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Unspecified Codes Among Issues Being Monitored

Medical Coding News - Wed, 01/27/2016 - 10:16

At the four-month mark of ICD-10 implementation, practice management vendors are continuing to look for trends and potential issues for their clients. Login to Read More

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Categories: Healthcare News

Revenue Cycle Management a Post-ICD-10 Implementation Focus

Medical Coding News - Tue, 01/26/2016 - 07:57

2016 may be a big year for revenue cycle management. Healthcare organizations see steady claims denial post-ICD-10 implementation and remain focused on value-based care models. Login to Read More

The post Revenue Cycle Management a Post-ICD-10 Implementation Focus appeared first on MedicalCodingNews.Org.

Categories: Healthcare News

Data Socialism

The Healthcare Blog - Tue, 01/26/2016 - 07:20

In an unusually candid editorial in the NEJM, Longo and Drazen say that data sharing may be problematic because some researchers fear that the data could be used to by others to disprove their results. The editors predicted a new class of researchers who use data created by other researchers without ever taking the trouble to generate data themselves – research parasites.

With this editorial, the NEJM has firmly established itself as descriptive (the way the world is), rather than normative (the way the world ought to be). I, for one, find this move rather refreshing. I have been pumped to a diabetic state by the saccharine naivety of the hopey-changey, “we need this and that” brigade. The editors merely said what some researchers secretly think, and how many actually behave.

Once, I asked the PI of an RCT a specific question about outcomes. I received a reply within seconds. The PI sent me a pdf of the data. The email ended with that banal academic signature “Best, MD.”

I was flattered by the promptness of her response – many PIs who publish in high impact journals don’t bother replying. Then I discovered she sent me the supplementary appendix, which was also available online. Unsurprisingly, my question was not answered. But it was not supposed to be answered. The unpublished data, which included the answer to my question, was going to be used by the PI for more papers in high impact journals, as it should be.

Another time I asked an economist to share an economic model of a technology, which I did not believe was as cost-effective as he said it was. After a few evasive responses, when it became apparent that I was not getting the message through my thick skull, he replied, “sorry I can’t show you my model. I spent my PhD developing it.” If he thought that I was a data parasite gagging to prove him wrong he was, to put it plainly, spot on.

Karl Popper, the philosopher of science, said that what tells science apart from astrology is that science is falsifiable – if it can’t be disproven it’s not science. Replication, the key to progress in physical sciences, is medical science’s Achilles’ heel.

We should dwell a bit longer on the hard sciences because they are instructive. No body had to do a meta-analysis of experimental evidence of the presence of ether (the mysterious substance believed to conduct gravity). Why? Because ether either exists or doesn’t exist, and it doesn’t exist. Since Michelson-Morley’s famous failed attempt to show the presence of ether, several physicists have tried, and failed.

There is no meta-analysis of experiments of possible curvature of space-time with I2 to measure the heterogeneity of sample size. Arthur Eddington showed that gravity bent space-time, during a solar eclipse, and several others have, since, verified Einstein’s theories. Publication bias is not an issue in physics.

While physicists seek truth which uncovers the mysteries of the universe, the objective truth in medical sciences is settling petty quibbles probabilistically, such as:

Should we give 150 mg or 75 mg of aspirin after a myocardial infarction?

Do patient-centered ward rounds improve outcomes?

Is cardiac CT superior to SPECT in the diagnosis of obstructive coronary artery disease?

A bunch of studies root for cardiac CT. Another set root for SPECT. Then we have a meta-analysis. Then an RCT. Then more RCTs. Then a meta-analysis of RCTs. Then finally an analysis of an administrative database with dodgy risk adjustment renders all previous research obsolete.

To which one is tempted to yell – FFS it doesn’t matter, use either or neither. But it does matter. It matters because we’re rational optimizers. We cannot ever, ever, not be doing the best we can, even if the best is like adding a gnome on top of Everest and celebrating the total height.

Optimization is endless quibbling because the differences are so small. Optimization like is a train which departs on a lengthy journey but never leaves the platform. Optimization makes careers. Optimization leads to lots of publications. Lots. There is an infinite number of ethers and space-times to prove and disprove in healthcare sciences.

But optimization is a methodological nightmare. Because when you’re dealing with such small differences, to make sure those Lilliputian differences are real, the measuring instrument has to be precise. And one cause of an imprecise instrument, other than inherent imprecision, is sloppy research.

If you tell physicists that facts have changed they’ll say “welcome to science and have a nice day.” If you tell physicians that facts change they’ll scream “research fraud.” If Einstein and Newton were doctors, Einstein would have asked Newton to retract his theory of gravity.

One reason why there is no culture of replication in the biomedical sciences is that falsification is suffused with moral outrage. Retraction should be a normal clearing house for biomedical sciences – like shedding hair or clipping nails. It has become a consumer watchdog.

I wonder if the illiteracy most urgently in need of redress in doctors is philosophy of science, rather than evidence-based medicine or statistics. Science is a provisional assumption. Facts are supposed to change. Changing facts doesn’t mean that science is broken. It means that science is happening.

Much angst against the NEJM editorial, mostly hilarious on Twitter, is a common misunderstanding of the ought-is dilemma – confusing the description of the way the world is with endorsement of the way the world is.

I stand with the detractors though. Data ought to be shared. But, as I have learnt painfully, there is a way to ask for it. You must endear yourself to the researchers – a few complimentary emails followed by a chance encounter at a national meeting where you prostrate with reverie of the PI. Parasites must be charming.

It takes a lot of effort to generate data in biomedical sciences. To expect researchers to surrender the data for the greater good is fuzzy, and lamentably boring, adolescent naivety. If we do not recognize the self-interest of researchers, data socialism, like other forms of socialism, is condemned to failure. This is what I think Longo and Drazen are warning us in their editorial.

Saurabh Jha is a radiologist based in Philadelphia and a contributing editor for THCB.

Categories: OIG Advisory Opinions

Why Are Physician Engagement Scores So Dismal?

The Healthcare Blog - Mon, 01/25/2016 - 18:34

Many hospitals around the nation have been stung by dreadful physician engagement scores. Engagement is a problem not only for demoralized physicians, but for healthcare organizations, their employees, and everyone they serve. They should take note, because low levels of engagement are associated with higher physician turnover, increased error rates, poorer rates of patient cooperation in treatment, and lower levels of patient satisfaction.

Definitions of engagement vary, but it generally includes pride, loyalty, and commitment. When engagement scores are low, physicians take little pride in the hospital, would not recommend it to a job-seeking colleague, and believe that the hospital’s mission and vision are not in sync the needs of patients. On the other hand, engaged physicians are more likely to perform better in every area, including patient care, education, and research, which benefits everyone.

To better understand the roots of poor physician engagement, I recently sat down for a conversation with a large group of students from the Indiana University Kelley Business of Medicine MBA program. Its students are practicing physicians from around the country who have realized that to improve patient care they need to become better leaders. Many work in hospitals that have identified engagement challenges and are attempting to develop solutions to the problem.

Challenged to explain declining physician engagement scores, the group pointed first to a lack of transparency. Many hospitals, they said, collect a great deal of information about the performance of their medical staff, but share little information in return. One physician described the situation in terms of a “one-way mirror,” in which data on physician performance are widely circulated, but the performance of the organization and its non-physician leaders remains largely opaque.

Another key problem, according to the group, is the fact that so many hospital administrators do not take care of patients. In contrast to physicians and nurses, whose work revolves around patients, hospital administrators typically have business backgrounds. Even health professionals who play leadership roles often “haven’t cared for patient in years,” said one participant. “This makes it difficult for them to understand what medicine is like on the front lines, and they seem out of touch.”

The group also pointed to the different standards by which physicians and hospital administrators are evaluated. The most important criteria of physician performance naturally revolve around patient care, while administrators are typically judged first on financial performance. This misalignment can frustrate both sides – physicians feel that administrators care about nothing but money, and administrators feel that physicians don’t understand the system-wide challenges the hospital faces.

Said one participant, “For many occupants of the hospital C-suite, the central operating principle is, ‘No margin, no mission.’ This means that, no matter how noble the hospital’s mission statement, revenue must exceed costs or the hospital will close.  In too many cases, though, ‘No margin, no mission’gets transformed into, ‘The margin is the mission.’” Financial priorities begin to take precedence over why the organization exists in the first place – to care for patients.

The group pointed to the growing bureaucratization of healthcare, driven in part by consolidation among healthcare organizations.  As hospital systems grow, their decision makingtends to rely more on impersonal policies and procedures and less on relationships.  Said one participant, “This is frustrating to health professionals,whose careers are devoted tobuilding trust.”  Many fondly recall a day when decision was based more on relationships than on policy and procedure manuals.

Another participant added, “To a hospital administrator, the corporation’s annual report might seem the most important thing, and the center of the universe might appear to be the hospital executive suite. But to health professionals, it is patients. When administrators put their own programs first, they inevitably seem out of touch with reality.” This can be especially frustrating when administrators come and go in just a few years, while many physicians maintain much longer commitments.

The physician-MBAs offered a number of suggestions for improvement.  One is for hospitals to start treating health professionals as partners in care. This means, among other things, ensuring that decision making involves strong representation by physicians, nurses, and others who care for patients on a day-to-day basis. When they are not present, even seemingly well thought-out initiatives can prove dangerously at odds with patient care.

Another suggestion is to ensure that hospital boards are well populated with people who regularly care for patients. It is all well and good to have health professionals involved in daily tactical decision making, but if they are not also present when organizational priorities are set and strategies are crafted, a sense that organizational management is out of touch with reality is likely to arise. As one participant put it, “Would any law firm operate with a board comprised almost entirely of physicians?”

A third is to pair each administrator with a health professional who understands what day-to-day patient care is like. The goal here is to ensure that administration and health professionals work in partnership, not only during formal decision-making sessions such as board meetings, but throughout each work week. This is likely to produce a much higher level of mutual understanding, which is precisely what many physicians think is lacking at the moment.

The ultimate goal here is not to make physicians and other health professionals happier, but to take better care of patients. Said one participant, “Physician engagement isn’t just about whether doctors happen to be happy or not. It’s about integrity. It does no good for the hospitalto make lots of money and reward its executives handsomely if the people who care for patients distrust it. Improving engagement scores is ultimately about ensuring that health professionals believe in their work.”

Richard Gunderman is a professor of radiology at Indiana University and a contributing writer at The Atlantic.

Categories: OIG Advisory Opinions

Data Parasites?

The Healthcare Blog - Sat, 01/23/2016 - 13:19

In just four years, it seems, data science has devolved from the “sexiest job of the 21stcentury” to a community of “research parasites.”

The latest assessment is courtesy of an editorial in the New England Journal of Medicine (NEJM), written by editor-in-chief Jeff Drazen, along with Dan Longo.

Essentially, Longo and Drazen argue that while the Platonic ideal of rich data sharing is lovely, reality is not so pretty.

First, Longo and Drazen allege, researchers who weren’t involved in gathering the original data often lack essential appreciation for how it was gathered, and thus may misinterpret it, as they “may not understand the choices made in defining the parameters.”

Second–and this is really the heart of the issue–Longo and Drazen worry that a new class of research person will emerge—people who had nothing to do with the design and execution of the study but use another group’s data for their own ends, possibly stealing from the research productivity planned by the data gatherers, or even use the data to try to disprove what the original investigators had posited. There is concern among some front-line researchers that the system will be taken over by what some researchers have characterized as “research parasites.”

Instead, Longo and Drazen urge would-be data scientists to work collaboratively with the original investigators, and to share co-authorship, and cite as an exemplar a paper in the current issue of the NEJM where just this model was successfully pursued.

My Twitter feed exploded in response to this editorial:

Michael Eisen, geneticist at UC-Berkeley: “One of the most shockingly anti-science things ever written.”

Sek Kathiresan, cardiologist/geneticist at MGH/Broad: “Shocking to see disparaging term ‘research parasite’ to describe use of data often created w/ public funds.”

Michael Hoffman, computational genomicist at the Princess Margaret Cancer Centre, Toronto: “Fear that others may use data ‘to try to disprove what the original investigators had posited’ is a dangerous misunderstanding of science.”

In contrast, I was delighted to see this editorial.

Not because I agreed with it–my heart is truly with the data scientists–but because I was grateful that someone had the courage to articulate a perspective I’ve come to believe is shared by the vast majority of academic researchers, but publicly voiced by no one–until now.

The result: a classic case of stated preference vs. revealed preference, where every academic researcher dutifully claims to be interested in sharing their data widely and freely, but somehow, tend not to actually do this.

Why? I’m sure the reasons vary, but somewhere near the top of the list is that most researchers perceive very little upside in generously and richly sharing their raw data. At a minimum, it’s regarded as a thankless hassle (one of the reasons negative results are often not published, and one of the reasons submissions to public resources like ClinVar usually come in much slower than many might anticipate), and beyond that, someone may look at the data differently and come to a different conclusion.

True, that might be how science is supposed to work–there is that–but it’s incredibly difficult to motivate individuals to act in a fashion they view–not unreasonably–as against their self-interest.

This may not be how the world should work–but is how it often seems to work, and without some acknowledgement of this perspective, efforts to spur data sharing among academic investigators will simply consume everyone’s time and arrive at high-minded conclusions not likely to be actioned.

The perfect example of this: our endless discussions about sharing data from electronic health records (EHRs). Everyone publicly agrees data should be shared easily, but somehow, progress is almost unimaginably slow–almost as if the key stakeholders really aren’t that interested in seeing it happen (see my comments about data silos here, and interoperability here).

Imagine how much better off we might be if a hospital executive wrote a similarly honest editorial about reluctance to share EHR data for competitive reasons. True, the author would be pilloried and then fired, but at least the candid perspective might meaningfully inform the national conversation.

I would like to live in a world where research data is shared in the expansive fashion envisioned by Atul Butte, rather than as described by Drazen and Longo. I would like to live in a world where clinical data is shared in a generous, intuitive and friction-free manner, rather than needing to pried forcibly out of an EHR.

But until and unless we come to grips with the gritty, human, competitive reasons why data aren’t shared, we’re headed to a future of righteous proclamations–and little data movement.

David Shaywitz is based in Mountain View, California. He is Chief Medical Officer at DNAnexus, a Mountain View based company and holds an adjunct appointment, Visiting Scientist, in the Department of Biomedical Informatics at Harvard Medical School. 

Categories: OIG Advisory Opinions

The Patient-Centered Health Record

The Healthcare Blog - Fri, 01/22/2016 - 23:17

The other night I participated in a very useful Google+ hangout with Adrian Gropper, Michael Mascia and Michael Chen. The discussion focused on a subject I think is incredibly important: the patient-centered health record. Unfortunately, this topic is hard to discuss without drowning in technical terms and acronyms. I consider myself fairly tech-savvy and still struggle.

A (55 minute) YouTube video is here: Click here

I think it is worth watching. before watching it, consider reviewing the following basic information to help set the stage, first without tech terms or acronyms, and then repeated with some of the key jargon.

The current EHR model is that each office or institution owns and manages an electronic record that contains information about the patients in that system. Despite the obvious need and lots of talk, there has been little actual progress towards making these separate and mostly proprietary systems ‘interoperable’ and therefore able to share information. The result is that clinicians routinely work with incomplete or outdated information, patients are locked into their home system, and it is extremely hard for patients to access their own information in any meaningful or useful way. Care is less safe and less reliable, patients are prevented from actively managing their care, and clinicians are frustrated.

The model discussed in this video takes a different approach, one that appeals to me for both philosophical and technical reasons.

In this model:

  • The basic unit is a one-patient record unique to the individual patient.
    • It is ‘open source’ meaning that the code is public, maximizing the ability to improve or modify it and create added pieces for new functions.
    • This basic unit and its information are owned and controlled by the patient.
    • This is where all the health and medical information about an individual patient is stored.
    • It contains the most current, complete and up-to-date information.
    • The patient has full access to their individual record.
  • This patient-centered health record has a component that allows the patient to control access by others, essentially inviting their clinicians (or others) to see and use the information.
  • Clinicians can access the system through their own software using one of two mechanisms:
    • Using a straightforward process which gives them access to multiple separate patient records, and they work in the actual patient record.
    • Using their proprietary clinician or institution owned system, which is linked to and synchronized with the patient’s individual record.
    • In both cases, the ‘official’ version of the information is the patient-centered record, fully accessible to the patient.
  • There are standardized connections between the clinician-based systems and the multiple patient-based records.

That was English. Now a version of the same information with some jargon:

  • The patient has a record (EHR) to store his or her health information
    • Ideally it is ‘open source’ such as NOSH (New Open Source Health Charting System) by Michael Chen.  Read more about this at
    • It is owned and controlled by the patient.
    • It is where all the health information about an individual patient is stored.
    • It functions as the ‘Source of Truth.’
    • The patient has full access.
  • The patient-centered record (such as NOSH) has a component that allows the patient to control who can see, change or use the information.
    • This is sometimes called UMA (for user management and authentication).
    • It has other names such as HIE of One (health information exchange of one).
    • This is what allows the patient to manage who has access.
  • Clinicians access the system through their own software using one of two mechanisms:
    • They use a parallel open-source software system that has a list of the patients using individual patient records they have been authenticated to use.
    • They use (work in) their institution’s proprietary system which is linked to and synchronized with the official patient-owned record.
    • In both cases, the patient’s record is the Source of Truth and fully accessible to the patient.
  • There are interfaces that make connections work.
    • FHIR (pronounced fire) is the one talked about here.
    • Other ‘application program interfaces’ (APIs) can be developed or used, especially if the system is open source.

There are several important considerations in a system like this:

  • Open source improves security, adaptability, flexibility
  • It is based on the assumption that patients should have full control over their health information according to their own needs, not just be given limited access by clinicians or their systems.
  • If patients have full control over access to their health information, it goes without saying that they can access their own health information without either delay or barriers.
  • It can be adopted incrementally rather than requiring the entire US healthcare system to turn a switch.
  • Patients and clinicians can help us move from where we are now to a patient-centered health record system by:
    • Understanding the concept.
    • Being at least somewhat familiar with the terminology.
    • And MAKING NOISE about wanting a system like this in their local setting.

      Peter Elias is a family physician in Maine. He blogs at

Categories: OIG Advisory Opinions

Will the Pharmaceutical Industry Learn From Past Mistakes?

The Healthcare Blog - Fri, 01/22/2016 - 17:12

Awash in negative headlines, public condemnation and government scrutiny, the pharmaceutical industry faces a public relations problem that, left untreated, could bring new regulations or sanctions either from governments or the courts. At the same time, though, the recent scandals over price gouging could offer an opportunity for responsible, research-based companies to distance themselves from the profiteers.

The industry has come under fire at a time of unprecedented innovation. As a physician who trained in the 1990s, I am in awe of the recent breakthroughs. Immuno-oncology drugs like Keytruda (pembrolizumab) and Opdivo (nivolumab) offer hope for patients with previously untreatable cancers. Entresto (sacubitril/valsartan) – the first novel treatment in over a decade for congestive heart failure, a condition deadlier than most cancers – was approved this year. There is a cure for many forms of Hepatitis C with Sovaldi (sofosbuvir) and vaccines for dengue fever and maybe even malaria may become available soon. More patients in developing countries than expected have access to antiretroviral drugs for HIV/AIDS and companies are devoting resources to achieving the same for the new scourge of noncommunicable diseases.

At the same time, some in the industry have been seeking to tackle the image problems. Overeager sales representatives are being reined in. Financial ties to physicians and clinical trial data are being disclosed. The main industry bodies in the United States, PhRMA and BIO, disowned Turing Pharmaceuticals, the company behind the notorious 5,000 percent price increase for Daraprim, a critical drug for certain infections in immunocompromised patients.

But more needs to be done and, in my opinion, the challenge is that most large companies are still being ruled by executives who are laser-focused on quarterly numbers and short-term profit; and lawyers who instinctively prefer established business strategy because its risks are known and manageable. This combination creates a blind spot for the coming tectonic shift in the health care system from fee-for-service to pay-for-value. This shift will radically change how health care is organized and financed over the next decade, and the industry will only get to help shape its future operating environment if it is seen as a responsible partner. Otherwise it will be at the receiving end of fundamental reforms that may well include price regulation in the United States, price negotiations by Medicare or permissions to reimport drugs from other countries.

An important step would be for the “research-based” companies, who truly innovate, to distance themselves from companies that operate like hedge funds, seeking out investment opportunities rather than focusing on research. The hedge fund business model focuses on generic but essential drugs that are only made by one or two manufacturers, because the market is so small, as in the Daraprim example above, or because they are costly to manufacture relative to their price, such as some intravenous drugs.

Companies buy up those assets and then raise prices substantially. Customers have little choice but to accept the new prices, because those drugs are essential and because the weak manufacturing base makes finding alternative suppliers hard. An example is Isuprel, an intravenous drug to treat certain arrhythmias in ICU patients. Isuprel was already a generic product when I trained, but its price increased by over 500% last year after Valeant Pharmaceuticals, a well-known protagonist of the hedge fund model, acquired the rights to it.

In themselves, eye-popping prices for breakthrough drugs do not generate lasting public perception problems, if the prices reflect true innovation. Even notoriously skeptical institutions have come to accept the high price of newly developed drugs. The U.K.’s health technology assessment body, the National Institute for Health Care and Excellence, endorsed Sovaldi, albeit at a discount to the $1,000 per pill list price. The feared Institute for Clinical and Economic Review, an independent evaluation organization in the United States, ruled Entresto’s price about right.

It would not be difficult for the research-based companies to distance themselves from the likes of Valeant, which spends about 5 percent of its revenue on R&D, compared to a typical 20 percent for the research-based companies. Their problem, however, is that they exploit similar, though less radical, pricing strategies for their own established products, just more quietly. So they are unhappy about the attention that companies like Turing draw to price increases, but they are not in a good position to squarely denounce the practice.

A solution could be for the research-based companies to adopt a voluntary code of conduct that would limit price increases on established products to inflation or to the cost of inputs. The short-term hit to profits would help protect the industry from getting thrown in with “hedge-fund pharma.” Moreover, the code of conduct would signal that its subscribers want to be rewarded for improving patients’ lives with innovative products, not for using market power for short-term gains. This would be a small step for multi-billion dollar companies, but a giant leap towards becoming a respected partner when decisions about the future of healthcare are being made.

Soeren Mattke is a senior scientist at the nonprofit, nonpartisan RAND Corporation and the managing director, RAND Health Advisory Services.

Categories: OIG Advisory Opinions