Steven R. Peskin, MD, MBA, FACP

One of the four 2011 Malcolm Baldridge National Quality Award winners in health care is Southcentral Foundation, a nonprofit organization established in 1982 to serve Alaska Natives who live in and around Anchorage. The Southcentral Foundation (SCF) describes itself as a Nuka system of care — Nuka being an Alaska native name given to strong, honorable structures or living things.

Steven R. Peskin, MD, MBA, FACP

So many gaps, so little time.... That would be a ready conclusion from the extensive body of literature on gaps in patient care, medical errors, and patient safety. A recently released in-depth report from the American Medical Association, Research in Ambulatory Patient Safety, chronicles gaps related to diagnostic, laboratory, clinical knowledge, communication, and administrative (potential) errors. The possible combinations among these five domains is extensive.

Steven R. Peskin, MD, MBA, FACP

The following paragraph is from the American College of Physicians Ethics Manual, 6th Edition:

“Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available. In making recommendations to patients, designing practice guidelines and formularies, and making decisions on medical benefits review boards, physicians' considered judgments should reflect the best available evidence in the biomedical literature, including data on the cost-effectiveness of different clinical approaches. When patients ask, they should be informed of the rationale that underlies the physician's recommendation.“

With synonyms for parsimonious that include miserly, stingy, and frugal, it is no surprise that this word choice evoked some criticism. The preponderance of the Ethics Manual advocates that the physician’s primary obligations and duties are to the patient, exercising beneficence, confidentiality, and honesty, with the best interest of the patient being paramount. The paragraph above is a small, but important, segment of the Ethics Manual.

Steven R. Peskin, MD, MBA, FACP

A visit to my dental hygienist this week began with a conversation about diagnostic tests. Before the dental x-rays, I asked Dottie if I needed x-rays, and she replied that it had been 18 months, and, based on my age and past dental history, every year to two years was a reasonable interval. Not wanting to debate this point before confronting the Cavitron, I accepted that rationale.

Steven R. Peskin, MD, MBA, FACP

This post is not about coronary artery disease. Nor is it about the “stiff” ventricles in diastolic heart failure.

Like “Never Rest”, which I posted several weeks ago, this brief discussion was inspired by Saturday morning Torah study. “Harden Heart” refers to the Pharaoh at the time of Moses and the Exodus from Egyptian slavery. What struck me from our discussion on Saturday morning that relates to health plans and health benefits is that those of us who have responsibility/authority over what is reimbursed, or not, how it is reimbursed, and at what level are — metaphorically — in a parallel role to the Higher Power in the Torah passage. Those whom the purchasers and payers are influencing, or who are on the receiving end of attempts at influence by the purchaser or payer are, metaphorically, in the position of Pharaoh (No implication or suggestion intended about virtue or lack thereof on either side of this analogy!). They are employees, plan members, health care professionals and facilities, ancillary providers, and any other entities that are being paid for services.

In the story, it takes many sticks (no carrots) to ultimately influence Pharaoh to free the Jews. The question that we discussed and debated is to what degree God hardened Pharaoh’s heart and to what degree did Pharaoh, using free will, refuse to set the slaves free even in the face of punitive actions — the plagues.

Steven R. Peskin, MD, MBA, FACP

After grand rounds this morning at the University Medical Center at Princeton, the director of the recently created transitional care program, Kathleen H. Seneca, MSN, was speaking with one of our nephrologists about the purpose of the program. It fills the transitional gap for people discharged from the hospital that do not qualify (in terms of reimbursement guidelines) for home care, but would benefit from additional education, care planning, and hands-on instruction.

Steven R. Peskin, MD, MBA, FACP

Leaving the gym on an unseasonably warm night, I struck up a conversation in the parking lot with a vascular surgeon acquaintance. He recounted a technically demanding procedure that he had done the day before with a reported 10 percent risk of stroke and a 3 percent mortality risk.

Steven R. Peskin, MD, MBA, FACP

What do these characteristics bring to mind?

  • Flexible appointment scheduling
  • Advanced electronic communication
  • Care coordination
  • Counseling and education
  • Electronic prescribing
  • Electronic health record with patient portal

If you thought Level 3 Medical Home, you were correct. If you thought retainer (concierge) practice, you would also be correct. To me, it seems eminently rational for people who have sufficient discretionary income to choose to use it to obtain more rapid access to a personal physician of her/ his choosing through a retainer (concierge) practice.

Steven R. Peskin, MD, MBA, FACP

The drumbeat of EBM — Evidence Based Medicine — seems less vigorous in the wake of enthusiasm for new models of care — Medical Homes and Accountable Care Organizations — and reimbursement based on performance, outcomes, or episodes of care.

A good definition of EBM from Sackett, et. al:

Steven R. Peskin, MD, MBA, FACP

In my Saturday morning Torah study, we focused on Jacob’s “settling in” with his family. After years of struggle, Jacob becomes complacent, comfortable. We discussed whether Jacob’s complacency — his relative inaction — contributed to the animosity that led Joseph’s brothers to sell him into slavery and to report to their father that his then youngest son had been killed.

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Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.