Hey Doc, Please go Away

Aaron Carroll,  over at The Incidental Economist,summarizes a study suggesting that patients do better when cardiologists are away at academic meetings.

High risk patients admitted with heart failure during meetings had a 30-day mortality rate of 17.5%, compared to 24.8% when more cardiologists were there. Cardiac arrest 30-day mortality was 59% during meetings and 69.4% at other times. 

Why is this?

There are a number of ways to interpret this. Maybe the best cardiologists were the ones who stayed home. Maybe with fewer cardiologists available, fewer invasive procedures get done, and that leads to better outcomes. Maybe they tell more low-risk patients to wait when fewer cardiologists are available, which gets the higher risk patients more attention and better outcomes. Maybe it’s something else.

I favor the second explanation and am reminded of the excellent judgment of my PCP back in 2007 when I was asked by the touring company to take a stress test before a two-week long kayaking trip to Patagonia.

She says, “No. I refuse to order a stress test for you.”

“Huh?” I reply intelligently.

“Here’s the deal,” she says. “If I order the stress test, our especially attentive (knowing who you are) cardiologist will note some odd peculiarity about your heartbeat.

 He will then feel the need, because you are president of the hospital, to do a diagnostic catheterization. Then, there will be some kind of complication during the catheterization, and you will end up being harmed by the experience.”

Minor ST segment changes, may be non-specific.

” I will not authorize a stress test.”

PPACA AND OUTPATIENT PROCEDURES

HealthCare LeadersMedia expects the Affordable Care Act to cause the number of outpatien proceures to increase for those opted-in for Medicaid expansion in the PPACA. And according to figures there is a spread seen as examined by state.   By 2015 California stands to perform 46 million outpatient procedures, while a state such as Texas (opted-out for Medicaid expansion) will decrease by 53 million cases.  (reported by Truven Health Analytics)   

These figures are further broken down by specialty. Two specialties which create a significant number of ambulatory surgeries, and among the top tier of expense are cardiology and orthopedics.  Medicaid opt-in vs opt-out produces some signifcant differences in reimbursement that outweigh numbers of cases.  The split per  specialty mirrors that of the total number gained or lost in 2016.  

Mental health services (Psychiatry) are already in short supply and  have previously been throttled by the lack of reimbursement by insurers.  PPACA has mandated an increase in these services as a covered benefit. For those states who are opted out the medicaid eligible population will suffer relative to states opted-in. Those who live in states opted-out of Medicaid expansion will not have access to insured  care for outpatient psychiatry services.

As expected the variance is greatest for California and Texas which are outliers in the data. In 2016 the volume of Cardiology cases in Califonia will increase by 672,000, while Texas will forgo 840,000 cases.  These figures also reflect population differences and the number of medicaid eligible patients in each state.

For orthopedic surgery California (opted-in) will benefit from over 299,000 outpaitent orthopedic cases, while states such as Florida and Texas (opted-out) stand to lose near 300,000 orthopedic cases.

The choice to opt-in vs opting out not only effects who will receive benefits in the eligible  population but will have significant effects on the hospital industry.  The number of outpatient surgerie outweighs the number of inpatient surgeries.  Using the present fee for service reimbursement rates under FFS hospitals have been advantaged by higher reimbursement reflected by higher cost.  The loss of coverage for medicaid eligible patients not only places them in jeopardy, it also creates significant differences in the infrastructure necessary to deliver these services.

Outpatient services in states who have opted-in will need a business plan to expand capacity which includes not only physical plant, but skilled workers, such as surgical techs, surgeons, expendables as well as revising operating schedules, reducing turn-a-round times and the like.

DME suppliers will reap these benefits in opt-in states.

The figures represent the number of cases gained vs the loss of gain by opting out. The opt-out numbers are a speculation, and do not represent an actual decrease in cases.  The number of procedure in any case will not decrease in states that have opted-out.

Increased demand for services always encourages efficiency and technical breakthroughs, to decrease loses and encourage profitability, much as occured with small incison cataract surgery and the development of small incision surgery in cardiology,general surgery and orthopedic surgery.

While ‘futurists’ attempt to predict the effects of the new law, serendipity and the butterfly effect should be expected.

This article also appears in Health Train Express, February 22, 2014. http://healthtrain.blogpot.com

The author also publishes at Digital Health Space http://digitalhealthspace.blogspot.com

If you wish subscribe, or follow  us  at our RSS feed

Technology Advances In The Clinic and Cost Savings

Eric Topol is on a mission to get health care out of the mess it’s in.

Topol is known for his sounding the  alarm about Vioxx a drug which was very popular but carried with it significant risk.

He’d had a busy morning seeing patients and, by about noon, was claiming to have already saved the medical system thousands of dollars using his iPhone and a pocket-sized ultrasound machine. Then he pointed to the stethoscope in his pocket and said he hasn’t used it in three years. “I should just throw it out,” he said. “This is basically a worthless icon of medicine.”.

This profound statment spoken by a cardiologist articulates what most physician's may already have concluded.  Topol is perhaps the most prominent advocate in the U.S. of how digital technology can lead to less expensive health care, and he invited me to see the savings in action. As we lope toward the exam room, Topol, slightly hunched and repeatedly turning to deal with questions flying at him from his staff, seems a little rattled by the commotion and barrage of demands, but a calm sets in the moment he enters the exam room. He folds his arms across his chest as a young colleague updates him on the patient’s history. Topol introduces himself to the 85-year-old man, who has been tiring easily as of late, and then the doctor immediately pulls out his iPhone.

Topol, who since 2007 has aggressively promoted digitizing medicine, does not check his e-mail, Google a fact, or call a pharmacy. Rather he slips what looks like a protective case onto the phone. The outside of the case has two oval, metal pads that are electrodes, and Topol asks his patient to place his thumbs on them.

“He’s bradyacardic without any good reason to be bradyacardic,” Topol says to his colleague, Hashim Khan, watching as a graph of blips rollercoasters across his phone’s screen. He looks at me. “We save $100 for every one of these we do.”  

The add-on to the iPhone is a $199 version of a hospital-grade electrocardiogram machine that sells for much more. By getting the reading of the heart rhythm himself, Topol says, he’s saved the patient from going to a special station with a trained technician who will spend 15 minutes hooking up wires.

The old ways of ultrasound:

Moments later, Khan pulls out a Vscan, an ultrasound device made by GE Healthcare that resembles a large flip phone. With Topol looking on, Khan squirts gel on the man’s chest and then scans his heart’s chambers with a wand attached to the device. “His function looks actually not so bad,” says Topol, adding that most doctors charge $600 to perform an ultrasound using a $350,000 machine. But Topol bills nothing when it’s done as part of a routine physical exam like this. “There are 125 million ultrasound studies done in the United States each year,” says Topol, shaking his head. He says “probably 80 percent” of those could be done with the Vscan at no extra charge.

Topol promotes the use of wireless technology for diagnostics. The savings will be enormous, not just in the capital required for instruments, but the efficiency and utilization of small handheld devices in the clinic, devices that can be carried in the doctor's pocket (or bag). Included in his 'deck of cards' are things like  another of Topol’s projects, a collaboration with Caltech, aims to put a wireless sensor into an artery. The sensor would be about a third of the size of a grain of sand, and will stay put and potentially detect an imminent heart attack. If it works better, it could prevent heart attacks—an outcome that Topol says doesn’t require a cost-effectiveness study, ZioPatch, a Band-Aid sized heart monitor that people wear for up to two weeks, can more readily detect heart arrhythmias than the clunky Holter monitor used for 50 years. Consider sleep labs. Topol says smartphone add-ons that measure oxygen use and pulses can diagnose sleep apnea without requiring someone to spend a night in a sleep lab, which costs thousands of dollars. “Talk about putting them out of business,” says Topol. “We can do a screening test which is basically free through a smart phone.”

Another of Topol’s projects, a collaboration with Caltech, aims to put a wireless sensor into an artery. The sensor would be about a third of the size of a grain of sand, and will stay put and potentially detect an imminent heart attack.

It is a 'brave new world" and these devices are only the beginning. Continuing miniaturization of processors, and new developments in materials,nanotechnology, chemistry and physics will drive innovation.  

These events will radicalize medical education.