Resilient Ambassadors of Change

Pay for performance (P4P)--How's my driving?

The first time I heard about P4P, I thought what a great old idea!  Didn't they call it "piecework" back in the day?  Why shouldn't I be paid more if I could churn out 60 widgets in an hour compared to the guy next to me making only 43?  Well for one, maybe his widgets were better than mine.  Maybe I was working with inferior widget parts.  Maybe someone on the widget part line slowed him down.  There may be reasons why we are no longer paid by the "piece." 

Surely churning out patients was not what health insurance companies had in mind, so P4P must be tied to patient outcomes or satisfaction or some other measure that the physician is performing at his best.  So what's the fuss?  As a patient, I certainly would like to know that my physician is a top performer.  Why wouldn't they want data about their patient outcomes and satisfaction collected, analyzed and shared with insurance companies and patients?  Maybe their patients are sicker, poorer, and unable to afford to comply or follow up.  Maybe they have no control over the interactions between staff and patients. Maybe they are powerless to fix system problems within a hospital. There may be reasons why physicians are leery of embracing P4P sponsored by insurance companies. 

Today, buried in an otherwise engaging post on The Medical Quack, I found a reference to a kind of P4P that could affect me more directly in the not so distant future. On it's face,like piecework and physician P4P it seemslike a great idea. I drive carefully and I pay less money for car insurance. I have a spotless driving record--no accidents or tickets (except the parking tickets my sons get when they borrow my car).  I should be paying less for car insurance. It seems Progressive Insurance has a device that tracks your driving habits, coupled with a program called My Rate promising lower rates. You can even log on to the website and track your projected renewal rate based on your driving. What if my rates go up? What if I can't get insurance anywhere?  Maybe the device was faulty. Maybe I lent my car to my son (the one who gets the parking tickets).  Maybe I was driving erratically while dodging the other nuts on the road. Maybe there are reasons to suspect the motives of insurance companies.

I'm not sure money is the best motive for improving your widget making, driving, or patient care. I'm pretty sure insurance companies and other third parties that stand to gain while we lose are NOT the best choice to drive improvement. 

Is increased regulation in the Internet's future?

I was tempted to answer the question posed in the subject line with a simple, definitive "yes", but I realized I should probably elaborate a bit - after all, "yes" isn't much of a blog post. 

  The concept of identity has been intimately linked to the Internet since its beginnings - after all, computers have identities, users have identities, and all have to be managed as part of the Web.  We choose usernames and passwords and use them to manage our online identities; but a lack of a pervasive standardized identity management system like Microsoft's .net software (a la Identity 2.0) enables users to hide behind a layer of anonymity.  MrKewlD00D22 isn't afraid to speak his mind on the discussion board of his favorite science magazine, even if he is painfully shy in person.  PunkRockGrrl87 and MackDaddy00 chat online each day, but their real-life counterparts have never met.

However, as the lines between reality and virtual reality become more blurry, it seems identity is more of a sticky situation. Take for example the recent, very unfortunate story of a mother pretending to be a teenage boy on Myspace for the sole purpose of harassing one of her daughter's female classmates, which ultimately ended in the 13-year-old girl's suicide.  The mother had been facing up to 20 years in prison for conspiracy charges, but the conspiracy charges were thrown out and she now faces 1 year in jail and $300,000 fines for 3 misdemeanors.  This situation brings to light all sorts of regulatory issues around the Internet. For example, if one is to be held personally accountable to the Terms of Service on a site, then somehow their online identity must contain meaning that links to their real life.  And how many "teeth" do the Terms of Service have in terms of the law?  Do the same rules apply online as they do in real life? 

These are important questions, and are becoming even more important as future generations engage with and build upon the giant information monstrodome that is the Internet.  Frankly, I think the time for more regulation with regard to identity (and information veracity) is far past its due date.

Finding Doctor Right

In a special section Decoding your health, the New York Times provides some solid information and advice to consumers in a variety of articles around topics like Googling your health, popular medical websites, FDA approval for medications, alternative medicine, and more. 

One of the articles, You can find Dr. Right, with some effort, gives consumers some direction for selecting a physician, using what little objective data is currenty available, as most consumers continue to rely largely on word-of-mouth referrals from family and friends.

The article suggests contacting the usual suspects like your State Medical Board for licensing information, your health plan (as some are beginning to provide some quality measures) and the American Board of Medical Specialties for specialty certification information, as well as some of the emerging services offering physician ratings.  Still, this is precious little information as the basis for a most intimate doctor/patient relationship--no quality measures of physician performance or even descriptive data about physicians' practices.

No surprises here, good objective data is hard to get, and volumes of subjective physician rating data will likely not provide the basis for good decision making.  The relevance and timliness of our discussions around physician matching, performance measures of physians in practice, physician practice profiles, and data compilation and report out continues to be supported by the increasing public demand for quality measures for physicians.

"...patients cannot get their hands on a wealth of information about physicians that is compiled by government agencies....  The Medicare program recently started a physician quality reporting iniative,...information is not yet public."

In an attempt to obtain data about procedures done by physicians (e.g., knee replacements, prostate surgery, etc.), last year the nonprofit group Consumers' Checkbook won a lawsuit granting access to Medicare's physician records.  The government is appealing the decision--there goes that big, publicly-available data set that we've been dreaming about.

Healthcare Facts

While scouting, I happened upon the Healthcare Facts website.  According to the website, through a collaborative effort among Blue Cross and Blue Shield plans, they deliver "health care information as easy to understand as a nutrition label."  Well, it's not exactly what I was thinking of as "health care information," but rather health care provider information in a format that I found much more useful than what is available to me through my own healthcare provider's website. 

To enter the site you must select your state (currently only Minnesota and Louisianna) from a drop down list, which directs you to the "Shopping for Care" page, where you are able to shop for a hospital or a health care provider.  Membership in BC/BS is not required to use the service.  You can select by region, county or city.  Once you've selected your provider or hospital, you are presented with a factsheet that looks very much like the typical nutrition label found on all food products. 

I was able to do a side-by-side comparison of two healthcare providers of interest to me.  It was very similar to comparing digital camera features on circuity.com or bestbuy.com.  Features were categorized by Accessibility, Safety and Quality, Services and Technology.  Have a peek at the output from my comparison.  I would have liked the opportunity to compare more than two at a time, and the data is a bit skimpy right now, but objective information about features offered by each practitioner is a good start. 

Surgery with a warranty

Geisinger Health System, a hospital group in central Pennsylvania, is trying a new approach to improving medical care and reducing costs by guaranteeing their work.  For their bypass procedure, they charge a flat fee that includes 90 days of follow-up care.  This care is delivered at no extra cost to the patient or insurer and includes additional hospital stays, if necessary; the hospital absorbs any extra costs.  Preliminary results of their one-year trial indicate that standardizing the way they do bypass surgery and devising procedures to ensure that the essential steps are followed results in better care for patients, which in turn results in fewer adverse events and subsequent expensive hospital stays.  Future plans include developing standards for other procedures and marketing the idea to insurers and employers.  They learned some lessons about the value of standardizing care, with input from the healthcare team, on patient outcomes. Me, I'm waiting for the "money back" guarantee--then I'll know they mean business!

Massachusetts Hospitals Posting Bed-sore Data Online

Massachusetts hospitals today are revealing the rates of pressure ulcers their patients have acquired during hospital stays, another in a series of statistics made public by the Massachusetts Hospital Association on its Patients First website. Boston.com/The Boston Globe