HEALTH TRAIN EXPRESS
Mission: To promulgate health education across the internet:
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Flip a coin or guess is as good as the online web diagnosis sites.. This study from the British Medical Journal.
Researchers entered symptoms for 45 patients into the checkers, sourced from standardized vignettes used in medical student training (WBUR/Kaiser Health News, 7/9). The patients' conditions included:
Acute liver failure;
Bee stings;
Meningitis; and
Mononucleosis ("Shots," NPR, 7/9).
Study Findings
Overall, the study found about:
One-third of the sites named the correct diagnosis as the patient's first option;
51% of the sites named the correct diagnosis in their top three options; and
58% of the sites named the correct diagnosis in their top 20 options (Semigran,BMJ, 7/9).
Overall, researchers said the checkers were about as accurate as diagnoses made through primary care physician phone services, which usually offer insight on whether patients should seek urgent care. Further, lead author Hannah Semigran, a research assistant at Harvard Medical School, said the online symptom checkers were "pretty good at effectively directing people with an (emergency) situation to seek some kind of appropriate care, and to do so quickly" (Mozes, HealthDay, 7/9).
Comments
Ateev Mehrotra, one of the study authors, said the findings show patients should use symptom checker sites with caution (WBUR/Kaiser Health News, 7/9). He said, "People who use these tools should be aware of their inaccuracy and not see them as gospel. They shouldn't think that whatever the symptom checker says is what they have" ("Shots," NPR, 7/9).
Mehrotra added, "These sites are not a replacement for going to the doctor and getting a full evaluation and diagnosis.
Conventional print magazines, newspapers have weathered a sea-change in their business model.
And so has medicine and health process.
Health care financing, and administration also are struggling to change even as our current medical system is overwhelmed with increased expenses. The similarity between magazine process and health process are remarkably alike.
Prominent news publishers, such as the Washington Post, New York Times and many others went out of business at the same time re-inventing their 'product' in a more efficient manner. In some cases ownership shifted quietly behind the scenes. There were major reductions in staff, overhead and outright elimination of tasks that served no purpose or had been replaced by digitalizing the industry.
Even as this is occurring health organizations are burdened with daily organizations while being mandated by government, CMS, the Affordable Care Act, Insurers, and expansion of new covered benefits such as remote monitoring, telehealth and mobile health care. The uptick in expenditures for health IT is overwhelming many, both large and small. There is no room for error. During the past five years some large institutions spent millions of dollars to purchase EHRs only to find they could not perform as advertised. Providers, and hospitals did not know or have experience in systems that were new and untested in a real world setting.
Health care operated mostly on a cash basis until the birth of managed care, capitation, and other obtuse forms of risk management. In health affairs risk management used to have to do with risk of disease and/or treatments. Insurance companies were required to have an actuarial basis for setting premium rates against history of their insured disease risks.
Today this risk is carried not just by the insurance company, it has been shifted to hospitals and providers. Other calculations are being considered such as quality of outcomes, measured by re-admission rates to the hospital. The latest in the quirky world of health high finance is the 'accountable care organization. (ACO).
The name was coined by Elliott Fisher as a philosophical term during it's germination period. Theoretically the organization that saves the most gets a 'kickback' a larger reward incentive than the rest of the providers/hospitals.
The health care company of 2005 is gone. its processes, procedures and priorities would be nearly unrecognizable today. In fact, the medical practice that existed in 2010 is gone too. In a period of accelerated transformation, nothing is more striking than the scope—and pace—of change in the processes through which these companies engage their customers (patients) The very terms physician and patient devolved into provider and consumer. Physicians are no longer generalists or specialists they are primary care providers. It’s not just peripheral or incremental change, either. What the industry is going through in 2015 is a revolution in processes. In advertising, content creation, marketing, back-office functions and everything in between, what was done just a few years ago has been rendered obsolete, as new ways to interact with and serve stakeholders push the old ways into the trash bin. What’s changed is that technology is transforming every single phase of the business. It’s ubiquitous. It’s impacting the business on a wholesale level.” It’s a new world of “VUCA,” says Lenny Izzo, group president of legal media at ALM. “That’s an acronym for Volatility, Uncertainty, Complexity and Ambiguity. It’s an old military term Providers and hospitals have become 'punch-drunk' much like boxers and football players suffer from TBD or traumatic brain disorder.
Uncertainty comes in the form of new competitors. It comes with the decline in traditional branding-based display advertising, and the rise of new formats like cost-per-lead sales and programmatic advertising. Complexity comes in the form of tying together new expensive technologies that cross email, web, billing, production, ad-management, and content creation. Ambiguity comes in the form of not having the expertise to evaluate expensive new systems, and sometimes not knowing the right KPIs. Volatility? How about not knowing whether a new software system that cost $1 million will be relevant in 18 months?
This report is an on-the-ground look at process change in magazine media companies and how it’s affecting, well, nearly everything, from organizational structure and staffing needs, to assumptions about efficiency and newly essential skillsets. We’ll look at overall philosophies and approaches, and then explore, mainly through case studies, what publishing companies and executives are actually doing.
Radical changes in process are driven by several things, of course. But mostly, it’s a function of two things: emerging technologies that enable new methods of serving markets, and a quest within companies for efficiency driven by economic necessity.
The revolution in health is not just in health IT, it includes changes in medical group administration, payment reform, relationships between providers, hospitals and providers, referral patterns and a new dynamic between regulators, licensing boards and providers of health care.
Interestingly, for health provider and magazine publishers, there’s a significant paradox in process change. Because the business model is in a seemingly permanent state of flux, and because technologies become obsolete so quickly, both types of companies find themselves betting huge amounts of money on unproven ideas. “Maybe the paradox of process is that you’re forced to be hyper-efficient in the things you understand, to finance what you hope is our future,”
Note: Much of this article has been taken word for word from anaticle found on FOLIO an internet magazine about the publishing business. It was a simple task to substitute health for magazine or publishers.. A true example of 'convergence'
"Half of heart disease , for example, is preventable and related to five risk factors-f high cholesterol, hypertension, diabetes, obesity and smoking. Although the death toll has steadily declined over the past 30 years due to prevention and treatment measures, heart disease is still the leading cause of death in the U.S., causing one in every four deaths, or 610,000 deaths each year, according to the Centers for Disease Control and Prevention. Yet, about 80% of people reported exposure to at least one of the five risk factors. Getting them to change is a big challenge.
Research like this is giving us a better understanding of patient psychographics and what makes them tick, particulary when it comes to changing their behavior. Giving people data alone does not change behavior. For information to be effective , they need the tools to change and the motivation to do so. Until then, throwing data at doctors and patients might be an interesting way to try to make a few bucks, but it's unlikely to improve outcomes."
Sick care and disease prevention has become one big data management exercise. Patients are data sets and doctors are data managers. In addition, in the gap between the data and the doctor, are many others including data scientists, navigators, care coordinators, and, of course, the payers.intervention has to change but, in order for any of this to do any good, there needs to be an intervention based on identified risk factors and that behavior.
Reading information taken from data does not extrapolate to changes in behavior. It is that last mile that resists change.
If you took the time to take the test, you will get some understanding of why it's so hard to change human behavior and habits and why people don't. Simply put,we're all built differently, were brought up differently and have different approaches to changing our habits Gretchen Rubin is the author of several books, including the blockbusterNew York Timesbestsellers, Better Than Before, The Happiness Project and Happier at Home.
Atul Gawande M.D. is a well known physician-author. Soon after he began hisresidency, his friendJacob Weisberg, editor ofSlate, asked him to contribute to the online magazine. His pieces on the life of a surgical resident caught the eye ofThe New Yorkerwhich published several pieces by him before making him a staff writer in 1998.
A June 2009 New Yorker essay by Gawande[12] compared the health care of two towns in Texas to show why health care was more expensive in one town compared to the other. Using the town of McAllen, Texas, as an example, it argued that a revenue-maximizing businessman-like culture (which can provide substantial amounts of unnecessary care) was an important factor in driving up costs, unlike a culture of low-cost high-quality care as provided by the Mayo Clinic and other efficient health systems.
Gawande published his first book, Complications: A Surgeon's Notes on an Imperfect Science, in 2002. It was a National Book Award finalist, and has been published in over one hundred countries.[18]
His second book, Better: A Surgeon's Notes on Performance, was released in April 2007. It discusses three virtues that Gawande considers to be most important for success in medicine: diligence, doing right, and ingenuity. Gawande offers examples in the book of people who have embodied these virtues. The book strives to present multiple sides of contentious medical issues, such as malpractice law in the US, physicians' role in capital punishment, and treatment variation between hospitals.[19]
Are you confused yet ? I am. No one is telling me that my health and health care are better than it was twenty-five years ago. We've spent billions of dollars on improving our health system however today it is much more complex. We are told that knowledge has grown and readily available for the asking on the internet, and mobile devices. Interestingly television is not even on the map.
Medical education has shifted. At one time having an M.D. was sufficient (in addition to a specialty training program) however now an M.D./MBA carries more weight. It took me about 10 years of belonging to my own C-suite running a medical practice to earn my O.J.T. credentials. That in itself should be worth some type of certificate and/or CME credits.
Where do you go when sick ? Do you call your M.D, or seek an E.R. or urgent care clinic ? Perhaps you 'Google' your symptoms or disease for an answer.When and if secure email becomes readily available you can email your doctor for help.
Eventually your M.D. will see a pop-up notification from your EHR and/or PHR indicating you need an appointment. Then you will receive an automatic response with a time and date. There will be no or little human-human interaction. Once you arrive at the office you will sit down at a work station that weighs you, takes your pulse, BP, and temperature. A skin sensor senses your blood glucose and electrolyte levels as well as kidney and liver function tests.
Today we are not at that level, and are wandering in a sea of confusion about it all. Patients and consumers are overwhelmed, as most of we physicians are. No one quite know what technology to invest in that really matters or improves quality and/or outcomes. It seems to obsolete itself every five years or so, fueled by governmental regulations, and intense marketing by device manufacturers, or software vendors..
Meaningful use has devolved into meaningless spending.
John Lynn writes at EMR & HIPAA, which you can subscribe to here.
His topic gels with my own thoughts about Health Care Confusion.
As we continue our journey to change provider reimbursement to a “Pay for Value” system, the lines between health insurers and health care providers are blurring. Physician/hospital systems, like Partners HealthCare, where I work, are taking on risk for populations of patients through contracts with the Federal government and local payers. According to Secretary of Health & Human Services, Sylvia Burwell, this trend is going to continue. She stated recently that HHS set a goal of tying 85% of all traditional Medicare payments to quality or value by 2016 and 90% by 2018. Since the whole insurance industry is based on risk, we inevitably have to start thinking more like insurers if we’re going to be taking on risk. Sadly, I didn’t learn much. Not because I didn’t listen and not because the speakers were less than talented. I walked away feeling like I hadn’t learned anything because I felt I had gone to a foreign land and was listening to talks in a foreign tongue. I simply couldn’t decipher the health plan lingo.
Is this our inevitability, from Genesis? As the King James version of the Bible puts it: 4 And they said, “Come, let us build ourselves a city, and a tower whose top is in the heavens; let us make a name for ourselves, lest we be scattered abroad over the face of the whole earth.” 5 But the Lord came down to see the city and the tower which the sons of men had built. 6 And the Lord said, “Indeed the people are one and they all have one language, and this is what they begin to do; now nothing that they propose to do will be withheld from them. 7 Come, let Us go down and there confuse their language, that they may not understand one another’s speech.” 8 So the Lord scattered them abroad from there over the face of all the earth, and they ceased building the city. 9 Therefore its name is called Babel, because there the Lord confused the language of all the earth; and from there the Lord scattered them abroad over the face of all the earth.
At the highest level, it seems like we should be natural collaborators, as we bring very complimentary skills to the shared goal of building a health care system. As providers, we excel at understanding physiology, pathophysiology diagnosis and therapy. In most cases, we have strong relationships with the end users of the services offered, our patients, which often includes a high degree of trust. When someone’s doctor recommends a course of action, most people at least take it seriously and many often follow that path.
Payers, on the other hand, have always been challenged connecting with their members (you see, we are all a member, a consumer and a patient – all in different contexts – an example of the babbling). Payers excel at understanding risk and setting premium costs, something we as providers have no feel for. But if we’re going to take on risk, we’ll have to learn. Can these former negotiating foes come together to help improve your health? The current landscape does not lead to enthusiasm.
I’ll use some telehealth implementations as examples. Several national payers are adopting virtual visits as a tool for their members. For me, this is a dream come true! BUT, most payers are doing so in collaboration with one of the major vendors in the space and creating shadow physician networks to offer the service to their MEMBERS. When that member’s primary care doctor eventually sees them in the office, she will be puzzled that her PATIENT had an encounter via their health plan that she did not know about.
Walgreens just rolled out a virtual visit program as well. This could create even more confusion, as it brings in a new entrant — the pharmacy — into the battleground for that relationship. Will EMR interoperability solve this confusion? It certainly helps, but I’m also concerned about mixed messaging to the consumer/patient/member. It seems like we’re all fighting for your attention, which may lead to conflicting messages.
This reminds me of a time, about 25 years ago, when this new thing called disease management sprung up. Payers were frustrated by the cost of managing patients (members) with chronic illness. They got no help from providers, so they took matters into their own hands, hiring call centers staffed with nurses to contact patients/members with tips on how to manage their illness, and often sent generic brochures about high blood pressure and other conditions. Payers may have influenced the care of some patients/members, but no one was ever able to prove that this was an effective strategy.
There were numerous stories about patients receiving conflicting advice from these ‘disease managers’ compared to their own doctor’s advice, leaving patients confused. Doctors would get faxes from these same disease management companies and (perhaps arrogantly) throw them in the waste basket without reading them. As a result, the disease management industry collapsed in the middle to latter half of the last decade.
In the meantime, we now have workplace wellness programs, virtual visits offered by your health plan, retail clinics, virtual visits offered by pharmacies and — dare we forget — advice your doctor gives you, which should be more in tune with prevention now that providers are taking on risk.
See what I mean by a Tower of Babel? How do we fix it?
Adding to this conundrum we face increasing health information technology guiding consumers on another journey via a personal health record, a clinic portal, and numerous websites on disease, symptoms, and treatments.
In the near future "Watson" looms, a portender of artificial intelligence developed by IBM.
John Lynn concludes:
Joseph’s comparison to the Tower of Babel is a good one. The solution to all these new healthcare modalities is to make sure that everyone is speaking the same language. It doesn’t solve all of the problems, but it does help everyone get on the same page. I just hope that the business interests of many involved in healthcare don’t get in the way of this goal.
Who is practicing medicine really ? You are going to be surprised. The horse is out of the barn.
We only have about a million physicians in the United States — but they’re about to get reinforcements. I don't mean nurse practitioneers, physician assistants, or other "mid-level" providers. It's not Minute Clinics, either.
If you think about the CAT scan that an MD is using, if you think about almost any modern device that a doctor is using — it’s useless without the code in it. That code was likely written by someone without an MD, someone who was evaluated as competent and hired by a commercial vendor of mission-critical medical instruments. The instruments that represent the foundation of modern medicine are thus today typically programmed by people who know how to code (but lack MDs) and used by people who have MDs (but usually do not know how to code).
So a large percentage of medicine is already being effectively practiced by non-MDs.
Moreover, the interior workings of the instruments are black boxes; MDs interface with them through vendor-provided UIs and interpret the readouts by looking up data stored in their head. As these UIs get better and smarter, less interpretive skill is required by the MD. The MD is happier — the instrument gets the right answer with less work. It’s used more frequently. Through successively more sophisticated engineering the instrument thus begins to move from the hands of the specialist to the generalist to the nurse practitioner to the nurse… and then, perhaps, to the general population in the form of a phone accessory or an app.
That last step is starting to happen as various personal genomic, quantified self, and mobile diagnostic technologies become more accessible. These technologies produce data from the body, and that data is going to be stored in our phones. The interpretation of that data is going to be performed by software.
And so that large percentage of medicine that is effectively being practiced by non-MDs is going to expand.
One center of action is likely going to be the mobile programmable medical record — the container for all diagnostics and test results — something like what Apple’s HealthKit may evolve into. Essentially just a bunch of data containers for your heart rate history, your blood pressure history, your exercise history, and the like.
All this diagnostic history isn’t necessarily “big data”; it’s just never been tracked and cross-correlated before in one place. Once technologies like HealthKitget a little more traction, millions of software engineers without MDs can build new applications on top of that data store.
A report issued this week by the Government Accountability Office reports that the Centers for Medicare & Medicaid Services overpaid the Medicare Advantage program run by private health insurers by between $3.2 billion and $5.1 billion for the years 2010-2012.
The overpayments, according to GAO, were the result of CMS inadequately adjusting based on health status for members enrolled in Medicare Advantage.
Insurers who run MA plans are paid a set amount per beneficiary, adjusted by a risk score that calculates the expected consumption of health services in the coming year for each beneficiary.
In practice, the risk scores for beneficiaries with the same health conditions and with the same demographic profile should be the same. However, the GAO discovered in its analysis that coding differences between Medicare Advantage enrollees and those enrolled in the traditional fee-for-service Medicare plan led to “inappropriately high MA risk scores and payments to MA plans.”
Fraud, What Fraud?
The Medicare Advantage (MA) program was established in 2003 in order to incentivize health plans to provide better care for the elderly and control expenses in doing so. Nearly 16 million seniors are presently enrolled in MA, costing an estimated $150 billion in taxpayer’s money every year. The MA program has grown in popularity with Medicare beneficiaries because it has lower out of pocket expenses than traditional Medicare, offers more benefits, and fills some gaps in coverage.
Unlike the fee-for-service payment arrangement in traditional Medicare, where each service is billed directly to the government, Medicare Advantage plans receive a monthly, set capitated payment to provide care for their enrolled Medicare beneficiaries. However, health plans do receive a higher monthly capitated payment to care for sicker patients, based on the patient’s “risk score”. The risk score is determined by a variety of factors, but is primarily based on the patient’s Hierarchical Chronic Conditions, or HCC score, which are conditions tied to specific ICD-9 diagnoses. Risk scores are required to be backed-up by medical record documentation, but the government still has difficulty verifying each diagnosis. (no simple process)
While the problem of false or improper billing is essentially eliminated in the MA program, fraud remains an issue nonetheless. Recentinvestigationsby The Center for Public Integrity have highlighted some of the more egregious practices occurring in the Medicare Advantage program related to risk scores, which are not only damaging to the program’s reputation, but have also cost America’s taxpayers an astounding$70 billion since 2008. However, the most shocking part of their investigation is highlighting how little control the government has in reigning in this problem.
Research has shown that MA Plans exhibit greater “coding intensity” in documenting disease conditions, so that an MA enrollee’s risk score grows substantially faster than an FFS enrollee’s riskscore. Once Medicare enrollees switch from the traditional Medicare fee-for-service program to a Medicare Advantage plan, their HCC scores increase. Medicare Advantage plans contend that the higher scores are due to sicker patients, but without intense auditing, it is difficult to support or disprove that logic.
In addition to the diagnoses obtained from primary physician records, another method gaining ground among Medicare Advantage plans to bolster risk scores is viahome health visits. While home health services may legitimately uncover previously unknown medical conditions, more unscrupulous health plans may leverage home health visits as a tool to inflate risk scores, and thus increase their profits from these patients by thousands of dollars each year. Health plans argue that these visits improve patient care, but opponents claim they unnecessarily inflate costs without actually providing more medical services.
Health Care Financing, CMS and HHS have devolved to a dysfunctional chaotic state. The OIG reports these matters to Congress. So why do your legislators do nothing about it?
Perhaps it is because they are not smart enough to plan health care while running the rest of the government.
Prospective medical students MCAT test updated for first time in 20 years. Major new emphasis on social science students. Meaning of life, quality of life, Humanities weighted more heavily......21st Century Medicine
The invention of the ACO is associated primarily with one man – Dr. Elliot Fisher, director of the Center for Health Policy Research at Dartmouth Medical School.
Fisher’s statement that he can invent rules for assigning patients to doctors and doctors to hospitals is no more or less logical or useful than the statement by the inventors of the Kevin Bacon game that they can assign a Kevin Bacon number to virtually any actor.
Elliott Fisher, shown here with Dartmouth Atlas founder Jack Wennberg, is credited with coining the phrase Accountable Care Organization.
By Kip Sullivan, October 2010
The “accountable care organization” (ACO) is the latest fad in American health policy. It remains an unknown concept to the vast majority of the public, including most doctors, but it is all the rage among health policy analysts as well as lawmakers who sit on heath policy committees in Congress and in state legislatures.
Although the assumptions used by ACO proponents to justify ACOs have been around since the dawn of the HMO movement, the ACO label is relatively new. It was invented late in 2006 during a discussion at a public meeting of the Medicare Payment Advisory Commission (Medpac). The seminal article announcing the concept appeared in December 2006. By 2009 the ACO had become so fashionable among congressional Democrats it was mentioned in all three draft health care “reform” bills prepared by Democrats during the first half of 2009 (two of those bills originated in the Senate and one, the Tri-Committee bill, was written in the House). The ACO movement’s crowning achievement to date is the inclusion of ACO provisions in the final “reform” legislation – the Patient Protection and Affordable Care Act (PPACA)
The Affordable Care Act created a new kind of “cooperative” health insurance arrangement heralded by supporters of health reform. The co-ops were founded on the idealistic belief that community members could band together to create health insurance companies that would be member-driven, service-oriented, and would not have to answer to shareholders or turn a profit. But the 23 co-ops that were created had significant start-up costs, no experiential data upon which to set premiums, generally had to pay extra to lease physician and hospital networks, and had few people in the companies and none on their boards with insurance experience. The idealism has quickly faded. After receiving hundreds of millions of dollars in government start-up loans, most co-ops are surviving now on what remains of more than $2 billion in federal “solvency loans” and on the promise of future “shared risk” payments that are likely to produce only a fraction of the revenue co-ops have booked.
The History and Definition of the “Accountable Care Organization”
The definition of “ACO” bears a striking resemblance to the definition and history of “HMO,” a term coined in 1970. As was the case with the HMO, the ACO has been promoted primarily for its alleged value as a cost-cutting tool. Like the HMO concept, the ACO concept is vague and has multiple definitions which vary depending on who you ask. Like the HMO, the ACO is defined as an entity that will be “held accountable” for providing comprehensive health services to a defined population. As was the case with the HMO, “accountability” for cost will allegedly be achieved by shifting some or all of the insurance risk now born by insurance companies and public programs like Medicare to providers, and “accountability” for quality will allegedly be achieved by subjecting providers to report cards.
The principle difference between HMOs and ACOs, at least for the foreseeable future, will be their size. Whereas HMOs, like most insurance companies, generally have enrollees in the hundreds of thousands, the ACO has so far been defined as having a much smaller number of enrollees, possibly as few as 5,000 (that’s the minimum number of Medicare beneficiaries who must be in an ACO according to PPACA’s Section 3022). The other major difference between HMOs and ACOs, at least for the near term, will be the extent to which they bear insurance risk. Whereas HMOs function like insurance companies (they bear 100 percent of the risk that the premiums they charge will not be enough to cover all necessary services for their enrollees), ACOs will bear little or no insurance risk for the first few years. However, judging from published papers by Elliot Fisher and other proponents of ACOs, proponents want ACOs eventually to bear all insurance risk, just as HMOs have.
