There's No Place Like Home

Once upon a time -- no, this isn't a fairy tale -- much of health care happened at home.  You were born there, your doctor made house calls, and you probably died there.  Then came the "modern" era and gradually more and more health care happened elsewhere -- a hospital, a nursing home, an ER, an outpatient facility, or a doctor's office.

That may no longer be progress.

Take, for example, the Hospital at Home movement.  Originally developed by physicians at Johns Hopkins and now also in place at several other institutions, it seeks to identify patients who can remain at home with targeted support, rather than being admitted to a hospital.  Writing in The New York Times, Daniela Lamas, M.D., profiled such efforts at Mt. Sinai Hospital (NYC) and Presbyterian Healthcare Services Hospital (Albuquerque).

The trick, of course, is to identify the right patients.  Johns Hopkins originally started with four diagnoses, and the list is gradually being expanded.  The program has already demonstrated its effectiveness in several studies, including one looking at Presbyterian Health Services' efforts.

Dr. Bruce Leff, one of the original founders of Hospital at Home, predicts a changing future for hospitals: "My sense is that over time, hospitals will become places that you go only to get really specialized, really high-tech care."  I hope he is right.

Sometimes patients in such programs can still end up needing to be hospitalized, but Presbyterian Healthcare Services, for example, says this only happens 2.5% of the time.  That means a lot of averted admissions, and a lot of happier patients.

Dr. Leff has described hospitals as "toxic" for patients, and he's not speaking only metaphorically.  An article in the Wall Street Journal about the Hospital Microbiome Project points out that 1 in 25 hospital patients acquire an infection there, killing some 75,000 patients each year.  Half of the infections are due to bacteria that have become specialized in hospitals.

As is true with virtually all microbiome research, these researchers are finding eye-opening numbers and diversity of bacteria.  I especially was struck by one finding:  "Typically, people came in and out of each room 100 times a day, trailing invisible plumes of bacteria."

All things considered, I'd rather stay at home.

The home movement isn't just about avoiding hospitals, of course.  I've already written plenty about telehealth, which can help avoid office visits, and I don't need to cheer it on further here.  Instead, look at home-based diagnostics.

One highly touted start-up is Scanadu, which analysts love to describe as offering a medical tricorder.  Dr, McCoy might disagree, since Scanadu's Scout currently can "only" check temperature, blood pressure, and heartbeat.  Scanadu expects to soon offer a urinalysis test, Scanaflo.  According to The Wall Street Journal, Scanadu also hopes to eventually offer a blood sample and nucleic-acid diagnostic device that can provide information on blood-cell count and genetic markers, which can provide early warnings of health problems or risks.  Dr. McCoy might start to be more impressed.

Scanadu sees its devices as consumer devices, and is getting FDA approval for them.  CEO Walter De Brouwer thinks he's in the data business, not the hardware business, telling Fortune: "The data will eat physiology...there will be triple or quadruple Moore's Law in these things, and it will go through the phone which is the remote control of our world."

I might quibble that the data still relies on the physiology, and that even the smartphone has a limited lifespan as our data intermediary, but I couldn't agree more that we're going to see a Moore's Law kind of effect due to better use of data in health care.

Scanadu is far from alone in the field, of course.  We've had at home pregnancy tests for years, and the first home HIV test kit has just gone on sale in the UK.  The home tests aren't limited to pregnancy or HIV, of course.  I've written before about Theranos and Diagnostics for All, for example, who are both making a broad-scale testing from home a reality.

Blood draws have been a limitation for home testing, but Tasso Inc. now has a device that eliminates the need for needles, making it easier for consumers to draw blood themselves. Tasso's device still requires the consumer to mail the sample off for analysis, but I'm willing to bet it's only a matter of time before someone -- hello, Scanadu! -- figures out how to analyze the sample immediately or wirelessly transmit the data.

Why go to a lab for testing when you can do it at home?

We've already got portable ultrasound devices and may soon have portable MRIs, yet we keep sending people to imaging centers.  Maybe we should be sending the devices to the patient, not vice-versa.  One of these days these kinds of devices may be cheap enough to sell directly to consumers, with the results again interpreted real-time or at least sent wirelessly.

Looking further out, a professor at Leigh University has developed what he believes will become an at-home test for cancer.  Why not?  Researchers at UCLA have just rolled out a device that "can turn any smartphone into a DNA-scanning fluorescent microscope."

I suspect we're not going to go back to having surgeries at home, but it's hard to see what other services are necessarily off the list.

The good folks at Scripps Health recently issued a thought piece on the "emerging field of mobile health," reviewing its progress, opportunities, and key challenges.  I was struck by one comment in particular:

Too often, studies of mHealth technology have been designed to answer the question “How can ‘these technologies’ fit into existing systems of care?” Instead, the more appropriate question is “How can systems of care be altered to best take advantage of ‘these technologies’?”

I.e., we need to be moving past the current exploratory attitude of "what can be done at home?" to a more aggressive "what can't be done at home?" (or, if you are a glass half-empty kind of person, "what shouldn't be done at home?").

Every time I see hospital construction -- and I see it often -- I think, well, there are resources not being used to keep people at home.  Maybe hospitals are the wrong organizations to be trying Hospital at Home.

In a prior post, I argued that we weren't going to really change how our health care system is structured until hospitals and physicians start looking at each admission as a failure, analyzing what could have been done, when, and how, in order to keep that person healthy and/or at home.  We're not anywhere near there yet.

I've also argued before that the breakthrough emphasis in health care may not be value, or even quality, but rather consumer convenience.  Healthcare facilities can and certainly should become more convenient, but it's hard to beat care at home for convenience.

Not all care will ever be able to be done at home, or even in the community, but those situations should be our treatment choices of last resort, not our default options.

Does Patient Satisfaction Matter?

In a provocative article for The Atlantic, Alexandra Robbins posits that we may have a "problem with satisfied patients."  Ah, only in health care...

Ms. Robbins fears that hospitals may be focusing too much on making patients happier, rather than on making them well.  She cites how hospitals are rushing to provide "extra amenities such as valet parking, live music, custom-order room-service meals, and flat-screen televisions," which may help patients have a better experience but which mean resources not going directly to patient care.

She may have a point.

Ms. Robbins' analysis found that hospitals that do poorly on three or more categories of patient outcome measures actually score above average on patient satisfaction.  In her words: "Many hospitals seem to be highly focused on pixie-dusted sleight of hand because they believe they can trick patients into thinking they got better care."

Ouch.

Ms. Robbins cited a 2012 study by Fenton, et. alia, that further quantified the patient satisfaction "problem."   According to their research, patients with the highest satisfaction also have higher odds of inpatient admissions, greater prescription drug expenditures, higher overall expenditures, and higher mortality.

The authors speculated that, in some cases, physicians may be acceding to patient requests for services that are of little or no medical value, thus potentially raising satisfaction but also costs.  Any way you look at it, though, the correlations are not good news for patient satisfaction advocates.

Patient satisfaction is clearly in vogue, as evidenced by CMS unveiling its star ratings on Hospital Compare last week, based on HCAHPS results, and by Medicare's increased focus on value-based payments.  The 2015 HIMSS Leadership Survey found that 87% of respondents listed patient satisfaction as their organization's top priority, higher than even sustaining financial viability (85%).

I was worried that CMS would cave to special interests and publish a Lake Webegon ranking, where all the hospitals ended up above average, but the data appear only moderately skewed upwards.  As reported by Kaiser Health News, out of some 3500 hospitals receiving ratings, fewer than 10% -- 251, to be exact -- received the highest rating of 5 stars.  Forty percent received the average (3 stars), and 34% received 4 stars.  Three percent got only 1 star.

The KHN analysis asserted that many of the 5 star hospitals are small hospitals that focus on "lucrative elective operations such as spine, heart or knee surgeries."  In other words, they may be essentially cherry-picking the patients and patient experiences that end up leading to higher scores.  I suspect Ms. Robbins would agree.

AHA's official response to the CMS ratings was cautionary: "There's a risk to oversimplifying the complexity of quality care or misinterpreting what is important to a particular patient, especially since patients seek care for many different reasons."

OK, fair enough...so what does AHA propose instead?

In a post on The Health Care Blog, Ashish Jha, MD, did a deeper dive on the results.  213 of the 5 star hospitals were small hospitals; none were large hospitals.  Teaching status seemed to hurt patient satisfaction, as did being an urban or safety-net hospital.  Interestingly, both for-profit status and higher margins tended to result in higher ratings.

Dr. Jha isn't sure what drives the results: "It may be that sicker, poor patients are less likely to rate their care highly. Or it may be that the hospitals that care for these patients are generally not as focused on patient-centered care. We don’t know."

He is, however, relatively sanguine about the somewhat counter-intuitive results, noting that CMS is using the "gold standard" for patient satisfaction.  He acknowledges that there may be a disconnect between the types of hospitals that we traditionally assumed were high quality and the star ratings, but says: "Whether that is a problem or not depends wholly on how you define what is a high quality hospital."

Another study on patient satisfaction, by Vanguard Communications, looked at patient reviews of physicians, and also found some unexpected results: "Ironically, the analysis indicates that generally as a doctor’s level of education and training increases, patient satisfaction actually decreases."

I didn't see that one coming.

Even more curiously, the Vanguard results found that, on average, non-M.D. providers scored higher than M.D.s, with the highest rating going to naturopaths, a category I have to admit I didn't even know existed (naturopathic doctors, or ND/NMD, are licensed in 17 states).  Audiologists were second, with psychiatrists coming in last (family doctors also scored near the bottom).

Vanguard believes that the ratings reflect more about customer service than clinical quality.  Ron Harmon King, Vanguard's CEO, says:  "Does that mean more highly trained specialists deliver poorer customer service? We can’t say with any certainty, although we found a correlation."

The Physicians Foundation 2014 survey found that 42% of respondents did, indeed, list a customer-service related reason for why they were satisfied with their family physician, way ahead of actual treatment related reasons (26%).  Then again, only 30% of those patients blamed physicians for rising costs of health care, versus the easier targets of insurance companies (75%) and drug companies (74%).  In that they are like their physicians.  Both groups are somewhat myopic on that issue, which doesn't give one much confidence about the satisfaction scores either. 

Ms. Robbins is thus not alone in being skeptical about patient satisfaction scores.  She backed up her skepticism with a quote from nurse Amy Bozeman: "The patient is NOT always right. They just don’t have the knowledge and training."  

I hate to break it to either of them, but even with all our health care professionals' knowledge and training, our health system's record on quality is pretty dismal.

Look, patient satisfaction is not a perfect measure, nor should it ever be the only measure used, but it has to be an important measure.  I can see patients being initially swayed by amenities or even simple courtesy, neither of which have typically been in abundance in our health system.  But we can't afford to forgo the burgeoning effort to focus on improving patient satisfaction.  At some point we have to trust that patients will see through smiles and nicer waiting rooms, and judge quality based on whether they are actually getting better.

And, in fact, research from Johns Hopkins suggests that patients may not fall for "pixie dusted sleight-of-hand" tricks after all.  The study concluded that:

"Patients responded positively to pleasing surroundings and comfort, but were able to discriminate their experiences with the hospital environment from those with physicians and nurses...Hospital administrators should not use outdated facilities as an excuse for suboptimal provider satisfaction scores."  

As Abraham Lincoln famously said: "You can fool all of the people some of the time, and some of the people all the time, but you cannot fool all the people all of the time."

The Doc Fix That Doesn't

Much has been made of the legislation Congress (finally) passed  to address the "draconian" cuts required by the Sustainable Growth Rate (SGR) formula -- the so-called "Doc Fix."  The bill's sponsors claim to have not only removed the need for the annual Congressional short-term fixes but also to have revamped how Medicare pays physicians.

In signing the bill, President Obama praised: "...it starts encouraging payments based on quality, not the number of tests that are provided or the number of procedures that are applied but whether or not people actually start feeling better.  It encourages us to continue to make the system better without denying service."

Not so fast.

The bill is the talking pig kind of news.  It's not that the pig talks so well as that it talks at all.  Given the recent bitter partisan atmosphere that has prevented Congress from passing virtually any legislation, passage of this bill is noteworthy.  The President is going to have a reception next week to "salute" Congress for its work.

What the bill primarily does, of course, is to prevent the 21% cut in physician payments that SGR would have required as of April 1 (not that the Senate acted before then, of course).  It also removes, or at least pushes further off, the prospect of future SGR reductions.

It does so by a much heralded focus on value, by linking future increases to participation in an Advanced Payment Model (APM), such as an ACO, and to performance under a Merit-Based Payment Incentive System (MIPS).  MIPS consolidates and expands several existing pay-for-performance programs.  MIPS will base rewards on four types of measures: quality, efficiency, meaningful use of EHRs, and clinical practice improvement activities.

(For a more detailed summary of SGR and the Doc Fix legislation, please see Billy Wynne's Health Affairs post.)

Congress is patting itself on the back for merely doing its job, even though their fix neither leads to any changes in the near term nor is paid for, except for the portion borne on the backs of Medicare beneficiaries.  Even the HHS Chief Actuary is rather bearish in his analysis of the bill's impacts, especially long term.

Basically, physicians trade immediate cuts for guaranteed increases the next four years, then face subsequent increases that will be partially based on these new value incentives.  I suspect the AMA and specialty boards are already developing their lobbying strategies for how to ensure that most physicians will qualify for full increases.  Given their track record, I wouldn't bet against them.

Push will come to shove when CMS starts having to define how they plan to define the measures, especially quality.  Instead of starting with existing measures, they're to develop "evidence-based" measures that have undergone a peer review process.  This is already making people nervous.   As Meredith Rosenthal, a Harvard health economist, told The New York Times,  there is no clear agreement on how to measure most types of physician quality.  "Once we're out of primary care, we're in kind of a neverland of measurement," she notes.

I'm not so sure we should think primary care is much different.

The Times also quoted Dr. Daniel Craviotto with what I think is a typical physician complaint: "All of a sudden you have nonmedical entities and people outside of medicine deciding what is value."  Physicians don't usually offer better ways to measure it, mind you; they just don't want anyone else trying.

Here's my favorite part of the bill: as The New York Times reported when the House first passed it, whatever quality measures end up being used for MIPS can't be used in malpractice suits.

An executive at a physician-owned malpractice insurer explained to The Times: "What a doctor thinks is best for a particular patient is not necessarily what the government thinks is right for groups of patients with that condition."

Let's think about this.  Considerable time and effort is going to be spent developing the measures.  Even more effort is going to be spent collecting the data, analyzing them, and using the results to adjust payments.  The measures are going to force some consensus about how to measure value for a wide range of physicians, and will most likely start being used by other payors.  And none of that will matter when a court is trying to figure out if a physician acted appropriately for a patient.

Huh?

I'm no fan of the existing malpractice system.  It takes something that should be more like a quality improvement activity -- identifying errors, systemic flaws in processes, and other aspects of care that harm patients -- and turns it into an adversarial system that gives providers no incentive to disclose problems and every incentive to overtreat.  It becomes more like a playing slots in a casino, where random patients can get big payouts but most patients get nothing, even if they actually had poor care.

In this analogy, the malpractice lawyers are the casinos, because they end up being the only consistent winners.  

So why would we proclaim this new era of value but explicitly prevent its quality measures from being used for malpractice?  Perhaps we should be honest that the "new" approach may end up being just a different way to justify continuing payment increases.

It's kind of sad that the only ones really at risk in our system -- even once MIPS goes fully into effect -- are patients.

A few months ago I proposed a relatively simple approach to value-based purchasing that would firmly put providers on the hook for sub-standard care.  Under it, physicians with patients who ended up worse after treatment wouldn't just get smaller payment increases, they'd actually get payment cuts.  In some cases, such as when patients ended up substantially worse after treatment, the provider could end up owing money.  

That kind of approach may sound extreme, but that's only because we've become jaded by our current system.  We're used to thinking that even when care does no good, or actually harms a patient, we should still pay the provider the same amount as if the outcome was what was desired.  Oh, sometimes we might "penalize" a provider a few percent through incentive programs, but nothing dramatic, nothing that might cause poorly performing providers to either get much better or stop providing care.

For that, we throw them into the malpractice lottery, where they now have new protections from being expected to perform well on objective measures.

I'll believe we're serious about value when providers offer "money-back" guarantees for the care they provide.  I'll believe it when providers want to publicize performance data, not argue against it.  I'll believe it when "do no harm" returns to being an operating practice, such as being tried at the University of Colorado.  I'll believe it when malpractice is part of the process to improve care, not a way to punish providers.

Maybe all that will happen at the ACO/PCMH level instead of for individual physicians or hospitals.  Maybe.  Even if so, will they be any more transparent to patients?

In the meantime, forgive me for not getting too excited about the Doc Fix.

The Goldilocks Principle

The so-called Goldilocks Principle can be paraphrased as: not too little, not too much, just right.  The health care version of it, though, goes something more like this: if some is good, more must be better.

People have been complaining about overutilization/waste/fraud and abuse for, well, all the time I've been in health care.  A few recent stories reminded me how topical these concerns remain.

One study in Health Affairs, by Ong and Mandl, postulates that false positives in mammograms and breast cancer diagnoses cost the U.S. an estimated $4b each year.  Given that total spending on breast cancer is around $16b, that's a lot of "excess" spending.

Of course, the American Cancer Society was quick to respond.  Richard Wender of ACS told CBS News: "There was no attempt to balance the costs with the benefits."  Of course, as Dr. Mandl pointed out, by definition there are no medical benefits to false positives.

Dr. Wender believes the authors "made a very selective choice of estimates" in coming up with their results, although why they might have chosen ones that would produce artificially higher estimates is unclear.  He went on to assert: "There is no debate about the benefits of mammography."  Dr. Wender must not have been paying attention these past few years, such as to the recent study that concluded they don't really reduce the number of women dying from breast cancer.

Pretending there is no debate about, nor any negative consequences of, testing is simply irrational.

That Health Affairs issue was devoted to cancer.  One study found the greatest mortality improvements between 1995 and 2007 did come in countries that spent the most.  Those results are balanced by another study that attempted to look at costs versus "quality-adjusted" costs, taking into account the value of survival gains.  Their three examples "provide starkly different answers to the question of whether society got what it paid for."

In other words, more spending may be good...but it may not be.

The second article that caught my attention was a piece Jenny Gold did for Kaiser Health News.  The title pretty much says it all: "Ritual, Not Science, Keeps the Annual Physical Alive."

Despite the fact that 92% of Americans think it is important to get an annual physical, Ms. Gold quotes Dr. Ateev Mehrotra of Harvard Medical School, "I would argue that we should move forward with the elimination of the annual physical."  He further noted that randomized trials over the last 30 years have not supported their value, despite costing an estimated $10b annually.

Ms. Gold brings up the same problem Ong and Mandl found; the direct costs are bad enough, but the cost of all the false positive is what really drives up spending.

The third story actually revolves around some advice Mark Cuban, of all people, gave on Twitter last week.   He tweeted:

1)If you can afford to have your blood tested for everything available, do it quarterly so you have a baseline of your own personal health 

2) create your own personal health profile and history. It will help you and create a base of knowledge for your children, their children, etc

3) a big failing of medicine = we wait till we are sick to have our blood tested and compare the results to "comparable demographics" 

 Mark Cuban stirring up controversy is nothing unusual, of course.  His interest in health is new, to me anyway.  His suggestions drew widespread responses, mostly discouraging people from taking his advice.

For example, Charles Ornstein, a reporter for ProPublica, had a lengthy back-and-forth with Cuban.  Cuban maintained it is important to have the data, and Ornstein brought up the issues about false positives (including how annual physicals are overrated).

Saurabh Jha, a radiologist at HUP, had a similar exchange, which he elaborated on at The Health Care Blog.  Dr. Jha uses the thought experiment of Lucky Mark, whose repeated tests do pick up a pancreatic cancer at an early stage and thus save his life.  He contrasts this experience with all the Unlucky Marks, whose preemptive testing produce lots of false positives, which end up killing some of them through complications from biopsies and other interventions.

Dr. Jha claims that the repeated tests are like asking to "prove" that you are healthy.  Mr. Cuban argues that it's always better to have data than to not have data.  They both have points.

I am deeply sympathetic with Mr. Cuban's point-of-view that consumers should have their own data and proactively use it to guide their care, such as in discussions with their physicians.  Still, as Dr. Jha points out, if we're trying to "prove" we're still healthy we could get scans every two weeks and biopsies every other month, but is that really what we want to do?

We talk about data in health care as though medicine was a science, and now worship at the altar of Big Data, but what we don't talk enough about is that much of that data is, for lack of a better word, fuzzy.  We have no shortage of data in health care, but it often doesn't tell us what we want to know.  And we have a disgraceful shortage of data that is either accessible or meaningful to patients.

I've already referenced false positives several times.  If you've read economists like Steven Levitt (Freakonomics) or statisticians like Nate Silver, you've probably seen examples of how easily false positives can impact far more people than true positives.  Given that we are a nation of virtual math illiterates, these examples don't resonate with most of us.

A 2009 study showed that, for a variety of common cancer screenings, in as few as four tests 37% of men and 26% of women will have had false positives.  By 14 tests 60% of men and 49% of women will have had false positives -- resulting in invasive diagnostic procedures for 29% of men and 22% of women.

False positives aren't the exception; they become the norm over time.

If the above examples aren't enough, we could look at our overuse of CT scans or surgeries, but the poster child for "more must be better" has to be antibiotics.  A study last year by Consumers Union found that 97% of physicians were concerned about their overuse.  Eighty-five percent (85%) had a patient(s) with multi-drug resistant bacteria infection within the last year -- and 35% had patients who died or suffered significant complications as a result.  There are a number of other known or suspected consequences of antibiotic overuse as well.

Yes, penicillin was truly a wonder drug, but its success came too quickly and too easily for us to figure out when to most effectively use it.  Like much of what we do in health care.

Too bad our health care system doesn't follow the real Goldilocks Principle.