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QUALITY QUICKIE: Follow up to Kentucky nurse dismissals

A cardiologist wrote to me about my post concerning the nurses fired for administering drugs without physician approval. The response suggests that there should have been standing orders, which sounds logical to me:

    In regards to intubated patients, 1) almost all ventilated patients have standing orders for either Diprivan, Versed, or Ativan; 2) these sedating medications are held prior to extubating patients; 3) in my experience, (for what it’s worth), patients who extubate themselves usually stay off the vent, either because they were ready to be extubated, or because they would rather die than be re-intubated. I don’t know why those nurses were disciplined. If they willfully ignored the MD’s order, they should be fired (unless the MD was grossly incompetent). If said MD did not given standing orders for Diprivan, etc, s/he deserves to be paged throughout the night.  . . . One other possibility:  the physicians were so incompetent, the nurses took it upon themselves to initiate sedation orders. But again, if standing orders were present, this would not be a violation..

TECHNOLOGY: Dump the stent, have a by-pass

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You may recall that when I wrote about the market for drug-coated stents, I made an off-hand remark about a Canadian health services researcher who told me that stents were a waste of money because, from a health services research point of view, you get more bang for your buck by just doing angio. Well it appears that some health services researchers–who are even smarter than the Canadians, because they’re at Stanford–have gone even further and concluded that drug-coated stent or not, bypass surgery is more cost-effective than angio! (Full disclosure: I went through the Stanford HSR program & I studied under/with three of the report’s authors. I don’t know anything about this research, but I do know that they are a hell of a lot smarter than I am).

The researchers built a complex computer model based on a study done 10 years ago comparing angioplasty with cardiac bypasss surgery. They built in corrections that made the data look as though today’s rate of stent use was used at that time, and adjusted for the improved impact of today’s stents.  They then looked at the outcomes and costs of follow-up treatment over the next five years. It turns out  that the five year cost was about the same and that quality of life was actually better for those who’d had the bypass.  In fact the advantages by the ten year mark were considerable.  Here’s a detailed press release explaining the study’s methods and conclusions.

Even more direct is what the authors say in the abstract:

    "Primary stent use cost an additional $189,000 per QALY* gained compared with a strategy that reserved stent use for treatment of suboptimal balloon angioplasty results" and they conclude that "Bypass surgery results in better outcomes than angioplasty in patients with multivessel disease, and at a lower cost".

Traditionally in this country, we’ve ignored health services research as it often tells us that less care is better care, but less care means less money to those in the industry and those supplying it. Here’s a case where something that costs a little more up-front and has its own constituency (bypass surgery) saves money and improves outcomes over the long-run compared to its more recently developed rival. If this was paid for by insurance companies that expected their members to be in another plan within two years, they’d be right to go for the cheaper option.  But in this case the majority of people undergoing these procedures are in one insurance plan called Medicare, paid for by you and me. And if they’re not in Medicare when they undergo the procedure, they will be soon enough when the added costs from recurring blockages that follow angio often require another procedure. So it’s not unreasonable to expect that the folks at CMS are reading this study too and may start taking a long look the use of stents. Prepare for this study to be widely ignored by the stent industry who right now I’m sure are working on their own research to refute it. $5 billion will not go quietly into the night.

*QALY is Quality Adjusted Life Year–a measure of life expectancy that takes into account the patient’s health, so that a year lived in good health is valued more highly than one lived with serious health conditions restricting activities of daily living or requiring significant medical care.

PHARMA: The pipeline needs filling

There’s been substantial worry in the pharma business about the future of the pipeline–and rightfully so.  More than any other business, pharma companies tend to rely on one huge hit, and the spin-offs from it, rather than a steady stream of new products. The recent round of consolidation in which Glaxo and Pfizer got much, much bigger was in part an attempt to diversify their portfolios by acquiring other blockbusters, and also an attempt to make the overall corporation less vulnerable to the patent expiry of others.  As I wrote about a while back, the specter of Claritin’s disappearance removing billions in revenue off Schering Plough’s income statement haunts all pharma CEOs’ nightmares.

So how does the potential pipeline look for the latter part of this decade, when many of today’s blockbusters come off patent? Well according to a Datamonitor study quoted in this Forbes article, Pfizer has 5 potential biggies with a guestimated revenue of up to $5 billion in 2008.  GlaxoSmithKline (GSK) has only one with estimated revenues of only $700 million. Pfizer’s 2001 sales in the US were $17 billion, whereas GSK’s were $15 billion.  So it appears that GSK is more likely to be doing what it can to find more ways to fill its pipeline. Expect more activity in both big pharma M&A and looking to biotech to fill the pipelines from the big players in the next year or so.

For a good general report on the pharma industry from (believe it or not) the CMS, click here.

TECHNOLOGY: Wireless vulnerability

According to AIS’ Business News wireless networks can create major HIPAA vulnerabilities.  This seems obvious but if the network is not secure and doesn’t require authentication, anyone within range can get on the network and with a tiny amount of knowledge get into other computers on the network.  Of course that’s a huge security vulnerability. That’s well known. 

Let me give you an example not in health care but very close to a home I know well–mine.  I have wireless LAN in my office on the ground floor. To get onto my network you need to know an authentication code, so it’s very secure.  But upstairs in my house, while my LAN doesn’t go up through the floor, I can pick up no less than 4 other networks in my apartment building, for which you do not need an authentication code to get on.  Last night I was watching the baseball and (I guess illegally) using one of those networks to post on my blog.  I then shut off Explorer and email and was working on a word document (while Oakland decided that it was time for a Red Sox/Cubs world series). I then got a call from my neighbor.   My computer was still active on his wireless LAN, he had found it on his network and had found out who I was by poking around in my files, called me up and asked to get off his network!  So as an amateur "wardriver" my computer was vulnerable too.

So given the number of people who like me use other people’s LANs in an unregistered/illegal way, how many clinicians are exposing patient information without knowing it?

QUALITY QUICKIE: Kentucky hospital dismisses 14 nurses

I am deeply puzzled by this one.  Apparently patients on respirators sometimes try to pull their tubes out of their throats in a panic, and administering such patients Diprivan immediately calms them and potentially saves their lives. A hospital in Louisville, Kentucky has  fired 14 nurses for giving the sedative to patients on respirators without a doctor’s order.  Now I am not an expert on clinical procedures so take everything I say as opinions held very gently, but…..

a) Wouldn’t there or shouldn’t there typically be a standing order from the doctor as to what a nurse should do if a patient starts trying to pull their respirator out?
b) If (at least) 14 nurses were routinely doing this, it is definitely a system problem.  Should not the hospital have been educating the nurses about the rules before they fired them, as they apparently are doing now for those not fired? Has anyone in the hospital management been fired for allowing so much to go wrong on their watch?
c) Is it realistic for nurses to know these rules? On Saturday I watched a baseball play-off game where a hitter being paid over $4 million a year failed to score the winning run because he mis-interpreted a rule.  Yet he’s in the game I’m watching as I type this on Monday night!
d) A nurses’ association is trying to unionize this hospital.  Were those nurses fired purely for the sedative offence or were they involved in union activities?
e) Who creates the Kentucky Board of Nursing standards? Am I suspicious, or might a core of doctors be involved here. Don’t forget that several states restrict midwives from delivering babies, and even prosecute them, when in most other countries they are a core part of the labor and delivery system*, and there is very credible evidence that using midwives for routine births is safer than using OBGYNs.  Those rules came from the political power of organized medicine. Is something similar going on here regarding the ability of nurses to encroach on anesthetists turf?

I don’t know the answers to this issue.  But this mass firing looks like a symptom of a wider disease at this and probably other hospitals.  If you have comments, please email me and I’ll follow up later.

*For example, while the United States has 35,000 obstetricians and about 5,000 midwives, Great Britain has 32,000 midwives and fewer than 1,000 consultant obstetricians.

QUALITY QUICKIE: Managed care works in California (according to Managed Care)

While the managed care industry generally has more or less given up the concept of trying to manage the way physicians practice, it’s not quite so in California. The CCHRI, a mostly payer/provider funded group, albeit with representation from organized medicine, reported late last week that both clinical performance indicators and member satisfaction are getting better.

How come the connection between managed care and quality is still alive in California, after a combination of physician and consumer outrage beat managed care to death with a stick in the rest of the USA? Well, like everything else it’s mostly an accident of history.  California has big medical groups.  They tend to have the management structures in place that allow them (even if they haven’t always) to both measure their physicians’ clinical performance and work to actively change their behavior.  Outside the left coast physicians still tend to practice in smaller groups and the groups that do exist tend to be smaller, looser or affiliated with a clinical teaching practice (and therefore be unmanageable!).

So how did California get that way?  Well, by dint of historical accident, it had the Kaiser Permanente organization. Because of the inherent price advantage Kaiser’s pre-paid (or capitated) plan had over the traditional insurance companies, in the late 1970s and early 1980s Blue Cross went actively looking for physician organizations that looked something like the Permanente Group on which to base their incipient HMO, the forerunner of HealthNet.  They found several groups mostly in southern California.  Of course they were historical accidents too.  One, Friendly Hills, was a group of family docs who’d covered for each other on call and gradually developed closer business links.  Another, Mullikin, was (I was once told) a haven for gay doctors who couldn’t find other places to practice. By the mid-1990s these groups and their ability to deliver high quality population-based care in a heavily internally-managed environment was well known in the industry. I spent many a session frightening East Coast hospital management teams with the specter of what would happen to their  occupancy rates if those crazy Californians brought their "bed-days per thousand" rates to their town. It even got the attention of the east coast medical intelligensia. Unfortunately both the greed aggressive business tactics of the health plans and the greed incompetence of the Medpartners organization which bought the vast majority of these groups had driven them into chaos and bankruptcy by the late 1990s.

It appears that the medical groups are recovering from that era of chaos and are now getting back onto the "good" managed care track.  With employers paying more and health plans not being under the financial gun they were in the mid-1990s, the CCHRI report shows that there’s potential within California for real improvement in those population clinical improvement measures that we were all talking about 10 years ago.

POLICY: Pay or Play in California signed into law

In what may be one of his last acts in office depending on how tomorrow’s recall vote goes, yesterday Gray Davis signed SB2. I’ve written more extensively about what SB2 is and more importantly what it isn’t in this post. Essentially it’s a play or pay mandate for businesses with more than 20 workers who don’t provide health insurance.  If the business has more than 200 employees it will also have to provide insurance to the families of the workers. Most importantly it won’t take effect for more than two years or more than 3 years for smaller businesses (20-200 employees), and it doesn’t impact businesses under 20 employees at all and business between 20-50 employees will get a tax credit to cover (some of) the costs of the insurance they have to buy.

So we can expect:
a) a hell of a fight in the next two years by California’s business lobby (in particular the fast-food industry)  to overturn the law in the courts and by referendum
b) a lot of consultants emerging explaining how to restructure your business into several businesses with less than 50 or 20 employees each (depending on how that tax credit works out)
c) (when the law takes effect) some combination of job losses/higher prices for consumers as we see in Hawaii —  all dwarfed by the real driver of the employment market in California which is the national economic state of high-tech, entertainment and the defense industry.
d) gradual acceptance of that fact that that’s a cost of doing business here which the vast majority of employers were paying anyway (OK some editorial in that comment from me!)
e) more legislation to reduce medical care costs (as there is no cost control in SB2).

Of course the major issue behind all this is that 75% of the uninsured in America are full-time workers (and their families)  in low wage industries. Most of them work in businesses too small to be affected by this law, so it will only get some 1 million of California’s 7 million into insurance.

Friday Funny

So I’m a very messy guy who’s insensitive to what’s happening around me and likes using the TV remote control — a massive P rather than a J on the Myers-Briggs scale. I have had several girlfriends who are extreme Ps, i.e. total neat freaks, who somehow have found this a problem.  Medical Rants today explains that it’s not that I’m a slob, it’s my brain’s fault!

PBMs: The very, very begining of the end for PBMs?

You may remember my post somewhat facetiously titled The End of Managed Care. The concept was that managed care plans had stopped trying to manage physician behavior and had given up in the face of aggressive class action lawsuits from doctors who wanted to get paid more quickly and objected to being "down-coded".

Well the lawyer behind that suit is turning his sights on the PBMs on behalf of some smaller pharmacies. The new suit filed today alleges that the PBMs are forcing patients to use their mail-order services instead of the local pharmacies (which seems likely but probably not illegal to me) and are forcing unfair contracts upon small pharmacies (which if your definition of "unfair" means "using your buying power to extract lower prices" also seems likely but not illegal). Still, worth watching this space and seeing if yet more legal antics for the PBMs actually has any effect on their business. As someone who completely underestimated the impact of the backlash against managed care, I’m loathe to say that this seemingly hopeless suit will have no impact on PBMs.

TECHNOLOGY: Health tech spending grows

Gartner says healthcare IT spending is going to $41 billion next year and will be $46 billion in 2005. This sounds like a very big number to me. Back when I was looking at this intently in the late 1990s, estimates of healthcare IT spending varied from $4 bn to over $2O billion. Of course it all depends what you mean by health care and what you mean by IT spending.  The $4bn number probably only really means software and some hardware for the provider sector–and is equivalent to the revenues for the top 100 health care software companies. The bigger number probably includes communication technology as well as hardware and all software for all health care companies including the pharma market.

In any event the reasons given for the increase are HIPAA concerns, increased pressure for CPOE and the move to wireless.  That’s clearly all true, and given the reduction in IT spending in other industries, it’s good news for the health care IT industry.  It’s hard to parse out the data for those HC software companies as the two biggest, SMS and HBOC are part of Siemens and McKesson respectively.  McKesson’s information unit (the old HBOC) only had a 4% year on year increase last quarter. However, another big player, Meditech,  does post its numbers in its Annual report, which show a big revenue increase from $216 million the dark days of 2000 to $256 million last year–more than a 10% annual growth rate.