The Truven Health Blog

The latest healthcare topics from a trusted, proven, and unbiased source.

Stand-Alone Healthcare Services Can Produce Lower Overall Quality

By Michael L. Taylor/Friday, March 29, 2013
Michael Taylor imageA recent article in the New York Times describes a 21st century approach to health care – a stand-alone telemedicine service for employees paid by their employer. While I think telemedicine solutions have a great deal of promise, I am not in favor of a “stand-alone” solution. One of the problems with health care delivery in the U.S. is fragmentation of care, leading to duplication and waste. Care needs to be completely connected and integrated, under the direction of a trusted clinician, especially in the area of chronic disease which accounts for nearly 70% of all medical costs.

Without doubt, instead of stand-alone services, a better solution is the team-based approach of the patient centered medical home concept, with appropriate use of telemedicine as part of a comprehensive care plan. Telemedicine holds great promise in the management of simple, acute medical problems that may not require an office visit; it also holds promise for coordination of complex medical problems such as congestive heart failure. But telemedicine services need to be delivered as part of a comprehensive solution, not in isolation.

Data gathered during a telemedicine intervention should be part of the employee health record, and the intervention itself needs to be held to the same quality standards being developed for the medical system.

Poverty and Obesity: This Is a Link That We Need to Break

By Michael L. Taylor/Thursday, March 21, 2013
Mike Taylor imageIt’s no secret that obesity has become a significant health risk in the US, especially in the last 25 years. In many states, more than 30% of the population is obese, and the rates are climbing every year.  As has been reported, obesity can lead to diabetes, heart disease, arthritis, certain cancers and many other chronic diseases that lead to billions of dollars in healthcare costs annually. As a society, we certainly have a financial incentive to reverse our weight gain. Those who would benefit the most are, sadly, too often the people who have no real means of achieving this.

The link between obesity and poverty has been recognized but often under-reported.  Many inner cities are effectively “food deserts”, with few if any sellers of high quality food. Fruits and vegetables are often in short supply and may be prohibitively expensive. Gardening is often not an option or an available skill.  High calorie foods laden with fat and carbohydrates are much cheaper and more available than high quality foods in inner cities. On top of these challenges in obtaining decent food, even pound-shedding physical activity can be out of reach because safe areas to exercise are often not available.

The US obesity problem is complex—only for some is it a matter of diet; for many people living in poverty, obesity is just one result of a socio-economic dilemma. Public health solutions need to be wide reaching and address more than dietary approaches for this unhealthy part of our population.

Michael L Taylor, MD FACP
Chief Medical Officer

Doctors “Clocking Out?” Not So Fast

By Michael L. Taylor/Tuesday, March 19, 2013
Mike Taylor imageRecently I noticed an article that projected drastic declines in physician productivity, increasingly fragmented care, and higher costs due to hospital-based care monopolies – all due to ‘ObamaCare.” Of course these are not the results we expect from healthcare reform and I wonder if the point of the article was simply to be provocative. 

It is true that employed physicians may be less productive, but in my experience this is often a temporary adjustment to new processes, new IT systems and other transition issues. Do hospital-employed physicians become hourly wage earners? Hardly. They are salaried, and they are employed to provide care to patients during standard office hours which typically are quite similar to the hours of their private practices. Nevertheless, becoming a hospital employee is attractive to many physicians who see their incomes shrinking in private practice – especially primary care physicians – or who find themselves spending increasing time managing the business side of their medical practice. 

The US healthcare system is dysfunctional and delivers fragmented care regardless of the employment status of the physicians. Hospital-based primary care physicians, also known as hospitalists, improve care (as do intensivists), and while the communications between inpatient and outpatient providers can be tricky, this has nothing to do with the ACA. I know, because I set up a hospitalist program in 1997, well before anyone knew who Obama was!

It is also true that procedures performed in the hospital setting are reimbursed at a higher rate than when performed in the the doctor’s office, and this has been a longstanding issue for all insurance plans. However, hospitals are buying practices to maintain and grow market share – and, yes, now to prepare for ACOs – as a matter of survival. This is not about getting paid more for procedures. In fact, in the ACO world, we will see even more shifting of services to outpatient facilities where effective care can be delivered more efficiently.

The tight association of physician compensation with volume of services has been described for decades as a ‘perverse incentive,’ and shifting payment from volume based to value based is exactly the sort of free market solution that we need. This will lead to  better quality – the right care, at the right time, in the right setting, by the right provider, for the right results  as we have seen at respected institutions with integrated delivery care systems. 

The good old days of unlimited spending for unquestioned healthcare services are over. The era of evidence-based decision making, measuring and rewarding quality, transitioning away from fee for service is approaching—as a country, we have every reason to embrace its arrival with open arms.

Simple Patches Won’t Fix a Broken System

By Michael L. Taylor/Friday, March 15, 2013
Mike Taylor imageDr. Farzad Mostashari, the National Coordinator for Health Information Technology at the U.S. Department of Health and Human Services, is correct in his assertion that the US health system is not performing well. He points to less than one half of those patients with hypertension under adequate control, and less than 10% of those with diabetes at goal for well accepted standards.  A key reason for this poor performance is because, in many regions of the country, a health ”system” is not in place. Although there are some shining examples of regional systems caring for populations, across the country far too many regions offer only a patchwork of medical care, and only for those who can afford the cost and time to see a physician. Doctors may do a great job helping patients achieve optimal care, but only for those who seek the care. In many parts of the country, doctors have no means to determine who needs care; they only know about those who present for care.

A true health system approaches the health of a population differently, with processes in place to care for all in its region, not just those who show up at a doctor’s office or in an emergency department. Part of our problem is that medical care in many regions of the country is still a “cottage industry” with fee for service payment methods that don’t pay for population health efforts and no sharing of health information.

Electronic health records are a tool to help improve the system, but simply installing electronic records without systematic process improvements is doomed to failure. Decision support tools, population health management tools, and payment reform (to pay for better health among a population, not for providing more services) are all necessary components. My contention is that higher quality care supported by health information - not just more data - will ultimately cost less, not more. 

Michael L Taylor, MD FACP
Chief Medical Officer

How will we measure the endpoints for Meaningful Use goals?

By Michael R. Udwin/Wednesday, March 13, 2013
Michael R. Udwin imageThe goals embodied by Meaningful Use, directed at population and patient health as well as reduced costs, are to be commended.  Of course the challenge lies in the details as providers successfully navigate each of the envisioned Stages, including data acquisition, process management and improved outcomes. 

As the breadth and depth of such information expands how will we determine and more importantly measure best practice?

To date, rating organizations have relied on the combination of administrative billing data, core measures and patient satisfaction scores.  As our goals and data tracking capabilities have evolved, extended measures have been incorporated, including readmissions and 30-day mortality.  Yet, Meaningful Use encompasses both patient and population health.  How shall we assess an organization’s ability to manage care for a community?   

The answer to this question may be close at hand.  The Healthcare Effectiveness Data and Information Set (HEDIS) provides an analytic roadmap to quantifying our nationwide objectives, with broad categories including “Effectiveness of Care”, “Access/Availability of Care”, “Experience of Care”, and “Utilization and Relative Resource Use”.  Such content cuts across multiple aspects of our delivery system, including inpatient and outpatient encounters, preventive care and population health.

So as we embrace the spirit of Meaningful Use and specifically the goals of reducing cost and promoting a healthy patient and population, identifying “wellness” leaders may hinge on the successful integration of traditional and evolving healthcare data sets. By doing so, we may shine a light on those attributes critical to the creation of a vibrant healthy community of tomorrow.

Michael R Udwin, MD, FACOG
Medical Director