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15 posts from November 2008

November 26, 2008

Engage With Grace

As patients, as family members, as friends, as health care providers, we have all faced end-of-life issues at one time or another, and we will face them again.  And again. 

This weekend, the "Engage With Grace" message is being broadcast virally, through a "blog rally," at a time when many people are with family and friends over the long weekend.  (Thanks to Paul Levy and Charlie Baker for getting the issue out of the blogosphere and onto page one of the Boston Globe today, too.)  The point is: we all need to have the potentially uncomfortable conversation with people close to us about what kind of treatment we would want, and they would want, if incapable of making or communicating health care decisions.  (If you really want to monopolize Thanksgiving dinner conversation, you could also start the family health history conversation being promoted by the Surgeon General.)

End-of-life decisionmaking has long been an issue of great personal and professional interest to me, and I am proud to have played a role in having out-of-hospital DNR orders recognized in Massachusetts by EMS providers, as an example. 

Download your copies of the Massachusetts health care proxy form or other states' proxy or living will forms -- and add specific instructions about nutrition, hydration, and anything else that is important to you so that everything is crystal clear.  My mom kept a stack of living will forms in the dining room when I was growing up, and was not shy about raising the issue with dinner guests and offering to witness their directives.  Having the conversation is a starting point; we all need to follow through and make sure that our loved ones' wishes are documented, placed in medical records, discussed with physicians and other caregivers, and honored. 

When I have the opportunity to speak to groups of lawyers or health care providers, I often ask for a show of hands: how many of you have health care proxies?  The percentage seems to have increased over time, but it is still not where it needs to be.  If groups that should be above average in this respect are not all raising their hands, then we clearly have a lot to do in terms of educating the general public about the need to have the sometimes difficult conversation with friends and family members.  That's what the Engage With Grace project is all about.  And with that, I turn over this post to Engage With Grace:

*    *    * 

We make choices throughout our lives - where we want to live, what types of activities will fill our days, with whom we spend our time. These choices are often a balance between our desires and our means, but at the end of the day, they are decisions made with intent. But when it comes to how we want to be treated at the end our lives, often we don't express our intent or tell our loved ones about it.

This has real consequences. 73% of Americans would prefer to die at home, but up to 50% die in hospital. More than 80% of Californians say their loved ones "know exactly" or have a "good idea" of what their wishes would be if they were in a persistent coma, but only 50% say they've talked to them about their preferences.  But our end of life experiences are about a lot more than statistics. They're about all of us.

So the first thing we need to do is start talking. Engage With Grace: The One Slide Project was designed with one simple goal: to help get the conversation about end of life experience started. The idea is simple: Create a tool to help get people talking. One Slide, with just five questions on it. Five questions designed to help get us talking with each other, with our loved ones, about our preferences.

And we're asking people to share this One Slide - wherever and whenever they can.at a presentation, at dinner, at their book club. Just One Slide, just five questions. Lets start a global discussion that, until now, most of us haven't had.Here is what we are asking you: Download The One Slide and share it at any opportunity - with colleagues, family, friends. Think of the slide as currency and donate just two minutes whenever you can. Commit to being able to answer these five questions about end of life experience for yourself, and for your loved ones. Then commit to helping others do the same. Get this conversation started.

Let's start a viral movement driven by the change we as individuals can effect...and the incredibly positive impact we could have collectively. Help ensure that all of us - and the people we care for - can end our lives in the same purposeful way we live them. Just One Slide, just one goal. Think of the enormous difference we can make together.

(To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team)

*    *    *

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

November 25, 2008

Health 2.0 roundtable webcast on Read Write Web; HealthBlawg on twitter

Listen in on some Health 2.0 luminaries chatting at Read Write Web.  The live podcast was yesterday afternoon.  Tip of the hat to Scott Shreve (twitter: @scottshreve) and Unity Stoakes (twitter: @unitystoakes).  Scott, and Unity's colleague Steven Krein, were two of the discussants.

And yes, thanks to the continuing social media revolution, HealthBlawg is on twitter now too. Follow me: @healthblawg

Watch this space for an intro to twitter for lawyers (applicable to human beings too), and also for instructions on subscribing to my twitter posts via RSS or email, for those of you not ready to take a two-footed leap into the twittersphere (though the interactive nature of twitter would be lost in translation).

Update 11/25/08:  I've added a "subscribe to my twitterfeed in a reader" button to the sidebar, just below the "follow me on twitter" button.  I strongly recommend following on twitter, but, again, if you prefer RSS or email, then that's your right.  I would welcome your feedback on the "tweets," or microblogging posts, on twitter that are going out in addition to links to full HealthBlawg posts.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Grand Rounds is up at Canadian Medicine

Check out this week's edition of Grand Rounds, hosted by Sam Solomon at Canadian Medicine.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

November 24, 2008

Legal eagles on the Beagle

A survival-of-the-fittest-themed Blawg Review is up at LawyerCasting (insert Darwin/lawyer joke here) and host Joshua Fruchter, on the masthead, looks like he's winking at me (just as Sarah Palin did that night she was debating the man formerly known as Amtrak Joe).

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

November 23, 2008

Medicare managed care, high costs, and the blame game

Robert Pear's piece in Sunday's NY Times is about the bajillionth article or MedPAC report recounting the fact that Medicare Advantage and Medicare fee-for-service plans cost the federales more than traditional Medicare -- 12% more and 17% more, respectively -- and it points to some Health Affairs papers on Medicare managed care that will be released on Monday. 

The campaign trail was littered with candidates' plans to bring fiscal discipline to the Medicare Advantage and Medicare fee-for-service plans, due to the spotlight shone in recent times on these excess payments, and also on the "slamming" or "cramming" hard-sell tactics of some brokers who pushed elders into Medicare fee-for-service plans that may not have been right for them.  Descriptions of these tactics have led to stricter marketing regulations.

It seems that what's lacking in the discussion is an emphasis on how we came to this pass: It is important to remember that Medicare Advantage started life as "good" capitation, with Medicare laying off risk to HMOs at 95% of average Medicare fee-for-service costs.  The Medicare Advantage plans and, to an even greater extent, the Medicare fee-for-service plans, exploded in volume after Congress managed to turn the program inside out by authorizing payment at higher rates.

Congress and the new administration have a ton on their plates, but rolling back Medicare payments to private plans to the 95% of cost levels would be an easy win, would maintain appropriate levels of care and care coordination -- one of the good things about "good" capitation -- and Obama and Daschle have indicated their interest in moving in the right direction. 

Update 11/24/08:  The invisible hand sees the writing on the wall too.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

November 21, 2008

Patient Safety Organization regulations finally finalized

PSO regulations under the Patient Safety and Quality Improvement Act of 2005 have finally wended their way through interminable process and have made it to publication as final regulations in today's Federal Register, effective January 19, 2009.

The introductory commentary on the rule explains that it

create[s] a voluntary system through which providers [may] share sensitive information relating to patient safety events without fear of liability, which should lead to improvements in patient safety and in the quality of patient care. The [rule reflects] an approach to the implementation of the Patient Safety Act intended to ensure adequate flexibility within the bounds of the statutory provisions and to encourage providers to participate in this voluntary program. The . . . rule emphasize[s] that this program is not federally funded and will be put into operation by the providers and PSOs that wish to participate with little direct federal involvement. However, the process for certification and listing of PSOs will be implemented and overseen by the Agency for Healthcare Research and Quality (AHRQ), while compliance with the confidentiality provisions will be investigated and enforced by the Office for Civil Rights (OCR).

AHRQ explains further:

The goals of the Patient Safety Act are to encourage the expansion of voluntary, provider-driven initiatives to improve the safety of health care; to promote rapid learning about the underlying causes of risks and harms in the delivery of health care; and to share those findings widely, thus speeding the pace of improvement. The Patient Safety Act:
  • Encourages the development of Patient Safety Organizations (PSOs)—organizations that can work with clinicians and health care organizations to identify, analyze, and reduce the risks and hazards associated with patient care.
  • Fosters a culture of safety by establishing strong Federal confidentiality and privilege protections for information assembled and developed by provider organizations, physicians, and other clinicians for deliberations and analyses regarding quality and safety.
  • Accelerates the speed with which solutions can be identified for the risks and hazards associated with patient care by facilitating the aggregation of a sufficient number of events in a protected legal environment.

The integration of state peer review protections, HIPAA protections and PSO confidentiality rules will serve to close some gaps that existed in the patchwork system we have had to date.

All in all, this is a welcome step forward for the further development of evidence-based medicine, taking into account details of negative outcomes and using those outcomes as learning opportunities for the system as a whole without exposing individual providers to additional potential liabilities.  Through the improved protections, these regulatory changes will enable provider organizations to realize more fully the patient care improvement promise of EHRs as well.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

November 18, 2008

Grand Rounds coming to a billboard near you

Dr. Deb has cued up the iPod playlist edition of Grand Rounds.  No DRM issues to be concerned with . . . put on your headphones and enjoy.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

MGH prepares for its next Joint Commission survey

The fact that a hospital has a Joint Commission survey due within the next year or so is not ordinarily newsworthy.  However, the Boston Globe spilled some ink today on the Massachusetts General Hospital's upcoming survey and the General's preparations -- including a mock survey, which is a standard preparation tool, particularly for facilities that have been working on improving their performance.  Last survey cycle, MGH was dinged for issues including recordkeeping and lax handwashing practices (look down a few grafs), and the mock survey was not quite perfect.  Then again, who's perfect?

The Globe's Jeffrey Krasner reported:

In a recent e-mail to staff, Dr. Peter Slavin, Mass. General's president, said the survey showed some areas still need improvement and must be addressed "immediately."

Slavin said the hospital has to make sure staff members better follow "universal protocols," or sets of instructions for individual procedures; ensure that patients have physicals 24 hours before surgery; improve the documentation of anesthesia and sedation procedures; and more closely monitor patients who are in pain.

The hospital has also begun an internal communications program, called Excellence Every Day.

The General seems to be emphasizing the continuous quality improvement approach to hospital operations, which is laudable.  It also brings to mind the focus of the Joint Commission's new rival, DNV.

The article continued:

It found that while there is perfect compliance with universal protocols in operating rooms, throughout the entire hospital the step was only followed 84 percent of the time . . . . In conducting a universal protocol, doctors and nurses review an upcoming procedure, make sure they have all the necessary supplies, and come to a "full stop," in which everyone stops what they're doing and makes eye contact before proceeding.

Survey or no, this is clearly an important effort, and one the General can devote resources to as it strives to maintain its level of clinical excellence.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

November 17, 2008

CMS imaging efficiency measures released for public comment

The latest comment period for imaging appropriateness measures is underway.  CMS announced last week that through The Lewin Group and its subcontractors, the National Imaging Associates, Inc., (NIA) and Dobson | DaVanzo & Associates, LLC, it is developing a preliminary set of outpatient imaging efficiency measures, and is seeking input through December 14, 2008 at the Imaging Measures website, which has a wealth of information on the measures (descriptions of the four measures are excerpted below) which, interestingly enough, are entirely different from the four measures featured at the same URL a year agoThe measures may be used by CMS under MIPPA as part of the accreditation regime and are certainly preferable to the prior authorization regime currently in favor.

Here are the four measures:

MEASURE ONE: SPECT MPI AND Stress Echocardiography for Preoperative Evaluation for Low-Risk Non-Cardiac Surgery Risk Assessment

Setting: Outpatient
Numerator: Patients having a low-risk surgery (i.e., endoscopic procedure, superficial procedure, cataract surgery, breast biopsy) preceded, within 30 days, by a single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), Stress Echocardiography, or Stress magnetic resonance imaging (MRI) study
Denominator: Patients having a low-risk surgery (i.e., endoscopic procedure, superficial procedure, cataract surgery, breast biopsy)

A review of stress echocardiography appropriateness criteria for specific clinical scenarios was recently completed and published by The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE). Review of SPECT MPI appropriateness criteria for specific clinical scenarios was completed and published by ACCF and the American Society of Nuclear Cardiology (ASNC). The purpose of the published criteria is to "help guide a more efficient and equitable allocation of health care resources."

The proposed measure seeks to calculate relative use of stress echocardiography, stress MRI, and SPECT MPI prior to low-risk non-cardiac surgical procedures.

The appropriateness criteria provided specific guidance that use of stress echocardiography and SPECT MPI are not appropriate tests for preoperative evaluation of patients undergoing low risk non-cardiac surgical procedures. The appropriateness score assigned to the use of stress echocardiography and SPECT MPI for the indication is the lowest at one (1). Scores of 1-3 are defined as inappropriate (the test is generally not indicated).

The criteria define low risk surgery as cardiac death or MI in less than 1 percent of performed procedures — endoscopic procedures, superficial procedures, cataract surgery, and breast surgery (biopsy).

MEASURE TWO: Use of Stress Echocardiography or SPECT MPI Post-Revascularization Coronary Artery Bypass Graft

Setting: Outpatient
Numerator: Patients who have had a stress echocardiography or SPECT MPI study in the five-year period following a coronary artery bypass graft (CABG) procedure.
Denominator: Patients who have had a CABG procedure.
Exclusions: All tests performed in the first six months post-CABG; any patient with clinical risk predictors for silent ischemia or accelerated coronary artery disease (CAD) (e.g., diabetes); and any patient who undergoes a catheterization, percutaneous coronary intervention (PCI), or CABG procedure in the six months following the post-revascularization Stress Echocardiography or SPECT MPI.

A review of stress echocardiography appropriateness criteria for specific clinical scenarios was recently completed and published by The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE). Review of SPECT MPI appropriateness criteria for specific clinical scenarios was completed and published by ACCF and the American Society of Nuclear Cardiology (ASNC). The purpose of the published criteria is to "help guide a more efficient and equitable allocation of health care resources."

The proposed measure seeks to estimate relative use of stress echocardiography and SPECT MPI in asymptomatic patients less than five years after a CABG procedure.

The appropriateness criteria provided specific guidance that use of stress echocardiography is not appropriate for risk assessment within five years for asymptomatic patients. The appropriateness score assigned to the use of stress echocardiography for the indication is two (2). Scores of 1-3 are defined as inappropriate (the test is generally not indicated). Use of SPECT MPI for the indication was scored at six (6). Scores of 4 -6 are defined as uncertain.

MEASURE THREE: Use of Computed Tomography in Emergency Department for Headache

Setting: Emergency Department (ED)
Numerator: ED visits with a presenting complaint of headache with a coincident brain CT study
Denominator: ED visits with a presenting complaint of headache
Exclusions: Patients who are hospitalized (admitted), patients who are transferred to another acute care hospital, patients with a lumbar puncture, diagnosis codes indicative of dizziness, paresthesia, lack of coordination, subarachnoid hemorrhage, or thunderclap.

Clinical guidelines and literature indicate that there is a general consensus that neuroimaging is rarely productive for [headache] patients with normal physical and neurological exams and medical histories. Unnecessary CT is costly financially, in false positive interpretation, and in excess radiation. This measure seeks to identify inappropriate practice patterns.

MEASURE FOUR: Simultaneous Use of Brain Computed Tomography and Sinus Computed Tomography

Setting: Outpatient
Numerator: Patients with a presenting complaint of headache who have a brain computed tomography (CT) and sinus CT study performed simultaneously (i.e., on the same date at the same facility)
Denominator: Patients with a presenting complaint of headache who have a brain CT study
Exclusions: Patients with trauma diagnoses, tumor, or orbital cellulitis

Clinical guidelines and literature indicate that there is a general consensus that neuroimaging is rarely productive for patients with normal physical and neurological exams and medical histories. Even when neuroimaging is required, there are no indications for simultaneous Brain CT and Sinus CT. Moreover, unnecessary CT imaging is costly financially, risks false positive interpretation, and exposes patients to excess radiation.

(Emphasis supplied.)

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

November 14, 2008

Health Wonk Review is up

The post-election edition of Health Wonk Review is up at Colorado Health Insurance Insider.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting