Debate: Is Kaiser good for medicine? (Part 1)

With over 8.7 million health plan members and 167,178 employees, Kaiser is the biggest managed care organization in the country.

Oct 19, 2011 - Doximity Blog


Editor’s note: Doximity Advisory Board member Peter Alperin, MD, is a
board certified internist currently practicing at the San Francisco VA Medical
Center
. He previously led informatics at Brown and Toland Medical Group,
and has also worked at Epocrates.

In 2010, the New England Journal of Medicine published a study conducted
by the Kaiser Permanente Division of Research showing that since 2000, heart
attacks among a group of over 46,000 of its Northern California patients had
declined by 24%. To be sure, some of this could be attributed to possible broad
public health trends in that area, but the researchers also noted that the
decline coincided with improved control of cardiovascular risk factors at
Kaiser.

This alone might not be quite so remarkable, but for the fact that
consistently, Kaiser scores at the top of almost every single quality care
measure it’s in. Just recently, it was one of nine health plans awarded
five stars by Medicare Advantage. Time and again I’ve seen the organization
take a rigorous approach toward analyzing what it’s doing well and what it’s
not doing well in the interest of improving processes of care. In other words,
the NEJM story reflects something of Kaiser’s DNA.

There are many factors at play here but one of the clear incentives is
financial—Kaiser realizes that it makes good financial sense to invest in
prevention and the systems needed to provide preventive care in a
cost-effective manner. Last year, Kaiser reported a combined net income of
$2 billion, and $44.2 billion in operating revenues. With over 8.7 million
health plan members and 167,178 employees, Kaiser is the biggest managed care
organization in the country. Large technological and programmatic investments
make more sense in an integrated system such as this, one that simultaneously
controls insurance, hospitals, and doctors–effectively, all three legs of the
healthcare stool.

Thirty years ago, Kaiser was cynically viewed as a place for doctors who
couldn’t make the cut of private practice. How misguided that view was. I’ve
found it interesting to see how far the pendulum has now swung: Not long ago, I
was asked to talk at a residency event at UCSF. Among the seven of us on
our panel, the vast majority of the questions went to the person from Kaiser.
To me, this spoke volumes of the changing face of medicine. The residents in
our audience (a large number of whom were women) were asking about quality of
life and flexibility of day care.

Much of this has, of course, been enabled by the fact that private practice
simply isn’t as lucrative as it once was. And I would argue that growing pains
notwithstanding, there are notable advantages to this new landscape. Physicians
tend to go to medical school because they like medicine, not because they want
to be business people. One big advantage of an integrated system like Kasier is
that doctors don’t have to think about making payroll, renting office space, or
finding a call service. Furthermore–and this is the secret sauce—working in a
group environment forces collaboration, something at which doctors have perhaps
not historically thrived, but from which ideas and progress can spring.

Is Kaiser perfect? Of course not. It isn’t the most nimble. By dividing itself
into regions, Kaiser works hard at mitigating the inevitable bureaucratic
slowdowns that come with size, but even so, each individual Permanente group
remains much larger than an average medical group. It can take a long time to
implement best practices across an organization of such size and complexity.

I do worry that Kasier is so dominant in some markets that without the promise
of growth or the threat of competition, there’s the risk that progress will
slow, and that the goal becomes more about making the cut than breaking new
ground, be it in patient care or keeping costs affordable. However, Kaiser has
to date consistently performed and it remains, in my opinion, the gold standard
for healthcare delivery in the US. In fact, if we broaden our view to
incorporate other health systems that are on the vanguard of change, like the
Mayo Clinic, Geisinger, or Intermountain Healthcare to name a
few, what is apparent is that a great deal of overall innovation action is
currently in integrated delivery systems, what’s apparent is that a great
deal of innovation action is currently in integrated delivery, suggesting a
real relevance for these systems as healthcare continues to change.

Come November, we’ll revisit this issue–from the opposing perspective.

The business of practice: Are resumes the new roadmap?

New and evolving paradigms of healthcare provision have already led to some large-scale shifts—hospitals buying up private practices

Oct 04, 2011 - Doximity Blog


Editor’s note: Alex Blau, MD, is Doximity’s Medical Director.

In 2000, nearly 60% of physicians were practicing independently. Compare that
to two years from now, when it’s predicted that just 33% will continue to
practice solely outside of a larger health system. According to a report from
Accenture
, the global consulting company that released those figures,
between now and 2013, the rate at which independent doctors are being employed
by larger systems will increase by 5% per year.

You probably don’t need numbers to tell you that practice models are changing
dramatically. New and evolving paradigms of healthcare provision have already
led to some large-scale shifts—hospitals buying up private practices, for
example.

The incentive for such large scale practice consolidation is clear from the
hospital perspective, as it allows them to capture referrals and keep
lucrative procedures (e.g. endoscopies, elective surgeries) in-house. But what
is driving so many physicians to abandon the private practice model?

Hospital-based employment offers stability in an uncertain economy,
particularly for young doctors entering the job market with considerable
educational debt. According to the Association of American Medical Colleges,
new physicians are leaving medical school with an average debt burden of
$158,000.

In addition, work-life balance is becoming increasingly important for newer
generations of doctors. Hospitals offer better call coverage and more
predictable schedules. Moreover, they allow doctors to offload countless
administrative responsibilities, such as billing and staffing, while
simultaneously providing access to state-of-the-art IT tools and equipment. All
of this helps physicians eliminate much of the noise in their daily workflow,
allowing them to focus on patient care.

The consequences of the changing landscape of clinical practice has been the
subject of a great deal of discussion. There is one outcome, however, that
hasn’t gotten much coverage. The way in which physicians think about and
develop their careers is undergoing a fundamental shift.

Specifically, the business of being a doctor is becoming less dependent upon
the horizontal connections between specialists and referral sources, and more
dependent upon vertical relationships within an organizational heirarchy.
Resumes are replacing business plans, and time once spent on marketing and
cost-management is now being devoted to the pursuit of career-building
opportunities, like taking on leadership and administrative roles, conducting
internal research or developing QI initiatives.

As this trend continues, the growth challenge for doctors will be more about
career management and less about business development, a change that may favor
residents and young attendings, who are more accustomed to the competitive
landscape of academic medicine. Competition for chief resident spots,
publication opportunities and stage time at grand rounds and specialty
conferences may prove to be the ideal training for a new generation of
career-oriented physicians.

Facebook for physicians: a primer from Mayo Clinic's Lee Aase

The broader question is what can we say and where can we say it when we talk in a professional capacity about health

Oct 03, 2011 - Production Blog Author


Editor’s note: Alex Blau, MD, is Doximity’s Medical Director.

Type “Facebook” into a PubMed search and you’ll get 19 academic articles,
letters or reviews, all from the last three years. For Twitter, there are 105.
Social media has tremendous potential to improve the way physicians
communicate, yet we’ve all read the stories of doctors being censured by
employers or licensing boards
because of errant comments on Facebook. Though
rare, each such incident underscores a lack of understanding of what these
tools are for. Indeed, we’re just beginning to define their utility in the
healthcare sphere.

There are, of course, some very clear contexts in which social media is not
appropriate. Neither Facebook nor Twitter are HIPAA-compliant environments, for
example, and it’s mainly discussions of patient care that have led to problems.
(There’s clearly a need among physicians to communicate about clinical issues.
We’re building Doximity specifically to allow those kinds of conversations.)
But the broader question is what can we say and where can we say it when we
talk in a professional capacity about health.

This week, I asked Lee Aase, Director of the Mayo Clinic’s Center for
Social Media
to offer his insights on Facebook use, in particular. Here, he
took a little time away from preparing for the Mayo Clinic Social Media
Summit
(Oct 17-21) to weigh in with some well-tested insight:

Anything you put online has the potential to be seen. I always say that you
shouldn’t have anything on the Web that you would be mortified to read in
your local newspaper. Fortunately, Facebook still has privacy settings, so
you can really be thoughtful about whom you accept as friends. For example,
we recommend that in most cases you shouldn’t accept a friend request from a
patient. Nor should you have to: You can communicate on Facebook without
having a friend relationship.

Not long ago, in a blog series we do for the Center for Social Media
called Friday Faux Pax, we covered the story of a woman in Scotland who
posted a picture from the operating room on her Facebook profile. That would
have been a privacy violation in real life, so putting it on Facebook is an
extension of that. Advice like this seems so obvious in hindsight, but what
often happens is that people are caught up in something and they’re letting
off steam so they confuse a post with a conversation. It’s understandable:
Facebook’s whole tone is conversational. For that reason, it can really help
to take a ten-second pause before you post something. Ask yourself whether
what you want to say is productive and helpful to be posting, or whether it’s
just venting.

This isn’t to say you should shy away from posting anything–the way things
work these days, you will have an online footprint no matter what. That’s not
something you can control. What you can manage, though, is your opportunity
to make it good. Strong professional posts tend to consist of content in your
area of expertise. You always want to be talking in general terms; don’t get
into practicing medicine online. Even if you’re not using names or
identifiable information, remember that complaining about patients almost
always lowers the esteem of physicians in the public eye.

The broad rule-of-thumb is to keep it positive. Laughing at yourself rather
than making jokes about anybody else makes you seem trustworthy and credible.
More importantly, have a sense of what your personal boundaries are as you go
in. The physicians who have taken a little time to assess this question tend
to have the most rewarding experiences.

How doctors connect: mapping physician networks

This week, we’re sharing a tool we’ve put together that we think does that job especially well

Sep 20, 2011 - Doximity Blog


Editor’s Note: Jey Balachandran is a software engineer at Doximity.

For some time, we’ve been playing around with different kinds of data visualizations designed to help Doximity members learn more about how their peers are interacting with each other. To wit, this week, we’re sharing a tool we’ve put together that we think does that job especially well.

Sample size: Over 600,000 physician colleague connections made through Doximity.

Top 5 Most Connected:

  1. Internist
  2. Family Medicine
  3. Psychiatrist
  4. Ob / Gyn
  5. Pediatrician

Top 5 Least Connected:

  1. Radiation Oncology
  2. Infectious Disease
  3. Thoracic Surgeon
  4. Endocrinology
  5. Rheumatology

The graphic you see above represents the typical number of connections made for and between an array of medical specialties, each component circle sized according to how many members it has on our site. Our thinking is that this can be used as a comparison tool–a way for individual users to think about how they’re building their network relative to others in their field.

To give an example, say you’re a gastroenterologist and you find that your peers are on average linked to twice as many primary care physicians as you; that knowledge might well hold value in how you pursue future connections. More broadly, it can lead to some interesting questions about hospital/clinic layout, and which specialities might be best served sharing space in order to facilitate the most needed communication. For non-doctors, seeing which groups connect most frequently and robustly can also be pretty fascinating.

Is early hospital discharge worth it?

Patients receiving hospitalist treatment initially experienced shorter stays and cost $282 less than those seen by primary care physicians.

Sep 13, 2011 - Production Blog Author


Editor’s note: Doximity Advisory Board member Peter Alperin, MD, is a
board certified internist currently practicing at the San Francisco VA Medical
Center
. He previously led informatics at Brown and Toland Medical Group,
and has also worked at Epocrates.

Last month, the Annals of Internal Medicine published a report
challenging the notion that hospitalist medicine is more cost-effective than
the traditional model of inpatient care. According to data culled from nearly
60,000 Medicare subscribers, patients receiving hospitalist treatment initially
experienced shorter stays and cost $282 less than those seen by primary care
physicians. Yet during the month following their discharge, those same patients
were more likely to be readmitted and averaged medical bills about $332 higher
than their counterparts–an overall net loss.

One of the compelling arguments in favor of using hospitalists has been that if
you have somebody on hand who is versed in inpatient medicine and can react to
information more quickly, better results will follow. For example a blood test
ordered at 8 AM can be responded to at 2PM, with subsequent therapy being
instituted more efficiently–ultimately leading to an earlier patient discharge.
Money is thereby saved. But this study poses a provocative question: By cutting
down the length of stay, are hospitalists short-circuiting that truism of
“tincture of time,” that it often just takes time for a patient to get better?
By completing the work more efficiently and discharging patients earlier, they
might simply be letting people out before they’re ready.

Another place to look for possible causes for these readmissions is the patient
handoff: Back in June, the American Medical Association blogged about a
perceived rise in handoff-related liability claims, citing a recent Archives
of Internal Medicine study
that highlighted significant disparities in
perceived communication among primary care doctors and specialists. For
example, 69.3% of PCPs say they nearly always notify specialists of patients’
histories–but only 34.8% of specialists report they receive them. While this is
far from conclusive, it warrants further investigation.

There’s no question that there are a lot more people involved in care now than
there have been before, and care itself is more complicated. Much of this has
to do with the fact that, today, many of the less acute cases are treated in
outpatient settings. This means that the patients who are admitted to acute
care hospitals are considerably sicker than they were 30 years ago, and the
need for specialized treatment is greater. Moreover, even when a specialist
might not be needed, there’s no disincentive on the part of a hospitalist
doctor to make such a referral. The referring physician loses none of his or
her own money on the arrangement. Indeed, it’s a move that diffuses individual
liability and might even be encouraged in the interest of ”relationship
management.”

Taking all these factors into consideration, I’d argue that the core problem
appears to revolve around misaligned incentives. Therefore, I’m predicting that
a key step toward ultimately rectifying these issues is the adoption of
integrated delivery networks such as the proposed Accountable Care
Organizations or other integrated organizations. We need to move to a model
where one health care organization is responsible for the entire continuum of
care–where no money will be saved by discharging people who are sicker and
physicians themselves have a stake in both the quality and financial well-being
of the system. ACOs and other moves towards clinical integration are steps in
the right direction but are only the beginning. We also need physicians trained
to work in these integrated systems, which they traditionally have not been–but
that is a topic for another day.