Tag Archives: patient

5 Questions to Ask About Cyber

Cyber security placed first in a list of emerging casualty risks among insurance buyers, according to a survey of 135 insurance professionals conducted by London-based specialty lines broker RKH Specialty. 70% of respondents put cyber risk in the top spot. According to a Best’s News Service article about the survey, healthcare and retailers have been the major buyers. Logic will tell you that the reason for the growing demand for specialized cyber coverage is the simple fact that losses stemming from cyber-related attacks and business interruption can be catastrophic.

Of course, not all policies are created equal, so here are some things to consider when purchasing cyber security coverage to help ensure that policyholders are adequately protected from the losses after a cyber attack.

#1 If your business has a cyber attack, will your operations cease or be interrupted? If so, you need to make sure the cyber coverage you procure has “business interruption coverage.”

#2 Does your cloud contract stipulate that your third-party cloud vendor must meet all the federal regulatory requirements in encrypting personally identifiable information (PHI) and healthcare records? If not, you need to verify how the third-party vendor is protecting your employees’ and patients’ information from cyber attacks and whether its cyber coverage will protect you.

#3 Do all mobile devices – such as smartphones and tablets – have proper encryption software to protect personally identifiable information and healthcare records? HIPAA security regulations require healthcare providers to use encryption as a means of protection for their patients electronic PHI. If they don’t do so, healthcare providers can be heavily penalized by federal regulators. Most cyber policies have a stipulation that, to be covered, all insureds must adhere to the most recent encryption requirements for electronic protected health information (ePHIs).

#4 Does your legal counsel have experience responding to cyber attacks? Businesses often have their own attorneys and use them frequently for everyday operations. However, the likelihood is that the in-house counsel does not specialize in the legalities of cyber attacks. Having an attorney who specializes in data breaches can make the process run more smoothly and ensure that important details are not missed or mishandled – such as notifying regulatory agencies, properly setting up notification of employees and patients as well as advising PR staff on all media inquiries and other external communications.

#5 Does your business have an expert consultant they can call on to make recommendations on cyber coverage or risk management strategies to reduce the risk of attacks – or to help manage the crisis after an attack? Enlisting the help of a cyber-liability expert and mapping out a plan can help mitigate the potentially catastrophic losses related to a data breach event.

5 Tips to Reduce Outpatient Lawsuits

If a patient or her attorney believes a physician is responsible for a bad outcome at an outpatient medical facility, the facility itself will be sued, not just the physician. Therefore, it is up to the facility to have established procedures and protocols in place to deter the risk of lawsuits. Here are five tips for outpatient medical facilities that may help reduce the risk of lawsuits.

#1. Good patient communication

Communication is the No. 1 issue in any medical setting – outpatient care is no exception. Within outpatient services, patients don’t typically have the same depth of relationship with the doctors as they do with their own primary physician. This often makes them more inclined to pursue legal action in the case of a bad outcome or adverse event. If facility physicians and staff take even a few minutes of extra time to answer all questions and address all concerns, patients and their families will walk away feeling as though they had all the information – even if a bad outcome occurred.

#2. Confirmation of informed consent

The patient is at the outpatient facility because of a medical problem – usually determined by his primary physician – who then referred him to the outpatient facility. It is the facility’s job to confirm that informed consent has occurred between the patient and physician, so policies must be in place to ensure this happens with each and every patient encounter. Patients must be informed of the details of the procedure, the risks and benefits and any alternative treatment options. A procedure should not be performed until informed consent has been confirmed. When patients or their families feel they were provided all available information, they are much less likely to pursue a lawsuit in the case of an adverse outcome.

#3. Proper documentation

Documentation can make or break a case when attorneys become involved. Be sure everything is documented, including all test results as well as the date, time and subject of all conversations with both the referring physician and patient. In the event of an adverse outcome where the court becomes involved, the ability to show all conversations is essential. For example, it can be invaluable to show that the referring physician was spoken to on a specific date and that the patient was given specific recommendations.

#4. Thorough and safe medical records

The outpatient setting leaves many opportunities for accidental breaches simply because so many patients are cycled through the facility on any given day. Printed medical records must be kept safe and strictly out of the public view – and that includes being locked away each night. It’s essential that facilities have protocols in place that diligently track the security of medical records at every step.

#5. Prompt diagnosis

Patients often don’t realize how long it may take for medical tests to return. Some lab tests can take days or weeks. Outpatient medical facilities must have an efficient procedure in place for obtaining results and delivering them to patients and the ordering physician in a timely manner. Let’s say a patient had an MRI because of an unidentified growth in breast tissue. If the MRI indicates suspicion for cancer, how does the facility ensure that test results aren’t getting lost in the shuffle? The cancer could spread and lead to a bad outcome. A system of checks and balances must be in place that helps the ordering physician see the results, and act quickly based on the findings. In an outpatient facility, all staff must be informed as to which test results need to be called in to the referring physician immediately.

Bottom Line – All of these reasons come back to the No. 1 issue: communication. For a busy outpatient facility, it can feel as though there simply isn’t enough time to talk to patients, but, from a risk management perspective, the importance cannot be stressed enough. It’s important to take the time to communicate every step of a patient’s care with her – to listen and answer her questions. Not only does this help to build trust, it can also minimize the risk of a lawsuit. Excellent communication between the provider and patient almost always creates a “win-win” situation.

A New Focus for Health Insurance: ‘Negaclaims’

Historically, the “do more, bill more” fee-for-service model of healthcare measured success by increased billings. In the fee-for-value era, we need a new framework for assessing healthcare results. Quality indicators are logical, but they are mostly geared toward measuring actions taken. We can borrow a concept from the energy sector for an additional metric.  We need a concept for removing waste and unnecessary care that could be inspired by a concept from the energy sector described in this blurb from Wikipedia for something called Negawatts.

Negawatt power  is a theoretical unit of power representing an amount of energy (measured in watts) saved. The energy saved is a direct result of energy conservation or increased energy efficiency. The term was coined by the chief scientist of the Rocky Mountain Institute and environmentalist Amory Lovins in 1989, arguing that utility customers don’t want kilowatt-hours of electricity; they want energy services such as hot showers, cold beer, lit rooms, and spinning shafts, which can come more cheaply if electricity is used more efficiently. Lovins felt an international behavioral change was necessary in order to decrease countries’ dependence on excessive amounts of energy. The concept of a negawatt could influence a behavioral change in consumers by encouraging them to think about the energy that they spend.

The healthcare parallel would be a “Negaclaim™” — i.e., an unnecessary claim avoided. This isn’t about simply denying care. Just as consumers aren’t interested in kilowatt hours, patients aren’t interested in claims — they want health restored and diseases prevented, which can be done more efficiently and effectively. When individuals are fully educated on the trade-offs associated with interventions, they generally choose the less invasive approach. A nice byproduct is that the invasive approaches are frequently more costly and medically unnecessary. The following are a few of many examples of how unnecessary care can be eliminated while improving the patient experience:

  • Day-to-day and chronic disease care: One of the key reasons Direct Primary Care (DPC) has proven itself to be the Triple Aim  leader is that a proper primary care relationship involves time spent with patients to explain trade-offs of various medical options.  Without incentives to push for “more,” DPC providers have demonstrated that they can reduce unnecessary utilization by 40-80%. By contrast, “hamster wheel” primary care has effectively turned primary care into 7-minute, drive-by appointments that leave little time to do anything but direct patients toward additional costly items, whether it’s ordering a prescription, test, hospitalization or specialist visit. In many cases, those could be avoided with a robust primary care relationship.
  • High Cost Procedures: Leah Binder wrote about what major employers such as Walmart, Loews, Pepsico and others are doing to reduce risk to their employees while also saving money, in What We Can Learn From Walmart: How Our Healthcare System Can Save Lives and Dollars. Employees found that 40% of the transplants that were recommended by local hospitals were deemed medically unnecessary by top physicians at the Mayo Clinic and other nationally renowned facilities. Employees were thrilled to avoid risky (and expensive) procedures. It also sent a great message to employees that their employer valued them enough to send them to the best medical centers in the world for second opinions.
  • End of Life: Quality of life is affected dramatically by the end-of-life decisions we make. This was outlined in How Not to Die. The system is oriented to do more even if it is at odds with quality of life. Doctors themselves recognize this when they are the patient, as described in Why Doctors Die Differently. While quality of life is the driving factor for patients and families, there is a second-order benefit that the procedures that reduce quality of life are typically very expensive.

The problem in healthcare has been that providers have incentives to do stuff because of the flawed reimbursement models that dominate our present healthcare system. Respected studies such as from the Institute of Medicine demonstrate that there is more than $750 billion in waste. PwC stated that more than half of healthcare spending is waste. Incentives have driven providers to encourage more interventions, and consumers have been led to believe that more is better even though, in many cases, less is more.

That has added a challenge for health insurers. The general perception is that health insurers reflexively deny claims (sometimes getting in trouble for that). This has resulted in health insurers having the lowest Net Promoter Score of any industry. Consumers have clearly decided that health insurers aren’t doing this for consumer benefit. Fair or not, they have concluded it’s simply for the financial health of the insurer. Clearly, health insurers need a different approach if they want to improve their image and the health of their customers while ensuring their financial viability.

One incentive that has changed revolves around the Medical Loss Ratio (see Aetna’s explanation here).  In contrast to “customer service” reps focused on claims, an investment in patient engagement can have the same or greater effect on reducing claims while qualifying as a healthcare expense. Enter patient engagement.

Patient Engagement Is the Blockbuster Drug of the Century
Leonard Kish made the case that if patient engagement was a drug, it would eclipse all blockbuster drugs before it. Kish cited results of studies showing benefit when patients were successfully engaged in their health.

Compared to those not enrolled in the study, coordinated care “patients have an 88 percent reduced risk of dying of a cardiac-related cause when enrolled within 90 days of a heart attack, compared to those not in the program.” And, clinical care teams reduced overall mortality by 76 percent and cardiac mortality by 73 percent.

Rather than reflexively denying claims and building up a mountain of ill will, insurance companies should invest resources in helping their customers get engaged in their health. Their customers would, in effect, “self-deny” their own claims.

Note that when I describe patient engagement, I’m including family members and caregivers. Did you know that families provide care valued at more than $450 billion per year  – more than our total spending on Medicare! Thus, much of what is outlined below speaks to caregivers (particularly with elderly patients), not just the patient. Having more resources/tools as a caregiver would be welcomed, as most of us have no clinical background and are thrown into a caregiving role virtually overnight.

[Disclosure: My patient relationship management company is one of the organizations providing patient engagement tools to healthcare providers, which is why I'm familiar with these examples.]

Just about every myth has been debunked about how patients of all types supposedly won’t get engaged in their health, whether it’s low-income diabetes patients, native American populations or the elderly. However, providers are largely failing in their efforts at engaging patients as they haven’t had the incentives, tools or training.  Provider-patient communications guru Stephen Wilkins points this out clearly in a few pieces.

Despite less than stellar results that Wilkins highlights, the initial attempts by providers at engaging patients are welcomed just as a muddy puddle of water in the Sahara Desert is welcomed. However, much more can be done.

Catalyzing Patient Engagement in Health Plans’ Best Interests
A wave of new requirements and challenges have crashed on top of providers. Insurers could help if they focus in the right areas and are mindful of the challenges. JAMA recently wrote a piece highlighting one facet of patient engagement — shared decision-making (SDM). Physicians aren’t going to magically take on this challenge without a change.

The brevity of visits constrains the opportunities to address these elements of SDM. Furthermore, clinicians are not adequately trained to facilitate SDM, especially eliciting patient values and preferences for treatment.

[Note: Resources to train clinicians on patient engagement are emerging. One would expect that a host of continuing education courses will emerge. One example is HIMSS (the professional association for healthIT), which released a seminal book on patient engagement.]

In the places where providers have successfully achieved the Triple Aim objectives with challenging patient populations, they have had payment aligned with outcomes. Teams were unleashed, led by doctors, to get creative about how to tackle the challenges. While doctors are vital, they use non-physicians for a substantial part of the interaction with patients. It turns out, for example, that doctors and even nurses can be less effective at effecting behavioral change in patients than non-typical care team members. Rather than being relegated to low-level tasks, medical assistants and health coaches play a vital role in the successful models. Once again, while the goal is an improved health outcome, there is a second-order benefit that being more effective lowers costs by avoiding complications, and the medical assistants and health coaches are generally paid less than doctors and nurses. Unfortunately, in a typical fee-for-service reimbursement model, these types of services typically aren’t compensated despite their impressive results.

Dr. Rob Lamberts described this problem in detail in Washington, We Have a Problem. He summarizes the conflict between people’s desires and healthcare’s flawed reimbursement framework.

This is why, I believe, any system that profits more from people with “problems” than those without is destined to collapse. Our system is opposed to the goal of every person I see: to stay healthy and stay on as few drugs, have as few procedures, and avoid as many doctors (and drug companies) as possible.

Health insurers have implicitly viewed their customers as adversaries by creating a claim-denying framework as the default. The smart health plans will figure out how to harness the consumer goals. This isn’t some fanciful dream as it has been demonstrated (profitably, I might add) by the physician-entrepreneur organizations outlined in The Hot Spotters Sequel: Population Health Heroes.

This isn’t about minor tweaks to a fundamentally flawed model. Rather, as one physician-entrepreneur put it, too many models are “putting wings on cars and calling them airplanes.” Rather, it’s supporting proven models where they have rethought care delivery – here’s how one physician-entrepreneur describes rethinking care delivery from the ground up (video).

While financial rewards are important, most physicians are not motivated primarily by money but by autonomy, mastery and purpose. In the successful models, the physician-entrepreneurs created their own autonomy and recognized that the focus of their mastery and purpose had to fundamentally shift. A nice byproduct was the growth of “Negaclaims” as the educated and empowered patients better understood the significant risks of overtreatment and errors.

Too frequently, health plans have tried to micromanage clinical processes. With proper financial incentives combined with a move toward enabling clinical teams to become masters at driving patient engagement, the health plan is much more likely to achieve the desired outcomes. As the Stephen Wilkins pieces referenced above illustrate, clinicians haven’t been trained or rewarded directly or indirectly for encouraging patient engagement. It should be no surprise that most haven’t achieved mastery in helping their patients achieve patient engagement. Instead, the language of medicine has been punitive and demeaning, talking about “non-compliant” patients as though they were petulant criminals. That doesn’t further the partnership between patients and their care teams, which is necessary for optimal outcomes.

Previously, I outlined the strong business case for patient engagement. Those who have understood that business case have moved on to practice the 7 habits of highly patient-centric providers. It’s clear that past efforts by health plans to reduce claims have fallen short and created ill will and sub-optimal health outcomes. Putting the patient/member at the center need not be a marketing gimmick. Rather, it’s central to the notion of “Negaclaims” and to a winning strategy in the fee-for-value era.

It's Not Cost, Stupid – It's Care Transparency!

In my article last month — Care Transparency: What Employers Are Missing! — I wrote about how employers are missing an understanding of how employees are making health care decisions, and how that crucial factor impacts health care costs.

Employers need to meet employees where they are — online. Employers need to provide them with tools that can help their research and decision-making process with robust, accurate, unbiased and evidence-based information. Employers can significantly improve the quality of care consumed by their employees and reduce health care costs by focusing on creating care transparency.

In this article, we have explained the types of tools that will be effective in supporting employee decisions and that employees will really use in making care and treatment decisions. WiserTogether's research of patient decisions across the top 200 health conditions shows that of the 22 unique factors that patients typically use in evaluating treatments, quality of care tops the list. Cost does not even make the top five. In other words, cost is not the primary decision driver for patients, and consumers do not seek out cost tools when they begin making decisions. This explains the low utilization that organizations see when they offer cost transparency tools as a stand-alone service.

Health Affairs1 recently published an article that found that patients object both to discussing health care costs with clinicians and to considering costs in deciding among comparable clinical options. It is also well-known that despite the payer's best efforts, patients do not factor in payer and employer cost burdens when making health and care decisions, despite the fact that payers cover a majority of the costs. Economists have a term for this phenomenon that patients exhibit, called the “Tragedy of the Commons.” This concept means individual decision making is driven by personal benefit and ignores the implications of those decisions on third parties and the common good.2

Studies show that patients faced with a treatment decision can only process a limited number of factors. In its 2012 research that showed quality of care is the most important factor patients consider when making health care decisions, WiserTogether found that only seven of the 22 factors carry enough weight to qualify as first-tier factors for patients. Those seven factors are explained below.

Importantly, patients also indicated differences in how open they were to information about a factor coming as an expert opinion versus information coming in the form of experiences of other patients.

WiserTogether found that for the following four factors, patients want accurate information about the experiences of other patients. For each treatment, patients wanted to know the following:

  • Treatment Effectiveness — How effective did other patients say the treatment was for them?
  • Treatment Popularity — What percentage of patients in a situation like mine use the treatment?
  • Treatment Speed — How fast did other patients start to see a difference, and how long was the recovery?
  • Treatment Side Effects — What side effects have other patients experienced, and how severe were they?

For the remaining three factors, patients wanted expert opinion:

  • Scientific Evidence — Which treatments are best supported by medical evidence?
  • Consequences of Delay — What might happen if I wait to have the treatment or decide not to have it?
  • Treatment Duration — How long will the treatment last?

The results seen were independent of whether the information was available. Patients ranked out-of-pocket costs as a second-tier factor they are willing to consider when making a health care decision. Patients also report that finding information about any of the seven top-tier factors is extremely hard, and the current tools/support systems provided are inadequate.

Research has shown that patients seek out such information prior to making a health care decision, and the information gathered influences their commitment to follow through on a treatment.

Employees repeatedly state that they are overwhelmed with health information and need help finding content that is relevant to their situation. Tools that help them understand their options, evaluate those options based on personal preferences and constraints, and succinctly communicate their questions and concerns to their providers can supply the missing link. Treatment selection and shared decision support tools — whether used by the patients directly or in consultation with a provider — help support patient decisions and effective interactions with providers.

Effective and engaging tools need to offer the following:

  • Personalized treatment selection based on the patient's demographics, co-morbidities, personal preferences, and financial constraints.
  • Need to provide (at least) the seven top-tier decision-making factors to assist employees' evaluation of options along with cost and plan coverage.
  • Be easily accessible online anywhere, including at point of care set-ups.

Employees are adopting these tools at very high rates, as these tools are aligned with the natural behavioral process people follow in making health care decisions. Such tools are helping employees become informed health care consumers who understand choices and are able to make wiser choices based on their values. These tools also are helping to reduce the knowledge gap between the providers and patients and to create more confident health care consumers who can start engaging with providers in making shared and effective health care decisions.

Having said that, WiserTogether's Patient-Centered Care Index (PCCI) shows that the provider community is a long way from treating patients as an equal partner. In my next article, I will write about specific areas where providers are underperforming in delivering patient-centered care and how they often treat themselves differently than they treat their patients.

Authors
This article is co-authored with Gregg Rosenberg, Ph.D., Chief Product Officer at WiserTogether, Inc. and author of A Place for Consciousness (Oxford University Press).

1 “Focus Groups Highlight That Many Patients Object To Clinicians' Focusing On Costs,” Sommers, Goold, McGlynn et al.; Health Affairs, 32, no.2 (2013): Pgs 338-346.

2 “The Tragedy of the Commons Revisited,” Rafid Fadul; New England Journal of Medicine, no. 10 (2009): Pg 361.