Doin it, doin it, doin it well

Sarah Kliff at Vox highlights the problem of readmissions after kidney stones are busted:

That makes the removal of a kidney stone one of the most basic, most common procedures in the United States – not the type of thing that you’d think would land you in the emergency room a few weeks later.

Except it turns out that, after the extremely routine surgery, one in seven patients actually do make an unexpected trip back to the doctor – and that can cost upwards of $30,000….

 how many of these unplanned visits are preventable….Scales, for his part, thinks a good number might be preventable. He points to the fact that people seen at really high volume facilities – places that do lots of kidney stone removals – tend to have 20 percent fewer unplanned follow-up visits than people seen at places that do fewer procedures. That suggests having some kind of expertise in the procedure can lead to better outcomes.

This makes sense.  As someone or a team does a task more often,they get better.  Their technique gets better, their recognition of that odd little detail which could lead to problems gets better, their supplies are better suited for a particular task and their ability to recognize and recover from an error gets better.  It is a simple division of labor and skill.

Right now, the scope of practice for a specialist can be fairly wide.  A general surgeon can go to town from neck to ankles.  She might have a gallbladder operation on Tuesday, a bile duct repair on Wednesday, a hernia repair on Thursday.  An orthopedic surgeon might rebuild on ankle on Monday morning, insert pins into the elbow after lunch, and replace a hip before dinner. 

This could change in the future.  The broad scope of practice is a necessary skill base, and it can be a necessity in more remote areas, but insurance companies may modify their payment models for better and in the long run, cheaper care in urban areas.

Centers of excellence for elective or non-urgent care may be a major change in the business model of insurance companies.  Instead of being willing to pay high benefits to any in-network general surgeon who removes a gallbladder, the insurance company could designate half a dozen surgeons at a couple of facilities to be their “gall bladder docs”.  Another set of surgeons at different facilities could be the ACL/PCL/MCL pit crew.  Another three or four teams would be the regional hernia groups. 

The goal would be to develop very deep experience and a standardized protocal of care.  If every person who is having a hip replaced receives the same spare part, the ability to buy in bulk means a much better deal should be received.  Training time and learning by doing time would also be reduced as instead of three hundred surgeons in network who need to stay current on a surgery that they’ll only perform a couple of times a year, most surgeons would only need reminder/refresher trainings, while the core team would be involved in daily replacements.  The goal is to reduce errors, reduce mistakes and get people better faster and cheaper. 

Cheaper is achievable even if the per-operation rate increases as this metholody should result in significantly fewer re-admissions. 

There are a couple of big problems with this business practice change.  The first is that it would be an insurance company dictating independent business decisions by providers.  Integrated payer-providers like Kaiser would have a much easier time making this change than insurance only companies like Wellpoint.  The second, major problem, is the teaching hospitals would have a much harder time teaching.  It is highly unlikely that an insurer would choose the major regional academic medical center as a center of excellence/preferred slicer and dicer for all major categories of surgery.  Medical students would still continue to see all of the unusual and emergency cases that they currently see, but they would probably be classes of common procedures that they would not see on a regular basis.






24 replies
  1. 1
    hoodie says:

    The second, major problem, is the teaching hospitals would have a much harder time teaching. It is highly unlikely that an insurer would choose the major regional academic medical center as a center of excellence/preferred slicer and dicer for all major categories of surgery. Medical students would still continue to see all of the unusual and emergency cases that they currently see, but they would probably be classes of common procedures that they would not see on a regular basis.

    Don’t you think the university systems have already seen this coming? At least around here, the big university systems (Duke and UNC) have gone around and bought up multiple practices and facilities outside of the university hospital mothership, and offer everything from brain surgery to yoga. If they add health insurance arms, they end up as integrated provider systems a la Kaiser, with the added feature of having a basketball team.

  2. 2
    Sterling says:

    “This makes sense.”

    Whenever you think something like this after seeing a single statistic, you should stop yourself and take a second, deeper look at the issue. You don’t know the hows or whys of the situation and are just guessing at why that 20% rate exists. For example, there may be a difference between the populations that use centers and those that use hospitals. The centers may be getting more patients with very minor problems that don’t need surgical intervention, so these patients may not suffer complications at the same rate. There’s not enough information to draw a conclusion when you’re working from a single stat like that, so you shouldn’t be suggesting any kind of policy at all here.

  3. 3
    Richard Mayhew says:

    @Sterling: This is an ongoing insurance industry trend:

    Mississippi Centers of Excellence http://www.bcbsms.com/index.ph.....lence.html

    Anthem on Bariatric Surgery: http://www.anthem.com/shared/n.....=ahpfooter

    UHC Center of Excellence model http://www.uhc.com/individuals.....tworks.htm

    The trend right now is for higher end care to go the CoE route as the logic has been clear — better care, fewer complications and lower long run costs if only a few facilities and teams do almost all of the very complex work as the teams/facilities build a depth of knowledge on doing it right.

    At most, I am proposing the thought to bring this logic down the complexity chain. At least, I’m explaining a long term trend by using an interesting hook.

  4. 4
    PST says:

    I have had quite a bit of specialist medical care over the past 15 years, and for the most part I have been grateful for and satisfied with the care I received. With one exception, though, I had little genuine role in picking the doctors. I went to the specialists my primary care physician recommended. While I have no doubts that they were all doctors he has confidence in, I don’t think he engaged in a rigorous comparison of possible specialists, and I feel sure he didn’t take cost into account. He mentioned in a couple of cases that they play golf together. A partner of mine and I have had an uncannily similar medical history, and when we compared specialists, we had to laugh that mine were almost all Irish and hers were almost all Jewish. In short, innocent cronyism plays a huge part in referrals, as ties of friendship and business govern our choices. I’m a lawyer, and I have to admit I think first of my partners and my friends when someone needs a legal specialist, and they are people I think do a good job, so why should I be shocked if it is the same for my doctor? If the trends Richard describes come to pass, there will be many complaints about loss of choice. However, to a large extent, what I think of as my freedom to choose my medical care providers is an illusion. I might be better off with a strong push from someone in a position to actually compare results with statistical rigor rather than the casual networking that rules most of my choices now.

    The exception I referred to in my history of going where I’m sent was a surgeon for colon cancer many years ago (I’m fine). I did a lot of research then, and there is a demonstrable difference in outcomes going to a surgeon and a surgical team that resect colons pretty much full time. Why this is so isn’t altogether clear. But in my legal specialty of medical malpractice defense, I see it as well. When it comes to procedures, practice makes perfect. Dabblers make mistakes.

  5. 5
    Fuzzy says:

    Maybe I am lucky as there are two campuses of the same hospital within 10 miles and they have divided specialties. One has top oncology and cardiac facilities and the other has ortho, maternity and gastro theaters. Both are new or totally remodeled within the past few years. They claim to be non-profit but the board members all seem to have surrounding offices, clinics or scanning operations. Interesting business plan that works for patient’s easy access.

  6. 6
    Mandalay says:

    As someone or a team does a task more often,they get better. Their technique gets better, their recognition of that odd little detail which could lead to problems gets better, their supplies are better suited for a particular task and their ability to recognize and recover from an error gets better. It is a simple division of labor and skill.

    Indeed. And the person recognizing those odd little details doesn’t necessarily need to be a doctor. This is how it works in India….

    The transfer of responsibility for routine tasks to lower-skilled workers leaves doctors free to focus on complicated medical procedures. Several hospitals have created a tier of paramedic workers with two years of training after high school to perform routine medical jobs. As a result, surgeons, for example, are able to perform two to three times as many surgeries as their U.S. counterparts….

    Another impediment to task-shifting in the U.S. is the false belief that lesser-trained caregivers, like nurse practitioners or physicians assistants, are not adequate. This is ludicrous. In my field, there is ample evidence that nurse-directed care can even be better than doctor-directed care. Why wouldn’t it be? If all you do each day is listen to and care for patients in just a couple of disease states, you become skilled, regardless of the letters that follow your name..

  7. 7
    dr. bloor says:

    @Mandalay:

    Mandrola should get out of the ER more often, and not just go to India. The use of NPs, PAs and other technical types for the sorts of things he describes is quite common, and Physician Assistant is a “boom” category in any job outlook article you read. Might not be happening quickly enough to suit his tastes, but it is happening.

  8. 8
    Barry says:

    @Sterling: ” The centers may be getting more patients with very minor problems that don’t need surgical intervention, so these patients may not suffer complications at the same rate. There’s not enough information to draw a conclusion when you’re working from a single stat like that, so you shouldn’t be suggesting any kind of policy at all here. ”

    My guess would be both – the specialized centers have greater (but narrower) skill, *and* they refer cases which present a likelihood of complications to less specialized centers.

    Which is what they should be doing.

  9. 9
    BruceJ says:

    @Sterling: This has also been shown to be true for heart bypass and organ transplant surgeries as well: the rate of a favorable outcome without complications is pretty directly proportional to the numbers of such procedures performed annually at the facility.

    Again, the basic underlying premise is “If you do something more often, you get better at it.”

    It works for golf, tennis and writing, why would surgery be any different?

    Also, facilities that do more of these procedures tend to be able to afford the best talent. There’s a reason the NY Yankees have won so many world series…

  10. 10
    Mandalay says:

    @dr. bloor:

    The use of NPs, PAs and other technical types for the sorts of things he describes is quite common

    But isn’t that just perpetuating the problem? Mandrola mentions “a tier of paramedic workers with two years of training after high school to perform routine medical jobs”. Hardly NPs or PAs.

  11. 11
    Mandalay says:

    @dr. bloor:

    The use of NPs, PAs and other technical types for the sorts of things he describes is quite common

    But isn’t that just perpetuating the problem? Mandrola mentions “a tier of paramedic workers with two years of training after high school to perform routine medical jobs”. Hardly NPs or PAs.

  12. 12
    Andrew says:

    Atul Gawande wrote about repetition and expertise improving outcomes back in his 2002 book “Complications: A Surgeon’s Notes on an Imperfect Science”. At least I think it was that one.

    Anyway, his point was that when surgeons do just one kind of surgery and they do it in a facility dedicated to performing just that kind of surgery, the developed expertise improves outcomes and (by reducing complications) reduces cost.

  13. 13
    Joel says:

    I was representing Queens she was raised up in Brooklyn.

  14. 14

    Richard’s representing Queens but was raised out in Brooklyn.

  15. 15
    Stella B. says:

    @Mandalay: Nope. When I was an undergrad in the 70’s, my roommate — who was 2 years out of high school — worked as an OR tech to pay for school. She assisted in the early morning and took afternoon classes. I doubt that you’ll find a hospital anywhere in the US without them. I suspect that in India the surgeon is not liable for malpractice when a tech screws up, unlike the US which makes it easier to give the Indian OR tech greater scope.

    I bullied my nephew into getting a BSN and RN instead, because that is the path to becoming an NP which is much better paid.

  16. 16
    Stella B. says:

    I need an unusual joint replaced. The local guy who does the most surgeries of this type is a jolly, jerky jock. I’m not about to let a nicer, but less experienced surgeon do the job. For now I’m going to use a cane and limp until the pain overwhelms my dislike of Dr. Jock.

  17. 17
    cmorenc says:

    @PST:

    However, to a large extent, what I think of as my freedom to choose my medical care providers is an illusion. I might be better off with a strong push from someone in a position to actually compare results with statistical rigor rather than the casual networking that rules most of my choices now.

    An especially interesting case of “networking” in choice of physicians for a given problem is who physicians themselves pick when it’s themselves or a close family member who has the problem. Although this particular subclass of choice decisions still lacks anything approaching the sort of technical “rigor” statisticians have in mind, and still relies to a great extent on “social networking” within the local medical community to make an intelligent decision, nevertheless it can be quite effective in producing an optimum outcome for the need.
    The networking is most often used to timely produce at least two available choices:
    1) Which specialist(s) have the very best skill set for the problem at hand?
    2) Which specialist(s) have an adequate skill set for the problem at hand, who are more likely to have faster, more convenient availability?
    3) Of course, insurance coverage talks, and the former world of physcian mutual courtesy walks…and so choices #1 and #2 are colored by who’s in-network for the physican’s own health insurance and who isn’t (AND BTW: PHYSICIANS DON’T NECESSARILY HAVE ANY BETTER HEALTH INSURANCE COVERAGE THAN MANY ORDINARY PEOPLE DO! Medical professionals and coverage of practice members are not exempt from the forces of medical insurance economics any more than you are).

    The most often-used advantage in being a member of a physician’s family is:
    a) having the social networking juice to cut ahead a bit in line for a medical appointment – it’s more likely a busy specialist’s practice will try a bit harder to find an available hole in their schedule for you than any joe or jane blow;
    b) for very casual low-risk low actual-overhead stuff, a close physician-friend might even see you in-office outside of regular hours (e.g. need a physical for your child to play on a school sports team).
    c) OTOH if there’s REALLY an acute problem – social bullshit walks, rep for expertise talks, and you’re guaranteed to get referred to someone who’s at least solidly competent, even if they’re not necessarily THE top dog in that specialty.

    How do I know this? (I’m not a medical professional myself): my father was a physician, my wife is a physician, my older daughter has finished medical school and is in residency, my younger daughter is just completing nursing school, and I’ve seen this process operate (and how it’s changed with the changing insurance and medical practice landscape) literally my whole life. And I’ve benefitted from this process on numerous occasions.

    BTW: for relatively minor medical problems, sometimes we’re at a disadvantage: you get told to suck it up and bear with it, unless it really is something that needs formal medical attention. Quit whining.

  18. 18
    Mnemosyne says:

    @Stella B.:

    I have to admit, at first I didn’t like the orthopedic surgeon who was assigned by worker’s comp to replace my ACL because I didn’t like his bedside manner. (Most (in)famous quote while pointing to my MRI: “See that little ball of goo there? That used to be your ACL.”) But he also made a point of calling me at home the evening of the surgery to make sure I was recovering okay and didn’t have any questions for him.

    (I also really like my endodontist and recommend him to anyone who will listen for the same reason — he always calls me the night of a root canal to make sure I’m not in too much pain and don’t have any questions.)

  19. 19
    JaneE says:

    Kaiser has a lot of bariatric patients, all of whom had to be referred outside kaiser facilities for treatment. If I had had surgery it would have been at a hospital 150 miles from home, because that is where the specialists did their thing. After eating the cost, Kaiser decided that the new hospital being built would have a bariatric surgical suite, and they hired their own surgeons, saying that the goal was for Kaiser to become a center of excellence for bariatric surgery. Just keeping the patients in a Kaiser facility instead of going outside, and paying for your spouse to accompany you and bring you home, would have to be a big cost saving.

  20. 20
    Fuzzy says:

    @cmorenc: @cmorenc: Quit whining huh. All you have to do is ask a relative anytime your tummy hurts. Try the real world and after waiting on the phone or in line for awhile and being told to dial 911 twenty times and paying for the advice and script you get for free. Then comment.

  21. 21
    dr. bloor says:

    @Mnemosyne:

    “See that little ball of goo there? That used to be your ACL.”)

    Obviously little comfort to you, but I’d bet he was trying to establish an alliance there with a bit of informal ortho slang. You don’t want to know the various nicknames neuro specialists have for space occupying lesions.

  22. 22
    priscianus jr says:

    “That suggests having some kind of expertise in the procedure can lead to better outcomes.”

    Imagine that.

  23. 23
    cmorenc says:

    @Fuzzy:

    @cmorenc: Quit whining huh. All you have to do is ask a relative anytime your tummy hurts. Try the real world and after waiting on the phone or in line for awhile and being told to dial 911 twenty times and paying for the advice and script you get for free. Then comment.

    You miss the key point here:
    1) If you have a bona fide serious problem, it’s an advantage to be in a family of medical professionals;
    2) If you have some sort of routine, but truly necessary medical issue, it’s an advantage to be in a family of medical professionals.
    3) Otherwise, It’s SHUT UP AND QUIT YER WHINING, WIMP – take a zantac or an ibuprofin, drink some water, and the matter will heal or go away on its own within a few hours or a few days. The advantage is: you don’t have to go to the doctor’s office to be told that; the disadvantage is: the doc isn’t going to feel any need to say that in a polite, diplomatic way like they would for a regular patient. You’ll be told quite directly to STFU and man up, mate.

    BTW: you might be able take a shortcut to getting scripts for some very routine, safe medicals, but the threshhold where a physician is taking an unacceptable risk in prescribing meds for family members is LOTS LOWER than you think, mate. For example, just last week I had to divert the better part of a morning to take my 92yo mother to a routine office visit to her primary care physician for the sole reason that otherwise, they wouldn’t renew the script for the same dose of synthroid which she’s been on for literally 40 years (!)

  24. 24
    Luthe says:

    The only problem I can see with this approach is the increased burden of travel time/cost on the patients if the specialists for their procedure are located in another city/state. Is that factored into these considerations?

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