Understanding the Supreme Court’s Obamacare Discussions

March 29, 2012 by Leave a comment

By Matthew Kopetsky

Monumentally important Supreme Court discussion regarding the future of our healthcare industry took place this week as the Affordable Care Act (ACA), nicknamed “Obamacare,” was debated. Unless you have four hours, 53 minutes, and eight seconds to listen to the recordings of the Supreme Court’s oral arguments, trying to interpret the outcomes of these discussions can be very confusing. Throughout the week, I attempted to boil down these discussions.

Day 1 (3/26/12): Does the Anti-Injunction Act prevent the Supreme Court from ruling on Obamacare until 2015?

  • Background:  What is the Anti-Injuntion Act? – A 1867 law which prevents anyone from challenging a tax until after it has been paid and a refund has been pursued
  • Key Issue:  Are the penalties for not having health insurance, which would be incurred under Obamacare, a “tax?” – If these penalties are deemed a tax, some argued that the Supreme Court can’t rule on Obamacare until after these penalties begin to be incurred (in 2014). This would likely delay a Supreme Court ruling until 2015.
  • Key Quotes:
    • “[in the wording of the ACA legislation], they did not use that word tax”– Justice Stephen Breyer (liberal)
    • “This is not a revenue-raising measure because, if it’s successful, nobody will pay the penalty and there will be no revenue to raise” – Justice Ruth Bader Ginsburg (liberal)
    • “” – Justice Clarence Thomas (conservative)
  • Possible Outcome:  The Supreme Court seems to consider these payments for not having health insurance to be “penalties,” not “taxes,” and therefore, will continue this week’s Obamacare discussions as planned

Day 2 (3/27/12): Is the Individual Mandate an over-reach of Congress’ power?

  • Background:  What is the Individual Mandate? – A provision in the Affordable Care Act which would require Americans to buy health insurance by 2014 or pay a penalty
  • Key Issue:  Does Congress have the power to require Americans to buy private goods (health insurance)? – Congress has the power to regulate interstate commerce and since the healthcare industry operates across state lines, it seems to fit this definition. However, the Supreme Court questioned where the “limiting principle” (limit to federal power) of the ACA legislation lies. Is healthcare truly a good that is universally required and would this ruling set a precedent for other similar industries?
  • Key Quotes:
    • “Can the government require you to buy a cell phone because that would facilitate responding when you need emergency services” – Justice John Roberts (conservative)
    • “Everybody has to buy food sooner or later. So you define the market as food, therefore everybody is in the market. Therefore, you can make people buy broccoli.” – Justice Antonin Scalia (conservative)
    • “It was a big fuss about that [Social Security] in the beginning because a lot of people said – maybe some people still do today – I could do much better if the government left me alone” – Justice Ruth Bader Ginsburg (liberal)
    • “It’s different because of the nature of the healthcare service. You are entitled to healthcare when you go to an emergency room, when you go to a doctor, even if you can’t pay for it.” – Justice Elena Kagan (conservative)
    • “The young person who is uninsured is uniquely, proximately, very close to affecting the rates of insurance and the costs of providing medical care in a way that is not true in other industries. That’s my concern in the case.” – Justice Anthony Kennedy (conservative)
    • “You can get burial insurance. You can get health insurance. Most people are going to need health care, almost everybody. Everybody is going to be buried or cremated at some point. What’s the difference?” – Justice Samuel Alito (conservative)
    • “” – Justice Clarence Thomas (conservative)
  • Possible Outcome:  Both conservative and liberal justices seemed to agree that Congress could require people pursuing healthcare to buy insurance but conservative justices don’t seem to believe that people can be forced to buy insurance before they have a medical need for it. Many are predicting that the five conservative justices (including Justice Anthony Kennedy who was originally thought to be a swing vote) will hold off the four liberal justices and deem the Individual Mandate in the law unconstitutional.

Day 3 (3/28/12):  Is the federal government’s “coercion” of state run Medicaid programs constitutional? If the Individual Mandate is found unconstitutional, can the rest of the bill still survive?

  • Background:  What is a severability clause? – A clause in legislation (or any legal document) which dictates which aspects of a law shall remain if any specific components are deemed illegal/unconstitutional
  • Key Issues:  (1) Is the federal government’s coercion of state run Medicaid programs – forcing states to expand their programs over six years to provide more coverage to uninsured/underinsured – constitutional? (2) Since the ACA lacks a severability clause, is it the Supreme Court’s responsibility to decide which aspects of the 2,700 page law shall remain? – Could the guaranteed-issue provision that no one can be denied coverage, the community-rating provision that you must charge people the same for health insurance, and/or Medicaid expansion survive individually?
  • Key Quotes:
    • “My approach would say if you take the heart out of the statute, the statute is gone” – Justice Antonin Scalia (conservative)
    • “Would you be making the same argument if, instead of the Federal Government picking up 90% of the cost [of Medicaid expansion], the Federal Government picked up 100% of the cost?” – Justice Elena Kagan (conservative)
    • “When you say judicial restraint, you are echoing the earlier premise that it increases the judicial power if the judiciary strikes down other provisions of the Act. I suggest to you it might be quite the opposite… We would have [created] a new regime [law] that Congress did not provide for, did not consider. That … can be argued at least to be a more extreme exercise of judicial power than striking the whole [law down].” – Justice Anthony Kennedy (conservative)
    • “” – Justice Clarence Thomas (conservative)
  • Possible Outcome:  The nine justices appeared sharply divided along ideological lines (five conservative and four liberal).

Like everyone else on the internet trying to interpret the Supreme Court’s discussions over the past three days, in reality, I’m likely wasting my energy. No one, except maybe justices John Roberts and Anthony Kennedy (considered to be possible swing votes), can predict what the June decision will bring.

Filed under Clinicians, Executives, Industry Trends Tagged with , , , ,

In Pursuit of Preventive Medicine

December 2, 2011 by 1 Comment

By Matthew Kopetsky

During grad school, I benefitted from the mentorship of one of healthcare’s masters of change, David Gustafson.  During his more than 40 years as a professor in the University of Wisconsin’s Industrial and Systems Engineering Department, he has directed the NIATx, CHESS, been the principal investigator of the TECC project, chaired the department, and found time to mentor, in addition to myself, two of my relatives.  I remember, during one of Gustafson’s guest lectures in a change management course, his account of the inspiration for the Network for the Improvement of Addiction Treatment (NIATx).  Instead of reading about addiction, he actually posed as an addict and actively pursued recovery, eventually checking himself in to rehab for several weeks.  The broken processes and unsupportive rehabilitation environment that he observed shocked him enough that he has dedicated decades of his life to improving them.

A few months ago, I accidently had my own Gustafson-esque inspirational experience as a consumer of healthcare.  It had been several years since my last physical and, as a healthcare consultant, I began to feel hypocritical not maintaining my own personal long-term health plan.  My intentions were noble – pursuing preventive medicine – however, the experience left me wondering why, despite my good health, that I even bothered.

Finding a PCP

A family friend Physician suggested that I pursue a Primary Care Physician (PCP) in my area who is known for being “great with young, healthy males.”  Unfortunately, due to my travel schedule, I’m only available for appointments on Fridays and he only saw patients Monday through Thursday.  So, since the Physician practiced within the network of a large medical teaching facility, the receptionist suggested that I see a Resident.  My appointment was made for the following Friday and I assumed that the all-important “referral” had just taken place.

Getting to the Appointment

Since I hadn’t received driving directions after making my appointment, I arrived (early) at the address listed on all of the pre-appointment paperwork that I had received in the mail and already filled out.  After many blank stares from the business office personnel who had sent me snail mail, I finally obtained the Resident’s number and learned that he was at an office on the other side of town.

The Appointment

Two hours after my appointment was supposed to occur, I was in an exam room with a Resident (and my boss was wondering why I still wasn’t back from my appointment).  The Resident asked me why I was there and, after I explained my desire to get a physical so that I could have peace-of-mind for another several years, he was shocked that I would get a physical in perfectly good health.  In response to being asked what I would like him to do, I suggested several things which I thought to be normal male physical protocol.

The Bill

Several months later, while enjoying my healthy peace-of-mind, I received my hospital bill for the charges which my insurance company deemed Patient Responsibility (~$200).  Then, a couple weeks later, I received the entire Physician Bill because my insurance company had denied the entire Physician balance, deeming the visit out of network (~$400).  So, after an inconvenient visit to a Physician for preventive reasons, I was left with a $600 bill and the quality of my health was exactly the same.  Unfortunately, most consumers don’t understand their insurance plan’s detailed Explanation of Benefits (EOB) well enough to know when charges are denied in error (in defense of consumers, I have had to review EOBs professionally and they can be very confusing).  Since I knew the referral for my care was legitimately from the office of my PCP, I pursued an appeal of the denied Physician charges.  After several phone calls, I was informed that I could either fax or mail a formal appeal of the denial decision to my insurance company (no e-mail since the process needed to be as difficult as possible).  After the fax number that I was provided didn’t work, I sent an old-fashioned letter and hoped that (in 4-6 weeks) my appeal would be honored (and my credit score wouldn’t be affected by my delinquent Physician balance).  Fortunately, the insurance company approved my appeal and paid nearly the entire ~$400 Physician balance.

 

What would Gustafson do?

“…hopefully by the time my loved ones need complex critical care, I will have solved enough of the simple issues that their healthcare experience will be more positive.”

Unfortunately, the healthcare industry hasn’t evolved into the most user friendly experience.  Even when consumers try to be proactive about their care, it is at the very least an inconvenience.  However, in my non-urgent care experience, there are many simple things that could have been handled differently which would have left me with a more positive experience.  The biggest positive outcome from my experience was a revitalizing reminder of what inspired me to enter the healthcare field – hopefully by the time my loved ones need complex critical care, I will have solved enough of the simple issues that their healthcare experience will be more positive.

Filed under Health Systems, Industry Trends, Young Professionals Tagged with , , , , ,

What’s Your Improvement Mantra?

November 18, 2011 by Leave a comment

By Tom Best

Even if you’re not a football fan, you’ve probably heard phrases like these before:

  • Our team just needs to “get a win”, and we’ll turn this program around!
  • Let’s prepare for “one game at a time”, and in the long-run we’ll end up on top!

Successful coaches have used such phrases to make seemingly impossible goals feasible.  I’ve also found these two phrases helpful in guiding healthcare improvement efforts.

“Get a win”

While many projects require long-term effort to achieve sustained improvements, we sometimes undervalue the benefits of a short-term “win.”

I once worked with a hospital to increase the reliability of their med and lab specimen transportation system.  The bulk of items were transported via pneumatic tubes.  To the frustration of many, tubes were often unavailable.  Hoarding tubes at each care unit only seemed to make matters worse.  As a result, many had deemed this problem too difficult to fix. 

To start the project, our team decided that I set aside an afternoon to walk from unit to unit, releasing any stockpile of extra tubes back into the system (with help from unit management). 

As you might guess, I wasn’t too excited to build a reputation as the tube police.  But, you know what?  The effort served its purpose.  Although the improvements to tube availability were short-lived, a primary goal of our project became crystal clear to unit management after only one afternoon’s work. 

To sustain improvement, we implemented an annual education competency for all clinical staff on the proper usage of the tube system.  But the initial walkabout was just the “win” we needed to get improvement started.  It effectively communicated our long-term improvement goals, and demonstrated that we were going to address this problem directly.

“One game at a time”

Another project aimed to reduce the frequency of mislabeled lab specimens.  While the definition of a properly-labeled specimen was practically universal, each care unit had a different set of challenges impeding proper labeling.  It was next to impossible to recommend one solution for all units; previous efforts along these lines had not fixed the problems.

Our team decided that labeling procedures throughout the hospital should be addressed sequentially, group by group.  We first analyzed data to identify departments with a high percentage of mislabeled specimens.  We then started working with one department at a time.  We used a standard framework to guide our efforts (i.e. the SEIPS Model) but the details of the approach were dependent on the situational factors, such as the initial level of leadership engagement and the current state of the unit’s labeling process.  During these efforts, we shared our progress with the rest of the organization, highlighting the improvements that resulted in the areas we had visited.

There is a word of caution when applying the “one game at a time” mantra.  If misinterpreted, it can produce unsustainable improvements.  In our context, after moving to the next unit’s specimen labeling procedures, the team still needed to periodically circle-back with previously-visited units to ensure the problems were permanently fixed.  Revisiting an area can be done efficiently if standardized data collection and reporting mechanisms are in place.

In closing, “get a win” and “one game at a time” are just two mantras that apply across multiple industries. 

What other phrases guide your healthcare improvement work?

Filed under Health Systems, Industry Trends Tagged with , , ,

The power of a question

November 10, 2011 by 1 Comment

By Todd Schneider

Often in improvement work, we rely on Lean tools, Six Sigma methodologies, classic Industrial Engineering methods, etc.   However, perhaps we often overlook one of the most valuable skills of a change agent – Asking questions. 

Most often, improvement professionals are not the subject matter experts in the clinical or operational area in which they are improving.  This provides the perfect excuse to ask questions.  Sure, some questions are part of other tools or methodologies.  Obviously we ask questions when we apply the 5 Whys.  And it’s common to ask “what happens next?” when constructing a flowchart.  But do we ask the questions of “what if” or “why not” enough?  When done correctly, the questions asked are not so much for your learning, but instead to stimulate the group’s creativity and awareness.

 Several years ago, I was working with an organization that had been awarded a grant from the Robert Wood Johnson Foundation.  As part of the grant, the organization was provided technical assistance from the Institute for Healthcare Improvement (IHI).  One of the project teams was working to improve the care of the Acute Myocardial Infarction (AMI) patients, which typically present to the ER with chest pain.  At that time, there were two main goals the team was working to achieve: 1) Obtain an EKG within 5 minutes of arrival, and 2) Go to the Cath Lab and open the vessel within 90 minutes of arrival (commonly referred to as “Door to Balloon”).  We were reviewing this project with staff from IHI during a site visit.  During the discussion, Don Berwick, then President/CEO of IHI, asked a simple, yet important question.   “If I told you that a chest pain patient would arrive to the ER at 5:00 p.m. today, would you be able to meet the goals for Door to EKG and Door to Balloon?”  Almost immediately the team leader responded, “Yes, of course.”  Berwick responded, “Then go do it.  Get ready.  And if the patient doesn’t come at 5:00, keep waiting.  We know the patient will come.”

 The team did just that.  They figured out how to get the process right for that next patient.  That conversation was a pivotal turning point for this project team.  It helped them focus on how they could do it right once, and then figure out how to do that every time for every patient.  This organization went on to become an early leader in the care of the cardiac patient and several years later still referred to that moment as an important stimulus for their work.  It didn’t change their overall goal or even their general focus.  But it did re-frame the project, which allowed the team to look at the project from a different perspective.

By all means, we need to continue to use all the tools we have available, but we must not forget about the power of asking questions.  The questions may be simple; they don’t need to be complex or technical.  However, the questions should stimulate new ideas and help the team see the potential for new solutions. 

 Speaking of questions, have you asked a few today?

Filed under Clinicians, Executives Tagged with , , , , , ,

Applying Manufacturing Quality Paradigms to Healthcare in South Africa

November 4, 2011 by Leave a comment

By Maria Treurnicht

Quality management has played a vital role in the improvement of effectiveness and efficiency in the manufacturing industry. Over the past century the manufacturing industry has grown systematically in the way quality is understood and managed. The focus on quality and effectiveness in the manufacturing industry is largely a result of the competitiveness in this industry. Public healthcare, in contrast, especially in the developing world, is not driven by competition. Public healthcare could therefore benefit considerably from using quality management principles of the manufacturing industry. In this post I will discuss how different manufacturing quality paradigms correlate to South African public healthcare provision.

Custom-Craft Paradigm

This paradigm is best explained using the primitive example of a blacksmith making swords exactly to their customers’ specifications.  Kings and knights had their swords made to fit their exact specifications. The direct communication between the craftsman and the customer assured a high quality product and high customer satisfaction. Nevertheless, this time-consuming and costly process had a low production rate that made it infeasible for the general population to have custom-made swords. This paradigm closely correlates to private practice consultations where patients can make direct appointments with their GP. The quality of care received is of a high standard, but unfortunately these consultations have high cost implications and are time-consuming.

Mass Production Paradigm

Thanks to Henry Ford, assembly line manufactured cars and appliances changed the lives of the middle class of the world. Mass production of standardized parts allowed for almost continuous improvement of efficiency and reduction of real costs since the 1920’s. In 2004, the national antiretroviral (ARV) treatment program was launched in South Africa. This led to the introduction of many ARV clinics that specialize in ARV treatment to HIV-infected individuals. Another application of mass production in South African healthcare is the introduction of tuberculosis clinics and hospitals. Through specializing on specific treatments and thus improving their productivity, these clinics are able to implement lean processes. Therefore these mass production healthcare facilities are able to deliver services efficiently, while providing quality care to the large proportion of HIV patients in South Africa. However, in cases where a patient does not fit the typical profile, it is likely that the ARV clinic would refer the patient to a hospital. These patients are therefore examined twice, consuming unnecessary resources, similar to unnecessary production that is targeted as waste. Nevertheless, just like mass production reduced costs and improved accessibility for the broad population, the ARV clinics are effectively bringing basic healthcare to the broad population.

Mass Customization Paradigm

Mass customization is a paradigm that combines the custom-craft and mass production paradigms to produce products or services that have near mass production efficiency and simultaneously meet individual customers’ needs. The Primary Health Care model where patients visit low-level care facilities and are referred for specialist care could be argued as mass customization. The referral process contains elements of both mass production and custom-craft. Administrative processes during the referral are standardized whereas consultations are customized and specific patient need focused. Unfortunately the referral system requires transportation and accommodation, moving away from the manufacturing paradigm of sustained effectiveness, when moving from mass production to mass customization.

The introduction of telemedicine referrals in South Africa is playing a vital role in improving mass customization processes. Telemedicine, using Information and Communication Technologies (ICT) in patient referrals, reduces the need to transport patients between hospitals. Telemedicine could improve the quality of a consultation by including a remote specialist using ICT. The standardization of these telemedicine and other healthcare processes is the Industrial Engineer’s opportunity to play a similar role in healthcare as in the manufacturing industry, to bring quality care to the general population, specifically in the developing world.

Filed under Health Systems Tagged with , , ,

Patient safety: What if you can’t speak up?

November 1, 2011 by Leave a comment

Everyone in healthcare has stories of being silenced with a look or comment.  You need clarification, or think something might be wrong, and when you try to tell the physician, s/he snaps at you, or is sarcastic, or condescending.  In some cases, the physician may even be verbally abusive or threatening.  You quickly learn, at least with that physician, to keep quiet.   This can happen in any communication where there is a strong power differential:  between nurse or doctor and patient, between senior and junior healthcare professionals, between managers and their staff, etc. 

Still worse, many people have pointed out this situation to their manager or someone else in authority, only to be told to just deal with it, or to become labeled a complainer.  Or the manager may respond attentively and with concern, but then nothing changes. 

All of these situations work to stifle concerns healthcare professionals have about the quality and safety of patient care.  This is demoralizing:  your perspective is unimportant, you are not worth listening to.  You come to understand that the organization in which you work is not committed to quality and safety, but that the organization often chooses to protect the egos of powerful people (like physicians who are not employees but control a large revenue stream) over the safety of patients (and of other healthcare providers).    You are in a double-bind situation, and feel increasing stress and frustration. 

Yes, physicians are under tremendous pressure — but that’s when they are more likely to make mistakes, and more likely to need the situational awareness of the others on the care team to prevent these mistakes from harming the patient.  In a complex adaptive system such as healthcare delivery, where error-proofing is often not possible, we need to rely on the dynamic awareness of everyone involved in patient care to catch mistakes before they cause harm.  

Most physicians, and most managers and administrators, do not habitually intimidate people or dismiss their concerns.  But anyone can be under so much stress that s/he sometimes or occasionally responds this way. 

According to The Joint Commission, in Sentinel Event Alert Issue 40,

Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments.  Safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment. To assure quality and to promote a culture of safety, health care organizations must address the problem of behaviors that threaten the performance of the health care team.

Intimidating and disruptive behaviors include overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities. Intimidating and disruptive behaviors are often manifested by health care professionals in positions of power. Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions. Overt and passive behaviors undermine team effectiveness and can compromise the safety of patients.  All intimidating and disruptive behaviors are unprofessional and should not be tolerated.
. . .
Several surveys have found that most care providers have experienced or witnessed intimidating or disruptive behaviors.
. . .
Organizations that fail to address unprofessional behavior through formal systems are indirectly promoting it.

Lucian Leape, in an article about problematic physician behavior, notes that:  “Performance failures of one type or another are not uncommon among physicians, posing substantial threats to patient welfare and safety. Few hospitals manage these situations promptly or well.” 

So what can we do?

At the organizational level, the Joint Commission has already required that hospitals set behavior standards and implement a process for managing disruptive and inappropriate behaviors.  It has also made a number of further recommendations, including training, contractual provisions, non-retaliation, and leaders modeling appropriate behavior.   

At the individual level, Maxwell et al. use positive deviance to identify what enables some people to successfully speak up in spite of an environment that is less than fully supportive.   These include:  work behind the scenes if the situation is not urgent;  avoid provoking a defensive reaction; keep your own frustration and anger in check; explain your intention to help the caregiver as well as the patient. 

As the organizational culture begins to change, scripted interventions may be very helpful.  In one hospital, “Doctor, I have a concern…” was used as an indicator that something might be going wrong, and requesting the physician’s attention.  If that didn’t work, the same person would follow up by saying, “Doctor, I have a patient safety concern.”  Regardless of whether the concern is founded or not, perspicuous or misguided, the physician or other caregiver who is being questioned should always thank the person who raised the concern, in order to encourage this behavior in the future.  (This can be very hard to do when the concern is unfounded, and the caregiver is irritated — but it is crucial to remember that this is how we prevent our mistakes from causing harm.) 

In your organization, do all staff members have the skills they need to speak up tactfully?  Will they be encouraged to speak up, and supported when they do so?  Are the behavioral standards applied equally to everyone in the organization?  “Respect for people” is a pillar of the Lean approach.  Are hospitals that have adopted Lean more likely to encourage and support speaking up? 

Filed under Clinicians, Executives Tagged with , , , , , , , , ,

Diagnostic errors: a challenge for systems engineering

October 21, 2011 by Leave a comment

In a recent study of high-severity patient injury cases, the underlying cause was almost nine times as likely to be diagnostic error than medication error.  Furthermore, the injuries caused by diagnostic errors cost more than all other error categories combined.   So I chose this topic as generally important, but also a timely contribution to Healthcare Quality Week 2011 (for Twitter users, #hqw11).

AHRQ’s patient safety indicators, JCAHO’s sentinel event registry and IHI’s Global Trigger Tool don’t even include a category for diagnostic error.  Malpractice and autopsy cases may not generalize well, but they are the source of most of the published data.  In an AHRQ-funded study of physician-reported diagnostic errors, 28% of the errors were rated a major, resulting in patient death, permanent disability, or a near-life-threatening event. 

Detection of diagnostic errors is difficult, but estimates of their prevalence generally range from 5% to 15%, depending on specialty.  Causes of diagnostic errors include both systemic (poor training, poorly defined procedures, etc.) and cognitive (premature closure, representativeness bias, confirmation bias, etc.) .   I will write another post which discusses cognitive errors in more detail. 

What does all of this have to do with systems engineering?  First, systems engineers understand that the kinds of cognitive errors that contribute to misdiagnoses are themselves errors of systems design.  Extending the argument Donald Norman makes in his classic book, The Design of Everyday Things predictable human errors in using machines or objects are really design flaws.  Norman’s argument applies equally well to systems.   Second, we should design systems to reduce or eliminate errors.   Of course, the current “system” in which physicians work is, for the most part, not explicitly designed, which is a large part of the problem. 

If we want to design a system to reduce errors in medical diagnosis, here are some recommendations: 

  • improve feedback.  In some cases this involves creating feedback loops where none exist.  Many diagnostic errors occur in physician offices, and if the error is detected later in the treatment stream, the physician who made the error may never know.  The increasing use of EHRs provides great opportunity here. 
  • track and analyze diagnostic errors.  The information we have thus far about these errors and their causes may be skewed, and as we learn more, we can design our systems to mitigate or eliminate the causes. 
  • in some cases, elimination of error is not possible.  There may be tradeoffs between increased accuracy and delay in diagnosis, or between false positives and false negatives.  In these cases we should use our industrial engineering tools to try to find the optimal tradeoffs.    
  • technical support systems to correct for cognitive biases (such as premature closure, anchoring, and the availability bias) and lessen reliance on the memory of individual physicians.  These technical support systems can include information about base and temporally and geographically localized conditional probabilities, alternative diagnoses which should be considered, and perhaps even automated reading of radiological scans.  The particular tools chosen should focus on diagnostic errors with the greatest frequency and impact on patient outcomes. 
  • in cases where technical support systems are not an option, having review and input from other physicians can significantly reduce cognitive errors — especially confirmation bias. 
  • improve communication among everyone involved:  physicians, nurses, laboratories, patients, etc. 
  • in repetitive tasks, attentiveness declines as a function of the number of repetitions — so we should design work patterns and schedules to take this into account. 
  • educate physicians about cognitive biases and about best practices (as they evolve) in decisionmaking under uncertainty.

The measures of “correctness” should vary depending on the stage of the treatment stream.  As Mark Graber et al. point out, early in the stream the best measure would be inclusion of all clinically significant diagnoses, not simply inclusion of the correct diagnosis.  

The ultimate question is whether we have the will to tackle the problem of diagnostic error.  There are many reasons for its relative neglect thus far, but Thomas et al. in a recent article in the Archives of Internal Medicine suggest that business motives may be the underlying factor: 

Finally, though, we should ask whether the health care system will support interventions to reduce diagnostic errors. It has not done so thus far. It would appear that the health care system tolerates some background rate of errors, so long as practitioners or hospitals are not wild outliers.  There is little business rationale for improving diagnosis because most of the costs of diagnostic AEs are never uncovered and are absorbed quietly by payers. Money is made in health care by moving forward with ever more costly interventions, not by looking back at errors that could have been avoided.

The authors go on to suggest that this might change with the advent of ACOs and a focus on population health.  Any reform structure which includes accountability for health outcomes will have an incentive to analyze and reduce diagnostic error.  (Systems engineers should favor such structures anyway, because health outcomes should be the clear purpose of health care.)  So is there reason to be optimistic?  I welcome your comments.

Filed under Clinicians, Executives Tagged with , , , , , , ,

The History of Electronic Health Records (EHR)

October 12, 2011 by 1 Comment

By Matthew Kopetsky

Hippocrates mandated the first known medical records in the fifth centry B.C. so that records could be passed on to other physicians. 2400 years later, medical records went digital. Today, the Electronic Health Records (EHR) market is very complex (the Electronic Medical Records [EMR] market even more so). On a regular basis I try to help the Health Systems that I work with to determine if their current system is effective enough and which software program can provide their operational silver bullet. How did we get here? To better answer this question, I created the following timeline, summarizing the humble, yet revolutionary, beginnings of Electronic Health Records.

EHR History Timeline

The History of Electronic Health Records (EHR) Development Timeline

Sources:

  1. Epic Systems: An Epic timeline
  2. Problem-Oriented Medical Information Systems
  3. Medical Records that Guide and Teach (Weed)
  4. NASBHC – History of EMR
  5. NIH – Electronic Health Records Overview
  6. Computer Stored Ambulatory Record (COSTAR)
  7. Regenstrief Medical Record System (RMRS)
  8. The Medical Record (TMR)
  9. THERESA
  10. Composite Health Care System
  11. VistA
  12. Technicon Data Systems
  13. Allscripts
  14. eClinicalWorks News
 Readers: If EMRs have been around since the 60’s, why is it taking so long to fully integrate electronic health information management into the care environment?

Filed under Health Systems Tagged with , , , , , , , ,

Single-Payer Healthcare – Part 1: Benefits 
Reducing Waste in the Hospital Revenue Cycle


					

						

							August 19, 2011
															by 
																						2 Comments
																				

					


					
By Matthew Kopetsky


On 5-26-11, Vermont became the first state to sign a bill into law mandating the development of a statewide single-payer healthcare system.   In this two-part post, Tom Best and I will explore the potential implications of single-payer healthcare – both positive and negative.


Although the critical path in implementing Vermont’s new system (called Green Mountain Care) is estimated to be a minimum of six years, in my current world of hospital revenue cycle improvement, this development brings with it exciting implications for my good friend TIM WOOD:


T:  Transportation

Although most large payers today process claims and communicate with healthcare providers electronically, some small payers still require faxing, phone calls, or even mailing documents such as required medical records.  This inefficient means of communication could be eliminated and claims could instead be sent electronically to a single-payer.  Additionally, many payers rely on intermediary companies to produce Electronic Remittance Advice (ERA) files (835s).  These intermediaries provide 835s for numerous payers all in one bulk file and if delayed in processing payments, money from every payer could be delayed.  With one payer, there is less opportunity for variability in this process.  Finally, technical and procedural support could be much more readily available and in a closer physical proximity.  Healthcare providers would no longer have to work with out-of-state or even overseas support for claim processing issues.


I:  Inventory

By Little’s Law, a decrease in processing time will eventually result in an overall decrease in inventory in steady state.  If a single-payer is successful in achieving larger efficiency gains than individual payers are currently capable of, the volume of pending, Work In Process (WIP) claims will be reduced.  In practice, I have seen commercial payers averaging about 28 days from submission of a claim to actually paying it.  I have seen Medicare, however, average merely 19 days from submission to payment.  Whether Vermont is able to achieve these same processing times that have been achieved on the federal level is yet to be seen and will be explored further in the opposition article.





Payer
Timely Filing Claim
Submission Deadline		
Timely Filing Appeal
Submission Deadline		




Aetna
180 days
365 days




Beech Street PPO
90 days
90 days




Beech Street W/C
90 days
90 days




Blue Cross Healthy Families
90 days
90 days




Blue Cross MCS
180 days
180 days




Blue Cross
90 days
90 days




Blue Cross Non-MCS
180 days
180 days




Blue Cross Out of State
180 days
N/A




Blue Cross W/C
180 days
N/A




Blue Shield
180 days
180 days




Brown & Toland
180 days
N/A




Care Advantage
180 days
N/A




Caremore
90 days
90 days




CCN
N/A
N/A




Champus-Tricare/Triwest
365 days
N/A




Choicecare Humana PPO
365 days
365 days




Cigna
180 days
365 days




First Health/CCN
N/A
180 days




Greatwest/One Health
90 days
90 days




Health Net
180 days
365 days




Hills Physicians
180 days
180 days




Interplan
N/A
365 days




Kaiser
180 days
180 days




Multiplan
360 days
365 days




On Lok Senior
365 days
365 days




Pacificare Commercial
120 days
N/A




Pacificare UHC EPO/POS
120 days
120 days




Pacificare UHC HMO
120 days
180 days




Pacificare UHC PPO
120 days
365 days




PHCS
360 days
365 days




PHCS PPO
90 days
N/A




Physicians Foundation
N/A
180 days




PMGSJ
Follow Health Plan
Follow Health Plan




SJMG
60 days
N/A




SCCIPA
150 days
N/A




SCAN
180 days
365 days




SCFHP Medicare Advantage
120 days
N/A




Secure Horizons-UHC
120 days
N/A




Three Rivers Provider Network
N/A
180 days




UHC
180 days
N/A




Valley Health Plan Commercial
180 days
180 days




Valley Health Plan Medi-Cal
90 days
90 days





M:  Motion

The hundreds of payers that compete in the current healthcare world each bring with them shockingly different technological capabilities, payment contracts, expected reimbursement amounts, and processing requirements.  As one example of the standardization that hospital billing and claim follow-up offices would benefit from, a list of timely filing requirements for many of the current California payers is included to the right.  The difficulty in tracking the statuses of thousands of claims as they approach the hundreds of different timely filing deadlines would be streamlined under a single-payer system and healthcare organizations will collect many claims which were previously written off.


W:  Waiting

For healthcare organizations, following-up on claims pending hundreds of different payers (each with different contracts and requirements) is very time consuming.  A single-payer could maintain a single source of the statuses of all of an organization’s pending claims.  The availability of online claim statuses could greatly reduce the need to follow-up on claims and one day it could even become unnecessary.  However, this process change, while greatly simplifying hospital processes, places a much greater burden on the single-payer entity (Tom will explore this further in Part 2).


O:  Over-processing

With many payer contracts requiring different levels of detail for payment of a claim, excessive amounts of detail are often also provided unnecessarily to the less stringent payers.  For instance, a complete 100+ page medical record may be provided to a payer when only a small section of the record was actually required to process the claim.  This excessive work could be avoided because organizations would only have a single contract to adhere to.


O:  Over-production

Since tracking payers’ receipt of claims sent both electronically and hardcopy can be difficult, many claims are sent to a payer more than once before payment is actually received.  A single-payer will hopefully greatly improve this process.


Upstream from the revenue cycle, doctors would no longer be incentivized to issue unnecessary medical tests/treatment and overall cost of care will hopefully subside.  However, Vermont’s plans to curb preventative medicine and the legal ramifications of medical malpractice remain to be seen.


D:  Defects

Complex payer requirements, coupled with the ever changing world of procedure codes (ICD-10 will replace ICD-9 in the US on 10/1/13), can result in claims being billed to payers incorrectly.  Incorrect claims, and hence the need to send corrected ones, will hopefully be greatly reduced with a single-payer.


This article is continued in Part 2 – Opposition:  Don’t Scrap Multi-Payer Healthcare – Redesign it!




				


				

					

						Filed under Health Systems, Industry Trends
						Tagged with , , , 					

				


			


		
			


				


					
Single-Payer Healthcare – Part 2:  Opposition 
Don’t Scrap Multi-Payer Healthcare – Redesign it!


					

						

							August 19, 2011
															by 
																						1 Comment
																				

					


					
By Tom Best


A major difference between single- and multi-payer insurance is the level of choice.  The single-payer system significantly limits the health insurance options for individuals and companies.


I’m not saying anything new here.  Many of us acknowledge this difference.  Some of us are comfortable with sacrificing choice on this manner if that sacrifice leads to the better care for society and stalls or stops the rise of healthcare costs.


I emphasize the “if” in the previous paragraph.  In my opinion, that “if” is unrealistic:  I believe healthcare costs to society will not decrease and care will not improve by switching to a single-payer system.  A redesigned version of the multi-payer system has a better chance of achieving those goals.  TIM WOOD chimed in with some support:


T:  Transportation

The private and public development of useful digital networks for sharing health information between providers and payers is already occurring in our multi-payer system.  A single-payer umbrella would only help the adoption process if it (1) improved the results and/or (2) expedited the design and implementation when its valuable to do so.


    

  1. If any single-payer oversees the implementation of the networks, it will (at best) only introduce additional communication requirements between the entity’s oversight body and the developers.  At worst, the overseers will take some of the developers’ losses as their own (and redirect those losses onto taxpayers), stifle developer competition before the market determines the best option, and thus reduce the quality of the networks in the long run.
    2. 

  2. Instead of expediting the adoption of the networks by eliminating the payers who aren’t on-board, I agree with an indirect approach:  a third-party regulator incentivizes the current multitude of providers to utilize these networks.
    3. 



I:  Inventory

There are no guarantees that a single-payer system will reduce processing time or total WIP.  On the other hand, if the single-payer creates a bottleneck in claims processing (e.g. an approval checkpoint with limited capacity to quickly manage a large volume of claims), overall processing time may actually increase over the multi-payer model.  High processing variability would still be likely, since the volume of claims through a single-payer would require division of responsibility within the single-payer’s umbrella to address them quickly (e.g. state-level or city-level microcosms of the overall entity).


The leaders in a multi-payer system will find ways to reduce their own process inefficiencies if the market rewards them for doing so.  A single-payer system will only extend the current “top-down” incentives (e.g. P4P), and the rewards and punishments from these new incentives may or may not be necessary or realized in a less-regulated market.  Even a small payer may be able to process a particularly complex type of claim more quickly and effectively than a large payer, and thus capture enough of this market segment to remain viable as a company and benefit society with its superior service.


M:  Motion

To me, Motion is a reference to the activities of those completing the work, and Transportation references the movement of the work itself.  Both a single and multi-payer system will have similar potential for wasted Motion, since the single-payer would need a very large operating budget to satisfy the total demand of the multi-payer system.


In addition, true reductions in Motion waste will require a careful analysis in either payer system.  One way in which a governing regulator could be beneficial in this model is to provide a central network for expertise in addressing wasted Motion in this office environment.  Industrial engineers trained in Human Factors would be a good fit for this role.


W:  Waiting

In addition to the WIP arguments above, there are other reasons why Waiting (in its general sense) will increase in a single-payer system.  Without competition from other payers, it’s less likely that the single-payer can sustain a burning platform for improvement.  While the initial leadership of a single-payer system may be motivated to eliminate the current problems with claims processing, the lack of a third party also trying their best to make profit in the industry will make it very difficult for successive leaders to maintain the same level of effort and incentives towards substantial improvement.  As a result, society would have to wait a long time for these changes, especially if those changes were initiated only by a select few at the top of the single-payer’s long hierarchy.


O:  Overprocessing

The tendency in a single-payer system may be to eliminate some necessary variation in the claims processing work system, in favor of the simplicity and feasibility of “over-standardization” and a “single contract” like my colleague Matthew mentions.  If the single payer does eliminate necessary process variation, it may result in a simplified process, but the process might impose potentially unnecessary actions on a given claim (e.g. double-checks) just to satisfy the requirements of all the different original types of claims.  These unnecessary actions are (to me) the same as overprocessing.


O:  Overproduction

In a broad sense, overproduction is providing products or services where they are not needed or desired by customers.  In this sense, overproduction helps us define the universal coverage that may or may not be mandated by a single-payer system.  In my novice opinion, there are a variety of strong arguments for and against mandated, universal coverage, and it’s likely that a carefully designed compromise is the solution with the least waste.  Either way, it seems feasible to incorporate this compromise in a multi-payer system.


D:  Defects

Let’s step back from insurance claims processing and consider how we prevent defects in general.  There are three categories of defect detection (in order of their strength):  auto-correction, auto-shut-down, and warnings. 


It is difficult to develop a truly practical auto-correction solution, but such development arguably has a higher chance for success in an organizational structure with competition.  Even if the single-payer system manages to keep competition intact, they will likely increase the current level of supervision of those who develop the ideas, and decrease the means (e.g. $) for the competitors to test their ideas.  In summary, the single-payer can only further stifle the current pace of progress toward error-reduction in our already regulated multi-payer system.


Also read Part 1 – Benefits: Reducing Waste in the Hospital Revenue Cycle.


 


Conclusion


By Matthew Kopetsky and Tom Best


A single-payer system may succeed in simplifying the revenue cycle from a provider/hospital’s perspective by refocusing the need for process improvement and standardization on the single-payer itself.  However, the long-term success of either single-payer healthcare or multi-payer healthcare will depend on the ability to eliminate waste and pursue continuous incremental improvement.  If our nation’s healthcare can establish and sustain this burning desire for improvement in a single-payer, it may be successful.  If not, the spirit of competition that only a multi-payer healthcare system can bring may be required.




				


				

					

						Filed under Health Systems, Industry Trends
						Tagged with , , , 					

				


			


				
		

			
← Older posts