Archive for Chief Medical Officers
by Scott MacStravic
April 2, 2008 at 3:11 pm · Filed under Chief Medical Officers, Business of Health, Hospital Administration, Retail healthcare
The impending shortage of physicians, particularly primary care specialists such as family practitioners, internists, pediatricians and geriatricians, has been shouted about by medical professionals as well as health care gurus of many stripes. It has been used as a reason to criticize concierge practices, despite their affecting only about 1/1000th of all physicians so far. It has also been used as an argument for rescinding Medicare cuts to primary physician payment schedules, and for adding new payments for their “medical home” and “proactive health management” services.
More recently, the medical profession has taken on developments such as retail clinics which use nurses or physicians’ assistants, rather than physicians, on grounds of quality concerns. The fact that these clinic offer more convenient care at lower prices, hence take away lucrative patients and visits from physicians is by no means ignored, though never mentioned by physicians, themselves, as a reason for their objections.
Meanwhile, the vast majority of proposed solutions to the impending if not already arrived “health care cost crisis” and even the promotion of health insurance for all, depend to a great extent on the mis-labeled health care system actually moving more to health vs. sickness care. This would normally be the logical jurisdiction of primary physicians, except that there are nowhere near enough of them, and they are not particularly adept at it, plus being the most expensive source of health management care available. Though some have proven their abilities in disease management, only those functioning in concierge practices, which many physicians also object to, seem to be making a go of health management.
While they may argue as much as they wish about nurses and other non-physicians being involved in sickness care, there are few and far weaker grounds for objecting to nurses, physicians’ assistants, pharmacists, etc. from being primary sources of health management services. Nurse coaches already function as the main sources of coaching for people participating in health risk and chronic disease management programs offered by insurers, specialized suppliers, and healthcare organizations who provide such services.
Pharmacists have been demonstrating for years their high level of cost-effectiveness in managing the conditions of chronic disease patients, such as diabetics, whose care is largely dependent on medications and adherence to their prescribed use. The Asheville, NC example of diabetes management using pharmacists has been delivering amazing results for a decade. The Diabetes Ten City Challenge combines pharmacist diabetes management with value-based insurance operates in ten cities for 29 self-funded employers. [L. Masterson “A Prescription for What Ails Us?” HealthLeadersMedia News: Health Plans, Apr 2, 2008 (healthplans.hcpro.com)]
The use of non-physician health professionals to deliver the vast majority of the kinds of services that will be needed to achieve the kind of reduced incidence of disease and injury on which the survival of our health care system depends is not merely a desirable, but an essential reality. Perhaps it is time for physicians to work on how to engage and coordinate their special expertise with the rest of the wide range of health professionals out there, rather than devote so much energy to protecting their own jurisdictions.
by Scott MacStravic
October 5, 2007 at 2:47 pm · Filed under Chief Medical Officers, Hospital and Health System CEOs, Business of Health, Retail healthcare
Solutions have frequently been cited as a major part of the healthcare cost crisis. Their wide variation in how aggressively and expensively they treat sick patients is one example often cited. Their modest adherence to best practices in such treatment, barely over 50%, is another. Physicians have been criticized for not providing enough prevention, wellness, and risk reduction, as well as not managing chronic disease cost-effectively, though since they are rarely paid for such services, this can hardly be surprising.
But there are exceptions, and there have been significant recent moves toward creating practice models that balance sick care with true health care, protecting and improving patients’ health, managing their chronic conditions, and as a result, actually saving money for patients and payors. One example is the “concierge medicine” development, where physicians collect an annual retainer from patients, to cover the added costs of delivering health as well as sickness care.
The MDVIP organization of primary retainer practices has about 175 physicians practicing in 16 states the last time I checked. For an annual retainer of $1500-1800, they offer a comprehensive program of health protection and improvement to each patient, and with no more than 600 patients per physician, they have the time as well as money to do so. As a result, they have reported dramatic reductions in the average hospital and ER costs per patient, compared to patients in traditional practices in the same states. (www.mdvip.com)
An even more radical and recent example is the practice of Dr. Jay Parkinson, in New York City. He opened this practice on Sep 24, so it could hardly be more recent. It combines a “prepaid” visit program, where patients get up to two visits a year, the first to obtain basic information on each patients’ health history, current medications, etc., as a foundation for subsequent care. These visits are made at patients’ homes or work sites, since Dr. Parkinson does not operate an office practice, thereby keeping overhead minimal. In addition to these prepaid visits, patients get e-mail or phone consultations, referrals to specialized care when needed, prescriptions and advice for routine problems, and ongoing health or disease management support.
Dr. Parkinson intends this practice for adults aged 18-40, without traditional health insurance. It fits well with CDHP insurance, since the deductible may be satisfied, or at least largely satisfied by the prepaid payment, while the practices services will tend to keep patients from incurring the total deductible unless they are really sick. And the “catastrophic” insurance of CDHP, or any major medical insurance plan, would fill in for specialist physician, hospital, and other costs that exceed the deductible.
He also intends to help patients save money by having information about the prices charged by specialists, lab tests and diagnostic scans, prescription vs. generic drugs, etc. so that patients may choose the “best deal” available as they see it. And by promoting healthier lifestyles, risk behavior and condition reversal, and disease management, he will save them money on sickness care, if they cooperate in such efforts.
Unlike the MDVIP retainers of $1500-1800 per year, Dr. Parkinson charges $500, with additional house calls when needed at $200 each.
With unlimited access to phone, online ,video chats, instant messaging or wireless communication, patients may aim to lose weight, quit smoking, manage diabetes, reduce cholesterol, handle chronic migraines, improve fitness, diet, or any similar proactive health goal.
This practice is specifically designed to serve employers well, in addition to patients. The age group of 18-40 is most likely to be employed, compared to seniors, for example. By making worksite “house calls”, he saves employees the need to seek care elsewhere and lose travel and waiting time away from work. By making lower-cost CDHP insurance work better for employees, it helps employers save money on health insurance, while still offering it in order to recruit and retain employees.
Moreover, since protecting and improving employees’ health saves employers, the practice is one both could love for that reason alone. With proven savings from employee health management in terms of health, disability and workers compensation costs – absenteeism, presenteeism and turnover costs – and even improved quality, customer satisfaction and new business and their related revenue increases – employers could gain far more than just saved physician visit time.
Physicians who are aware of the potential savings from practices that focus on both sickness care and proactive health management may find an interested audience among employers. After all, a large number of employers, mainly larger ones, pay for onsite medical clinics to provide precisely this mix of services for their employees. Physicians in practices such as the MDVIP organization, and Dr. Parkinson’s “placeless” care, should represent a significant source of support for this model, to say nothing of their employees.
by Scott MacStravic
September 10, 2007 at 8:05 am · Filed under Chief Medical Officers, Disease Management, Population health management, Treatments and Therapies
A report yesterday indicated that there is a strange chicken or egg question about how at least one medical diagnosis is made. The issue is: Does the diagnosis precede the choice of treatment, or does the choice of treatment come first, then cause the diagnosis in order to justify the treatment?
It has long been known that physicians are idiosyncratic in their approach to diagnosing patients. In some cases, they prescribe a treatment in the hopes that it will show what the diagnosis was by either working or not working. The character “House” in that eponymous TV show is fond of this approach. And it makes sense when the risks and side effects of the treatment are minimal, and no other approach to diagnosis has worked.
Physicians’ diagnoses and treatment choices are also understandably influenced by their specialty training and experience. Just as the “law of the hammer” notes that when you have a hammer in hand, more things begin to look like nails, so when you specialize in one kind of treatment, such as surgery vs. chemotherapy vs. radiation therapy for cancer, the choice of treatment is bound to be influenced by which the physician specializes in.
But “scientific evidence” for the dynamic “loop” of mutual causation emerged in a review of the rate of diagnosis of depression before vs. after “black box” warnings were issued by the Federal Drug Administration about the use of the class of anti-depressants called SSRIs. In the five years before the warning that these drugs can cause teen suicide, the depression diagnosis rate had climbed from 6 to 11 per thousand, among managed care plan members. Then when the FDA warning was issued in 2005, the rate decreased significantly, from 8.0 to 5.8 for men, and from 17.4 to 12.4 for women.
The use of SSRIs understandably dropped, as well, from 53% of depression episodes to only 22% and even non-SSRI anti-depressants were used less often. On the other hand, the number of patients who received at least some psychotherapy and alternatives to anti-depressants did not decline, as should be the case given that the warning only applied to anti-depressants. [“Depression Diagnoses Down After Drug Warning” MSNBC.comSep 5, 2007]
But what was the cause of the decline in the diagnosis of depression? There appears to be no logical connection between the decline in the use of anti-depressants as a cause of the decline in diagnosis. That is unless physicians were heretofore pressured by patients to prescribe anti-depressants for their depressed feelings, and when the warning was issued, the “popularity” of the diagnosis went down. Or perhaps, physicians were previously prescribing anti-depressants as a diagnostic test, and non longer used this test once the warning was issued.
As patients, we non-physicians may expect, and even prefer that diagnoses come first, and are based on something other than the need to justify a presumption or guess about the diagnosis. The fact that diagnoses of depression decreased so markedly, so fast, after increasing so dramatically before the FDA warning, at least suggests that diagnoses were being made on less than model criteria and using a variety of processes that may not fit “evidence-based medicine”.
There are technologies that can assist physicians in making diagnoses, involving computer programs that work physicians through a differential diagnosis program from symptoms to possible to most likely diagnosis. And physicians have been shown by autopsy studies to misdiagnose patients (at least the ones who die) between 8% and 24% of the time. Given this finding, one would think physicians might welcome technological assistance, but they are often described, and many times dismissed as “cookbook medicine”. [E. Donaghue “For Doctors, Diagnosing Gets a Technological Boost” USAToday.com Sep 5, 2007]
Even though cookbook medicine, where presumably computers take over completely in diagnosing and choosing treatments, is a threat to the “art” of medicine, most physicians are perfectly capable of using the technology as a guide to, rather than a substitute for their own judgment. And given the chicken vs. egg issue illustrated by the depression example, consumers might prefer that technology were used more often.
by Scott MacStravic
August 30, 2007 at 12:04 pm · Filed under Employer CEOs, Chief Medical Officers, Hospital and Health System CEOs, Disease Management, Business of Health, Health Management
The market for health management (HM), of employees, commercial insurance plan members and government insurance beneficiaries, is growing apace as payors and consumers as well recognize the advantages of reducing the incidence and prevalence of disease, along with reducing the crises, complications and worsening of chronic disease that already exists, as disease management (DM) does. This market is being served by a large number of DM and HM “vendors”, specialized healthcare organizations that only manage health or disease, though have their own medical staff and nurses, acting as medical directors and coaches.
These vendors have been joined by a number of commercial insurance plans that offer HM and DM programs of their own to their members, often charging employer clients extra for the added value thereof, and even offering these programs to employers that are not insurance plan clients. But there are also traditional healthcare organizations and physicians in private practice that are engaging in DM and HM efforts, as any combination of service to the community and revenue-generating service lines.
Hospitals have often chosen the “low-end market” for DM programs, serving people who are uninsured, or on Medicare or Medicaid for DM services, and often losing money as a result. They have more often chosen “high-end market” for HM services, however, with executive health programs charging thousands of dollars for one-day intensive predictive diagnostics and physician consultation, though some add continuing nurse coaching as well. The U.S. Preventive Medicine firm in Texas offers turnkey Centers for Preventive Medicine to hospitals, with three such centers signed up so far, with similar high-end charges for consumers, though also “Prevention Plan” programs for employers.
Physicians are active partners in the U.S. Preventive Medicine programs, and many offer their own HM services as part of “retainer practices” such as the 150 or so MDVIP practices operating in 16 states (www.mdvip.com). And many physicians, as well as nurse practitioners, offer HM along with other occupational and corporate health services in onsite medical clinics for employers, while a few nurse-practitioner-staffed retail clinics, those in the RediClinic chain, also offer HM services.
There is a large handicap that physicians and hospitals face when delivering DM and HM services, however. They have a long-established tradition of insisting on the best practices in sickness care, and have adopted a similar attitude toward DM and HM in many cases. For example, then Stanford University worked with the San Mateo County Hospital’s clinics, even though these serve as the safety net for un- and under-insured residents of the county, the result was an intensive, face-visit-based heart disease DM program involving physicians, nurses, and dietitians, with 14 extra visits over the 17 months of the program as recently reported.
This added $1250 to the “usual care” costs for participants compared to a matched comparison group. For this added cost, the program was credited with reducing heart disease risks by 1.6% compared to the comparison group. To cover the costs of all those who participated in this program, this 1.6% risk reduction would have to save $1250 divided by 1.6% equals $78,125 for the county in avoided medical and hospital care costs. [R. Stafford & K. Berra “Critical Factors in Case Management: Practical Lessons from a Cardiac Case Management Program” Disease Management 10:4 Aug 2007 197-207]
By contrast, Family Physicians of Western Colorado in Grand Junction were able to manage their 600+ diabetes patients, using the Chronic Care Model, for only $104 per year. This would require savings of only $6500 in medical and hospital costs if it reduced risks by 1.6%. Unfortunately, it had no data on cost savings, only on improved care quality, and only one of its local payors paid for the program, leaving it with over $25,000 in losses for the program. [P. Mohler & N. Mohler “Improving Chronic Illness Care in a Private Practice” Family Practice Management 12:10 Nov/Dec 2005 50-56]
Physicians, and for that matter hospitals and nurse practitioners engaged in HM and DM have to be able to answer the question as to what they add to the savings resulting from such efforts compared to what they add in costs. There is at least one example of physicians at worksite medical centers adding dramatically to the number of employees signing up for HM/DM initiatives they were offered. By simply advising their patients to enroll in these initiatives, they were credited with tripling enrollment in such initiatives. [“Workplace Disease Management Program Participation Boosted Three-Fold by Patient Contact with Trusted On-site Clinician” i-Trax/CHD Meridian Feb 22, 2007 (www.i-trax.com)]
Physicians have been repeatedly cited as the most effective source of recommendations for HM and DM program participation, as well as for lifestyle and behavior changes needed for such programs to succeed. The effectiveness of physicians in reducing sickness care utilization and costs has been demonstrated by the MDVIP practices, where reductions in the 30-90% range have been reported in the states where comparisons have been made. Physicians at CareSouth Carolina, with clinics in rural South Carolina, were able to manage diabetes patients with annual sickness care costs of only $343 compared to $1591 for patients treated elsewhere, but were not paid for their management efforts. [R. Chaufournier & K. Reims “Hidden Opportunities for Cost Savings in Disease Management” Healthcare Savings Chronicle (Coalition America, Inc.) Mar 10, 2005 (www.imakenews.com)]
If physicians are going to be involved in HM and DM, as adjuncts to “vendor” or insurer programs, or as sources of complete HM/DM programs for their patients, they will have to control the costs of their added value within the limits of that added value in terms of payors’ willingness to pay for their services. It has already been shown that providers charging between $80 and $444 a month per patient in a Medicare DM demonstration project have had a really tough time generating the net cost savings required to meet CMS expectations and gain pay-for-performance bonuses.
Physicians may add sufficient value by increasing participation of their patients. A threefold increase in participation should equate to something close to a threefold increase in savings resulting therefrom, so the added value of this service could be easily calculated. Physicians on their own may well be able to deliver significant savings at costs similar to the $104 per year per patient of the Grand Junction practice, or they could charge as much as the $1500-1800 retainer fees of MDVIP practices and deliver enough cost savings to justify such fees to payors.
Chances are very good that physicians engaging in HM/DM programs will have far better luck meeting expected and necessary savings if they work with employers, and are able to save not merely on medical/hospital expense, but through improving productivity and performance, which can yield two to five times as much savings as does DM for example when employees are involved. But they may play their most logical role as DM/HM leader and chief motivator for patients, while nurses, dietitians, physical trainers, and stress management counselors do most of the ongoing coaching of participants.
Whatever their roles, physicians will have to ensure that their contributions of benefits in any HM/DM intervention are greater than their contributions of costs, and in financial terms for most payers. Since physicians tend to be the most highly paid providers of HM/DM services, this will be a great challenge, though their potential as leaders and motivators can clearly be significant.
by Nick Jacobs
August 24, 2007 at 11:39 am · Filed under Chief Medical Officers, Business of Health, Health Management
Each day I prepare myself for work by playing the same CD in my head over and over again. “What if it was your mother, your wife, your daughter or son? How would YOU personally want to be treated? What is it about a particular facility that makes you uneasy?”
For the past 19 years, our mission in life has been to create an environment of care that provides a loving, nurturing feeling for families and their loved ones. It has been to provide a center of excellence that addresses not only the need to be competent, but also the need to be human.
It has been my goal to create a truly healing environment where patients have an opportunity to take part in their care and to make decisions about the type of care they receive. It has been about creating a place where Care Partners provide support for their loved ones and where they can actually participate in their loved one’s care. A safe place where massage, aroma, music, pet and reiki therapist roam from patient room to patient room to care for not only those patients but also for their physicians and staff as well.
When my tenure began as a hospital administrator, it was clear from day one that we were not in the hotel business. As it became more clear that this was my new home, my heart sank.
The hospitals of the 80’s and 90s were not exactly user friendly places, and many of the CEO’s were not normally absorbed in the soft side of care. They were usually forced to focus on reimbursements, unions, recruiting physicians, keeping budgets on target, and many other business considerations.
My initial thoughts were to apply the concepts learned from the hospitality industry, one of my previous careers, to healthcare. My dream was to bring chefs, hotel managers, and housekeeping professionals to the hospital. Of course, this concept was unheard of and rejected for all of the institutional reasons. It was the same set of criteria that probably dictated that the walls were to be painted white or that awful shade of institutional green.
How did we do it? We transformed our hospital into the best of a hotel and the best of a spa. Our philosophy was not just to create something that people would like. We, in fact, were interested only in creating something that people would absolutely love.
What did that mean? As a patient, it is typical that you must leave your dignity at the door of the hospital. You are entering a world that is foreign to most of us. It is filled with scientists who typically deal in life and death issues.
It would be better if patients very quickly move away from a world of fear and confusion and into a world of love and nurturing because Patient Centered Care represents a demystification of health delivery. It represents an open spirit of communication that allows individuals to make the same types of informed choices that they have been entitled and encouraged to make in every other aspect of their lives.
So, what are the answers? The answers are all based upon one universal belief, sincerity. Love can be produced through empowerment, through trust, through humanness, through nurturing; through the very best that mankind has to offer. The reality of sincerity will cut through every one of the concerns listed above. We made our change and it was a change forever.
by Hylton Jolliffe
August 23, 2007 at 12:30 pm · Filed under Blog News, Chief Medical Officers
We thought we’d let you know about several U.S. government officials who have recently joined the “blogosphere”:
Brad Perkins, Chief Strategy & Innovation Officer at the Centers for Disease Control and Prevention
The first, Brad Perkins, heads up strategy and innovation at the CDC and posts occasionally about the CDC’s activities, innovation initiatives, recent conferences and speeches he’s attended.
Mike Leavitt, Secretary of Health and Human Services
Following on the success of its pandemic flu blog, Leavitt, the Secretary of Health and Human Services, has recently launched another blog worth checking out. Says Leavitt: “Most of my postings will typically be about something I’ve learned or experienced during the day. What I value most about this job is the remarkable opportunities it provides to learn and gain perspective on problems. I hope I can share a small part of it this way. I may also invite some of my colleagues at HHS to share some of their experiences…”
Be sure to check both blogs out and if you find them useful let their authors know - it’s a unique opportunity to engage with senior government officials determining the future of health care in the U.S.
by Scott MacStravic
August 20, 2007 at 9:27 am · Filed under Chief Medical Officers, Health Plan/Payer CEOs, Disease Management, Health Management
Albert Einstein used the formula E = MC2 to describe the conversion of mass into energy, later demonstrated with the atomic bomb. A similar formula applies to health management (HM), whether applied to consumers paying for their own services, employees, commercial insurance plan members or government plan beneficiaries. The difference is that the terms are different:
- “E” represents effectiveness/efficiency if HM programs
- “M” represents motivation in HM participants
- “C1” reflects participants’ capability and confidence, self-efficacy
- “C2” reflects participants’ consciousness of how/when to act
While a wide range of interventions have been used to promote HM participant “compliance” or “adherence” to medication and lifestyle regimens, they all can be categorized as aiming to achieve increases in motivation, capability or consciousness. Many focus on just one of these, some on two, and a few on all three. But experience has shown that the best results are achieved when all three are affected by HM programs, rather than relying on one or two.
For example, a recent report on a diabetes disease management program, used with significant effect by HealthMedia, Inc. of Ann Arbor, Michigan, identified nine keys to success in promoting diabetes patients’ adherence to medications:
- Improving patients’ depression and stress coping skills
- Fitting adherence into individual patients’ daily routines
- Understanding and addressing each’s adherence barriers
- Helping them feel accountable for adherence
- Strengthening their relationships with providers
- Bolstering their confidence in medications and themselves
- Moving them toward intrinsic vs. extrinsic motivations
- Focusing on their life quality benefits vs. sponsors’ gains
- Understanding and communicating with each as an individual
[K. Wildenhaus “Improving Medication Adherence: The Missing Link to Better Outcomes” HealthMedia.com Aug 16, 2007 (webinar + slides)]
All nine of these essentials deal with one or more of the “MC2” factors. Improving coping skills, fitting adherence into daily routine, addressing barriers, bolstering their self-confidence – all relate to participants’ capabilities. Fitting adherence into daily routines, strengthening relationships with providers (physicians, pharmacists, nurse coaches), and dealing with them as individuals — all relate to promoting their consciousness of what and when to act. And helping them take ownership/accountability, strengthening provider relationships, moving them toward intrinsic motivations, and recognizing their unique personal benefits – all relate to promoting their motivations.
Addressing the changes in or reinforcements of participants’ personal and unique levels of motivation, capability and consciousness required for success is first a helpful basis for planning specific steps in an HM intervention. It is also a useful focus for evaluating the immediate effects of intervention elements – are there noticeable changes in one or more of these three essentials as each reports them. Unless one or more of these cognitive/emotional factors are increased, or at least reinforced by HM efforts, there is likely to be little if any effect.
By focusing on all three MC2 factors, HM sponsors can also create a “paper trail” that will enable or reinforce conclusions that their HM interventions are responsible for changes noted in participants’ health status, healthcare, disability and workers compensation insurance expenses, absences, productivity, performance, and overall economic impact. If changes in one or more of these factors are noted after implementing efforts aimed at changing them, then are linked to changes in behavior, health status, and subsequently in desired economic impacts, sponsors can be much more confident that the HM interventions actually produced the impacts noted than if they only measured the impact per se.
By evaluating the particular impact that HM interventions have on motivation, capability and consciousness, sponsors and providers can also learn which of these three factors make how much difference in achieving necessary enrollment, participation, and completion of each intervention, and to each of the many dimensions of cost savings and performance improvement. This will enable continuous “tweaking” of the HM interventions, themselves, and improvement of the predictive modeling methods used to identify and target prospects for particular kinds of interventions.
This is equally true with identifying the particular types of motivation, capability and consciousness dimensions, such as the nine examples identified by HealthMedia in its diabetes medication adherence program, that make the most difference to results. Continuous improvement in our understanding of MC2 factors is needed to increase and maintain positive returns on investment from HM interventions in general, and to this key component of the solution of our healthcare cost crisis.
