Monthly Archives: September 2009

The Best Care

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I’m at a conference at Harvard Medical School today, with various industry and policy luminaries. Federal CTO Aneesh Chopra and HHS CTO Todd Park were just speaking. Reginza Herzlinger is giving a talk right now. Clayton Christensen was here this morning. Gotta love Harvard, and I’ve got a number of thoughts which I’ll wrap into a set of posts over the next few days.

But until then, I wanted to draw out a single point that has recurred a lot in various conversations I’ve had over the last few days. Christensen brought it up again in his keynote this morning. It’s this: the best care for complex disease is delivered by groups of physicians who are coordinated with each other. That coordination comes from being in the same room.

Dr. Christensen’s example (from his book) is an acquaintance spent years looking for appropriate treatment for his asthma. Over several years he saw many different specialists, and they didn’t solve the problem. Then he saw the same set of specialists (different people, same expertise), all in the same room, after flying to Denver. And they figured it out in 30 minutes.

I saw something similar this winter after visiting a microvascular disease clinic at Massachusetts General Hospital. It was a volunteer effort, run on a Saturday morning, with 6 or 7 experience specialists and a few residents and fellows. They saw patient after patient, all of whom had been bouncing through the system – and more or less without exception, they knocked each problem down as fast as it came up.

So here’s a question for healthcare reformers and healthcare technology innovators. How can we create that same quality of care for everyone who has a difficult to diagnose condition?

A Final Word on Breach Notification

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The new data breach notification rules for covered entities and PCHR Platform providers go into effect on September 23 (for covered entities) and September 24 (PCHR Platforms and providers). There’s a nice wrap-up here.

One big change from the prior environment is that the business associates of a HIPAA covered entity are now directly covered by the rule. Previously, protections were extended by contract with the original CE. Practically, I don’t think this makes a huge difference, since the Covered Entities would have just gone back and renegotiated the existing agreements to share the notification burden. Extending those requirements through regulation probably even saves some money and lawyer time, since there’s now no need to go and revisit all of those agreements.

The final rule does, however, have a pretty substantial loophole. Notification is required only when there is a chance of substantial harm to the person whose data was released. And that determination is made by the covered entity. Obviously, there is a huge opportunity for things to go wrong here. But the opposite extreme – mandating disclosure at all times – would be overly burdensome and would also have the very negative side effect of scaring consumers who receive breach notifications for trivial things – their city and phone number were accidentally released to a contractor, who then had a laptop stolen while on vacation in Guatemala. Odds of harm to the patient are pretty close to zero, and putting the burden on them to worry about sophisticated identity thieves is not particularly fair.

So I don’t think they got this one entirely right. A public audit process might be the solution – all breaches need to be disclosed, and outside groups can choose to make a stink about situations where individual notifications should have occurred but didn’t. I suspect this would get behavior into line pretty quickly.

Cost Savings and Retail Clinics

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I’ve been interested in retail clinics for years. It’s a wonderfully simple idea: there are a range of conditions for which a doctor just isn’t the right tool for the job, any more than you need a trained engineer to change a light-bulb.  If someone has inflamed tonsils (pharyngitis), a urinary tract infection or an ear infection (otitis media – you’ll need the vocab for the next section) sending them to a physician or an emergency room makes no sense – you have an expensive provider delivering by-the-book care. And in the event that the patient has something serious masquerading as something common? They’ll almost certainly get the basic care anyway and end up coming back in later.

Retail clinics, such as CVS’ MinuteClinic chain, are intended to provide an alternative. Rather than going to the Emergency Room, you go to your local drug store, get checked out in a few minutes and are handed the prescription. If your condition goes off-script, they send you to a doctor or to the ER. The clinics are manned by nurse practioners or physician assistants, depending on the state, and supervised by a physician who may be off site.

Until recently we haven’t had much insight into the effectiveness of retail clinics. That’s beginning to change. In the current issue of the Annals of Internal Medicine, Ateev Mehrotra and colleagues analyze the long-term costs of care in retail clinics in Minnesota for the three conditions I listed above. You can read the abstract of the article here.  Here’s the summary:

Overall costs of care for episodes initiated at retail clinics
were substantially lower than those of matched episodes initiated at
physician offices, urgent care centers, and emergency departments
($110 vs. $166, $156, and $570, respectively; P < 0.001 for each
comparison). Prescription costs were similar in retail clinics, physician
offices, and urgent care centers ($21, $21, and $22), as were
aggregate quality scores (63.6%, 61.0%, and 62.6%) and patient’s
receipt of preventive care (14.5%, 14.2%, and 13.7%) (P < 0.05
vs. retail clinics). In emergency departments, average prescription
costs were higher and aggregate quality scores were significantly
lower than in other settings.

In other words – if a patient goes to the retail clinic rather than ER, the insurance company saves $460, and the patient gets care faster and suffers less discomfort.  The quality scores show that retail clinic customers do not suffer in terms of other healthcare services (such as scheduled preventive procedures) compared to those who seek initial care in a physician office.

As we like to say in healthcare economics, this is only an initial study. It’s biggest weakness is an inability to control for severity of the underlying condition – it’s conceivable that only healthier patients took a chance on the retail clinics, leaving the physician offices and emergency rooms to handle a much sicker group. I don’t think this is likely, however. With these three conditions it is difficult for the patient to judge severity when the disease presents itself. Minnesota is particularly well seved by retail clinics – it’s MinuteClinic’s home turf – so access issues are also unlikely to play a role.

In general, I think these are promising results, and they should help encourage insurance providers to reimburse for care delivered in the retail clinic setting. That should help with adoption – the market has not exploded, and MinuteClinic has even resorted to running some clinics seasonally.

Oh, and for those looking for an informatics connection: retail clinics tend to be pretty good at operating electronically and making patient data available to the patient upon request. MinuteClinic, again, was one of the early Google Health partners, and they’ve long seen electronic health information exchange as a key component of their integration with local health systems.