JustCare

Tag: Quality

  • New online information sources to help you choose a doctor

    New online information sources to help you choose a doctor

    How do you find a doctor that’s right for you?  Most people still rely primarily on the advice of family and friends, and the recommendations of other doctors. But there are increasingly good sources of information online these days, including consumer reviews, ratings and databases that show doctors’ ties to drug and device companies.

    In late March, Consumer Reports released a new resource–ratings of primary care group practices in six states and two metro areas.  Even if you don’t live in one of the eight states where Consumer Reports has rated doctors (California, Massachusetts, Maine, Michigan, Minnesota, Ohio, Washington and Wisconsin), you might want to check out how they did it and the advice they give on finding a good doctor.

    In addition, the cover story of the May issue of Consumer Reports magazine is entitled “What You Don’t Know About Your Doctor Could Hurt You.” It probes the failure of government and the medical profession to stop bad or troubled doctors from practicing medicine, even after they’ve been caught.

    Consumer Reports is just the latest media outlet to release physician ratings.  The online media organization ProPublica, for example, used Medicare data to rate some 16,000 surgeons nationwide in 2015, with a focus on complications after surgery, as I reported on Just Care back in July 2015.

    ProPublica also provides a searchable database of doctors who have received payments and gifts from drug and medical device companies. A recent analysis by the group provides strong evidence that docs who take payments prescribe more expensive brand name drugs than docs who don’t take the payments.

    The Affordable Care Act mandated creation of the database, and drug and device companies are required to divulge the payments.

    Another recent web launch, Amino.com, says it can match you up with doctors in your area who have treated the largest number of patients like you—same condition, gender, and age range.  Like ProPublica, Amino relies on Medicare data that it says encompasses 890,000 doctors and other providers, four billion insurance claims, and 188 million people. It’s still early days for this site, but over time, it could be a valuable service.

    What about web sites that allow consumers to rate their doctors?   A 2012 study found that one in four Americans had consulted such a site.  They can provide a slice of useful information, but buyer beware: many doctors listed on such sites have been rated by fewer than 10 patients.  That’s not enough to generate a meaningful, statistically valid rating, experts say.  Thirty consumer reviews is a minimum.  In addition, there’s still concern that the sites can be gamed by doctors, although there’s no proof that’s widespread. In sum, you might want to check out these reviews, but you should not rely on them to pick your doctor at this point in time. 

    For those interested in exploring this topic in greater depth, the April issue of the journal Health Affairs has a batch of relevant articles.   You’ll see my article on provider ratings.

    Enhanced scrutiny of physician quality of care and treatment results—and the reporting of that to consumers—has been building slowly for years.  It’s poised to accelerate in 2016 and beyond.  And that’s a good thing for consumers.

    Here’s more from Just Care on choosing a doctor:

  • Shared decision-making about health care can mean greater patient satisfaction

    Shared decision-making about health care can mean greater patient satisfaction

    Over the last several years, an increasing number of doctors are helping patients make informed decisions about their treatments to improve the quality of their care. Rather than telling patients and their families which treatment they should get for a disease, infection or health condition, doctors are working with patients and their families to choose the right treatment for them. Because the Affordable Care Act encourages shared decision-making about health care, it is getting greater attention.

    Health-care decisions should be about people’s priorities and goals, given the risks and benefits of different treatments. What is most important to you? What are you most worried about? In the best cases, people or their health buddies ask questions of doctors about treatment options and take notes so that they can make an informed choice.

    Decision aids such as pamphlets, videos and web tools can also be invaluable in explaining and helping people understand risks and benefits of different treatment options. The degree of  detail needed is not well understood, though more detail can improve people’s understanding of options and give them greater clarity on their personal values. The evidence suggests that these aids may keep people from electing optional surgery and have no evident negative effect on health outcomes or patient satisfaction.

    Shared decision-making can also lead to better health outcomes. In the case of acute respiratory infections, helping patients understand the risks of antibiotics, which offer few benefits, has led to fewer antibiotic prescriptions, without an increase in repeat visits for the same condition or a decrease in patient satisfaction.

    Indeed, shared decision-making generally makes for more satisfied patients. UCSF is a leader in this area with its Patient Support Corps.

    Here are four questions to ask to help ensure your doctor is meeting your needs.  And, here’s why it’s important to have a good primary care doctor. Your satisfaction depends on it. Here are some tips on how to choose one.

  • Financial incentives not improving quality in hospitals

    Financial incentives not improving quality in hospitals

    Since October 2012, the federal government has been using financial incentives to reward or penalize hospitals based on the quality of their care. A recent GAO report reveals that these financial incentives are not improving quality in hospitals yet.

    It’s not evident that the financial incentives are significant enough to drive hospital behavior. The typical amount of the hospital financial bonus or penalty is quite small, less than one half of one percent of hospital income. And, a large number of hospitals have been focusing more on quality since long before the new government program went into effect.

    So, it’s not surprising that the GAO did not yet see meaningful quality improvements from this new initiative. Among other things. mortality rates have not decreased and patient satisfaction has not increased in the three years studied. Hospital readmission rates have dropped, but a separate government initiative with financial incentives may be responsible for that drop.

    GAO said that new improvements could come in the future.

    The Centers for Medicare and Medicaid Services believes that this is a long-term initiative. And, there are more changes to the incentive program in the works.  Time will tell whether the added incentives for the hospitals to improve quality will deliver long-term results.

    To learn more about how hospital quality incentives may drive up costs for people with Medicare, click here. And, if you’re planning for a hospital stay, be aware that all surgeons are not created equal. To learn more about how to find a hospital that provides good care, talk to your doctor, family and friends and check out the Informed Patient Institute web site, which has information and ranking on different hospital report cards. And, click here to find out why you should choose a hospital emergency room carefully.

  • Emergency room closures are hurting patient care

    Emergency room closures are hurting patient care

    In the 13 years between 1996 and 2009, the number of emergency rooms has dropped more than 6 percent to 4,594, while emergency department (ED) visits have increased by 50 percent to 136.1 million from 90.3 million.  And, a new Health Affairs study shows that these ED closures has led to an increase in the number of people admitted to an emergency room who die; specifically, people whose nearby emergency room has closed are at higher risk of death.

    In short, ED closures have hurt the quality of care at nearby emergency rooms.  Many of the emergency rooms that have closed had served low-income vulnerable communities, people likely to be Black, Hispanic and female, have Medicaid, be uninsured and in poor health. Patients from communities whose EDs have closed often have travel further to get to an emergency room. The nearby EDs who have taken on more patients as a result of ED closures have been operating over capacity, requiring patients to wait longer for treatment and demanding more of their already busy staff.

    The study reveals a five percent greater likelihood of patient death in hospitals affected by ED closures than at other hospitals. Patients who had heart attacks, stroke and sepsis had a 15 percent greater likelihood of death than patients at hospitals unaffected by ED closures. Patients admitted with asthma or COPD did not have a greater risk of death.

    Emergency rooms are required to take all comers. They cannot turn a patient away for any reason.  Back in 2007, the Institute of Medicine described Emergency Departments as “at a breaking point.” And, more have closed since then. The study suggests a closer look at whether we need more Emergency Departments in vulnerable communities and incentives that would keep more Emergency Departments from closing, including higher payment rates.  The authors further suggest that “it may be time to reassess the extent to which market forces are allowed to dictate ED closures and access.”

    The study looked at more than 16 million ED admissions but only at Emergency Department closures in California. About 12 percent of the US population lives in California, but it is demographically different from the rest of the country, with a much smaller Black population and a much higher non-White population.

    Click here for tips on how to choose your emergency room, and here for how to keep your emergency care costs down.  Click here for how to plan for a hospital visit, particular an emergency visit.

  • To promote patient safety, hospitals and doctors should disclose more information

    To promote patient safety, hospitals and doctors should disclose more information

    Transparency in health care can be a powerful tool for ensuring patient safety.  But, it is too often not taken into account when considering patient safety measures.  As a result, serious mistakes may happen in hospital or at the doctor’s office, and no one can learn from them. Or, a medical device, such as an artificial joint may have a design defect, and few people will know not to use it.

    Medicare collects and reports some important patient safety information, including how hospitals rank on two types of avoidable infections and eight different types of avoidable complications such as bed sores and blood clots.  It’s worth looking at this information to see how your local hospitals rank. And, Consumer Reports also offers some patient safety data. That said, there’s a lot of critical information that’s not available to the public.

    The National Patient Safety Foundation’s Lucian Leape Institute is working to promote the benefits of transparency in health care and to demonstrate that the risks are minimal. Its recent report, Shining a Light: Safer Health Care Through Transparency, offers dozens of recommendations for providers on everything from safety data collection, to building a culture of safety, affording patients good information to make informed health care choices, and sharing best practices with other provider groups.

    Transparency is hard to achieve because hospitals and other providers worry about how information that shows medical errors and poor quality can hurt reputation. People also can easily misinterpret some quality measures. For example, patients may be readmitted to the hospital because their condition worsened but people may wrongly assume it was because their care was poor.

    The Leape Institute demonstrates the benefits of disclosing safety information. The data suggests that disclosing medical errors has not increased malpractice suits or cost hospitals more as some may believe. And, one national pediatric hospital collaborative that banded together to identify the biggest harms and stress safety to improve performance were able to reduce serious harm by 40 percent.

  • Should you care whether a hospital employs its doctors?

    Should you care whether a hospital employs its doctors?

    A recent Kaiser Health News article notes that doctors who once practiced on their own are increasingly working for hospitals. The idea, at its best, is that doctors who practice in a group setting, like a hospital, can better coordinate care and improve quality of services for patients. At its worst, the hospital sees the doctors as a means to generate more revenue. Should you care whether a hospital employs its doctors?

    In September, Broward Health, a non-profit hospital system based in Florida that employs its doctors, paid $70 million to settle charges that it was improperly kicking back money to doctors for making patient referrals to the hospital. For decades, policymakers have tried to prevent such arrangements on the theory that they can encourage doctors to deliver more care than necessary, driving up costs and potentially harming patients.

    The question remains whether promoting good care has anything to do with how doctors are paid? Or, is it about the goals of the people directing and providing care. Broward’s goals appear to have been revenue-based. But, not all hospitals who hire their doctors share those goals.

    The Veterans Administration (VA) doctors are employees. Based on many studies comparing patient safety and health care quality under different payment systems, the VA offers “the best care anywhere.”  The VA has been lauded for giving systematic attention to appropriate treatment in ways other hospitals do not. It encourages a team-based coordinated care approach to care.

    That said, not only is there huge quality and safety variations among hospitals, but there can be large variations within a hospital or a hospital system. The Wall Street Journal reports that patient care varies widely at VA hospitals.

    So, how is a person to choose among health care providers? For good reason, the public is not focused on health plan quality.  And the various hospital ratings will at best tell you a piece of the hospital quality story. A lot of data is still not available. But, make sure you look at hospital infection rates.  Moreover, keep in mind that the quality of care delivered turns in significant part on the doctors who are providing care. For more information about the different provider ratings available through Medicare and elsewhere, visit the Informed Patient Institute.

  • Are hospitals driving up costs for people with Medicare to improve quality ratings?

    Are hospitals driving up costs for people with Medicare to improve quality ratings?

    In a new Health Affairs post, David Himmelstein and Steffie Woolhandler argue that Medicare’s pay-for-performance system might be doing more harm than good, when it comes to hospital readmissions. Hospital readmission rates are not dropping as much as the data might suggest. Rather, they say that while some hospitals have redesigned their systems to improve patient care pre-discharge so that patients do not need to be readmitted soon after, other hospitals have been gaming the system to make it appear so.

    Medicare’s new payment incentive system financially penalizes hospitals with high readmission rates. To meet quality standards imposed by the Centers for Medicare and Medicaid services, some hospitals have been reclassifying patient visits within 30 days after discharge so they do not count as readmissions. They either classify patients as outpatients, on “observational” status, or they admit these patients to the emergency room.

    As a result, hospital quality improvement is likely not as significant as the Medicare readmission data would suggest. What’s worse, hospitals that fail to “readmit” patients who have been discharged within 30 days may be penalizing those patients financially. Even if they remain on observational status for several days, they will be ineligible for Medicare skilled nursing or rehab services. (To qualify for Medicare skilled nursing or rehab coverage, patients must be admitted to hospital as inpatients for at least three days in the 30 days prior to getting that care.) And, their out-of-pocket costs could be significantly higher while in hospital.

    To support their claims, Himmelstein and Woolhandler reveal that hospital outpatient stays increased 96 percent in the seven years between 2006 and 2013. The rise in outpatient stays represents more than half of the decline in reported hospital readmission rates. There has also been a notable increase in hospital emergency department visits.

    Hospital charges are already sky high in most areas of the country. And, competition is not reining them in. Some purchasers are using reference pricing to bring them down.  Health economist Uwe Reinhardt makes the case for an all-payer payment system.

  • What price patient satisfaction?

    What price patient satisfaction?

    Several years ago, Richard Angelo, a nurse, was convicted of killing several of his patients. He was so well liked that he was able to poison at least 35 of them over several years before hospital administrators realized he was the murderer. Unfortunately, you cannot judge your health care providers by their bedside manners. Indeed, a recent JAMA study reveals that higher patient satisfaction is linked to greater drug and medical spending and higher death rates.

    This study suggests that new Medicare payment incentive systems that reward doctors and nurses for high patient satisfaction ratings might end up hurting patients. These incentives may lead providers to behave against their patients’ interests. They might, for example, fail to discuss all health care options with patients thinking that it will make them happier. Or, they might overtreat their patients, providing them with unnecessary procedures they request.

    A new study from the Hastings Center finds that a focus on patient satisfaction could hurt efforts to improve quality of patient care. The report notes that there are three ways to define patient satisfaction: 1. The patient received the care that he or she requested regardless of whether it was needed; 2. The patient felt that the doctors communicated effectively and looked after the patient’s comfort; and 3. The patient received needed care that improved the patient’s health outcomes. The first two definitions have no relation to whether the care provided improved the patient’s health.

    Of course, patient-centered care that is evidence-based can also lead to patient satisfaction. But, at this time, the satisfaction data does not distinguish between this care and care that is not patient-centered that leads to patient satisfaction.

    In sum, you may not want to give great weight to patient satisfaction data in choosing a hospital or a doctor or a nursing home. For sure, be aware that there is no clear link between patient satisfaction and good health outcomes.

  • How safe are outpatient surgery centers?

    How safe are outpatient surgery centers?

    Medicare now covers surgeries in some 5,500 outpatient surgical centers. Patients often like receiving care from these surgical centers because they say they are often more convenient than hospitals, they don’t have to wait as long for treatment and they get more personalized care. And, according to Consumer Reports, about 54 million surgeries are performed each year at these facilities. The question remains are they as safe as hospitals?

    Lisa McGiffert, who runs the Safe Patient Project at Consumer Reports questions their safety. Outpatient surgery centers like hospitals are breeding grounds for bacteria that can cause serious infections if the facilities are not kept clean. But, these centers tend not to be as tightly regulated or monitored to the same degree as hospitals. So, it’s not possible to know as much about what’s going on inside them.

    In addition, these centers may not have the safety equipment available at a hospital in case of an emergency such as a defibrillator and other lifesaving equipment. Moreover, they may not have staff with the level of training and skills to handle an emergency that are on hand in hospitals.

    Before getting care at an outpatient surgery center, do some research. Try to learn about the center’s infection rates. Make sure that the center is accredited, that your surgeon has experience with the procedure you are getting and that your anesthesiologist is board-certified.

    Right now, it may be hard to find good data on outpatient surgery centers. We should expect it over time. If you have a serious health condition, you may be better off getting your surgery in a hospital, because they are better equipped to address complications. (You should also choose your doctors carefully.)

    We are beginning to see more data rating hospitals, surgeons and doctors on a number of different metrics, including patient safety data from Consumer Reports.

    If you get treated in an ambulatory surgical center, be sure you understand what will happen after you leave. Leaving has its own set of risks if you are not prepared.

    The Agency for Healthcare Research and Quality is currently funding a 12-month patient safety program in which outpatient surgical centers can participate. And in 2014, Medicare began asking these centers for reports on quality, providing payment increases for those centers that comply.

  • For good reason, public not focused on health plan quality and price information

    For good reason, public not focused on health plan quality and price information

    A new Kaiser poll shows that Americans are not focused on health plan quality and price information when making health care choices. Only a tiny fraction of Americans say that they use this information to make health care choices.  In fact, this data really should not be driving people’s health care decisions. Most available price and quality data is not yet ripe for meaningful use.

    Ideally, people would be able to know whether particular doctors and hospitals were delivering value (good quality at a good price) and which health insurance plan would deliver them the health and financial security they need, with good access and predictable costs.  But, a public plan, like Medicare, with open access to doctors and hospitals and predictable costs, is not available to them through the health care marketplace.  And, data that adds value in choosing doctors is limited even for people with Medicare. It’s often unavailable. Indeed, few Americans–less than 20 percent–say they have seen comparative information about doctors, hospitals and health plans.

    Even when price and quality information is available, there’s no evidence it’s reliable or comprehensive enough to tell you which hospital and which team of doctors will best meet your needs. To quote Drew Altman, President of the Kaiser Family Foundation, “pretty much everyone in the health-care sector agrees that the  ”state of the art” in the development of rigorous and reliable quality and price information has a long way to go.” This all said, it’s still important to take time to choose your doctors, hospitals and other care providers. Read more here about how to choose a doctor, here about how to choose a good hospital and here about how nursing home ratings can be misleading.

    Unlike quality information, which is in its infancy and largely unreliable, price information can be trusted and should be available. But prices for doctor and hospital services tend to be hard if not possible to learn.  Almost two-thirds of survey respondents (64 percent) said it was difficult to find out the costs of medical services.  In fairness doctors sometimes don’t know exactly which services they will be performing in advance of treating patients. But, unlike Medicare, health plans do not offer predictable out-of-pocket costs that allow people to budget for their care.  In many cases, rates insurers negotiate with doctors and hospitals are considered trade secrets.

    What’s the solution? Providing everyone in America with the choice of a public health insurance plan like Medicare that reins in prices and offers predictable costs and easy access to doctors and hospitals would help ensure people’s health and financial security. And, for now, choosing your doctors and other care providers as wisely as possible. Time will tell whether reliable quality information will ever be available.