weblinks 2011-3-27

In 2006, Washington created a board to scrutinize the cost-effectiveness of various surgeries and treatments, known as the Health Technology Assessment program.

Geographic Variation in Diagnosis Frequency and Risk of Death Among Medicare Beneficiaries, by H. Gilbert Welch, Sandra M. Sharp, Dan J. Gottlieb, Jonathan S. Skinner, John E. Wennberg (JAMA)

Context. Because diagnosis is typically thought of as purely a patient attribute, it is considered a critical factor in risk-adjustment policies designed to reward efficient and high-quality care.
Objective. To determine the association between frequency of diagnoses for chronic conditions in geographic areas and case-fatality rate among Medicare beneficiaries.
Design, Setting, and Participants. Cross-sectional analysis of the mean number of 9 serious chronic conditions (cancer, chronic obstructive pulmonary disease, coronary artery disease, congestive heart failure, peripheral artery disease, severe liver disease, diabetes with end-organ disease, chronic renal failure, and dementia) diagnosed in 306 hospital referral regions (HRRs) in the United States; HRRs were divided into quintiles of diagnosis frequency. Participants were 5 153 877 fee-for-service Medicare beneficiaries in 2007.
Main Outcome Measures. Age/sex/race–adjusted case-fatality rates.
Results. Diagnosis frequency ranged across HRRs from 0.58 chronic conditions in Grand Junction, Colorado, to 1.23 in Miami, Florida (mean, 0.90 [95% confidence interval {CI}, 0.89-0.91]; median, 0.87 [interquartile range, 0.80-0.96]). The number of conditions diagnosed was related to risk of death: among patients diagnosed with 0, 1, 2, and 3 conditions the case-fatality rate was 16, 45, 93, and 154 per 1000, respectively. As regional diagnosis frequency increased, however, the case fatality associated with a chronic condition became progressively less. Among patients diagnosed with 1 condition, the case-fatality rate decreased in a stepwise fashion across quintiles of diagnosis frequency, from 51 per 1000 in the lowest quintile to 38 per 1000 in the highest quintile (relative rate, 0.74 [95% CI, 0.72-0.76]). For patients diagnosed with 3 conditions, the corresponding case-fatality rates were 168 and 137 per 1000 (relative rate, 0.81 [95% CI, 0.79-0.84]).
Conclusion. Among fee-for-service Medicare beneficiaries, there is an inverse relationship between the regional frequency of diagnoses and the case-fatality rate for chronic conditions.

有关end-of-life care的名词：
In simplistic terms, palliative care focuses on improving quality of life and helping patients clarify their goals, regardless of prognosis. 与Medication(Drug Delivery)不同,Palliative care is a process that depends upon human interaction, especially since clarifying goals of care is important.所以Palliative Care的影响因素比较多，不可能有药物治疗那样直接的效果，所以即使随机控制试验(RCT)也未必能那么有效（如病人特殊性、咨询治疗时间长度的变异）。
Hospice is a subset of palliative care that focuses on persons who are believed to have a life expectancy of 6 months or less, and provides interdisciplinary care designed to address symptoms, maximize quality of life, and address the wholistic needs of both patient and family.

另：
2010年8月NEJM上一篇文章使用randomized control trial (RCT)的方法showed that patients receiving early palliative care had better quality of life, lower resource use (costs), and longer life expectancy (~12 months for treatment v. ~9 months for controls of patients with stage IV lung cancer)。毫无疑问，这样的研究内部效度肯定非常好。为了推进其外部效度的检验，一想NIH赞助的Palliative Care Research Cooperative 研究将开展多点临床试验。

what is PCPs?
primary care programs, such as family medicine (also called family practice or general practice in some countries), pediatrics or internal medicine. Some HMOs consider gynecologists as PCPs for the care of women, and have allowed certain subspecialists to assume PCP responsibilities for selected patient types, such as allergists caring for people with asthma and nephrologists acting as PCPs for patients on kidney dialysis.

面对21世纪医改八条-Arrow

Arrow K, Auerbach A, Bertko J, et al. Toward a 21st-Century Health Care System: Recommendations for Health Care Reform [J]. Annals of Internal Medicine,2009,150(7):493-495.
Arrow牵头政策专家、经济学家、商业领袖等各方stakeholders给出的八条医改建议（从delivery和financing两个大块）：
Delivery系统改革
1.以一个结合outcome measures的支付系统替代FFS，2.建立一个独立机构赞助评价比较效率研究(药物、器械、医疗干预)，3.简化合理化立法，4.以国家标准发展一个卫生信息技术基础架构推动数据交换，5.建立一个国家健康数据库(包括所有支付者、递送者、临床干预、患者产出、成本)
Financing系统改革
6.分析收益来源以资持全民覆盖，7.建立州/地区级别的保险风险交换池，8.建立一个健保覆盖委员会定期决策升级福利包(affordable standard benefit package)

Pilot Program--试点项目

做项目试点(Pilot Program)，然后当做工厂(工程)复制品一样推广--在美国和在中国都是一样的。上一个blog提到的Atul Gawande在Stanford医学院为医学生做的一个speech被鄙视了，又有一篇贴在New Yorker杂志上的长文，结果被Stanford的经济学大牛Alain C. Enthoven在HA Blog上大批一番。这个Alain C. Enthoven是1977Carter总统顾问时提出Consumer Choice Health Plan, a plan for universal health insurance based on managed competition in the private sector的大牛。

[Excerpt]

Moreover, we do have some excellent and outstanding prototypes of better care at less cost.  Gawande and the President name them:  the Mayo Clinic, Kaiser Permanente, Intermountain Healthcare, Geisinger, Scott and White, etc.   So if they are so great, why haven't they proliferated and taken over America? —a question I have been hearing and answering for at least 30 years.  --既然我们有一些出色的样本，连Oba毛主席都夸过他们，为什么他们没有在全美繁衍复制呢？

I wrote a paper called "Curing Fragmentation with Integrated Delivery Systems" for a June 2008 Harvard Law School conference, soon to appear in a book by Oxford Press.   Briefly, in the first half of the 20^th Century, the medical profession went all out to strangle these group practices with many reprehensible anti-competitive tactics.  The Supreme Court found that organized medicine had violated the Sherman act when trying to destroy the Group Health Association. When Russell V. Lee founded the Palo Alto Clinic, the Santa Clara County Medical Society expelled him, and  his  expulsion had  significant negative consequences for his malpractice insurance and hospital privileges.  Organized medicine got laws passed to outlaw "the corporate practice of medicine".  --历史啊，纠结

Then came World War II with the well known story of how exemption of health benefits from Wage and Price controls and income taxes put health insurance into employers' hands.  And, for various reasons, most employers don't offer choices of health insurers, blocking competitive market entry by the health plans affiliated with medical groups. Or, if they do offer choices, employers like the state of Massachusetts  pay 80-100% of the premium for  the plan of the employee's choice, thus depriving efficient plans the opportunity to market their superior cost-effectiveness.  On the other hand, a few employers like the University of California, Stanford — and, I believe, Harvard–  as well as  the states of Wisconson and  California offer choices and a fixed dollar contribution so that efficient systems can reach the market and sell their superior cost-effectiveness.  In these employment groups, large majorities usually choose efficient integrated delivery systems.  That experience ought to be replicated across America. --选择、效率、竞争才有得追求（只有最好没有更好的社会肯定是奴隶社会）

As I listened to the President and read Gawande's citation of the iconic delivery systems, I thought "I wish they would ask themselves what it is  about this health insurance market that prevents the Hondas and Toyotas of medical care from winning out."  There is an answer. If America  wants 1,000 pilot projects to blossom and grow into significant improvements in health care delivery, it must reform its system based on the principles of competition and wide, responsible, informed, individual consumer choice of health plans. Experience shows that people will join if they get to keep the savings. --人民的眼睛是雪亮的

Source: http://healthaffairs.org/blog/2009/12/22/would-reform-bills-control-costs-a-response-to-atul-gawande/

市场无形，卓越靠各自-- 医疗市场“异质性”

市场的特质 -- 卓越无法被复制:
(1) islands of excellence spring up in a sea of mediocrity and they tend to be distributed randomly—they're not correlated with anything; (2) they almost always exist because of the effort, ingenuity, enthusiasm, energy, and vision of a few people involved in actual production, and almost never are the result of anything that's happening on the demand side of the market; and (3) (most importantly) they tend not to have any objective characteristics that anyone else can copy.

三个检定好医疗市场异质性的研究：

A study of high-performing hospital regions (by researchers connected to the Brookings Institution) was unable to find any characteristics that could be replicated in a straightforward manner. Some had doctors on staff and paid them a salary. Some paid fee-for-service. Some had electronic medical records. Some did not. (See previous posts here, here, here.)

Another study, reported at the Health Affairs Blog, looked at 12 multispecialty group practices including such high-performing practices as the Cleveland Clinic, the Geisinger Clinic, the Intermountain Medical Group, the Mayo Clinic and the Virginia Mason Clinic. Of those practices, only two employed physicians directly and the other ten paid fee-for-service. Conclusion: salary without supplements or consideration for volume is the exception rather than the rule. We also learned that, driven by competition to recruit doctors, most of our multispecialty group practices compensate at levels that approximate or nearly approximate what the physicians could earn in private practice. As one of our participants told us: "Simply paying all physicians in the US on a salary basis will not be a panacea for our current [financial] ills

A third study by the Commonwealth Fund examined five high-performing health plans. The only commonalities researchers could find were subjective and qualitative (e.g., "forging and maintaining a strong relationship with physicians," plus that same idea expressed three or four different ways). Not the sort of things you can put in an operations manual and refer to as "marching orders."

 

Goodman提出的economic approach(见doctors as engineers)：
Start paying more to the islands of excellence that are higher performers. Start paying less to the low performers. Eventually, stop dealing with the low performers altogether. Encourage every doctor, every hospital administrator and every other provider to come forward and propose different ways of being paid. As long as quality doesn't suffer, be prepared to pay 50 cents for every dollar the provider saves Medicare.

Finally, search for ways to empower patients — give them control over their own health care dollars and give providers the freedom to repackage and reprice their services in patient-pleasing ways in order to compete for patients and their dollars.

但是，Atul Gawande explained how medicine should be practiced: (此君是哈佛PH教授，ObamaCare推动者之一)
This can no longer be a profession of craftsmen individually brewing plans for whatever patient comes through the door. We have to be more like engineers building a mechanism whose parts actually fit together, whose workings are ever more finely tuned and tweaked for ever better performance in providing aid and comfort to human beings.

Source: http://feedproxy.google.com/~r/TheJohnGoodmanHealthBlog/~3/NL-7Pf4tVq0/

医疗服务“价格透明”策略

[Excerpt]:

Health care is not the only industry in which price transparency(also called "sunshine policy", Many proponents of price transparency favor complete disclosure of all prices paid to every provider by every payer for every service. This strategy of openness resonates with a population frustrated by secret deals and payoffs that contribute to escalating costs, and it follows the lead of the Physician Payments Sunshine Act, which will establish a searchable database of all payments from pharmaceutical and device companies to physicians.) and MFN agreements ("most-favored nation") have led to higher prices.
政策危害：
Applying the sunshine rule in the provider–payer context, however, could have the opposite of the intended effect: it could actually raise prices charged to patients. To understand why, consider the case in which a well-regarded hospital contracts with two insurers. Suppose the hospital charges a lower price to Insurer 1 because otherwise Insurer 1 would steer patients to a different institution. If the hospital must publicly reveal both prices, it will be less likely to offer the low price to Insurer 1, because Insurer 2 would then pressure the hospital to lower its price as well. So the sunshine policy would create a perverse incentive for the hospital to raise prices (on average), and as a result its rivals could do the same. This adverse effect of price transparency would arise only in cases in which the buyer or supplier in question had some leverage (market power), but such leverage is fairly common in health care settings, including many local hospital markets.
实证研究：
Two recent studies found no effect of hospital price transparency in New Hampshire or California, but these analyses were (of necessity) limited to 1 or 2 years of post-initiative data.^1,2
对策：
To stimulate price competition, we believe that transparency initiatives should encourage or mandate disclosure of plan-specific patient copayments. Copayments, after all, are what patients actually pay. To make copayment information most salient, it should be presented in a way that reflects and improves upon consumer decision making. As Sinaiko and Rosenthal observe in their Perspective article in this issue of the Journal (pages 891–894), episode-based payments are more helpful than piecemeal reporting, and quality data should accompany prices.
总结：
The effort to promote cost-consciousness in health care is both noteworthy and laudable. Just as in other industries, consumers need to know what they are on the hook for when they purchase medical care. But complete transparency of prices negotiated between payers and providers could raise costs instead of lowering them, especially in markets where there is some degree of pricing power and where consumers are imperfect decision makers.

1. Tu HT, Lauer J. Impact of health care price transparency on price variation: the New Hampshire experience. Issue brief no. 128. Washington, DC: Center for Studying Health System Change, 2009.
2. Austin A, Gravelle G. Report for Congress: Does price transparency improve market efficiency? Implications of empirical evidence in other markets for the health sector. Washington, DC: Congressional Research Service, 2008.

source：Designing Transparency Systems for Medical Care Prices, NEJM, March 9, 2011, http://healthpolicyandreform.nejm.org/?p=13895&query=TOC

医疗集团 in US

美国的医疗体系是个巨无霸，即使里面的小个头（指：医疗集团）都能吓死人，这远比一般的跨国公司复杂，但是他们仍然在努力的从组织和管理上推进绩效改进。

System Appleton Medical Center and Theda Clark Medical Center, both part of ThedaCare, a 5-hospital health care system with 40 sites and 5,500 employees serving approximately half a million people in northeastern Wisconsin.
Key Innovation: Collaborative Care, a model of general acute care. Lean methodology was used to redesign and reconfigure clinicians' roles, all acute care processes, and the physical setting to make them more efficient, effective, and patient-friendly.

System UPMC Health System (formerly known as the University of Pittsburgh Medical Center), a not-for-profit, integrated delivery system in western Pennsylvania with 20 hospitals, 2,700 employed physicians, 400 physician offices and outpatient sites, and a health insurance division.
Key Innovation: The Patient and Family Centered Care performance improvement program, housed at the Innovation Center at UPMC, in Pittsburgh. At eight of UPMC's twenty hospitals, working groups are redesigning health care processes by viewing all care experiences through the eyes of patients and their families.

source：doi: 10.1377/hlthaff.2011.0087 Health Aff March 2011 vol. 30 no. 3 422-425
doi: 10.1377/hlthaff.2011.0139 Health Aff March 2011 vol. 30 no. 3 400-403 

weblinks 2011-3-21

P4P的效果？？Effect of pay for performance on the management and outcomes of hypertension in the United Kingdom: interrupted time series study (2011)
Conclusions Good quality of care for hypertension was stable or improving before pay for performance was introduced. Pay for performance had no discernible effects on processes of care or on hypertension related clinical outcomes. Generous financial incentives, as designed in the UK pay for performance policy, may not be sufficient to improve quality of care and outcomes for hypertension and other common chronic conditions.

自由健康照护市场Envisioning a Free Market in Health Care

独生子女政策的终结？The end of the one-child policy in China?

Last week, a two-child policy was proposed, to start in 2015. Experts have suggested that the one-child policy has resulted in an increase in older people and a decrease in younger workers, as well as a sex-ratio imbalance, which might threaten China's economic growth.

什么是真正的快乐幸福？区别短快乐和长期幸福感。Is Happiness Overrated?
Some of the newest evidence suggests that people who focus on living with a sense of purpose as they age are more likely to remain cognitively intact, have better mental health and even live longer than people who focus on achieving feelings of happiness. In fact, in some cases, too much focus on feeling happy can actually lead to feeling less happy, researchers say.
Some researchers say happiness as people usually think of it—the experience of pleasure or positive feelings—is far less important to physical health than the type of well-being that comes from engaging in meaningful activity. Researchers refer to this latter state as "eudaimonic well-being."
The pleasure that comes with, say, a good meal, an entertaining movie or an important win for one's sports team—a feeling called "hedonic well-being"—tends to be short-term and fleeting. Raising children, volunteering or going to medical school may be less pleasurable day to day. But these pursuits give a sense of fulfillment, of being the best one can be, particularly in the long run.
Team Leader：Carol Ryff, a professor and director of the Institute on Aging at the University of Wisconsin, Madison.

Residency Matching Day
According to the National Resident Matching Program, Primary Care Again a Top Choice on Match Day