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December 12, 2011

To Avoid Readmissions, Hospitals Trying Post-Discharge Clinics

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In recent years, hospitals have been under increasing pressure to keep their readmission rates low. The next bump in the road comes in October 2012, when Medicare will begin cutting back on reimbursement for facilities whose readmit rates are too high.

Hospitals are already hard at work at preventing readmissions due to preventable medical errors, which may not be reimbursed at all by Medicare at all. But it seems like they’re still far behind in the care coordination department.

In fact, research suggests that they’re facing an uphill battle, in part because patients often don’t get the kind of follow-up care they need.

In theory, fragile patients  should move smoothly from inpatient care to their PCP, ideally a medical home equipped to coordinate whatever follow-up care needs they have. Few primary care practices are up to speed yet, however.  In fact, some aren’t even sure when their patients are discharged.

How bad is the problem? According to one study quoted in The Hospitalist, only 42 percent of hospitalized Medicare patients had any contact with a primary care physician within 14 days of being discharged.

One solution to this problem might be a “post-discharge” or transitional care clinic offering primary care on or near a hospital’s campus, the article notes. This makes sense. After all, it’s more likely a patient will follow through and get follow-up care if it’s convenient to do so.

The idea behind these clinics isn’t to replace the patient’s existing PCP; instead, the clinic’s hospitalists, advance-practice nurses or PCPs are there to make sure patients absorbed their post-discharge instructions and are compliant with the meds prescribed during their stay.

Some hospitals have invested significant resources in building out transitional clinics, including Beth Israel Deaconess Medical Center, Seattle-based Harborview Medical Center and Tallahassee (Fla.) Memorial Hospital, which partnered with a local health plan to kick off the effort.

That being said, the idea is a new one and few other hospitals have taken the plunge as of yet. It will be interesting to see whether this approach actually works, and particularly, whether one model of transitional care stands out.

P.S.  I’d particularly like to know whether hospitals can accomplish some of these objectives by monitoring patients remotely after they’re discharged. After attending last week’s mHealth show, I’m betting remote monitoring would be cheaper than setting up a new clinic. Can’t wait to see whether hospitals try that route!





November 7, 2011

Hospital M&A Getting Tough (But Misguided) Scrutiny From Lawmakers

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As us in “the biz” know, the pace of hospital M&A isn’t going to slow down anytime soon. Hospitals are huddling together to scale up for countless reasons.

The reasons for hospital consolidation are just about unstoppable, of course, as they include  a) well-founded fears regarding reform, b) trouble carrying the capital capital costs involved in scaling up health IT infrastructure, c) long-term trends squeezing hospital margins and d) the need to participate effectively  in ACOs, HIEs and other alphabet soup organizations.

Unless the government takes over the entire healthcare system and spends these factors away, they’ll push execs into the arms of their peers regardless of what federal policies roll out.  Yes, the FTC can put mergers on hold, and notably, has gone medieval on a few mergers just to prove it can, but let’s not pretend it has the resources to slow hospital consolidation dealflow much either.

So, I must say I was sort of amused to learn that members of the  House Ways and Means Subcommittee on Health took a  stern look at hospital dealmaking and consolidation last month.  You know, to me it’s like standing in a flooded basement in a rainstorm and focusing on a few cracks in the wall — but I digress.

At the hearing, an economics and health policy professor named Martin Gaynor testified that consolidation was picking up speed. He also asserted that studies show hospital prices going up meaningfully whenever hospital markets consolidate.

Geez, Professor Gaynor, you say that like it’s a bad thing! Doesn’t classical economics allow for the supply side folks to work together too, without breaking the system? Whoops, I digress again.

The hearing, which took place in September, also included data from a Rand Corp. study noting that health plans were consolidating dramatically, and that these mergers were giving health plans too much power.  (Wow, imagine that — health plans having too much power?)

Oh, Lord, why does all of this seem beside the point?  Well, probably because it’s not going to help anyone.  Sure, knowing  what impact hospital M&A is having is part of a well-informed Health Subcommittee’s job description.  And I appreciate that the Subcommittee is trying to look at the bigger picture, one which includes both health insurers and hospitals.

But hearings like this, which assume that pricing indicators are the best way to decide whether the public good is being served, strike me as painfully uninformed. While I’m no economist, I have seen a few deals come and go, and some ill-considered attempts to control dealflow too. After following the health market for decades, I’m convinced that playing Whack-A-Mole and slapping down those “bad guys” who are overcharging/underpaying gets us nowhere.



April 27, 2011

Big hospital chains have outlived their usefulness

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Regardless of what Community Health Systems execs may think, big, massive, overstuffed hospital mergers aren’t going to work in the next decade.  No amount of economies of scale will make up for the dollars health systems will lose if they decide to operate their business if it were Walmart.

Look at the history of the market.   Massive scaling up of hospital infrastructure — remember the grand Medicare-fueled building party in the 1960s? — has always been followed by financial weakness, overbedded markets and vicious regional competitions nobody can win.  Hospitals that try to reproduce this technique in multiple markets are only going to do worse.

In truth, I imagine CHS and other large hospital players are more focused on generating leverage with payers.  (They mostly have to scream “economies of scale” to satisfy Wall Street investors who wouldn’t know an ICU from an inside pitch.) After all, as reform washes over the land, the big health plans are going to see big upward jolts in their covered base.   And since the newly-insured aren’t likely to be cash cows, health plans are going to be more cost-conscious than ever when they negotiate.

“Massive scaling up of hospital infrastructure — remember the grand Medicare-fueled building party in the late 1960s? — has always been followed by financial weakness, overbedded markets and vicious regional competitions nobody can win.”

That being said, I don’t think creating hospital megaliths will tilt the scales back into balance.  Hospitals will always be on defensive when it comes to health plan contracts;  the brutal fact is that health plans have the money, and hospitals don’t. Hey, you can scream, we’re the best in the region, but let’s face it folks, health plans are more in the quantity than quality game.

So, what do hospitals do to cope with their vulnerability?  Careful, gradual acquisitions in key markets, strategically positioned to streamline the way they run key service lines across a region.  And integration, Lord yes,  but I’d argue creating your own health plan is a much better bet than buying medical practices willy-nilly.  (OK, you can do both, but I’d argue that putting a health plan in place should be the priority.)

By the way, I’d argue that the growth of the ACo concept suggests that I’m not alone — that just about every policymaker thinks that managed care-style medicine needs to be nurtured by providers.

Under these circumstances, big hospital mergers look even worse, as it’s pretty hard to build tight collaborative relationships when all orders have to come from the mothership in Nashville or Dubuque.

No, I say, a time comes for all industries when it’s time to think small, and this is it.  Tenet, HCA, Community Health, the big Catholic systems — now is the time to decentralize aggressively or pay the price. You’ve got three and a half years before reform goes full tilt. Tick tock, folks.


August 21, 2010

Data from the Kaiser rollout – better than expected?

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As promised…

OK, before I get rolling, let’s back up a bit. To those that didn’t see my earlier feature, I’ve been dredging up the days when Kaiser caught a lot of heat for what was reputed to be a $3 billion EMR installation. Today, after four more years,  Kaiser’s EMR rollout is old news. But even though it hit full stride in 2006 or so,  it was such big news that the echoes still remain. So here you have what may be some data from those tumultuous times.

Below, consider the first set of data from (what appears to be) a Kaiser report on its Epic EMR performance. This coincides with the period during the period when whistleblower Justen Deal took his complaints about its performance. Of course, a little bird gave it to me, and as noted previously, I’m fairly sure it wasn’t Justen.

This report, which spans August through November of 2006, looks at a bunch of measurements of network and application performance.  I’m not a technical expert, so I can only guess, but truthfully, it looks like the organization did pretty well, especially since nobody, more or less, knew how to scale an EMR for such as large installation.

Not only that, it seems to me that if only 580,000 user hours were blacked out during those four months, vs. almost 63 million potential hours, it’s pretty good performance.

My main question here, having seen this doc, is whether these are cherry-picked network stats. Personally, I’d like to know more about how the application performed on the ground, what latency/response times were, whether the interface took eleventy-odd months of training to use, whether Kaiser did a good job of integrating other data silos, and perhaps most critically, whether clinical care took a disproportionate hit.

What data would you have wanted to see if you were running the show?  Check below and tell me what you think.

P.S.  By the way, if you want to lighten things up, feel free to check out this video of George Halvorson looking august and scholarly. But I digress…back to the data.

Topline Data from August through early November 2006 for KP HealthConnect

Usage Based User Availability: 99.09%
This represents (Potential User Hours- User Impact Hours)/Potential User

Unique Incident reports: 429
These are incidents which affected the deployment, regional or national totals.

Average Concurrent Users: 8,481
Average number of users on the system during a given month

Potential User Hours:  62,895, 096
Average concurrent users * the total hours in the month

User Impact Hours:
Calculated for every incident by multiplying the actual number of users affected by the duration of the incident.  




August 19, 2010

Possible Kaiser data, tomorrow, straight from the whistleblower's mouth

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OK, guys, if you know anything I don’t about the machinations around the $3 billion (or $5 billion, name your number) installation of Kaiser’s Epic EMR, now’s the time to share. 

I say that because tomorrow, I’m going to pull together what an anonymous source sent me from the early days of the Epic installation.  We’ll go over it, reader and editor, and see if there’s any news left.  Hope you’ll join me.

If you have anything to add, please do feel free to toss another log onto the fire.

Admittedly, even if genuine — and I have no way of proving that it is — it’s at least four years old. Still, I’m pretty intrigued by it and I hope you will be too.  (By the way, the e-mailer says he’s not the (in)famous Justen Deal, the young man who e-mailed 180,000 Kaiser employees with his EMR concerns. I’d tend to believe Mr. X, since I’ve met the actual Justen and he’s not the anonymous type.)

I’ll catch up with y’all tomorrow.


August 10, 2010

Kaiser, the whistleblower and the $3 billion EMR

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Back in 2003, Kaiser Permanente CEO George Halvorson made a decision which would change the direction of the company.  Though few of his peers had taken the plunge, Halvorson bought an electronic medical records system from EMR vendor Epic and set plans to bring all of his clinicians online.

While there’s nothing so surprising about that — other than the fact that Kaiser was well ahead of the curve, time-wise  — the project’s trajectory was a bit unusual. The EMR installation, which stumbled at more than one point, sprawled over several years and cost a reported $3 billion dollars. Yes, I meant “billion,” in case you fear your eyes are failing you.

Of course, Kaiser is a $30-odd billion company, so if anyone can afford a billion-dollar EMR, it can, but that’s still a whopping health IT investment by any standard.

Not long after the deal got done, Kaiser and its leadership began taking a tremendous amount of flack over the system, which apparently ran into every obstacle an IT project can face. Apparently, doctors were complaining that the EMR was slow and buggy, and worse, that the system was down more than up. But Lord knows, Kaiser had no intention of breaking its 10-year contract with Epic, a vendor whose lock on big deals continues to amaze me.

Then, in 2006, all hell broke loose when a 25-year-old Kaiser employee named Justen Deal managed to get an e-mail message out to all of Kaiser’s 180,000 employees.  Deal argued that the new system, dubbed HealthConnect, was rife with technical problems and couldn’t scale to meet the demands of the organization. The trade press went nuts. Halvorson was forced to defend the installation to the press and even write a letter to the extremely junior employee who’d blown his cover. Hard to tell whether anyone bought Halvorson’s defense, but the bad press died down within six months or so.

OK, fast forward to today.  HealthConnect is fully deployed, and if Kaiser’s Internet folks aren’t shining me on, the system is working pretty well.  Not only is HealthConnect servicing 431 clinics and 35 medical centers, it’s also supporting a personal health record which serves 3 million of Kaiser’s members.

That, at least, was the news from Jan Oldenburg, senior practice leader with the Kaiser Permanente Internet Services Group, whom I spoke with a few months ago.  Patients use the PHR to fill half a million prescriptions, check out 1.2 million test results and make more than 100,000 clinic appointments each month, Oldenburg says.  (Note that she didn’t address how effective the EMR system has been for clinicians — that may mean nothing, but I was a bit curious about the omission.)

Now, my friends, here’s the pop quiz. If you had to guess, do you think that the $3 billion spend was ultimately a good investment?  Do you believe that the Kaiser HealthConnect system will be a greater success with patients than clinicians?  And if clinicians are still using it at gunpoint, should Kaiser shift gears entirely and focus on patient access?

Looking forward to your ideas…this is a tricky one.

July 21, 2010

Health plan doctor ratings: Will they ever be fair?

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Here’s a tough assessment of doctor-ratings schemes by my buddy Joe Paduda of blog Managed Care Matters:

“Some physicians and physician groups are quite upset about insurers’ recent moves to offer employer customers tight, small networks of providers based on quality and cost criteria. In an effort to block these new plans, the AMA and other groups are focusing on the few problems with ratings and avoiding the larger issue – some physicians are just bad actors.

What they should be doing is working closely with health plans and regulators to ensure the rating process is transparent, fair, and objective.”

I’m not sure I agree with Joe, though he is, to be sure, a guy one should take very seriously when it comes to healthcare strategy. I think a lot of the talk about “quality” is just an excuse to squeeze out expensive or challenging doctors and practices.  But what about you?

July 15, 2010

Video/satire: The real health plan business model

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The following song, by brilliant social and political satirist Roy Zimmerman, offers his view of health plans’ real business model. His take?  As far as health plans are concerned, sick patients would (literally) be better off dead:

Dear Number 1036924053887
Have you considered suicide?
It’s a healthcare plan you haven’t tried.
Enclosed please find a tab of cynanide…for your perusal
You’re getting to an age where your potential need for medical
Attention even intervention isn’t hypothetical
So, do it quick!
And solve this nation’s healthcare crisis
By not getting sick.

To hear more incredibly elegant rhymes (hey, there’s a reason Tom Lehrer likes this guy) here’s the full song:

Now, I’ll confess that I simply get a massive kick out of Mr. Zimmerman, whether in health parodist mode or not, but I think you’ll  be amused by this one too.  Maybe you’ll be inspired to lampoon some bad actors too.  Street theater, anyone?

BONUS: While we’re having a bit of fun, here’s blast from the clinical world:  Emergency Depatment rap!  Seems there’s quite a trend going on here — maybe a dozen ED hip-hop videos cropped up on YouTube when I recently checked — but this group, from the University of Alabama’s Birmingham hospital, seems to be the Grandmaster Flash and Melle Mel of the bunch.