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Though the title might apply to many aspects of our daily lives and the world as a whole, in this instance I am referring to how Medicare and other insurers interpret the word reasonable to make coverage and payment decisions. A recent editorial in the New England Journal of Medicine highlighted this enduring challenge for Medicare.

The authors begin with language from the Social Security Act:

No payment may be made. . . for any expenses incurred for items or services which . . . are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

The editorial takes the point of view that a legislative fix is needed for greater specificity surrounding reasonable and necessary services for coverage and payment determination. My view is that more complete definitions of reasonable and necessary —  definitions that might include "cost-effectiveness" or "adequate evidence" as the authors advocate — are not a meaningful part of the solution to Medicare's looming insovency and to addressing unsustainable cost increases.

But the authors note that "some may hope that the federal government can simply delegate coverage decisions to other parties, such as accountable care organizations, while forcing patients to consider the value of technologies through increased cost sharing." 

These two approaches are the path to the practice of cost-conscious care by clinicians and to cost-aware care among consumers.

The ability of providers to challenge evidence-based decisions with additional or alternaitve evidence when the economic incentives support volume over value has circumvented and will continue to circumvent payer efforts to control overuse. Aligning the collective interests of clinicians and their patients away from overuse and toward appropriate  care is the road to affordable health care.

Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School.

John Muir, the famous naturalist, wrote: “When one tugs at a single thing in nature, he finds it attached to the rest of the world.”  It’s a concept that’s long overdue but now fully ensconced in the field of population health management.  Employee health management (EHM) practitioners, in particular, are coming to understand that the environments in which health promotion interventions occur are a primary determinant of the effectiveness of the interventions.  What’s more, many now fully acknowledge that the sustainability of healthy lifestyle improvements in diet, exercise, or tobacco use is fundamentally linked to our surroundings.  Indeed, in last week’s “HEROForum12”, a conference featuring EHM solutions, a third of the session titles included references to culture.  Moreover, no matter what the topic, the phrase “building a culture of health” was stated at nearly every session. Read more »

As a baby boomer moving through middle age into the unspeakable age that follows “middle,” I was encouraged to read an article in the British Medical Journal that states that for seniors and super seniors, healthy behaviors that include regular exercise, not smoking, maintaining a normal Body Mass Index, and having a rich or moderate social network led to significant increases in longevity. From the study:

“Even after age 75 lifestyle behaviours such as not smoking and physical activity are associated with longer survival," the study authors write. "A low risk profile can add five years to women's lives and six years to men's. These associations, although attenuated, were also present among the oldest old (≥85 years) and in people with chronic conditions."

This study affirms the benefits of lifestyle and healthy behaviors for the hundreds of millions of people who are in or are entering their golden years in the United States and across the industrialized world. With these “prescriptions” or interventions, there is no need for elaborate quality-adjusted life year studies or comparative-effectiveness research to justify hundred-thousand-dollar sickness care interventions! The ROI is compelling.

Shaping or modifying our own personal behaviors or effecting positive health behaviors in others, whether as a health plan, an employer, or as clinicians, is no piece of cake but is well worth the effort.

Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School.

I have long held that leaders can’t fake authenticity. When you’re passionate about your vision, it is felt by others whether they support you or not. It’s a realization that has been easy to come by because I’ve had so many great mentors.

One of my favorites has been Stu Hanson, a pulmonologist, a health care executive, and a prime mover in Minnesota’s historic national leadership role in creating smoke-free workplaces. Stu would often say, “I’m trying to work my way out of a job.” Putting aside his recent retirement and the fat-chance odds behind his conviction even when he was mid-career, to know Stu is to understand that he wasn’t kidding.  Stu’s mantra was the ancient proverb: “When you are through changing, you are through.” Perhaps it is a philosophy born out of the Herculean-sized stubbornness needed to take on the intractability of an addicted smoker. Or maybe being wired to push for change helps you cope with the blowback and disappointments that come from working to change something as unyielding as a culture.

As a student of leadership as well as one interested in the intersections between health care business and public policy, I also can’t help but follow Toby Cosgrove, a cardiologist who became Cleveland Clinic’s CEO.  I have assumed that his equanimity about the controversy that surrounds his ban on hiring tobacco smokers is grounded in the righteousness that only a cardiovascular surgeon can feel at his core after having performed 22,000 operations, at least half of which were lifestyle-induced. What else explains his more recent foray into smoking bans at universities? In a speech to the Harvard Business School Club of Cleveland, Cosgrove said: “The fact that American universities are not smoke-free appalls me.” Though being right is a powerful buffer, it doesn’t change the likelihood that he’ll be disparaged. Read more »

In May 1999, Abigail Sulerzyski was born deaf and blind with cerebral palsy and multiple other medical complications. While Victoria, her mother, was learning how to cope with the needs of a severely disabled child, she was also learning how to fight with UnitedHealthcare.

Abigail required continuous feeding through a jejunostomy tube, and the insurer was denying the prescription nutritional supplements that Abigail needed to survive. As Victoria was preparing to mount a legal battle against United, “something changed around December of that year,” she said. The formula along with other specialized equipment was covered.

“I went from having to fight for everything to having their nurse call me every month to ask, ‘How can I help you?’” Victoria didn’t bother trying to understand this abrupt change; she was just grateful to have more time to take care of her daughter.

When I met Victoria a few weeks ago and she shared this story, I explained the dramatic shift that she experienced. The early hassles resulted from the “mother may I” medical necessity review that gave company medical directors the authority to supersede the judgment of treating physicians regarding patients’ clinical care needs.

But in November 1999, United made the bold and very public decision to stop interfering with the doctor-patient relationship. While other prospective and retrospective utilization management (UM) activities continued, second-guessing physicians came to an enterprise-wide halt. Read more »

A close friend of ours went with my wife to see a highly regarded physician for a persistent problem. This master clinician started with a warm greeting and a brief conversation about family, and then went through a detailed history of the problem that our friend had experienced for several months. He gave her an explanation of what he believed to be the underlying cause of her symptoms, gave a prescription for lab tests, and prescribed two medications. He also suggested that she see an ENT and recommended someone.

Our friend’s father had already recommended an ENT. The father, who happens to be a physician, had seen this ENT as patient.

 The contrast was stark. The physician was curt, made no effort to establish rapport, made a passing negative comment about the other physician’s medication selection without suggesting an alternative or the rationale for his disagreement, performed a 5-minute procedure of visualizing the inside of the nose (nasocopy), and, in closing, said “How do you breathe through that thing?? You should have it fixed.”

He charged $625.00 for the 5-minute procedure and $225.00 for the office visit.

The first physician followed up by phone, showed concern, and made recommendations about where our friend could follow-up within her health plan network.

Our friend, Doctor Smith (his real name), consistently shows genuine human interest, brings to bear keen diagnostic acumen, answers questions, and coordinates care. He has practiced this way for many years with patients from the C-suite and from homeless shelters. In sharp contrast is Dr. Rude, not his real name, who, sadly, gives our profession a black eye. Let’s reward and value the Doctor Smiths and devalue the Dr. Rudes.  Our provider networks, payment system, and, consumer information should align accordingly.

Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey — Robert Wood Johnson Medical School.

One of the key downsides of market-based health care  — that if your costs regularly exceed your income you go out of business  — is not typically associated with the National Health Service in the U.K. That is about to change. It has just been announced that the three hospitals that constitute the South London Healthcare Trust in London, England are to be effectively declared bankrupt, the board suspended, and the organization put under a special administrator. He or she will have just 45 days to provide the Secretary of State with recommendations on what to do with an organization that provides emergency an elective services to about 750,000 Londoners but has racked up nearly $100 million of debt in 2011–12 alone.

Why is this of interest to U.S. readers, aside from adding to the long-running debate on the pros and cons of operating a market in health care? It is because one option is to privatize one or more of the hospitals. By privatize, I mean a whole range of options from franchising out the management to a private company to taking over the assets lock, stock, and barrel and then providing services back to the NHS.

There are plenty of other NHS hospitals/trusts in England that are in severe difficulties, so this is likely to be repeated up and down the country in fairly short order. The political fallout is likely to be considerable, coupled with howls of indignation from local populations (and hospital staff) as the new regime takes action to try to balance the books.

If any reader knows how to save large sums  (SLHT’s annual revenues are in the region of $600 million, so they are spending $7 for every $6 they get in) without a lot of pain, that person should e-mail the Secretary of State for Health without delay! In the meantime the NHS is heading into unknown waters and commercial opportunities may well result that will be of international interest. For those brave (or foolhardy) enough to take on such troubled hospitals under a microscope of political and public scrutiny, there will be an opportunity to settle a another long running dispute: whether the private sector really is better at running hospitals than its public counterpart. Whatever the answer, I wish them luck. They will need it.

Robert Royce, PhD, is Director of Strategy at Barking, Havering & Redbridge University Hospitals NHS Trust in London, England. 

Paul Terry, PhD, is Chief Executive Officer of StayWell Health Management.

As is always the case when I return from working abroad, it takes me longer, metaphorically speaking, to unpack my bags. I was ostensibly in Brazil to teach and consult about innovations in our population health management movement in America. But, as I expected, I was surely the greater beneficiary of teachings from leaders of the wellness movement in Sao Paulo, the business nexus for the world’s sixth largest economy.

Leaders of population health programs in Sao Paulo offer a self-assessment of being a decade or more behind the United States in the maturation of employee health benefits such as employee assistance programs (EAP), disease management, pharmacy benefits management (PBM), and wellness. I anticipated we would be discussing the “leapfrog” opportunities that come with later adoption of trends. For example, developing countries garnered advantage by skipping much of the costly infrastructure of cable by embracing  wireless communications.

So I came to Brazil thinking about what aspects of American health care innovation I would skip over if I had a chance to learn from the trials and errors of America’s health reforms. Read more »

Amanada Bennett, a Pulitzer Prize winning journalist, chronicles the poignant journey that she and her now deceased husband, Terrence Foley, traveled in his seven-year battle with a rare form of kidney cancer. The Cost of Hope puts into sharp focus the convoluted compexity of our health care system even for two well educated, well insured individuals with superior skills to acquire, parse and synthesize information and data.

A recent experience helping a friend with advanced cancer to navigate within two large, highly rated health care systems brought home in a very personal way the frustration and fear that our sometimes seemingly impenetrable “system” may evoke. Like the Bennetts, my friend was well informed, well insured, and had superior abilities to access and analyze infomation about his own illness.

The cost in the Cost of Hope is financial as well as emotional. Over the past few days I have asked fifteen people — nurses, physicians, and non-health-care professionals, “How many CT scans do you think that a person with a diagnosis of kidney cancer received over seven years?” (Before you read further, make your estimate.)

My informal polling of these 15 people was 18 to 30.  Amanda Bennett and her husband decided to pore over the reams of information that they had received from insurers and providers to satisfy their curiosity about the number of CT scans performed. To their astonishment, the number was 76. Though the book does not do an evidence-based retrospective analysis of the appropriateness of each of these scans, the author's perception, shared by the 15 people that I polled, is that a substantial number of these scans were unnecessary.

In the aim for the Triple Aim, we were 0 for 3. For an excerpt, please link to the article below:

http://www.bloomberg.com/apps/news?pid=newsarchive&sid=avRFGNF6Qw_w

Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey — Robert Wood Johnson Medical School.

The May 17 New England Journal of Medicine 200th Anniversary edition article The Evolving Primary Care Physician highlights key structural, financial, and cultural challenges that confront primary care in the United States. Some of these include training and education that emphasizes ever greater subspecialization, reimbursement that rewards volume versus value, and an increasing reliance on testing versus well-honed history taking, physical diagnosis, and counseling and coaching of patients and their family members/care givers.

The article touches upon research conducted by Christine Sinsky and Thomas Bodenheimer, supported by the American Board of Internal Medicine Foundation,  in which they visited and observed 23 primary care practices.  A compelling distillation from Dr. Sinsky:

What I’ve really seen is a lot of waste within the health care system at the level of utilization of physician skills. I think two thirds of many [primary care] physicians' days are spent on documentation, administrative tasks, paper work completion, rote inbox management, data gathering, and data entry. It’s something that is hard to recognize when you’re the one doing it.

To re-invigorate primary care, training needs greater emphasis on history taking skills, motivational interviewing, physical diagnosis, synthesis of information, more judicious use of testing and imaging, and engaging patients in their health care.

For primary care clinicians to enjoy professional satisfaction and improve population health management, and to reduce primary care clinician time on administrative functions, team-based care is a powerful prescription for positive change.

Douglas Kelling, a general internist in Concord, North Carolina, is profiled in the article as a successful example of transformation to team-based care. Kelling’s personal analogy is to make medical care "more like NASCAR with the doctor as the driver and other team members responsible for the fuel and tires.”

Dr. Kelling’s practice is effective caring for a large population, including patients with multiple chronic conditions.

Emerging health plan and CMS models that provide payments for care coordination and outcomes-/ performance-based payments will result in many new primary care-anchored teams through the country.

Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey — Robert Wood Johnson Medical School.