Friday, March 27, 2015

Bigger is better? Not so fast!

Here's a useful report from the Leonard Davis Institute of Health Economics at the University of Pennsylvania:

A new study by LDI Senior Fellow Lawton Burns and colleagues challenges the conventional wisdom about the societal benefits and comparative advantages of integrated delivery networks (IDNs).  A literature review and detailed analysis of financial and quality indicators found “scant evidence” of improved quality, lower cost per case, or greater societal benefit.  From the abstract:

Looking at the benefits to society, the authors found that there is evidence that IDNs have raised physician costs, hospital prices and per capita medical care spending; looking at the benefits to the providers, the evidence also showed that greater investments in IDN development are associated with lower operating margins and return on capital. As part of this report, the authors conducted a new analysis of 15 of the largest IDNs in the country. While data on hospital performance at the IDN level are scant, the authors found no relationship between the degree of hospital market concentration and IDN operating profits, between the size of the IDN’s bed complement or its net collected revenues and operating profits, no difference in clinical quality or safety scores between the IDN’s flagship hospital and its major in-market competitor, higher costs of care in the IDN’s flagship hospital versus its in-market competitor, and higher costs of care when more of the flagship hospital’s revenues were at risk.

In a related piece at Modern Healthcare, the authors conclude:

After decades of strenuous policy advocacy, it is still not clear that, in the case of the IDN, the whole is greater than the sum of its parts, or that policymakers should be encouraging further IDN formation.

I share the authors' skepticism about this direction in health care policy.


Unknown said...

I would love you read your view of the alternative to IDNs. I expect that it is not a FFS cottage-industry medical system. Give us your view of where the middle ground is. Thanks.

Paul Levy said...

You don't need to have common corporate ownership to have care coordination among the various parts of the health care system. Clinical partnerships are possible without common ownership. It fact, if partnerships are based on true clinical coordination rather than center-driven business concerns, they are likely to be more effective.

A key requirement, though, is to have truly interoperable electronic medical records systems to reduce the friction of patients being held within one system.

FFS or capitation is not particularly relevant to the discussion, in my view. Clinical integration has occurred under both and has failed under both.

Barry Carol said...

I agree that a lot of possibilities for better medical management would open up if we had fully interoperable electronic records. Unfortunately, I don’t see a clear path for getting from here to there. It’s not like we patients could demand that doctors and hospitals adopt interoperability or we will go elsewhere for our care. Where would we go? At the same time, large hospital systems and IDN’s have an economic interest in making it difficult for patients to get some of their care outside of an enclosed system.

I was intrigued after reading in Health Affairs magazine about the smart insurance cards that are used in Taiwan’s single payer system. The cards contain information such as allergies, prescriptions, current diseases and conditions, and whether the individual has a DNR or not among other things.

A former colleague of mine is an EMT in his northern NJ town. He showed me a card that all of the EMT people carry that has a bar code on the back containing various medical information that they can choose to have included from a list of options. Why can’t that approach be made more widely available for a modest charge if necessary?

When time is not critical, records from other providers can be faxed or delivered in other ways. I’ve been told by doctors that the information ER docs need most is any allergies the patient has, what drugs he takes, who his doctors are, any disease or conditions he currently has and whether or not he has a DNR.

Anonymous said...

One of Paul's former co-workers (John Halama) at BID is a leader in the "Argonaut Project"

Which is designed to improve interoperability between EHR's.


The Argonaut Project Charter

The following is the first paragraph in that blog.

"Yesterday, a group of private sector stakeholders including athenahealth, Beth Israel Deaconess Medical Center, Cerner, Epic, Intermountain Health, Mayo Clinic, McKesson, MEDITECH, Partners Healthcare System, SMART at Boston Children’s Hospital Informatics Program, and The Advisory Board Company met with HL7 and FHIR leadership to accelerate query/response interoperability under the auspices of ANSI-certified HL7 standards development organization processes."

Do a search on Argonaut Project and Halama for more details.

But work is being done.

Other things are also being done. eclinicalworks has agreements with EPIC to allow ECW to feed doctors data to Epic etc.

It will take time.

But if Halama, who is an acknowledged expert in the field believes progress is possible, I'd believe him.

Debbie S said...

Not quite equivalent, but signing up with MedicAlert, one can arrange to store all those items (tho only 2-3 MDs) plus emergency contacts, so any ER can request the info by phone/fax using your MedicAlert ID #. An abbreviated version is available on wallet card (which could raise privacy concerns) along with the noting the most crucial items (very compressed) on the medallion bracelet or necklace.

Barry Carol said...

I’ve had a Medic Alert necklace for a number of years. When I landed in the ER last October, though, I later learned that I hadn’t renewed my membership for the past seven years! The information they had on file was likely out of date. I’ve since renewed my membership and updated the information.

As it happens, I got a new iPhone yesterday and it came with a health app. Part of the app includes the opportunity to enter such health information as prescription drugs, allergies, diseases and conditions, surgical history, blood type, height and weight, date of birth and emergency contacts which I’ve done. I also have my wife carry a copy of my drug list in her purse.

Every little bit helps but a more robust approach that would cover most of the population would be better and I think we should aggressively pursue the goal of electronic records interoperability so doctors and hospitals can easily access all relevant patient records when they need them.