending and overall economic growth tend to converge. As a result, health spending’s share of the nation’s gross domestic product (GDP) remained at 17.4 percent in 2013.

The study is being released today by Health Affairs as a Web First and will appear in the January issue of Health Affairs. It was discussed this morning at a reporters briefing in the National Press Club.

Read the rest of this entry »

Recalling To Err’s Impact — And A Small But Telling IOM Mistake


November 25th, 2014

This year marks the 15th anniversary of the Institute of Medicine (IOM)’s To Err is Human report, which famously declared that from 44,000 to 98,000 Americans died each year from preventable mistakes in hospitals and another one million were injured. That blunt conclusion from a prestigious medical organization shocked the public and marked the arrival of patient safety as a durable and important public policy issue.

Alas, when it comes to providing the exact date of this medical mistakes milestone, the IOM itself is confused and, in a painful piece of irony, sometimes just plain wrong. That’s unfortunate, because the date of the report’s release is an important part of the story of its continued influence.

There’s no question among those of us who’d long been involved in patient safety that the report’s immediate and powerful impact took health policy insiders by surprise. The data the IOM relied upon, after all, came from studies that appeared years before and then vanished into the background noise of the Hundred Year War over universal health insurance. This time, however, old evidence was carefully rebottled in bright, compelling new soundbites.

Read the rest of this entry »

Spreading Like A Wildfire: Interprofessional Education – The Vanderbilt Experience


November 20th, 2014

Well before the Affordable Care Act was passed in 2010, efforts to expand interprofessional education (IPE) were beginning to change the mindset that permeated much of health professional education in the US. One such example is the Vanderbilt Program in Interprofessional Learning (VPIL) that was established in 2010 with initial support from the Josiah Macy Jr. Foundation, and later from the Baptist Health Trust.

To learn about the challenges, successes, and surprises experienced by those who developed and lead IPE at Vanderbilt, I interviewed Linda Norman, Dean of Vanderbilt University School of Nursing, Bonnie Miller, Associate Vice Chancellor for Health Affairs and Senior Associate Dean for Health Sciences Education at Vanderbilt University Medical Center, and Heather Davidson, Director of Program Development for VPIL.

Peter Buerhaus: What were the key challenges faced when you started IPE at Vanderbilt?

Read the rest of this entry »

Continuity Of Care For Chronic Conditions: Threats, Opportunities, And Policy


November 18th, 2014

Continuity of care is a bedrock principle of the patient-doctor relationship and is believed to be a fundamental attribute of high-quality medical care. Mounting evidence suggests that continuity of care for patients with chronic conditions prevents hospitalizations, reduces health care costs, and may prolong life in some populations.

Because patients are most likely to have longitudinal relationships with their pediatricians, family physicians, and internists, taken together, these primary care doctors are integral to translating continuity into meaningful care coordination. However, within the rapidly shifting landscape of health care delivery in the United States, continuity of care is simultaneously threatened and promoted by emerging care models.

Read the rest of this entry »

Implementing Health Reform: ‘Minimum Value’ Plans Must Have Hospital And Physician Coverage


November 4th, 2014

“Minimum value” is an important concept under the Affordable Care Act.  An employee who is offered employer-sponsored health plan that is affordable (that is, does not cost the employee more than 9.5 percent of the employee’s modified adjusted gross household income) and offers minimum value (MV), is not eligible for premium tax credits or cost-sharing reduction payments.  A large employer that fails to offer its full-time employees an affordable health plan that provides MV is subject to a penalty of $3,000 for each full-time employee who receives premium tax credits through the exchanges.

Yet MV is not clearly defined in the ACA.  The ACA provides that a plan does not offer MV if the “plan’s share of the total allowed costs of benefits provided under the plan is less than 60 percent of such costs.”  It is not clear what is meant, however, by “benefits provided under the plan.”  It does not seem to mean that a plan must be the equivalent of a 60 percent actuarial value bronze plan in the individual and insured small-group market, because individual and insured small-group plans must cover the ten essential health benefits, and large-group plans are not required to do so.

MV cannot mean, however, that an employer can simply pay for 60 percent of the cost of whatever benefits the employer chooses to offer, no matter how minimal those benefits may be.  MV is quite obviously something more than “minimum essential coverage,” the “skinny benefit plans” which employers may offer to avoid the separate $2,000 for-every-full-time employee penalty.

Read the rest of this entry »

Learning From Missed Opportunities To Diagnose US Ebola Patient Zero


October 30th, 2014

Over a century ago American physician Richard Cabot wrote about misdiagnoses, recognizing: “A goodly number of ‘classic’ time-honored mistakes in diagnosis are familiar to all experienced physicians because we make them again and again. Some of these we can avoid; others are almost inevitable, but all should be borne in mind and marked on medical maps by a danger-signal of some kind: ‘In this vicinity look out for hidden rocks,’ or ‘Dangerous turn here, run slow.’”

Ironically, despite the dramatic changes in the nature of medical practice over the last 100 years, Cabot’s words ring more true than ever today. This has become especially clear in the last few weeks since Ebola first touched US shores, uncovering one of the biggest ongoing vulnerabilities of outpatient medicine – misdiagnosis.

Read the rest of this entry »

Health Affairs Web First: Noneconomic Damage Caps Reduced Medical Malpractice Payments, With Varied Effects


October 22nd, 2014

With the 2014 election weeks away, a provision of California’s Proposition 46, raising the cap on medical malpractice payments for noneconomic damages, has been in the news. This provision would increase the payment cap from $250,000 to $1.1 million. A new study, being released today by Health Affairs as a Web First, sheds light on the potential effect of this proposition.

Study authors Seth A. Seabury, Eric Helland, and Anupam B. Jena looked at the impact of medical malpractice reforms on the average size of malpractice payments in several physician specialties and compared how the effects differed according to the size of the cap. It found that caps reduced the average payments by 15 percent compared to no cap—and a $250,000 cap reduced average payments by 20 percent.

On the other hand, a less restrictive $500,000 cap had no significant effect. The authors also found specialty variations, with the largest impact involving pediatricians and the smallest for claims of surgical subspecialties and ophthalmologists.

Read the rest of this entry »

The $500 Billion Medicare Slowdown: A Story About Part D


October 21st, 2014

A great deal of analysis has been published on the causes of the health care spending slowdown system-wide — including in the pages of Health Affairs. Much attention in particular has focused on the remarkable slowdown in Medicare spending over the past few years, and rightfully so: Spending per beneficiary actually shrank (!) by one percent this year (or grew only one percent if one removes the effects of temporary policy changes).

Yet the disproportionate role played by prescription drug spending (or Part D) has seemingly escaped notice. Despite constituting barely more than 10 percent of Medicare spending, our analysis shows that Part D has accounted for over 60 percent of the slowdown in Medicare benefits since 2011 (beyond the sequestration contained in the 2011 Budget Control Act).

Through April of this year, the last time the Congressional Budget Office (CBO) released detailed estimates of Medicare spending, CBO has lowered its projections of total spending on Medicare benefits from 2012 through 2021 by $370 billion, excluding sequestration savings. The $225 billion of that decline accounted for by Part D represents an astounding 24 percent of Part D spending. (By starting in 2011, this analysis excludes the direct impact of various spending reductions in the Affordable Care Act (ACA), although it could still reflect some ACA savings to the extent that the Medicare reforms have controlled costs better than originally anticipated.) Additionally, sequestration is responsible for $75 billion of reduced spending, and increased recoveries of improper payments amount to $85 billion, bringing the total ten-year Medicare savings to $530 billion.

Read the rest of this entry »

Teaching Health Centers: An Attainable, Near-Term Pathway To Expand Graduate Medical Education


October 17th, 2014

Stakeholders in Graduate Medical Education (GME) and members of Congress eagerly anticipated the long delayed but recently released Institute of Medicine (IOM) GME report. While perceptively characterizing the defects in our GME system, recommendations of the report generated substantial controversy among participants at a recent GME forum hosted by Health Affairs. The IOM proposed limited and gradual changes in Medicare GME financing, but the lack of support for GME expansion was not well received by some.

At present there are multiple legislative GME proposals, but none has gained broad support among the various stakeholders. Congressional committees responsible for GME funding view this lack of consensus among GME stakeholders as a major obstacle.

We describe a near-term and attainable pathway to expand GME that could gain consensus among these stakeholders. This approach would sustain and expand Teaching Health Centers (THCs), a recent initiative that directly funds community-based GME sponsoring institutions to train residents in primary care specialties, dentistry and psychiatry. We further propose selectively expanding GME to meet primary care and other demonstrable specialty needs within communities, and building in evaluations to measure effectiveness of innovative training models.

Read the rest of this entry »

Click here to email us a new post.