Archive for the ‘Health care’ Category

This week’s The Numbers Guy column in the Wall Street Journal looks at how long patients wait for care (Long Medical Waits Prove Hard to Cure, May 25). The setting to have in mind is not how many minutes past your appointment time you spend in the waiting room. Rather, focus on actually getting an appointment to be seen for an ailment or to get a procedure scheduled.

That seems like a fairly straightforward question. One just needs to track how many patients have been referred for a procedure, when they are referred, and when the procedure is performed. The problem is that no one wants to just know what the wait is; they want to manage that wait. That means that targets will be set and comparisons made. That’s where things get tricky.

If you measure how long patients coming off a waiting list have spent on that list, a hospital has little incentive, while under evaluation, to clear those who already have been waiting longer than average. As soon as they are cleared, the hospital’s numbers get worse.

Measure the percentage of patients seen within, say, 48 hours, and those who can’t be seen in that time might instead find themselves waiting much longer, as earlier slots are saved for patients who call up later and can be slotted in the time frame, thus boosting a health provider’s numbers.

Count how many people are on a waiting list for a specialist appointment or nonelective surgery, and the provider being evaluated might change the definition of how long patients have to wait to be included on the waiting list.

Such responses have stymied efforts to cut waiting times and to determine if changes meant to alleviate delays have been effective.

“Any waiting-time measure can be thwarted or misrepresented,” says Michael Davies, an internist and acting director of high reliability systems and consultation at the U.S. Department of Veterans Affairs.


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One of the things I like about my undergrad alumni magazine is the classified ads. There is always something eye-catching. Like this one that was listed under “Employment Opportunities.”

Family Medical Coordinator: Highly intelligent, unusually competent individual with a background in science and exceptional communication skills sought by Manhattan family to research and coordinate family medical and healthcare issues. This person will manage a small team of professionals and interface with physicians, medical researchers, and consultants (in academia and otherwise) to ensure delivery of highest-quality medical care to family members. Considerable weight will be given to unusual academic distinction and other intellectual achievements. Clinical experience is a plus. This is a full-time position with a highly attractive compensation package and significant upside potential.

It got me wondering about what is the combination of family crisis and disposable income that makes trolling an Ivy League alumni magazine for someone to actively manage family medical issues is a reasonable plan of action. What it makes clear is that at least some consumers will insist on being co-producers in health care. Co-production here goes beyond taking one’s medication as prescribed or showing up for physical therapy. Rather this suggest that the patient wants an active role in determining the appropriate course of treatment.

Part of what intrigued me about this ad is that they day I saw it, the Wall Street Journal had a piece arguing against process standardization in health care (Rise of the Medical Expertocracy, Mar 31).

As the health-care debate heats up again in Washington, both Democrats and Republicans will try to convince us that they have the experts to answer all our health questions. President Barack Obama and the Democrats propose panels of government experts to evaluate treatments and, in the president’s words, “Figure out what works and what doesn’t.” Republicans claim that the free market (that is, insurance companies with their own experts) will pay for value and empower consumers. Both sides insist that no one will come between us and our doctors.

Democrats and Republicans share a fundamental misconception about medical care. Both assume that, as in mathematics, there is a single right answer for every health problem. These “best practices,” they believe, can be found by gathering large amounts of data for experts to analyze. The experts will then identify remedies based strictly on science—impartial and objective.

I find this an interesting proposition. On the one hand, if patients were willing to accept what was being suggested as an immutable best practice, there would be little need for a family medical coordinator. Given the diagnosis, the course to follow would be straightforward and clear. If patients — or at least those that can afford to — feel the need to take a more active part in determining care, then it suggests that at a minimum they question whether “best” practice is indeed best. (more…)

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The Daily had an interesting story on a handful of doctors who are paying their patients — either explicitly in cash or in the form of a gift — when they make their patients wait past their appointment times (Their Wait in Gold, Mar 19).

There’s a promising new trend afoot in doctors’ offices around the country: With average wait times growing in recent years, some physicians have begun offering goods, services and even cash to waylaid patients.

“Why is my time more important than my patients?” asked Dr. Cyrus Peikari of Dallas. “True service can only come when we put our egos aside.”

To make up for canceling some appointments last year, Peikari mailed each patient a check for $50.

Dr. Timothy Malia of Fairport, N.Y., keeps a supply of $5 bills on hand. He dispenses them to patients if they’ve been made to wait past their appointment time. …

Nationwide, most patients spend a lot more than 10 minutes waiting to see their doctor. The national average is 24 minutes past the appointment time, up from 18 minutes in 2002 and 16 minutes in 1989, according to studies.

“The trouble with a lot of health care offices is that they are designed by doctors with little training in queuing,” said David Belson, a professor of Industrial and Systems Engineering at the University of Southern California, who studies wait times. “In most business schools, there would be a class on queuing. There’s no need to have a couple of hours worth of patients queued up.”

So let me start by saying that as a patient, I kind of like this. It is nice to hear that MDs take service seriously and are at least somewhat cognizant that patients can have ungodly waits. As a business school professor, however, I think of lots of reasons why you might have “a couple of hours worth of patients queued up.” (more…)

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Much has been written about applying operations management techniques — many developed in manufacturing environments — to health care settings. Indeed, this has been a regular topic in this blog. One thing that has been missing from this discussion has been a view of preventing errors through better design. When making things, the argument goes that it is easier (or at least more cost-effective) to prevent quality issues at the design phase than once production has begun. That gets us to CareMore, a company profiled in a recent article in The Atlantic (The Quiet Health-Care Revolution, Nov 2011, with a hat tip to Suraj Mathew of EMP 87 for pointing me to this one).

CareMore specializes in taking of Medicare Advantage patients. Medicare Advantage is a capitation program. The health care provider is paid a fixed amount per patient and gets nothing extra when something catastrophic happens. That is, it shifts risk from the insurer to the provider. How has CareMore done in this market?

CareMore, through its unique approach to caring for the elderly, is routinely achieving patient outcomes that other providers can only dream about: a hospitalization rate 24 percent below average; hospital stays 38 percent shorter; an amputation rate among diabetics 60 percent lower than average. Perhaps most remarkable of all, these improved outcomes have come without increased total cost. Though they may seem expensive, CareMore’s “upstream” interventions—the wireless scales, the free rides to medical appointments, etc.—save money in the long run by preventing vastly more costly “downstream” outcomes such as hospitalizations and surgeries. As a result, CareMore’s overall member costs are actually 18 percent below the industry average.

What has driven these savings is upstream intervention to identify problems while they are still minor and easy to deal with and proactively making sure that patients adhere to their treatment plans.

One of CareMore’s critical insights was the application of an old systems-management principle first developed at Bell Labs in the 1930s and refined by the management guru W. Edwards Deming in the 1950s: you can fix a problem at step one for $1, or fix it at step 10 for $30. The American health-care system is repair-centric, not prevention-centric. We wait for train wrecks and then clean up the damage. What would happen if we prevented the train wrecks in the first place? The doctors at CareMore decided to find out.


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Slate’s technology writer Farhad Manjoo has had an interesting series of article on the increasing use of robots and automation in what many would consider white-collar profession. Despite the somewhat alarmist title (Will Robots Steal Your Job?), the series is a fairly evenhanded look at how technology is evolving. I found the piece on pharmacists particularly interesting (My father the pharmacist vs. a gigantic pill-packing machine, Sep 26). As the article suggests, Manjoo’s dad is a pharmacist so he has more than a passing interest in what happens in this market. What is happening is that pill sellers — whether hospitals or retail pharmacists — are relying more and more on machines to dispense pills. Here is a video of University of California-San Francisco’s pill-counting wonder:

Before installing the robot, UCSF needed about half of its more than 100 on-staff pharmacists to administer and check the drugs going out to patients on the floor; now nearly all have been reassigned to different parts of the hospital, where they make IVs, help adjust patients’ drug regimens, and perform other tasks that had been neglected when they were simply filling prescriptions The robotic pharmacy cost $7 million to install—less than one year’s salary for all those pharmacists—and when it’s running at full capacity, it can dispense more than 10,000 doses a day.  After it became operational last year, the robot filled 350,000 prescriptions without making a single error. (The first error it did encounter was a printer problem that was quickly caught by its human operators.) (more…)

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Here’s an interesting story from the BBC showing how incentives can lead to odd choices in managing queues (Royal Cornwall Hospital patients ‘jumping waiting list’, Aug 27).

Up to 670 people had been waiting for more than the government waiting time target, of 18 weeks, the hospital said.

It explained it was treating the newer referrals first to avoid penalties for further target breaches. …

Orthopaedic Surgeon, Andrew Lee, told BBC News: “We’re doing our very best not to make any more breaches.

“We’re therefore treating the people under 18 weeks as well as dealing with the breached patients as fast as we can.”


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Checkout this graphic from a recent Wall Street Journal article (ERs Move to Speed Care; Not Everyone Needs a Bed, Aug 2):

This is based on a survey of people who left ERs without being seen and breaks down how long they waited before bolting. The number of people who leave without being seen has been creeping up in recent years:

The national average of those who leave without being seen—called LWBS—was about 2.7% in 2007-08, according to the most recent government data available. This is up from 1.7% between 1998 and 2006, according to an analysis by Johns Hopkins University researchers. In some areas, as much as a fifth of patients who show up for care end up leaving before they see a doctor. Many of these may go elsewhere for care or end up feeling better, but studies show that as many as half who left without treatment were judged to need immediate medical attention. One study found that 11% of patients required hospitalization within the next week, including some who underwent emergency surgery.

“People who walk out without being seen are a measure of how we are basically failing as a health system in our ability to deliver important care in emergency departments,” says Renee Hsia, assistant professor of emergency medicine at the University of California San Francisco.

Beyond the impact on patient care, having patients walk out also impacts the hospital’s bottom line. According to the article, an ER seeing 50,000 patients per year is out $450,000 if 1% if patients leave.

So what steps are hospitals taking? (more…)

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OM meets healthcare

We haven’t written anything on applying OM principles to healthcare recently so here are two quick stories. The first is from Colorado. Denver Health is an  integrated healthcare system that serves many uninsured patients. It also has the lowest mortality rate of any academic medical center in the country and was the first healthcare provider to win the Shingo Prize. How did they do it? They embraced lean operations. Here is a report from PBS’s Newshour.

Vodpod videos no longer available.

You can find more on what they did to win the Shingo Prize here. (more…)

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Hospitals present a host of operational challenges. Patients arrive with a variety of ailments and the mix of work changes by the day or even by the hour. Resources are always limited and time can be of the essence. This is especially true in the emergency room. Sure there are challenges up in, say, the obstetrics ward, but they can at least keep non-obstetric cases out of the ward. The ER, however, has to take all comers and decisions have to be made quickly. Perhaps, then it is not surprising that ERs are a major source of malpractice suits (Hospitals Overhaul ERs to Reduce Mistakes, May 10, Wall Street Journal).

Often chaotic and overcrowded, with scant data available about new patients, the emergency room is among the top hospital departments responsible for malpractice suits—and diagnostic errors account for 37% to 55% of cases in studies of closed claims. The average payments and legal expenses for ER cases have more than doubled over the past two decades, according to the Physician Insurers Association of America, a nonprofit trade association whose members cover about 60% of emergency physicians.

Insurance broker Aon Corp. estimates malpractice suits arising from emergency-room incidents in 2009 alone will cost hospitals $1 billion.

Here’s a the article’s author discusses some of her finding and how hospitals are trying to reduce the number of errors.

Vodpod videos no longer available.


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Managing “patient flow” is one of the most challenging aspects of running any health care facility. Whether in a hospital or a clinic, there is a limited supply of resources but a seemingly unlimited supply of patients at least some of whom need care desperately. Managing capacity is then a critical issue. No where is the need for the careful management of resource more important than the intensive care unit. ICUs are set up to treat the most critically ill patients and it is here where the US health system can spend big bucks real fast.

One hospital that does very well managing its ICU is Montefiore Medical Center in the Bronx. The Wall Street Journal had an intriguing profile of just what they do (Critical (Re)thinking, Mar 26).

[H]andling the flow of patients in and out of the hospital’s 78 adult medical and surgical ICU beds, and anticipating who else might need such high-level care on any given day, requires precision management. Many hospitals struggle to do it effectively, but Montefiore doesn’t—thanks to several innovations spearheaded by Vladimir Kvetan, director of critical-care medicine, over the past decade.

Among them: Teams of critical-care specialists are dispatched to the bedsides of potentially critical patients before they are brought to the ICU to determine what kind of care they really need and where in the hospital that can best be provided. An “ICU Without Walls” system can provide ICU-level care anywhere if a bed isn’t immediately available. Terminally ill patients are offered palliative care instead of high-cost, high-tech interventions. And all of Montefiore’s ICUs—for medical, surgical, neurosurgical and cardiothoracic patients—report to the critical-care department, not individual medical services, facilitating patient flow and minimizing turf wars.

Such changes in critical care have helped Montefiore reduce its overall mortality rate from 3.5% in 1997 to 1.8% in 2009. In its medical and surgical ICUs, the mortality rate fell from 36% in the 1980s to less than 8% in 2004—in part because many terminally ill patients are now offered palliative care elsewhere.

Such aggressive management of the ICU has payoffs that reach beyond the units wards. Because beds are available in the ICU, for example, surgeries can happen on schedule and OR are not left idle. Similarly, the ER does not back up with people unable to move into hospital beds. At Montefiore, the emergency department has seen demand go up by 45% (according to the article) without overwhelming the ICU.

So what’s the secret sauce? It seems largely to be what my queuing theory friends call admission control. In plain English, that means not letting people in. (more…)

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