Category Archives: politics

complex adaptive systems, health market quality, healthcare, policy, politics

Economist on doctor review sites

 

 

 

http://www.economist.com/news/international/21608767-patients-around-world-are-starting-give-doctors-piece-their-mind-result?fsrc=scn/tw_ec/docadvisor

 

Patients’ reviews

DocAdvisor

Patients around the world are starting to give doctors a piece of their mind. The result should be better care

WHEN a patient in Illinois did not like the result of her breast-augmentation surgery, she reacted like many dissatisfied customers: by writing negative comments about her doctor on websites that feature such reviews. Her breasts, she said, looked like something out of a horror movie. Other unhappy patients joined her online, calling the doctor “dangerous”, “horrible” and a “jackass”. He sued them for defamation. (The cases were later dropped.)

Other doctors have filed similar lawsuits, mostly in America. Though few have won, their reaction illustrates a discomfort with patient reviews felt by many of their colleagues. Some question the accuracy and relevance of the feedback; others complain that privacy rules prevent them from responding. Sites often have just a handful of ratings per doctor, meaning results can be skewed by a single bad write-up.

But increasingly, doctors cannot afford to ignore them. They often lead the results of searches for doctors’ names. In America, the world’s biggest health-care market, firms that offer health insurance are making employees pay a bigger share, pushing them to search for guidance online. The most sophisticated sites are attracting more users by including reviews and other features. ZocDoc also lets patients make appointments. Offerings from Vitals include a quality indicator it has built using data from 170,000-odd sources. Castlight Health includes prices gathered from insurance bills and other data. The differences can be startling—the cost of a brain scan in Philadelphia ranges from $264 to $3,271.

With around 60 review sites, America leads the way. But they are also popping up in other countries where patients pay for at least part of their care. Practo, an Indian firm that schedules appointments with doctors, plans to start publishing patients’ reviews later this year. More and more Chinese patients, who generally do not have a regular family doctor, are using a site run by Hao Dai Fu (“good doctor”) to navigate their country’s unstructured health system, says Haijing Hao of the University of Massachusetts. It has profiles of around 300,000 doctors and over 1m reviews.

Increasingly, doctors, hospitals and health systems are seeking to turn the trend to their advantage. Some now offer incentives, such as prize draws, for patients to go online and rate them. A survey by ZocDoc found that 85% of doctors on its site looked at their ratings last year. And a handful of health-care providers have even started to publish reviews themselves. The University of Utah, which runs four hospitals and ten clinics, was one of the first, in 2012. Its doctors’ complaints about independent sites encouraged it to publish patient feedback that was already being collected for internal use. Some of its doctors now have hundreds of reviews.

Preparing staff for the publication of all the comments, good and bad, took a year, says Brian Gresh, who helped create the university’s system. But their worries appear to have been groundless: most reviews are positive, and patient-satisfaction scores improved after the move. Happy patients communicate and co-operate better with their doctors, says Tom Lee, the chief medical officer of Press Ganey, a firm that surveys patients on behalf of health-care providers, including for the University of Utah. Its boss, Pat Ryan, predicts that plenty of other hospitals will follow suit.

Some doctors are still sceptical, fearing, for example, that patients may judge a hospital on its decor rather than its care. But patients are rarely swayed much by such trivia, insists Mr Ryan: “If you have flat-screen televisions and your communication is poor, you will get very bad scores.” Moreover, the feedback reminds doctors that every meeting with a patient matters, so they try harder.

America’s government has started to link health-care payments with patient feedback: Medicare, a federal scheme for over-65s, recently started to give bonuses to hospitals that score well. The Cleveland Clinic, a big hospital, uses these data to improve its care. Britain’s National Health Service has surveyed patients for over a decade (though not on the performance of individual doctors) and published the results online—though some think it could use its findings better.

But many other governments do not even ask patients for their opinions. German doctors and hospitals, for example, have fought efforts to link funding with quality of care, says Maria Nadj-Kittler of the Picker Institute Europe, a research organisation, and are therefore hostile to patient reviews. This is a missed opportunity. Patients who hold their doctors accountable make them better and more efficient. That is good news no matter who pays.

From the print edition: International

complex adaptive systems, entrepreneurship, health market quality, healthcare, healthy habits, management and leadership, musings, policy, politics, quotes & aphorisms, rapid learning health systems, research methodology

Outsource physician behaviour change to the experts: Big Pharma

So pay for performance doesn’t work. This is hardly surprising when you see the compromise and mediocrity forced upon policy makers to get ideas through. There have been instances of success in health care. Indeed, one could argue that the exemplary success of big pharma in changing physician behaviour has provided a rod for its own back. Why not harness this expertise in getting under the skin of doctors, and pay big pharma sales outfits to guide physician practice in constructive directions, rather than being distracted by flogging pills that don’t really work that well anyway, and potentially harm? Might have a chat with Christian.

http://www.nytimes.com/2014/07/29/upshot/the-problem-with-pay-for-performance-in-medicine.html

THE NEW HEALTH CARE

The Problem With ‘Pay for Performance’ in Medicine

Magoz

Aaron E. Carroll

@aaronecarroll

“Pay for performance” is one of those slogans that seem to upset no one. To most people it’s a no-brainer that we should pay for quality and not quantity. We all know that paying doctors based on the amount of care they provide, as we do with a traditional fee-for-service setup, creates incentives for them to give more care. It leads to increased health care spending. Changing the payment structure to pay them for achieving goals instead should reduce wasteful spending.

So it’s no surprise that pay for performance has been an important part of recent reform efforts. But in reality we’re seeing disappointingly mixed results. Sometimes it’s because providers don’t change the way they practice medicine; sometimes it’s because even when they do, outcomes don’t really improve.

The idea behind pay for performance is simple. We will give providers more money for achieving a goal. The goal can be defined in various ways, but at its heart, we want to see the system hit some target. This could be a certain number of patients receiving preventive care, a certain percentage of people whose chronic disease is being properly managed or even a certain number of people avoiding a bad outcome. Providers who reach these targets earn more money.

The problem, one I’ve noted before, is that changing physician behavior is hard. Sure, it’s possible to find a study in the medical literature that shows that pay for performance worked in some small way here or there. For instance, a study published last fall found that paying doctors $200 more per patient for hitting certain performance criteria resulted in improvements in care. It found that the rate of recommendations for aspirin or for prescriptions for medications to prevent clotting for people who needed it increased 6 percent in clinics without pay for performance but 12 percent in clinics with it.

Good blood pressure control increased 4.3 percent in clinics without pay for performance but 9.7 percent in clinics with it. But even in the pay-for-performance clinics, 35 percent of patients still didn’t have the appropriate anti-clotting advice or prescriptions, and 38 percent of patients didn’t have proper hypertensive care. And that’s success!

It’s also worth noting that the study was only for one year, and many improvements in actual outcomes would need to be sustained for much longer to matter. It’s not clear whether that will happen. A study published in Health Affairs examined the effects of a government partnership with Premier Inc., a national hospital system, and found that while the improvements seen in 260 hospitals in a pay-for-performance project outpaced those of 780 not in the project, five years later all those differences were gone.

The studies showing failure are also compelling. A study in The New England Journal of Medicine looked at 30-day mortality in the hospitals in the Premier pay-for-performance program compared with 3,363 hospitals that weren’t part of a pay-per-performance intervention. We’re talking about a study of millions of patients taking place over a six-year period in 12 states. Researchers found that 30-day mortality, or the rate at which people died within a month after receiving certain procedures or care, was similar at the start of the study between the two groups, and that the decline in mortality over the next six years was also similar.

Moreover, they found that even among the conditions that were explicitly linked to incentives, like heart attacks and coronary artery bypass grafts, pay for performance resulted in no improvements compared with conditions without financial incentives.

In Britain, a program was begun over a decade ago that would pay general practitioners up to 25 percent of their income in bonuses if they met certain benchmarks in the management of chronic diseases. The program made no difference at all in physician practice or patient outcomes, and this was with a much larger financial incentive than most programs in the United States offer.

Even refusing to pay for bad outcomes doesn’t appear to work as well as you might think. A 2012 study published in The New England Journal of Medicine looked at how the 2008 Medicare policy to refuse to pay for certain hospital-acquired conditions affected the rates of such infections. Those who devised the policy imagined that it would lead hospitals to improve their care of patients to prevent these infections. That didn’t happen. The policy had almost no measurable effect.

There have even been two systematic reviews in this area. The first of them suggested that there is some evidence that pay for performance could change physicians’ behavior. It acknowledged, though, that the studies were limited in how they could be generalized and might not be able to be replicated. It also noted there was no evidence that pay for performance improved patient outcomes, which is what we really care about. The secondreview found that with respect to primary care physicians, there was no evidence that pay for performance could even change physician behavior, let alone patient outcomes.

One of the reasons that paying for quality is hard is that we don’t even really know how to define “quality.” What is it, really? Far too often we approach quality like a drunkard’s search, looking where it’s easy rather than where it’s necessary. But it’s very hard to measure the things we really care about, like quality of life and improvements in functioning.

In fact, the way we keep setting up pay for performance demands easy-to-obtain metrics. Otherwise, the cost of data gathering could overwhelm any incentives. Unfortunately, as a recent New York Times article described, this has drawbacks.

The National Quality Forum, described in the article as an influential nonprofit, nonpartisan organization that endorses health care standards, reported that the metrics chosen by Medicare for their programs included measurements that were outside the control of a provider. In other words, factors like income, housing and education can affect the metrics more than what doctors and hospitals do.

This means that hospitals in resource-starved settings, caring for the poor, might be penalized because what we measure is out of their hands. A panel commissioned by the Obama administration recommended that the Department of Health and Human Services change the program to acknowledge the flaw. To date, it hasn’t agreed to do so.

Some fear that pay for performance could even backfire. Studies in other fields show that offering extrinsic rewards (like financial incentives) can undermine intrinsic motivations (like a desire to help people). Many physicians choose to do what they do because of the latter. It would be a tragedy if pay for performance wound up doing more harm than good.

Aaron E. Carroll is a professor of pediatrics at Indiana University School of Medicine. He blogs on health research and policy at The Incidental Economist, and you can follow him on Twitter at @aaronecarroll. The Upshot provides news, analysis and graphics about politics, policy and everyday life. Follow us on Facebook and Twitter.
health market quality, healthcare, policy, politics, rapid learning health systems

AMA rejects price transparency

AMA at its best (worst).

It doesn’t want price transparency because its too hard to predict how much things should cost charging by the hour instead of by the procedure.

I’d want to know more about my surgeon than my dishwasher when making a purchasing decision.

So lets put up all those metrics and allow people to compare what matters.

http://www.smh.com.au/federal-politics/political-news/ama-rejects-call-for-more-fee-disclosure-20140729-3cs2y.html#ixzz396F0w0H6

AMA rejects call for more fee disclosure

July 30, 2014 Dan Harrison and Daisy Dumas

AMA president Brian Owler at the National Press Club in Canberra on Wednesday.

AMA president Brian Owler at the National Press Club in Canberra on Wednesday. Photo: Alex Ellinghausen

The Australian Medical Association has rejected calls for greater transparency on surgical fees, saying it was not possible for patients to compare prices for operations in the same way they might shop around for a dishwasher.

Appearing at a Senate hearing on Tuesday, AMA president Brian Owler, who is a neurosurgeon, said his organisation did not support the charging of excessive fees, but said the appropriate fee for a procedure depended on the patient’s condition.

”It is not possible to put up on a website all of our fees … and be able to go, like you’re buying a dishwasher, and be able to work out which doctor you’re going to on the basis of the fee that they charge,” Associate Professor Owler said.

”The experience and qualifications of many of the doctors will vary, their practices will vary, and really you need to see a patient to understand what their problem is, then formulate with that patient the best plan of management.”

Professor Owler’s comments follow a statement from the Australasian College of Surgeons in which it expressed concern about some surgeons, including some of its own members, charging ”extortionate” fees.

The president of the college, Michael Grigg, said it was working with the Australian Competition and Consumer Commission on ways to allow greater disclosure of surgeons’ fees without breaching competition rules.

Prominent neurosurgeon Charlie Teo said there were some surgeons who abused the ignorance of their patients.

But he said the recommended fee for some procedures, such as the approximately $2500 fee for the removal of a brain tumour, undervalued the work involved in complex cases.

”I can be operating on the world’s most difficult brain tumour and it takes eight to 10 hours and I still get paid $2500. Versus a plastic surgeon who charges $8000 to $12,000 for a breast augmentation,” Dr Teo said.

Dr Teo recommended Australia adopt a the American Medical Association’s ”22 Modifier” policy, which requires surgeons to supply evidence that the service provided was substantially greater than the work typically required for a certain procedure if they charged higher fees.

Greens senator Richard Di Natale, who initiated the Senate inquiry into out-of-pocket health costs, said patients needed greater transparency on costs.

”At the moment, the problem is that people become aware of the out-of-pocket costs when it’s too late, when they’re well advanced down the treatment pathway, and often there’s no way of turning back.”

The president of the Australian Society of Plastic Surgeons, Tony Kane, said its members were required to make a full written disclosure to patients of what the cost of their treatment would be, including the possibility of further costs, should revision surgery be necessary.

Dr Kane said members were required to make this disclosure at a sufficiently early stage to enable patients to take cost considerations into account when deciding whether to undergo the treatment.

business, complex adaptive systems, cool, data saving lives, entrepreneurship, file note, meaning, musings, politics, quotes & aphorisms, storytelling, technology

John Perry Barlow: Which side of history do you want to be on?

“The main thing here is for people to recognize that what we’re doing is creating the foundations of the future in a very fundamental way.

I mean we’re building the future that we all might want or all might not want, depending on our current vested interests.

I think it takes a really crummy ancestor to want to maintain his current business model at the expense of his descendant’s ability to understand the world around them.

And if you really want to figure out which side you’re on, ask yourself what’s going to make you a better ancestor?

John Perry Barlow
Co-founder, Electronic Frontier Foundation

Interviewed in the feature documentary “Downloaded” aired on SBS.

healthy habits, nutrition, policy, politics

UK privatising public health messaging – what could possibly go wrong?

 

 

http://www.londonlovesbusiness.com/8431.article?mobilesite=enabled

Source PDF: PHE-StrategyDoc-2014-10

Sophie Hobson: All public health messaging is now officially up for sale. Yes, you should be worried

3 July 2014 | By Sophie Hobson

Skull and cross-bones

The government has quietly announced a major change – but you need to know about it

Sophie Hobson is the editor of LondonlovesBusiness.com. Tweet her@sophiehobson

The government is making a radical change to the way it delivers public health campaigns.

It is a shift in the modus operandi that has been creeping in over the last couple of years, and has now been made universal in a new publication on Public Health England’s Marketing Strategy for 2014-17.

All government public health campaigns will now be launched in partnership with another organisation – as cheerily announced in a section titled “We will only ever work in partnership”.

Some of these organisations will be NGOs. (The government has worked in partnership with NGOs since 2002.)

But many will be corporations, paying for their involvement in public health messaging.

To give you an idea of the pace of the shift towards corporate-funded public health messaging, the report states that five years ago, the Change4Life campaign had only 10 commercial sector partners.

Today, it has more than 200 (including PepsiCo, hardly known for its healthy image).

The story has been uncovered by Russell Parsons at Marketing Week, and full credit to him, because Public Health England (PHE) is yet to release its forthcoming marketing strategy online at time of writing – though it has sent us a copy, which you can view by clicking on the ‘related files’ on the right (see pg. 22).

Why does this change matter so much?

Take a look at this chart from the report, which shows how financial/in-kind contribution from partners to the Change4Life campaign has now actually surpassed the amount of money the government is putting in:

PHE report - chart

If commercial partners are fronting up more cash for certain campaigns than the government itself, it’s not unreasonable to deduce that they will have as much – if not more – influence over the messaging of campaigns.

Who do you think is going to be most likely to put up the resources and cash for these public health campaigns?

I don’t think it’s far-fetched to suggest it might be those companies that need to clean up their reputation when it comes to health.

After all, Coca-Cola and McDonald’s didn’t pay mega-millions for worldwide sponsorship rights for the London 2012 Olympics out of the goodness of their corporate hearts.

This up-shift in government strategy opens the door to possibilities riddled with conflicts of interest: healthy eating campaigns brought to us in partnership with PepsiCo (see example above), obesity adverts supported by junk food multinationals…

So why is the government doing this?

In short, PHE needs the money.

PHE will invest £53m in the year to March 2015 into public health marketing campaigns.

In the year ahead, it aims to raise £25m of in-kind support from partners. This gives you an idea of how significant that external funding is.

As it happens, PHE has the largest partnerships team in government and works with 214 key national and 70,000 local partners.

And while the report claims that external partners are “interested in, and stand to benefit from, a healthier England”, I believe this new strategy puts the nation’s health at serious risk from influences that don’t necessarily have our best interests at heart.

Public health messaging should be in the interest of citizens, not corporates. It should not be up for sale.

If you agree, tweet me @sophiehobson or let me know in comments below.

READERS’ COMMENTS (1)

  • Rebecca Hobson

    Rebecca Hobson | Thu, 3 Jul 2014 12:17 pm

    Great, thought provoking piece – but I’m not sure I agree. I imagine there’ll be stringent measures in place around any corporate sponsorship of public health messaging, and effectively, these brands will end up subsiding PHE – which it badly needs? Also, if PHE puts out a message saying ‘drink only one can of pop a day’, say, won’t it be more powerful if it’s sponsored by the pop brand itself? Ppl are far more likely to listen to Pepsi than the government.

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complex adaptive systems, cool, policy, politics

Helsinki making car ownership pointless in 10 years

An interesting, challenging idea… why not!

http://www.theguardian.com/cities/2014/jul/10/helsinki-shared-public-transport-plan-car-ownership-pointless?CMP=twt_gu

Helsinki’s ambitious plan to make car ownership pointless in 10 years

Finland’s capital hopes a ‘mobility on demand’ system that integrates all forms of shared and public transport in a single payment network could essentially render private cars obsolete

Helsinki, Finland.
Urban mobility, rethought … Helsinki, Finland. Photograph: Hemis/Alamy

The Finnish capital has announced plans to transform its existing public transport network into a comprehensive, point-to-point “mobility on demand” system by 2025 – one that, in theory, would be so good nobody would have any reason to own a car.

Helsinki aims to transcend conventional public transport by allowing people to purchase mobility in real time, straight from their smartphones. The hope is to furnish riders with an array of options so cheap, flexible and well-coordinated that it becomes competitive with private car ownership not merely on cost, but on convenience and ease of use.

Subscribers would specify an origin and a destination, and perhaps a few preferences. The app would then function as both journey planner and universal payment platform, knitting everything from driverless cars and nimble little buses to shared bikes and ferries into a single, supple mesh of mobility. Imagine the popular transit planner Citymapper fused to a cycle hire service and a taxi app such as Hailo or Uber, with only one payment required, and the whole thing run as a public utility, and you begin to understand the scale of ambition here.

That the city is serious about making good on these intentions is bolstered by the Helsinki Regional Transport Authority’s rollout last year of a strikingly innovative minibus service called Kutsuplus. Kutsuplus lets riders specify their own desired pick-up points and destinations via smartphone; these requests are aggregated, and the app calculates an optimal route that most closely satisfies all of them.

All of this seems cannily calculated to serve the mobility needs of a generation that is comprehensively networked, acutely aware of motoring’s ecological footprint, and – if opinion surveys are to be trusted – not particularly interested in the joys of private car ownership to begin with. Kutsuplus comes very close to delivering the best of both worlds: the convenient point-to-point freedom that a car affords, yet without the onerous environmental and financial costs of ownership (or even a Zipcar membership).

But the fine details of service design for such schemes as Helsinki is proposing matter disproportionately, particularly regarding price. As things stand, Kutsuplus costs more than a conventional journey by bus, but less than a taxi fare over the same distance – and Goldilocks-style, that feels just about right. Providers of public transit, though, have an inherent obligation to serve the entire citizenry, not merely the segment who can afford a smartphone and are comfortable with its use. (In fairness, in Finland this really does mean just about everyone, but the point stands.) It matters, then, whether Helsinki – and the graduate engineering student the municipality has apparently commissioned to help it design its platform – is proposing a truly collective next-generation transit system for the entire public, or just a high-spec service for the highest-margin customers.

It remains to be seen, too, whether the scheme can work effectively not merely for relatively compact central Helsinki, but in the lower-density municipalities of Espoo and Vantaa as well. Nevertheless, with the capital region’s arterials and ring roads as choked as they are, it feels imperative to explore anything that has a realistic prospect of reducing the number of cars, while providing something like the same level of service.

To be sure, Helsinki is not proposing to go entirely car-free. (Many people in Finland have a summer cottage in the countryside, and rely on a car to get to it.) But it’s clear that urban mobility badly needs to be rethought for an age of commuters every bit as networked as the vehicles and infrastructures on which they rely, but who retain expectations of personal mobility entrained by a century of private car ownership. Helsinki’s initiative suggests that at least one city understands how it might do so.