We've all read stories about how DNA evidence is helping local police and the FBI figure out crimes that have gone unsolved for years. The stories are so common now that they receive much less attention than they used to. Still, the LA Times told one recently.
I tore the article from the front page of the Metro section, and tucked it under the tray that held my shrimp burrito. As I walked back to the office I became more and more agitated about the what I had read. I was also becoming agitated with the local schoolkids who, every day as I walk past, manage to vault one of their balls over the fence and into the street and then yell, "Hey Lady!" until I dash into the street and retrieve it for them. I had already retrieved a basketball when I walked south with my empty stomach. Full of shrimp, I walked north and again they asked me to chase after another one .
I always worry that one day I will miss the fence when I try to toss it back and suffer the humiliation that only a crazed ten-year-old can deliver.
But I digest. The article bothered me because while I was applauding the use of science to help discover the truth about murder and mayhem, I was also lamenting the fact that the same knowledge and data is not being used to help our troubled law enforcement system to improve itself. We're using DNA to root out killers and rapists, and it seems like we ought to be using it to root out problems in our system of criminal investigation. I hope that we already are, but I am not optimistic.
Retail stores use data to determine which sales strategies work the best (and which don't work at all). Physicians collect data to examine outcomes, and thereby determine which protocols and treatments work best ... or don't work at all. It's basic science. It's refinement. It tends to promote success. If ten customers in a row bit into their burritos and shouted, ick!, you can bet the restaurateur would examine that shrimp pretty carefully before serving it up again.
So, wouldn't it be great if we could improve the outcomes...er, shrimp...uh... accuracy of law enforcement methodology by examining DNA evidence to find where the system isn't working? Where an innocent person has been charged with a crime ... and supported by public funds? We pay a physician with public funds via Medicare, and ask the physician to defend his behavior. Shouldn't we ask the same of a law enforcement officer?
And wouldn't your average officer like to know when his strategies have worked and when they haven't? As excruciating as self examination can be, it frequently leads to self-improvement. Imagine a blind study where a neutral party would examine four hundred cases --past and present-- where DNA evidence is available, to determine the real relationship of conviction to guilt. Wouldn't that help law enforcement to do a better job --and make better use of public funds?
Goodness knows, the LAPD could use a little self-examination. The burritos at Casita, however, are perfect.
Let's applaud law enforcement for the difficult work that they do on our behalf, and let's help them to make their jobs easier by examining their successes and failures. We have the tools now, so let's do it.
Once we've accomplished that, maybe we can move on to what's really important: using DNA to determine just who is it that keeps throwing the ball over the fence.
TOBACCO REGULATION IN THE FDA's FUTURE?
Tommy Thompson says that he wants the FDA to regulate tobacco products. He said it at an event promoting a new report on women and smoking being published by his very own department of Health and Human Services.
He's in a tough spot. It sounds like he would like to do something about smoking, and he knows that by raising the tax on cigarettes as part of an aggressive anti-smoking campaign, California has decreased its lung cancer rate significantly. In women, the rate in My Fair State dropped by 5% during a period when national rates increased by more than 13%. Both Thompson and Surgeon General David Satcher have endorsed higher cigarette prices as one of several ways to discourage young people from smoking. But TT has stopped short of suggesting that the federal government mimic California's program on a national level. After all, he is part of an administration devoted to lowering taxes. He says that states ought to make the decision themselves.
So regulation through the FDA seems logical. He definitely appears to be a man who cares about the health of the nation.
Tobacco is a rotten and evil trick that nature has played on us stooges. I have always been rabidly anti-smoking, and I would love to know that some government agency could get its messy bureaucratic fingers on the stuff. You know, sorta like keeping a supermodel tied up in court and unable to work for years: even if she emerges unpenalized, she is likely less equipped to do her job by virtue of a few wrinkles and an age in years that finally exceeds the percent that her agent skims from her salary.
But it's not that simple. If we define tobacco as a drug and allow it to be regulated as such, then how do we differentiate between it and other drugs like marijuana, cocaine, and heroin? If the purpose of calling tobacco a drug and regulating it is somehow to have an effect on health, then why aren't we regulating all drugs ... like alcohol? Do we really want to open the doors for this kind of examination? The harbinger of regulation forces us to ask just why we pretend that tobacco in this case is somehow different from booze, and more frightening than that very question is the possible answer that all of the above are worthy of FDA regulation ... and more. We don't need another Prohibition era.
Besides, if we make the argument that cigarettes should be regulated because they are dangerous drugs, then we ought to just go ahead and make them illegal, like other "dangerous drugs." None of it makes sense. Goodness knows, alcohol can be terribly dangerous, and marijuana is not being blamed for 90% of lung cancer deaths in women. What do we really care about, here?
The only form of regulation that makes sense to me is the sort of regulation that is applied to things like food. Let's ask tobacco companies to tell us what's in their product so we can make an informed decision to abuse it...or not. Then, let's get real about what is a drug and what isn't and start acting with consistency.
A FELLOWSHIP IN .... BILLING?
Hospitals and physicians are learning that if they are going to survive in the era of managed care, they will have to understand the language of medical billing.
The ICD-9 and CPT codes that are used to generate hospital and physician billing are moving into the spotlight as reimbursement becomes the make-or-break factor for survival. The fatty insulation of funds that used to keep physicians ignorant of their financial situations has thinned to the point of transparency, and through this rheumy window, intelligent providers and facilities are seeing their future. It is 300.02.
That's generalized anxiety.
When I open the ICD-9 code book, I find myself somewhat 781.9.
But being catatonic is no response. The appropriate response for providers is to arm themselves with information. Doctors need to understand billing. Yuck.
As it turns out, just seeing a patient and writing down a diagnosis is not enough to ensure reimbursement. And simply admitting the patient is not enough to ensure reimbursement for the hospital. In both cases, the story of the patient's illness has to be told, and perfectly, using a language of codes that until now has only been understood by professional medical billers.
What physicians are realizing that the way that the biller translates the doctor's notes in order to tell the coded story has a very big effect on how much the physician (or hospital) receives in reimbursement. If the physician neglects to include the source of infection for sinusitis, for instance, the biller may not be able to generate the code that will in turn pay the office electricity bill. In California this summer, it may take a gross of sinuses to do that, but if the billing code is wrong a doctor might as well give up and see patients in the dark. Don't you guys use transillumination for sinuses, anyway?
The disconnect between the language of coding and the language of medicine turns out to be a very big deal. For instance, if a patient is diagnosed with having urosepsis, the DRG (or diagnosis-related group) for that condition will reimburse the hospital about $4,000 for the care of that patient. If, however, the physician chooses to include the information that the patient had "sepsis on admission," and the biller picks that up, the hospital can be reimbursed $8500. Same patient, same condition, different codes.
Billers aren't physicians. They can't add "on admission" to the chart, even if it's the truth.
There are two solutions: Well, three. The first is to send all billers to medical school. The second is to have medical billers see the patient with the physician ... you know, act something like a translator. The third is to educate physicians about the extent to which what they write on the chart translates into money.
Or, you can practice in the dark.
Editor
Janine Abercrombie
DISCLOSE, DISCLAIM, DIS CLARITIN
It is no surprise to any of us who have a television that drugmakers are permitted to advertise their products on the air. Likewise, whether you choose to read Rolling Stone or The New Republic, chances are you know that drugmakers also advertise their product in print.
I suppose that if you watch only certain satellite channels and read only Cost and Quality and 2600, there is a chance that you have not encountered a drug advertisement. (I would love to meet anyone out there who reads only 2600 and Cost and Quality. If that person is you, please write me here. I want to buy you dinner.)
In September of last year, Cost and Quality told us that the FDA cited drugmaker Schering Plough for misrepresenting their product Claritin in magazine ads. The FDA said that S/P had presented their advertisements with fun-size content that, by virtue of its sparseness, made them exempt from pesky FDA requirements to disclose drug risks. The shallow ads ran in groups: each individual page compliant with FDA regulation but collectively painting a picture of a drug refreshingly free of side effects.
Schering Plough (by the way, my spellchecker offers "Scheming Polish," in favor of Schering Plough) had found a loophole in the regulation, and made the best of it until the FDA caught on. Now, eight months later, Roche is doing the same thing, only this time it's on television. And according to theWall Street Journal, the FDA may not be able to stop them because they really aren't breaking any rules.
Like S/P, Roche has divided its ad content into mini-doses in order to circumvent regulation. Instead of advertising Xenical with a conventional 30-second spot, Roche instead offered up its weight-loss drug in two shorter ads, aired with a non-related commercial in between. Neither of the short ads is comprehensive enough to require disclosure, but together, they are every bit as saturated as one long ad, if not more.
The question is --does it matter?
I like TV commercials. They're little works of art. Not all good, but all real. I like advertising in general. It's an essential part of a robust market. And while it's irritating to know that drug ads might tend to make patients think that they know more than their physicians, the ads undoubtedly channel patients hungry for the next diet drug out of the drugstore and into the doctor's office, which --in spite of capitation-- has to be a good thing for physicians.
I think.
The FDA says that it plans to examine whether drug ads confuse consumers and adversely affect the relationship between patients and providers. Roche says that it would rather not mention the gas, oily discharge, and inability to control bowe... jeez, you know where I am heading. I don't particularly want to mention it either.
But about the FDA, and regulations, and disclosures: compulsory disclosures can be good. I asked a friend of mine who produces commercials if there were any disclosures that he felt good about including in his little artworks. He offered up toy ads that show kids playing only with the bits that are actually included in the toy set being hawked. You know... so that the babes don't think that Barbie comes with that smashing ball gown, or that the Lego package comes with enough pieces to build a theme park... stuff like that. Less misleading for kids that way, you know.
The same FDA has found that in spite of strict labeling laws, as many as 25% of food manufacturers fail to list on their labels common ingredients that can cause potentially fatal allergic reactions. So says the New York Times. Disclosure is called for on food labels, I think.
And then there was the LA Times' little boo-boo in their food section a week or so ago. Seems they accidentally included a photograph of a poison mushroom in an article about edible wild foods. Certainly, disclosure of that oversight was a good thing.
But exactly how much do we need to tell people about drugs before they've even seen a doctor? It's not like they're going to see the ad and then drive to the bad part of town, corner a suspicious-looking fifteen-year-old, and insist that they sell them a baggie of Claritin. It's not like they are going to buy a box of Drugs Ahoy! cookies and carefully check the label for drug interactions. They need to visit the doctor to get a prescription, right? They need to see a pharmacist to have the prescription filled, right? Why are we insisting on disclosure?
And in some way, is it possible that by disclosing the side effects --thus ostensibly de-mystifying the product-- that we are inducing a false sense of knowledge in the patient? I rather like the idea of the provider and the pharmacist being viewed as the authority, rather than the television. A voice-over artist carefully enunciating "oily discharge" confers no expertise.
It would be interesting to know exactly why the FDA feels that disclosure is necessary in the realm of advertising. Perhaps they feel that physicians can be pressured by patients into prescribing inappropriate drugs? If that's the case, I think that we have a lot more to worry about than a few gassy side-effects.
RICO (RICO)
According to Reuters, three state medical associations --representing more than 79,000 physicians-- have filed an amended Federal lawsuit against a group of major HMOs. The medical associations of California (CMA), Georgia (MAG), and Texas (TMA) claim that eight major health plans have violated racketeering laws (RICO) by exploiting physicians' (MDs) services. The lawsuit was filed in Florida (FL), after the first attempt to file was rejected (86d).
The medical associations say that the health plans (HMOs) --including WellPoint, PacifiCare, CIGNA (CIGNA), Humana, Aetna and United Healthcare-- deny (NO), reduce (LO), and delay (SLO) payments to providers.
A PacifiCare spokesman (SPO) told Reuters that the company was "still monitoring the situation." (QUO).
A spokesman (BRO) for the California Medical Association (SFCMA) said that the lawsuits consolidate more than two dozen (24) lawsuits ($$) that all had similar pleadings and evidence.
HOW TO FLY WITH STATISTICS
I had a blind date recently with an urban hunter-gatherer: a guy who stalks and collects statistics and then exploits them to make his living. He talked through the evening about every aspect of consumer data: how it can be collected, analyzed, extrapolated, massaged, used to line the bottom of a bird cage, etc.
It was a date saturated with detail. A data date. Now, I love detail, most of the time, but I found myself zoning out and thinking about tangerines about halfway through the evening. I mean, he was cute and all, but I just didn't want to absorb what he was saying.
Apparently he was pretty successful at applying the results of his calculation to the marketplace. He was (is?... I'll never know!) getting rich because he figured out how buyers act in a specific marketplace and exploited it. Aah, the power of data.
The numbers he was collecting were rolling directly into his database from, of all places, E-bay. But that's not the important thing here.
What's important, I think, is why I was zoning out, and why we see headlines like " ICU Savings of over $1.5 Billion if Benchmarks were Matched," so frequently.
The key word in that headline: "if"
See, I hate statistics. I mean, I love to browse them --census data is to a former geographer as krill is to a baleen whale-- but browsing data and applying it are two very different things. One is the realm of vague, messy, intuitive types who are prone to leaps of faith --like me-- and the other, a fertile plot needing only to be tended and the crop carefully stored and prepared, all with predictable results! Find your place on the curve and dive in. Statistics. Get it? I mean, that's the beauty of big data, right? And who can deny the power of the bell curve?
Well, me, I guess, because although I figured out a long time ago that the world was just one big dollar waiting to be delivered, provided the stastically appropriate effort is applied, I have always chosen the vague, messy, intuitive road. But I am a writer, not an ICU. I am also not nearing death from starvation, as are so many hospitals these days. I have the luxury to decide to think about tangerines.
Hospitals do not. They are obligated to act like my date did. They need to embrace the curve.
The Solucient Leadership Institute recently released a study that showed that if hospitals with ICUs would carefully adhere to benchmarks established by other hospitals with top-performing ICUs, money would be saved --big money-- and lives too. Cost improvement and quality improvement. It's all there in the Solucient study.
It makes lots of sense, too, since ICU patients chew up such a large chunk of a hospital's resources. (Just don't ask me the exact size of the chunk.) It's only logical that adherence to proven cost-saving and quality-improving methods would yield a big reward.
So, what data can ICUs embrace in order to save lives and money? The Leapfrog Group seems to know: in their November, 2000, ICU Physician Staffing report, they offer specific advice. Their suggestions? Use Intensivists, and use them in a "closed" ICU setting. That means let physicians who know intensive care manage patients in the ICU. They point to a study that showed that patients in hospitals without Intensivist-managed ICUs are three times as likely to die after surgery.
At least nine studies, says Leapfrog, have examined the relationship between ICU staffing and patient outcomes. In every case, Intensivist ICUs were associated with lower mortality rates. And, they say, Intensivist model ICUs may also reduce ICU lengths of stay and the number of unnecessary ICU admissions.
The group even went so far as to create the ICU physician staffing or "IPS" standard as one of its initial Safety Standards because of the profound potential benefits to patients. And their primary reason for being is to issue patient safety standards ... so they know, man.
So, by Leapfrog's standards, "Hospitals fulfilling this standard will operate adult ICUs that are managed by physicians board-certified or board-eligible in critical care medicine who are 1) present during daytime hours and provide clinical care exclusively in the ICU, and 2) at other times can return more than 95% of ICU pages within 5 minutes and, 95% of the time, arrange for a FCCS certified physician or physician extender to reach the ICU patient within 5 minutes."
This is the formula for cost savings and improved quality of care, Leapfrog says, and yet only 10% of ICUs in the world can meet this standard. Of course, with more ICUs than intensivists in the US, it's not simple. It would take 30,000 intensivists to cover all ICUs full time, and right now we have only about 5,500. We're a long way from making perfect use of what we know.
And health care is infinitely more complicated than selling Hot Wheels and Baseball cards on E-bay. Yep, that's what he is getting rich on. Embarrassing, huh.
We need more Intensivists. And we need to know more about the emerging Hospitalist movement. Hospitalists have training similar to, but not exactly like, Intensivists, and their presence could potentially alleviate the very real shortage of Intensivists.
Intensivists and Hospitalists will make a difference. Just ask the curve.
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ICU Costs as a percentage of total hospital costs in US:
1972: 5%
2000: 23%
Average cost of an ICU bed day in US:
Early seventies - $300
Today: $2500 - $3500
Total ICU Costs in US in 1999:
$92 Billion, or 1% of US gross domestic product.
Number of full-time Intensivists in US: 5,500
Number of Intensivists it would take to staff all US ERs: Approximately 30,000
Numbers of lives that could be saved each year if every non-rural ICU in the US had an Intensivist, according to Leapfrog Group: 54,000
Source: Advance for Managers of Respiratory Care - April 2001
100 Top Hospitals: Intensive Care Units
Source: Solucient Leadership Institute www.solucient.com
Arranged by State
University Medical Center Tucson AZ
Northwest Medical Center Tucson AZ
Summit Medical Center Oakland CA
Loma Linda University Medical Center Loma Linda CA
Exempla Saint Joseph Hospital Denver CO
Hospital of St. Raphael New Haven CT
MidState Medical Center Meriden CT
Middlesex Hospital Middletown CT
New Britain General Hospital New Britain CT
St. Francis Hospital Wilmington DE
Cedars Medical Center Miami FL
Lee Memorial Hospital Fort Myers FL
St. Anthony's Hospital Saint Petersburg FL
JFK Medical Center Atlantis FL
Aventura Hospital and Medical Center Aventura FL
Winter Park Memorial Hospital Winter Park FL
Palm Beach Gardens Medical Center Palm Beach Gardens FL
Florida Medical Center Fort Lauderdale FL
Blake Medical Center Bradenton FL
Southwest Florida Regional Medical Center Fort Myers FL
Orange Park Medical Center Orange Park FL
Columbia Putnam Medical Center Palatka FL
Brandon Regional Hospital Brandon FL
Largo Medical Center Largo FL
Oak Hill Hospital Spring Hill FL
Mease Countryside Hospital Safety Harbor FL
Grady Memorial Hospital Atlanta GA
Community Hospital East Indianapolis IN
St. Vincent Hospital & Health Services Indianapolis IN
Hardin Memorial Hospital Elizabethtown KY
Franklin Square Hospital Center Baltimore MD
Union Memorial Hospital Baltimore MD
Johns Hopkins Bayview Medical Center Baltimore MD
North Arundel Hospital Glen Burnie MD
Greater Baltimore Medical Center Baltimore MD
HealthAlliance Hospital Leominster MA
Mount Auburn Hospital Cambridge MA
UMASS Memorial Medical Center Worcester MA
Providence Hospital and Medical Center Southfield MI
Spectrum Health Downtown Campus Grand Rapids MI
Bon Secours Cottage Health Services Grosse Pointe MI
Sinai-Grace Hospital Detroit MI
Barnes-Jewish Hospital Saint Louis MO
Albany Memorial Hospital Albany NY
Montefiore Medical Center Bronx NY
North Shore University Hospital Manhasset NY
St. Joseph Hospital Health Center Syracuse NY
Ellis Hospital Schenectady NY
Crouse Hospital Syracuse NY
NYU Health Center New York NY
Erie County Medical Center Buffalo NY
Park Ridge Hospital Rochester NY
Seton Health System Troy NY
Mercy Hospital of Buffalo Buffalo NY
Mission St. Joseph Health System Asheville NC
Summa Health System Akron OH
Parma Community General Hospital Parma OH
Trumbull Memorial Hospital--Forum Health Warren OH
Fairview Hospital Cleveland OH
St. John West Shore Hospital Westlake OH
Southwest General Health Center Middleburg Heights OH
Community Health Partners Lorain OH
UMPC McKeesport Hospital McKeesport PA
Chestnut Hill Hospital Philadelphia PA
York Hospital York PA
St. Luke's Hospital & Health Network Bethlehem PA
Grand View Hospital Sellersville PA
Hamot Medical Center Erie PA
Western Pennsylvania Hospital Pittsburgh PA
Lancaster General Hospital Lancaster PA
Montgomery Hospital Medical Center Norristown PA
Lehigh Valley Hospital Allentown PA
Westmoreland Regional Hospital Greensburg PA
MercyFitzgeral Hosptial Darby PA
Easton Hospital Easton PA
Thomas Jefferson University Hospital Philadelphia PA
Crozer-Chester Medical Center Upland PA
Lankenau Hospital Wynnewood PA
Sacred Heart Hospital Allentown PA
Nazareth Hospital Philadelphia PA
Riddle Memorial Hospital Media PA
St. Clair Memorial Hospital Pittsburgh PA
Penn State Milton S. Hershey Medical Center Hershey PA
Jefferson Hospital Pittsburgh PA
Bristol Regional Medical Center Bristol TN
Baptist Hospital of East Tennessee Knoxville TN
Baptist Hospital Nashville TN
Parkridge Medical Center Chattanooga TN
University of Texas Medical Branch Hosp Galveston TX
Good Shepherd Medical Center Longview TX
All Saints Health System Fort Worth TX
Wadley Regional Medical Center Texarkana TX
Memorial Hermann Baptist Beaumont Hospital Beaumont TX
Southwest Texas Methodist Hospital San Antonio TX
Shannon Medical Center San Angelo TX
Metropolitan Methodist Hospital San Antonio TX
Doctors Hospital of Dallas Dallas TX
University of Virginia Health System Charlottesville VA
Augusta Medical Center Fishersville VA
Central Washington Hospital Wenatchee WA
Inpatient Surgery
(All figures are for U.S.)
source: cdc.gov
Number of Procedures Performed: 41.5 million (1998)
Number of Operations Performed on the Nervous System: 1,062,000 (1998)
Number of Operations Performed on the Endocrine System: 96,000 (1998)
Number of Operations Performed on the Eyes: 122,000 (1998)
Number of Operations Performed on the Ears: 57,000 (1998)
Number of Operations Performed on the Nose, Mouth, and Pharynx: 288,000 (1998)
Number of Operations Performed on the Respiratory System: 1,004,000 (1998)
Number of Operations Performed on the Cardiovascular System: 5,791,000 (1998)
Number of Operations Performed on the Hemic and Lymphatic System: 334,000 (1998)
Number of Operations Performed on the Digestive System: 5,116,000 (1998)
Number of Operations Performed on the Urinary System: 946,000 (1998)
Number of Obstetrical Procedures Performed: 6,640,000 (1998)
Number of Operations Performed on the Musculoskeletal System: 3,257,000 (1998)
Number of Operations Performed on the Integumentary System: 1,325,000 (1998)
Source: Advance Data 316
The NHCQA Bulletin is an official publication of the National Healthcare Cost and Quality Association. Published monthly. For information, contact the NHCQA at 11313 Weddington Street, First Floor, North Hollywood, CA, 91601. Telephone 818.761.6546, toll-free 888.761.3600. E-mail at info@nhcqa.org.
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