Just Read: Fee-For-Service, While Much Maligned, Remains The Dominant Payment Method For Physician Visits

The title says it all. From the current issue of Health Affairs (@Health_Affairs).

Note that the study looked at actual visits booked by physicians so it doesn’t capture payments made to physicians for patients who didn’t visit.

It can be a confusing world when a health professional is trained and emotionally incented to be rewarded for health but not physically/financially. That confusion doesn’t exist in integrated care, where as Ezra Klein (@EzraKlein) so eloquently put it in the Weeds Podcast recently:

Thanks to Health Affairs for hosting the briefing around physician practice yesterday in Washington, DC

Fee-For-Service, While Much Maligned, Remains The Dominant Payment Method For Physician Visits0426
Fee-For-Service, While Much Maligned, Remains The Dominant Payment Method For Physician Visits0426 (View on Flickr.com)

Just Read: In DC, there’s up to a 14 year life expectancy gap between blacks and whites that hasn’t changed in 15 years

The life expectancy of a black male in Washington, DC as of 2009 is the same as a man in North Korea as of 2012. For a white male, the life expectancy is higher than Israel, lower than Switzerland.

Sources: World Health Organization; Harper S, MacLehose RF, Kaufman JS. Trends In The Black-White Life Expectancy Gap Among US States, 1990-2009. Health Aff. (Millwood). 2014;33(8):1375–82. View Life Expectancy World and DC – Male – 46576 on Flickr.com

The life expectancy of black females in Washington, DC as of 2009 is in between The Russian Federation and Syria or Iran as of 2012. It’s higher than North Korea, which is 73 years. For white females in Washington, DC, it’s just below the highest life expectancy in the world, Japan.

Sources: World Health Organization; Harper S, MacLehose RF, Kaufman JS. Trends In The Black-White Life Expectancy Gap Among US States, 1990-2009. Health Aff. (Millwood). 2014;33(8):1375–82. View Life Expectancy World and DC – Female – 46577 on Flickr.com


This article caught my eye because of my recent trip to Anacostia, in Washington DC’s Ward 8, where health disparities are extremely tangible (underscore): The People of Washington, DC’s Anacostia are Building a Culture of Health | Ted Eytan, MD

They are not just tangible in Anacostia, they’re visible on my walk to work through the city, where I pass through about 8 years of life expectancy. Just do a search of “#activetransportation” on my Twitter feed to see photos of what this looks like; it’s obvious.

This paper, published in this month’s Health Affairs (Harper S, MacLehose RF, Kaufman JS. Trends In The Black-White Life Expectancy Gap Among US States, 1990-2009. Health Aff. (Millwood). 2014;33(8):1375–82) is an analysis of the disparity in life expectancy between whites and blacks in all 50 states and the District of Columbia, using census data.

It confirms what I see on my walk to work, and adds another piece of data that I don’t see, which is that this disparity has continued, unchanged, for the last 15 years:

The estimated state-specific racial gap in life expectancy among males in 1990 ranged from 14.4 years (95% CI: 13.3, 15.4) in the District of Columbia to 0.0 years (95% CI: −5.2, 5.3)

For females, the District of Columbia and New Hampshire also had the largest (10.4 years; 95% CI: 9.5, 11.2) and smallest (1.2 years; 95% CI: −3.9, 6.2) gaps, respectively, in 1990. In 2009, despite overall improvement at the national level, the enormous racial gap in the District of Columbia remained almost completely unchanged for both males (+0.4 years; 95% CI: −1.1, 1.8) and females (+0.2 years; 95% CI: −1.1, 1.6). Life expectancy there remained dramatically more unequal than in every other state.

And then if you compare the change in life expectancy for women (men show the same trend), it’s been constantly disparate since 1990.

And then there was New York

New York State has shown a different trajectory, as you can see from this chart. There has been a massive upgrade in life expectancy for black men and women compared to their white counterparts, narrowing the gap the greatest.

The largest decrease in the gap for males occurred in New York (−5.6 years; 95% CI: −6.0, −5.1), largely because of a dramatic increase in black life expectancy, from 63.9 years to 75.4 years. This was a gain of 11.5 years; the national average gain was 6.5 years.

I’ve written about this previously (New Yorkers Living Longer Than Ever, Outpacing National Trend, a look at the data | Ted Eytan, MD). It’s real. And since I’ve written about it, a review of what happened in New York has been published just this year (Preston SH, Elo IT. Anatomy of a Municipal Triumph: New York City’s Upsurge in Life Expectancy. Popul. Dev. Rev. 2013). A lot of New York’s success has come from identification and treatment of HIV, as well as the same for drug and alcohol related injury/death. It’s worth a read for sure.

Our cities are changing, we just need to make the change happen for all

A few more really important DC datapoints:

  1. Population in 1950: 802,178
  2. Population in 1990: 606,900, 70 % black
  3. Population in 2010: 601,723, 50 % black
  4. Population in 2013: 646,449

In this map you can see where the black and white population live. The green color represents black residents, the blue represents white residents:

You can grab and manipulate this map yourself at the continually awesome CommunityCommons.org (@CommunityCommon)

I cross the “dividing line” in the middle when I walk to work. Ward 8 (Anacostia) is in the lower right. Every other map you could draw, from bikeshare rentals to income to education is going to show the same disparity. With this visual, it’s not hard to tell why an “enormous” disparity still exists between black and white people.

I still see proclamations of Washington, DC as the “third thinnest” state, which badly misrepresents the huge disparities here and harms our ability to understand the health of our community.

Why this is not good

There is good news, which is that life expectancy for both black and white men and women has increased in Washington, DC (by 4+ years for both black and white women, by 8+ years for black and white men).

A significant inequality still exists and that’s a problem. This means that the opportunity of black men and women to achieve their life goals starting with a long life is blunted compared to white men and women.

Diversity brings with it a torrent of innovation. If this trend does not change, we’ll learn less every day, and enjoy our community and the world a lot less. And why would we want to do that?

We share our community with incredible leaders who don’t support the status quo:

I’m with Ruby. We are going to change everything ๐Ÿ™‚ .

Permission to reproduce the images courtesy Health Affairs (@Health_Affairs)

In the future, patients and families will help design and govern the health system. We’re from the future.

@KPSanDiego innovates. Dr. Susan Mahler and Dr. Jeff Benabio with Susan’s daughter Patricia, TEDMED, 2013 (View on Flickr.com)

A patient on a governance group for workforce Information technology? Yes!

For some reason, I haven’t posted about the fact that I am part of the National Quality Forum’s (@NatQualityForum) Patient and Family Engagement Action Team. We first got together in February and now it’s August.

I am also part of an effort at Kaiser Permanente to envision the future of health, AND at the same time an exciting part of my job is that I’m the medical partner to the Senior Director of Kaiser Permanente’s Digital Workforce Group, Melina Linder. The Digital Workforce Group exists to help the Kaiser Permanente workforce connect and collaborate, as part of the Digital Services Group, which also produces the world famous kp.org.

How does all of that come together?

For me, to a place where I envision the (not “a”) health system of the future as being one where patients and families are involved everywhere, from individual treatment experiences, to design, governance and policy.

There’s a great paper that reviews all of this: Carman KL, Dardess P, Maurer M, et al. Patient and family engagement: a framework for understanding the elements and developing interventions and policies. Health Aff. (Millwood). 2013;32(2):223–31.

We shouldn’t say patients should only be involved in governing parts of the health system that touch them in certain ways. Every part of the health system touches them. I grew up in a health system where member governance is not the exception, it’s the norm (@GroupHealth, you know, the magical health system of the future, in Washington State).

A member (patient) on the Digital Workforce Executive Governance group: Susan Mahler

(Dr.) Susan Mahler is an exceptional person, as exceptional as any one of our 9.5 million members. She has been an educational leader for 35 years, and is now a health system leader in her role as Kaiser Permanente member. Let’s allow video to do the teaching…

As she says, she is also the recipient of a heart transplant, and she is here today because of excellent medical care.

Earlier this year, we asked her to become a member of the Executive Governance group for Kaiser Permanente’s Digital Workforce Group. She said yes!

It’s a journey

I would not be telling the truth if I said, “everyone instantly saw the value of this idea.” I am telling the truth when I say, “everyone said, let’s try it,” because we work in a place where we understand what it means to be there for our members, and…our DNA is a powerful force for good :).

We actually thought about this for awhile – why should a patient helping to govern a group that primarily serves the workforce? Couldn’t she serve purpose better elsewhere? Maybe; however, who does the workforce serve? And as another leader, Gilbert Salinas, BS, MPA told me when I asked him about it (and I will never forget what he said):

Health systems have patient happiness committees and employee happiness committees. They should all be the same committee.

I created this short slide show for my colleagues and also showed it to colleagues on the NQF team, to show the impact of having members involved at the level of governance and more importantly the impact of not having them involved. The story of Mid-Staffordshire in England is beyond sad.

Kaiser Permanente happens to have a Patient and Family Toolkit available to the organization internally. I am working to see if it can be made more widely available, because it covers so many of the basic questions people have about making this happen. Susan herself has been engaged with Kaiser Permanente at multiple levels in the extremely innovative KP San Diego (@KPSanDiego) service area. This includes being part of several unit-based teams, which connect the workforce in solving problems for our members. Voila.

It’s happening + this is the future

So Susan is now with us as part of the team. When we speak of things “Digital Workforce” this includes technologies, tools, and people that enable our workforce to finance and deliver care. There are a lot of acronyms. A lot of systems. A lot of organizations and departments coming together. Susan asks awesome questions, and is patient in the not knowing what she doesn’t know.

The only downside/fear I have in all of this is that she is too much of an examplar. Will people expect every patient and family leader to have the same skillset and background? Not every patient who will design systems with us will. Will some patient and family leaders not work out? Sometimes. We deal with that with our colleagues all the time, though, and there we celebrate the diversity. It will be no different here.

If I envision a health system 10 years from now, yes, there will be more technology, a different generation, sustainable buildings, food and transportation :), all awesome.

I want the health system to think about something that’s not new technology that will have just as much impact, if not more…. listening. When we think about the model of health, it won’t just be about what we do for or to the people we serve, it will be how we do things with the people we serve.

This is what Susan had to say when I asked her if it was okay for me to talk about her role:

Trust me when I say -“I’m loving it!!!” My background includes a music and drama major from UOP with dreams of becoming “discovered”…….however, I did get my teaching credential just in case it took some time…..Well – after doing some stints in summer stock – Starlight, Music Circus, and Melody Land……..I did head into the education arena and really never looked back……..I loved education – However, if I’d known that there was a bit of fame in my future – gosh – I might have had the transplant (that which started all of this) years ago! No – kidding aside……I am thoroughly honored to be part of this vision – the true partnership between Kaiser Permanente and its members (customers)……….I am here today because of Kaiser and so, with that, I’m absolutely here for Kaiser in every way possible……….thanks so much, Susan

I’d say maybe the cross-irony here is that it’s Susan who’s making Kaiser Permanente famous, for showing the world what happens when a health system makes an investment in our members through excellent coordinated medical care, and then supporting our members in investing back for millions of other people who will come after them. 9.5 other million at least ๐Ÿ™‚ .

PS Writing this blog post doesn’t mean that “I” did this. That’s never how these things happen. Thanks to a very supportive group of business partners including Melina, the Kaiser Permanente San Diego team, Arlene Pergamit specifically, all of the other members of the group who’ve welcomed Susan as a co-student and teacher, and all of the nurses, doctors, family, and community members who have helped Susan stay healthy so that we may enjoy this innovation in listening.

I love living in the future, don’t you? 

Seeing the future 45 years later at the Brookings Institution: CHF and Payment Reform

When I was at the Brookings Institution ( @BrookingsInst @BrookingsMed )with fellow Permanente physician, cardiologist Priti Sood, MD, for MEDTalk: Treating Congestive Heart Failure and the Role of Payment Reform | Brookings Institution, this quote immediately came to mind:

We believe any group of physicians, or a foundation working with physicians, can easily duplicate the Kaiser Permanente success….freedom of choice is important; we believe that the choice of alternate systems, including solo practice, is preferable for both the public and physicians. – Sidney Garfield, MD, Scientific American, 1970

It’s this one because I noticed how changes in our health system are inspiring physicians today to learn and grow as leaders.

I also thought of this image comparison, from yesterday (shown by Darshak Sanghavi, MD @DarshakSanghavi)

And one of Sidney Garfield’s diagrams, drawn more than 45 years ago:

“Rationally organized medicine” – Sidney Garfield, MD (click to enlarge)

In the diagram, the physician is sleeping, there’s a metaphysical spider web in their office because patients are now being cared for within a system of care, that includes prevention and sick care in the right amounts, on a foundation of pre-payment and integration. Hospitals and a sick care system still exist in this world, they are used and available when needed, and they are top notch, fit for purpose. Today, the spider webs are still metaphysical (no doctor is sleeping in their office today, far from it), and the system of care is today’s Kaiser Permanente.

The innovation at Duke University and University of Colorado can be found on the Health Affairs Blog here (see: Payment and Delivery Reform Case Study: Congestive Heart Failure – Health Affairs Blog) , the blog about Sidney Garfield’s innovation 45 years ago can be found here (Where we came from – Sidney Garfield, MD, 1970 | Ted Eytan, MD). Compare and contrast, the future is coming true :).

Dont’ forget about leadership

Larry Allen, MD, MHS, Cardiologist from University of Colorado, touched on this in his talk when he mentioned that the better way of providing care that was developed wasn’t instantly adopted by his physician colleagues – it required leadership and cultural humility on his part to protect change in the interest of patients. This is true regardless of the payment model. Aligned incentives are important (and great), they do not magically change behavior though, they facilitate good leadership. That’s the part of Sidney Garfield, MD’s diagram above that isn’t obvious to many who see it for the first time.

Patients included

As it says on their web site, the format yesterday was very “un-Brookings,” more modern, intimate and maybe exposed/vulnerable of all of the discussion leaders, including the patient, Lee Satterfield, who is really Lee Satterfield, the chief judge of D.C. Superior Court, also Lee Satterfield, cancer survivor and heart failure patient secondary to the use of chemotheraphy, stroke survivor.

If you click on the first link about Lee, you can see the last four years of his service, in photographs, to the people of our (awesome) District. It’s a very important reminder about our role to focus on people’s life goals and how health makes that possible. Sometimes that’s forgotten. In the ideal health system diagrammed by Garfield above, the physician earns their salary, the hospitals start to empty (or in reality get used when needed) when the patient is achieving their life goals.

I was so glad that in the final panel discussion – a short sojurn to the pre-modern Brookings Institution – that Mark McClellan, MD made a point to ask Judge Satterfield for his thoughts, because the patient voice often gets lost when they are the one “non-expert” on a panel:

I have to say what I say on here all the time for cermonial purposes, I see many analogies to health and health care in this statement ๐Ÿ™‚

You can watch the entire session here, and it’s embedded below. Thanks again for your time, Darshak, Brookings Institution, Judge Satterfield and our future health care leaders, including patients and their families.

Now Reading: Another way to listen, Video Ethnography

This paper, published by esteemed colleagues at the Kaiser Permanente Care Management Institute, describes results from a program that now includes 37 teams and 130 people, who have engaged in in-depth training to understand the real experience of patients and those who care for them using video:

This method is particularly effective in helping increase understanding of vulnerable people who are not well represented in ap- proaches such as focus groups and patient advi- sory councils—for instance, frail elders, patients nearing the end of life, and those with multiple chronic conditions. Video ethnography also helps in focusing on pivotal points in health care, such as transitions between settings.4

This is a real technique that complements work to involve patients in the design and operation of the health care system. I have previously posted the link to the CMI Video Ethnography Toolkit – you can find out more about this here: Now Reading: Getting Started in Video Ethnography – Tool Kit – Kaiser Permanente Care Management Institute | Ted Eytan, MD.

Showing a video of the patient experience does not replace involving patients in other ways, however it does bring information that doesn’t come from other traditional sources. In the paper, work to uncover why medication reconciliation was not as effective as it could be, even in a system with a comprehensive electronic health record is described. A dose of reality is contained within, which is that an EHR is not enough – the ability to lead, and listen must come along with it.

Medication reconciliation at patients’ homes, in which home health nurses tried to verify pa- tients’ medication lists, was inconsistent and not comprehensive. Discharge instructions often lacked specific details. Home health nurses were unable to access Kaiser Permanente’s electronic health records while in patients’ homes and did not have a definitive list for medication reconciliation.

In a post-EHR health care organization, which hopefully the entire United States health system will be one day, the need to learn faster will never stop.

At Kaiser Permanente, we use video ethnography at various stages of the quality improvement process to identify care gaps, unmet patient and caregiver needs, and effective practices. We also use it to communicate insights to clinical and administrative organizational leaders, identify improvement opportunities, and help build collective will for change.

Here’s a link to the press release with a short video about this work: Kaiser Permanente Finds Videotaping Care can Produce Rapid Quality Improvement | Kaiser Permanente News Center

Take a look. I hope to enroll as a student this summer in a Kaiser Permanente video ethnography course, it’s my last chance in the 2012 training season. Listening can’t be beat.

Now Reading: About today’s Health Affairs study, HIT, EHRs, and impact on test ordering

This study, being released to the public at the exact same time of this blog post, should generate healthy discussion about whether health information technology, fully implemented, is going to deliver on one of the biggest promises made: reduced ordering of unnecessary tests.

This paper should be read carefully. It is very well done AND it does not answer that exact question – it wasn’t intended to, read on.

It answers the question about the era of electronic access to test results and images by physicians and what that has done to ordering of lab and imaging tests across a national sample of office visits. It is not focused on a single type of organization, it uses a nationally recognized survey tool (NAMCS) and is written by nationally recognized authors, from a pretty good journal :).

I got to speak with lead author, Danny McCormick, MD, about his motivation to do the study and to see if I understood the implications correctly. Danny’s currently a physician at Cambridge Health Alliance (who I so enjoyed visiting previously), on the faculty of Harvard Medical School. ย He related his experience seeing the predictions of cost savings by the now-infamous RAND study in 2005 while he was serving under Sen. Edward Kennedy in Washington, DC, on an RWJF Fellowship. I remember that study, too, and its rosy predictions.

Danny wondered if test ordering might stay the same (and not decrease as predicted by RAND), and not only found that they stayed the same, but they increased proportionally for patient visits at practices where electronic test results and images were available.

Exhibit 2: A different odds ratio for visits in integrated care/HMO practices. Courtesy of Health Affairs.

Integrated care and Community Health Center care bucks the trend toward more tests

I asked him about a finding of interest to me, which is that in the models there are some exceptions, most notably for visits that occurred in the “HMO Office” setting, where there was statistically significantly LESS ordering of imaging compared to private medical offices. ย Same is true for visits that occurred in Community Health Centers. Again, care must be taken in interpretation – across visits in all places, 40 – 45% greater likelihood that imaging tests were ordered when results/images were available electronically, I am showing the part of the model that compares different practice settings within that overall result.

To the left is the part of the table, Exhibit 2, that shows this difference (reproduction of just this part permitted by Health Affairs). I recommend reviewing this table, and also Exhibit 3 in the same article, which shows the same analyses of just MRI, CT, and PET, where the HMO Office and Community Health Center visits do not show any difference from their private office peers.

Excerpt of NAMCS survey tool, from CDC website

The reason I equate the “HMO Office” category with “Integrated care” is because of the way the NAMCS survey is designed. If you look at it, this is clearly the category for physicians practicing at Kaiser Permanente – it says Kaiser Permanente right there on the survey.

Danny cautioned me, appropriately, that the numbers of visits in this setting were small compared to the other settings (paralleling the number of such visits in the United States). The statistical significance holds, but since this is a big picture study, we don’t know what’s going on in this setting compared to others, exactly, just that there’s less association with test ordering.

Lots of caveats

Here’s my list, feel free to add yours in the comments:

  • This is based on electronic access to test results not EHR use. Therefore it doesn’t really test education/alerts/prompts (aka “clinical decision support”)
  • This is based on 2008 data, which is an eternity in EHR terms – even if an EHR was in place, it’s unlikely it had good decision support and would have modulated physician ordering habits
  • If an EHR was present in the practice, it didn’t significantly alter the results (they did this analysis too).
  • We don’t know that more tests are a bad thing in all of these cases. For example, these systems may alert physicians to order preventive tests, like mammograms (see great example below). In the area of advanced imaging, there is a common problem of follow-up exams not being done. It’s possible that seeing the results of the last test that said, ย “need follow-up exam,” would cause necessary care to be performed.

HIT + Patient and Family Access + Leadership = SUCCESS

This is a helpful, well done study by a talented group of researchers.

I never banked on the predictions of the RAND researchers, because they did not include a key ingredient in the recipe – leadership. HIT + Leadership = success

The most important power of health information technology is what it does for patients and how it connects them to their health care. With an EHR, there’s an efficient way for patients and families to understand what’s going in their care and change the conversation from being recipients “in front of the counter” to understanding and helping to fix what’s behind the counter. It’s revolutionary in that regard.

With regard to leadership, I’ve shown Mary Gonzales’ story on here before, here’s a new one, from the Kaiser Permanente Care Stories Blog, about what happened when Dale Gordon went in for a swollen knee, a lab test was ordered, and his life was saved. This requires the use of technology, the leadership to make a difference in care using the tool, and the work to integrate it into a system at all points for our patients. So not more tests, not less tests, the right amount of tests, which is now possible – check it out: