Entries in Riddle, Clive (271)

Sunday
Jun222008

Health Care Is Personal: In Memory of Karen

By Clive Riddle

Just a few months into my first administrative position at a hospital in 1981, just a year out of college, I remember feeling pleased with myself as I edited the Radiation Therapy Center feasibility study I had just spent countless hours and days preparing. It was a thick report full of projections, tables, charts, and narrative. Then in the background, I could year the sobbing outside my office.

My office had been converted from an admissions room, and was situated next to a quiet area for families, off the main lobby. I had never really paid attention my surroundings. I was too into my new job. But the sobbing persisted, and at some point I had to leave my office for a meeting. As I rounded the corner I spied the family, grieving for a loved one that had just passed away upstairs.

In the years to come, as I progressed in my career, becoming CEO of a regional provider owned health plan, I was typically far removed from the actual rendering of health care. Instead I was immersed in the business of it: budgets, monthly reports, department head meetings, actuarial projections, marketing campaigns, contract negotiations, board meetings, personnel issues.

Now and then, but never often enough, I tried to remind myself of that day outside my hospital office, so early in my career, when I first learned that health care is personal, and can not so lightly treated as just another business or commodity.

During my more than dozen years running that health plan, I had the great pleasure of working every day with Karen (Hutcheson) Speziale. She was the Chief Operating Officer of the plan, and she made the plan run, and run well. Karen passed away this past week, after a six and a half year battle with cancer. Karen should have been with us for at least a couple of more decades.

I remember sitting in my health plan office with Karen and our Medical Director, making decisions on proposed benefit and coinsurance levels for the coming plan year. We set a higher coinsurance level and benefit limitation for Total Parenteral Nutrition (TPN), which was at the time increasingly being used in the treatment of Crohn’s Disease. Years later, one of my children would be diagnosed with Crohn’s. We also set various new benefit parameters for several different prescription and treatment options for cancer.

Health care is personal.

After I left that health plan to start MCOL, Karen went on to take a position with Kaiser Permanente, developing and then managing their expansion in our market. Kaiser is now the dominant health plan in our area. Later, Karen moved away to San Diego, and really flourished there.

Karen volunteered significant time in elementary school classrooms. She became the advisor for the local chapter of her Sorority at the university. She spent countless hours on other civic activities. Several of her former department heads from our old health plan remained the closest of friends with her, taking really cool vacations together, and staying in constant touch. She also kept very close ties with her family. When Karen’s illness required that she fully retire from her job, she continued all her contributions to the community.

I very recently took a quick trip to visit with Karen. She had just returned from a visit to the Kindergarten class where she helped the kids learn to read. They had put on a program just for her. On the wall in her office was a plaque recently given to her by her Sorority as the national “Alumna of the Year.” The perpetual annual award will now bear her name.

Karen’s investment in community time should serve as a wake up  call to all of us working on the business side of health care, to put and keep some balance in our lives, as Karen did.

Karen shared with me how recently at the hospital she had an hour long conversation with a nurse on what was wrong with health care. Karen laughed about it, but its hard to argue that there is something significant that needs to be done with health care. We can start by remembering how personal it is.

Anyone reading this who knew Karen Speziale might be interested to know that donations in her memory can be made to San Diego Hospice at www.sdhospice.org

Monday
Jun162008

International Health Care Data and Comparisons

By Clive Riddle

With this election year, health care is a central topic of discussion for Presidential and Congressional candidates. Inevitably, references are made inferring either superior or inferior performance of the U.S. health care system compared to various other countries.
So just what kind of current data is out there reflecting various attributes of international health care? Below is collection of selected international health care factoids, compiled by Global Health Resources this year:

Health Spending And Insurance Systems in Seven Countries, 2007

Australia

Canada

Germany

Netherlands

New Zealand

United Kingdom

United States

National health spending

Per capita (U.S. $PPP)*

$3,128

$3,326

$3,287

$3,094

$2,343

$2,724

$6,697

Percent of GDP*

9.5%

9.8%

10.7%

9.2%

9.0%

8.3%

16.0%

Percent of primary care practices with:

Any financial incentive for quality

72%

41%

43%

58%

79%

95%

30%

Electronic medical records

79%

23%

42%

98%

92%

89%

28%

Percent uninsured

0%

0%

<1%

<2%

0%

0%

16%

*PPP is purchasing power parity. GDP is gross domestic product

Source: Toward Higher-Performance Health Systems: Adults’ Health Care Experiences In Seven Countries, 2007
Health Affairs, October 2007
http://content.healthaffairs.org/cgi/content/full/26/6/w717

Cost of Medical Procedures: United States and Abroad (in US dollars)

Procedure

United States

Costa Rica

Mexico

Korea

Heart bypass

$130,000

$24,000

$22,000

$34,150

Heart-valve replacement

$160,000

$15,000

$18,000

$29,500

Angioplasty

$57,000

$9,000

$13,800

$19,600

Hip replacement

$43,000

$12,000

$14,000

$11,400

Hysterectomy

$20,000

$4,000

$6,000

$12,700

Knee replacement

$40,000

$11,000

$12,000

$24,100

Spinal fusion

$62,000

$25,000

N/A

$3,311

Source: Medical Tourism Association, 2007 Survey

Procedure

United States

Costa Rica

Mexico

Korea

Heart bypass

$130,000

$24,000

$22,000

$34,150

Heart-valve replacement

$160,000

$15,000

$18,000

$29,500

Angioplasty

$57,000

$9,000

$13,800

$19,600

Hip replacement

$43,000

$12,000

$14,000

$11,400

Hysterectomy

$20,000

$4,000

$6,000

$12,700

Knee replacement

$40,000

$11,000

$12,000

$24,100

Spinal fusion

$62,000

$25,000

N/A

$3,311

Source: Medical Tourism Association, 2007 Survey

The Cost of Medical Procedures in Selected Countries (in US dollars)

Procedure

US Retail Price*

US Insurers' Cost*

India**

Thailand**

Singapore**

Angioplasty

$98,618

$44,268

$11,000

$13,000

$13,000

Heart bypass

$210,842

$94,277

$10,000

$12,000

$20,000

Heart-valve replacement (single)

$274,395

$122,969

$9,500

$10,500

$13,000

Hip replacement

$75,399

$31,485

$9,000

$12,000

$12,000

Knee replacement

$69,991

$30,358

$8,500

$10,000

$13,000

Gastric bypass

$82,646

$47,735

$11,000

$15,000

$15,000

Spinal fusion

$108,127

$43,576

$5,500

$7,000

$9,000

Mastectomy

$40,832

$16,833

$7,500

$9,000

$12,400

* Retail price and insurers' costs represent the mid-point between low and high ranges
** US rates include at least one day of hospitalization; international rates include airfare, hospital and hotel

Source: Medical Tourism: Global Competition in Health Care, National Center for Policy Analysis, November 2007
http://www.ncpa.org/pub/st/st304/st304.pdf

Wait Time to get an Appointment in Seven Countries

Percent of adults who waited 6+ days for an appointment to see regular medical doctor

Canada

30%

United States

20%

Germany

20%

United Kingdom

12%

Australia

10%

Netherlands

5%

New Zealand

4%

Source: Fixing the Foundation: An Update on Primary Health Care and Home Care Renewal in Canada, January 2008
http://www.healthcouncilcanada.ca/docs/rpts/2008/phc/HCC_PHC_Main_web_E.pdf

Percent of adults who waited 6+ days for an appointment to see regular medical doctor

Canada

30%

United States

20%

Germany

20%

United Kingdom

12%

Australia

10%

Netherlands

5%

New Zealand

4%

Source: Fixing the Foundation: An Update on Primary Health Care and Home Care Renewal in Canada, January 2008
http://www.healthcouncilcanada.ca/docs/rpts/2008/phc/HCC_PHC_Main_web_E.pdf

Access to “Medical home”* Among Adults in Seven Countries, 2007

Australia

Canada

Germany

Netherlands

New Zealand

United Kingdom

US

59%

48%

45%

47%

61%

47%

50%

*Medical Home: Has a regular doctor or place that is very/somewhat easy to contact by phone, always/often knows medical history, and always/often helps coordinate care

Source: Toward Higher-Performance Health Systems: Adults’ Health Care Experiences In Seven Countries, 2007
Health Affairs, October 2007
http://content.healthaffairs.org/cgi/content/full/26/6/w717

Out-of-Pocket Expenses for Medical Bills in the Past Year in Seven Countries

(in U.S. $ equivalent)

Australia

Canada

Germany

Netherlands

New Zealand

United Kingdom

United States

None

13%

21%

9%

38%

12%

52%

10%

$1-$100

11%

17%

17%

15%

17%

12%

9%

More than $1,000

19%

12%

10%

5%

10%

4%

30%

Source: Toward Higher-Performance Health Systems: Adults’ Health Care Experiences In Seven Countries, 2007
Health Affairs, October 2007
http://content.healthaffairs.org/cgi/content/full/26/6/w717

Mortality Amenable to Health Care in Selected Countries*

Deaths per 100,000 population

Country

1997-98

2002-03

France

76

65

Japan

81

71

Spain

84

74

Australia

88

71

Sweden

88

82

Italy

89

74

Canada

89

77

Netherlands

97

82

Greece

97

84

Norway

99

80

Germany

106

90

Austria

109

84

Denmark

113

101

New Zealand

115

96

United States

115

110

Finland

116

93

Portugal

128

104

United Kingdom

130

103

Ireland

134

103

*Deaths from certain causes before age 75 that are potentially preventable with timely and effective health care.
Source: Measuring the Health of Nations: Updating an Earlier Analysis, The Commonwealth Fund, January 2008
http://www.commonwealthfund.org/usr_doc/1090_Nolte_measuring_hlt_of_nations_
HA_01-2008_ITL(web).pdf?section=4039

 

Cost-Related Access Problems in Seven Countries, 2007

 

Australia

Canada

Germany

Netherlands

New Zealand

United Kingdom

United States

Percent in past year due to cost:

Did not fill prescription or skipped doses

13%

8%

11%

2%

10%

5%

23%

Had a medical problem but did not visit doctor

13

4

12

1

19

2

25

Skipped test, treatment or follow-up

17

5

8

2

13

3

23

Percent who said yes to at least one of the above

26

12

21

5

25

8

37

Source: Health Care: Solutions Without Borders, The Commonwealth Fund
http://www.commonwealthfund.org/aboutus/aboutus_show.htm?doc_id=597055

For More Information:

Global Health Resource
www.globalhealthresources.com

 

Tuesday
Apr222008

What's the current state of things in the Convenient Care Industry?

By Clive Riddle

After attending two sessions on retail medicine at the World Health Care Congress today, here's what we found out:

John Agwunobi, MD, EVP Professional Services for Wal-Mart shared the following statistics for Convenient Care visits at Wal-Mart locations, through their various contracted providers:

  • adults comprise 79% of visits, 21% of visits are for children
  • 55% of patients have no insurance coverage
  • Patient surveys indicate, had the Wal Mart convenient care location not been available, 40-50% of patients would have seen a primary care physician; 20-35% of patients would have used an urgent care facility; 10-15% would have gone to an ER; 5-10% would have foregone treatment
  • 90+% of patients indicate overall satisfaction
  • 25-40% of visits are for immunizations & screenings; and 60-75% of visits are to treat common illnesses

Doctor Agwunobi also discussed the Wal-Mart $4 Generic Prescription program, which is offered to all Wal-Mart customers and is proactively promoted through the Convenient Care locations. The program involves 361 generic prescriptions covering up to 95 percent of prescriptions written in the majority of therapeutic categories. Nearly 30 percent of $4 prescriptions are filled without insurance. The $4 prescriptions now represent approximately 40 percent of all filled prescriptions at Wal-Mart.

Web Golinkin, President and CEO, of RediClinic discussed RediClinic customer experiences, noting that RediClinic is a partner of Wal-Marts. Mr. Golinkin is also President of the Convenient Care Association and shared the following insights regarding the Association and industry as a whole:

  • There were 150 clinics when the Convenient Care Association founded less than two years ago to more than 950 today nationwide, with 1,500 projected by the end of 2008.
  • Overall, the clinics have treated more than 2.5 million patients in 36 states
  • Surveys indicate 16% of consumers have tried a clinic and between 34 to 41% say they intend to

Golinkin stated the potential obstacles or events that could slow industry growth would be if:

  • The industry suffered future systemic clinical quality issues
  • A shortage and/or increased cost of Nurse Practitioners (NPs) and Physician Assistants (PAs) occurred
  • If various states continue with additional regulatory impediments (clinic licensure requirements, restrictions on NP/PA scope of practice and prescriptive authority, physician oversight requirements, corporate practice of medicine prohibitions, etc.)
  • If increased Operator/business model failures occur. He noted that there have been some failures, commented that this should be expected with any industry having relatively lower barriers to entry but higher ongoing working capital requirements. He felt there will be a shakeout with consolidation.

Michael Howe, CEO of MinuteClinic, states their organization's strengths include:

  • They are "Right Size” engineered for efficiency and high quality
  • Proprietary Electronic medical record system embedded with standardized “best practice” protocols
  • Facilitates measurement of results and continuous quality improvement
  • Interoperability drives continuity of care back to the Medical Home
  • Consumer friendly - with convenient locations in consumer pathway, and “Lifestyle conscious” hours and “walk in” scheduling
  • “High touch” capability of practitioners drives compliance
  • Patient Referral system facilitates the creation of “Medical Homes”when lacking

He cited an independent external research study conducted by Market Strategies in April 2007 indicating a patient satisfaction rate, as well as the percent likely to recommend, of 97%. He noted that MinuteClinic adheres to national standards of practice guidelines, (which have been adopted by their Association) but also is the first retail health care provider to be Joint Commission accredited.

Howe also cited a peer reviewed study from September 2005 through September 2006 of 57,000+ MinuteClinic evaluations of acute pharyngitis, looking for outcome measures to include adherence to best practice treatment guideline in presence of negative or positive RST, use of back up confirmatory strep culture testing in presence of negative RST, and documented rationale when antibiotic was prescribed in presence of negative RST. The study indicated an overall adherence rate of 99.15%.

Monday
Mar312008

e-Visit Data

By Clive Riddle

Patient online e-visits, introduced at the start of this decade, continue to gain momentum as technologies improve, consumer demand increases, experience from prior pilot studies becomes more widespread and major health plans advance and adopt e-visit initiatives. Here's a collection of some recent data on e-visits, compiled in MCOL's March @How-TO newsletter:

  • Trinity Clinic in Whitehouse, Texas, reports e-visits average five minutes, compared with 15 to 20 minutes for comparable office encounters, and averages one to two billable e-visits per month per doctor (1)
  • Medfusion, an e-visit vendor, has process half a million e-visits for about 2,500 physicians during the last three years (1)
  • McKesson's Relay Health, an e-visit vendor, charges physicians $25 per month per doctor for use of the web visit tools (2). RelayHealth, has 15,000 subscribing physicians (3)
  • Manhattan Research survey results found 31% of physicians reported using some type of online communication with their patients in the first quarter of 2007, up from 24% in 2005, and 19% in 2003 (3)
  • "National surveys suggest that the majority of online consumers now desire e-mail access to their physician and are willing to pay about $25 for an online consultation. A recent Wall Street Journal Online/Harris Interactive Poll found that 62 percent of patients said the ability to talk to a physician electronically would affect their choice of doctors and a Harris Interactive poll conducted in 2006 found that 74 percent of patients would like to use e-mail to communicate directly with their physicians." (3)
  • "A recent Kaiser Permanente study of patients who used the medical group’s secure e-mail system between 2002 and 2005 to access their physicians found that they phoned their physicians nearly 14 percent less than did patients not using the system, while each doctor averaged about two e-mail messages per day." (3)
  • "A two-year study of a pediatric rheumatologist’s e-mail and telephone interactions with 121 patient families, published in last October’s Pediatrics, found that the physician received an average of 1.2 e-mails per day, while answering patient questions by e-mail was 57 percent faster than using the telephone." (3)
  • "75% of patients polled in the 2007 WSJ/Harris poll reported that their doctor does not currently offer e-Visits or other e-services" (4)
  • "Blue Shield of California has estimated that the use of online patient-provider communications tools by its members will save the organization $4 million a year in office visit claims." (4) 

(1) Demand for e-visits grows but uptake still sluggish
Managed Healthcare Executive, November 1, 2007
http://managedhealthcareexecutive.modernmedicine.com/

(2) Physicians diagnose their patients via mouse calls
Akron Beacon Journal, March 10, 2008
http://www.statesman.com/life/content/life/stories/health/03/10/0310housecalls.html

(3) Online physician communication 
Physicians News Digest, March 2008
http://www.physiciansnews.com/cover/308.html 

(4) e-Visits:The Tipping Point - Are We There Yet?
Rhondda Francis, TransforMed, 2008
http://www.transformed.com/e-Visits/e-Visits_Are_We_There_Yet.cfm 

Monday
Mar032008

Online Consumer PHRs in MicrosoftLand and GoogleLand: Winning Hearts and Minds

By Clive Riddle

Quest Diagnostics Inc. and Health Grades Inc. announced this week that they will partner with Google to provide patients online access to their diagnostic laboratory records and rating information regarding hospitals and physicians. Google also provided further information this week on its Google Health PHR initiative.

There has been much attention given to Google's announcement last week regarding their PHR  pilot initiative with the Cleveland Clinic. Google Health is being designed to "assist providers to create a new kind of healthcare experience that puts patients in charge of their own health information." The Clevland Clinic pilot involves an invitation-only opportunity for a targeted patient group of between 1,500 and 10,000 that are among Cleveland Clinic's more than 100,000 patients currently using their PHR system called eCleveland Clinic MyChart. The pilot "will test secure exchange of patient medical record data such as prescriptions, conditions and allergies between their Cleveland Clinic PHR to a secure Google profile in a live clinical delivery setting. The ultimate goal of this patient-centered and controlled model is to give patients the ability to interact with multiple physicians, healthcare service providers and pharmacies. The pilot will eventually extend Cleveland Clinic’s online patient services to a broader audience while enabling the portability of patient data so patients can take their data with them wherever they go — even outside the Cleveland Clinic Health System."

The Associated Press reports that the profiles will be protected by the same password required to use other Google services such as email. The previously available beta Google Health login screen stated: "With Google Health, you can: * Build online health profiles that belong to you; * Download medical records from doctors and pharmacies; * Get personalized health guidance and relevant news; * Find qualified doctors and connect to time-saving services; * Share selected information with family or caregivers"

Meanwhile, what' s going on with Microsoft's HealthVault initiative? Sean Nolan, the Chief Architect for HealthVault, opened a blog on that topic last month: http://www.familyhealthguy.com . He uses an interesting term: "we spend a bunch of time thinking about how to increase what we call "data liquidity" (a term only an engineer could love) -- how do we create pipes that let people easily and securely move data back and forth between their Vault and primary care doctors, specialists, hospitals, pharmacies, and so on, all under their consent and control." Sean states that "Microsoft will make the complete HealthVault XML interface protocol specification public. With this information, developers will be able to reimplement the HealthVault service and run their own versions of the system." Microsoft also just received publicity for its announcement to fund $3 million to outside parties to research and develop online tools to improve health. There has also been considerable discussion, in the wake of these announcements, regarding privacy concerns as consumer use these tools.

Microsoft, received less publicity, but may be making more of an impact, for its just announced accelerated push towards interoperability with its HealthVault PHR platform. Further down the page in Microsoft’s just issued press release, they stated that “the company will release HealthVault XML interfaces under the Microsoft Open Specification Promise (OSP). The OSP is a simple and clear way to help developers and solution providers working with commercial or open source software to implement specifications through a simplified method of sharing of technical assets, while also recognizing the legitimacy of intellectual property. Further reinforcing the company’s commitment to open interoperability, Microsoft is hosting a HealthVault community open source project — an implementation of the HealthVault API wrapper for the Java development environment — on Microsoft CodePlex, Microsoft’s open source project hosting Web site. This will be the first of many projects designed to make it easier for developers and solution providers to use the language and framework of their choice to deliver HealthVault-compatible applications.” What does all that technical jargon mean? That Microsoft has shifted, at least somewhat, from its historic total proprietary system stance, to a more open system that encourages interoperability. This should bode well for HealthVault, and PHRs in general.

Of course that PHR stakes are most definitely limited to Google and Microsoft. Steve Case's Revolution Health Group, Aetna, WellPoint and almost 200 other vendors are involved in this space. But, the Microsoft, Google's and other large vendor announcements have been greeted by privacy concerns in some corners. Gannett cites "Greg Sterling, an analyst at Sterling Market Intelligence in San Francisco, calls Google's initiative a 'good idea.' But, he adds, 'The problem and the challenge arise in the context of consumer privacy and data security.' " Also this week, the World Privacy Forum issued a report "Personal Health Records: Why Many PHRs Threaten Privacy". The report concludes that a number of PHR vendors, are not truly "covered by HIPAA", but rather tout that they are "compliant with HIPAA", which the report notes, could be subject to change. The report notes concerns that PHRs not covered by HIPAA include: Health records could lose their privileged status; records could more easily subpoenaed by a third party; and Information in some cases may be sold, rented, or otherwise shared.

What may be more significant in the long run, is the ultimate interoperability of these initiatives. If we want to simplify health care, technology must be a partner. But technology can become an obstacle if it consists of endless disparate tools and proprietary systems that can’t relate with other. Unfortunately, the latest survey and report on this topic indicates we're no where near close where we need to be. The California Health Care Foundation (CHCF) recently released three reports on Health Information Technology (HIT) adoption, regarding: HIT adoption and use in California; national HIT perspectives; and open source systems. Detailed information and downloads are available at http://www.chcf.org/press/view.cfm?itemID=133554

Jonah Frohlich, CHCF senior program officer, tells us "HIT can play a significant role in preventing medical errors, giving patients the appropriate level of care, and making health care more efficient. HIT is not a cure-all for what ails our health care system, but where it is used, it has helped support better care." CHCF points out that California has the highest rate in the nation for MD use of electronic health records (EHRs): 37% compared to 28% nationally. Still, that means the leading state, the home of Silicon Valley, barely has one in three doctors properly wired. According to their study, 'The State of Health Information Technology in California', "the larger the medical practice, the more likely it uses EHRs. Some 79% of Kaiser Permanente physicians reported using EHRs, followed by 57% of patients in large practices of ten or more physicians. But EHR usage dropped considerably among small/medium practices (25%) and solo practitioners (13%)."

In another CHCF report, 'Gauging the Progress of the National Health Information Technology Initiative: Perspectives from the Field' author Bruce Merlin Fried states "despite President Bush's 2004 plan to ensure that most Americans have interoperable electronic health records by 2014, the vast majority of practicing physicians, those who practice alone or in small groups, are no closer to using HIT now than they were three years ago."

Blogger Dana Blankenhorn gets it right in the ZDNet Healthcare blog: “In the context of the medical market, however, Microsoft’s process seems more reasonable. This is less about gaining the trust of consumers than it is about winning over doctors, hospitals, and payment processors.” In other words, this is about winning the hearts and minds of doctors, hospitals and payment processors, which requires interoperability.