2011 Potpourri XXX

An article in the Journal of the American Medical Association discusses determining whether a patient has medical decision-making capacity, an important topic given the numerous initiatives to involve patients more in their health and health care.  Unfortunately a lot of expense is for elderly patients with very severe illness who really can’t make decisions and for many others who may have various forms of dementia.  The authors note that incapacity is more common than typically thought and that few physicians have the training or experience to make good capacity determinations.  The authors reviewed several instruments designed to assist in capacity determinations and found that a few had a strong ability to ascertain capacity.  The results of the authors’ review suggests that more attention needs to be paid to training physicians on capacity issues and developing tools to help them make the determination.   (JAMA Article)

Another shocker–the Government Accounting Office finds that Medicare is making a lot of payments that it shouldn’t.  According to HHS, about $48 billion of the $516 billion in 2010 Medicare payments were improper, sometimes due to fraud, but other times to inadequate documentation, coding errors, medically unnecessary services and just wrong calculations of amounts owed.  Supposedly some of this $48 billion is underpayments, but everyone acknowledges that the vast majority is accounted for by overpayments.  It is a lot of money and this has been going on since the start of the program.  GAO is starting to get a little frustrated, noting that CMS seems to be ignoring its recommendations.  Only recently, for example, has CMS begun looking for fraud or abuse before it pays a claim, as opposed to paying and then having to chase the payee.  And you wonder why we are dubious about more government involvement in health care.   (GAO Report)

Accenture issued a report on The 7 Things Your Health Insurance Customers Are Not Telling You, aimed at health plans.  Based on a survey of 1000 consumers, the report features such insights as:  although consumers generally have high satisfaction levels, that doesn’t translate to loyalty or more revenue (really, insurance consumers are price-sensitive!); customer service expectations are rising; some consumers are frustrated with customer service; while technology in consumer service may save insurers money, it hasn’t generally led to a perception of better customer service; service is more important than price (this is a clear example of failing to watch what people do instead of what they say–price is the overwhelming reason for plan switching by consumers when they, as opposed to their employers, make the decision); customers want more social media engagement than payers use and, contradicting several of the report’s other findings, this consumer customer service dissatisfaction hasn’t been a major factor in switching insurers, but it might be in the future!  Thanks.   (Accenture Report)

Health Affairs reports on research regarding what happens to malpractice claims and why so many are voluntarily dropped.  The study looked at about 3700 claims in Massachusetts in the period 2006-2010.  About 59% of these claims were dropped by the plaintiff.  The most common reason for giving up was that the plaintiff learned new information in the course of the suit that led them to conclude their case was weak.  Notwithstanding the cases being dropped, they saw defense costs of an average $44,200 per case.  Other costs are imposed in terms of provider time, court resources, plaintiffs’ attorneys, etc.  These costs could be avoided if plaintiffs either never filed their cases or dropped them soon after filing.  To encourage this, the author suggests that defendants share more information sooner.   (HA Article)

Hospitalists are physicians who specialize in managing the care of patients while they are in the hospital.  Their number has increased greatly in recent years on the theory that they would do better than a patient’s primary care physician at improving quality and lowering costs during hospitalizations.  And several studies have shown that patients managed by hospitalists tend to have lower lengths of stay and less hospital spending.  But what happens when they are discharged?  Research in the Annals of Internal Medicine indicates that these patients have worse outcomes than similar patients managed by their primary care physicians.  Although length of stay was about two-thirds of a day and inpatient costs $282 lower, patients managed by hospitalists were more likely to be discharged to a place other than home, to have an emergency room visit, to be readmitted and they had $332 in average higher costs after discharge.  Oh well, seemed like a good idea.   In fairness, another useful comparison would be what happens to patients without a primary care physician.   (Annals Article)

It gets boring hearing us constantly warn about the paucity of evidence to support the supposed clinical benefits of electronic medical records, so we are just devoting a short item to that topic here.  Research in the Archives of Internal Medicine suggests that use of EHRs and clinical decision support systems is not associated with a higher quality of care.  Looking at over a billion visits, 30% of those had EHR use associated with them and 17%, a CDS system.   In only one indicator, diet-counseling for high-risk adults, was performance better in EHR-associated visits than non-EHR ones.  As the authors pithily put it “These results raise concerns about the ability of health information technology to fundamentally alter outpatient care quality.”    (Archives Article)