baystate medical center

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Better Doctor-Shopping Is On The Way — But Will You Use It?

The federal government has just announced that it will let more light shine on a great trove of Medicare data — medical claims records from its 47 million patients. And in particular, it will let employers, consumer groups and insurance companies mine those mountains of claims to help them rate the performance of individual doctors.

So does this mean that something on the scale of TripAdvisor.com — or Rotten Tomatoes! — is coming to American medicine? Not any time soon.

What does it mean? I asked Dr. Tara Lagu, a research scientist at Baystate Medical Center and an assistant professor at Tufts University School of Medicine, who studies the effects of making health quality data public.

Dr. Tara Lagu


Her bottom line: Probably within a couple of years, patients will be able to determine a given doctor’s volume — how many cases like theirs the doctor treats every year — and possibly quite a bit about how well those cases have gone. But quality ratings themselves are likely to remain contentious, and the big question is whether patients will be able to take advantage of the newly available data.

Our conversation, lightly edited: 

My main take on this new Medicare announcement has to do with how patients will digest the data. The great potential of this could be lost if it’s not presented to patients in the right way. We really could be missing an opportunity to help patients participate in the quality improvement process.

What exactly is the data that will be released?

Every time a Medicare patient receives health care, the place where they got that service files a claim with Medicare, and Medicare puts it into a big database. So it’s a set of billing records. It doesn’t have things like lab results; it doesn’t have a lot of clinical data. So the first thing patients should know is that their clinical data is not going to be available. All this is, is documentation of interaction with the health care system. Medicare aggregates it on a very big scale: How many patients in Boston saw Dr. X or went to hospital Y?

‘Only 6% of patients are aware that the data exist.’

Medicare also collects quality data, mostly through chart review. For example, how many patients who had a heart attack got a beta blocker? Most of that information is available at the hospital level and presented on the Hospital Compare Website. So part of the data is actually not a new thing — that’s been available for some time. But only 6% of patients are aware that it exists, and probably even fewer are able to see the information and comprehend it. Continue reading

Breaking: Medical Dispatch From Springfield Tornado

Tornado damage in Springfield

Baystate Medical Center in Springfield treated 25 tornado victims last night — people struck by flying objects, caught in collapsing buildings, picked up and thrown. Dr. Reginald Alouidor, a trauma surgeon, just spoke to reporters about the hospital’s experience:

It began as a rumor, around 5 p.m: a tornado had hit downtown Springfield, and one or more buildings had collapsed. Emergency plans went into effect: trauma bays readied, beds prepared. Because it was 5-ish, there were both outgoing and incoming shifts — an advantage when gathering staff. The Baystate emergency department is one of the busiest in the country at the best of times; “last night it was quite full,” Dr. Alouidor said.

The tornado patients began to arrive, with blunt-trauma injuries, shock, brain trauma, broken limbs, fractured spines, contusions and abdominal bleeding. Two needed surgery. One needed the Intensive Care Unit.

In all, of 25 total, seven needed to stay overnight. Five who were medically able to leave could not go home because their homes had been destroyed; they were referred to the Red Cross for help.

“Our trauma bays quickly filled up, and just as fast as the patients came in, we processed them,” Dr. Alouidor said.

The worst-injured remains in the ICU with a major liver laceration; she was in a building that collapsed.

This was Dr. Alouidor’s first mass casualty at Baystate, he said, but he is a Haitian citizen and helped out in Haiti after last year’s earthquake. He arrived a week after the earthquake, however, so it was a different sort of disaster situation. “The degree of emergency was much different than last night,” he said.

Today, patients continue to trickle in with minor injuries, he said. Among the sickest patients, none are in life-threatening situations, and of the seven still hospitalized, probably only three will require rehabilitation.

Q&A: How Can My Hospital Cost More But Help Me Less? Four Answers

Dr. Tara Lagu

Money can’t buy you love — and it can’t necessarily buy you better health care, either. On Monday, we posted about a new report — With Sepsis, Higher Cost May Not Mean Living Longer. Still feeling baffled, I spoke today with the paper’s lead author. Dr. Tara Lagu is a research scientist at the Center for Quality of Care Research at Baystate Medical Center, and an assistant professor of medicine at Tufts. I’ve lightly distilled her answers.

Q: This is going to be one of those “Talk to me like I’m stupid” interviews. How can this be, that higher cost doesn’t mean better results? I can’t help but think about paying for health care as being something like buying a car. In rough terms, if you pay $200,000 for a Ferrari you get a better car than if you pay $10,000 for a cheapo sedan. How is it different?

A: I think it’s a great question. It turns out hospital spending is much more complex than it would appear. There’s a difference between costs and charges. Charges are the numbers on a patient’s bill; cost is what it costs the hospital to provide those services. So because we have access to all these hospitals’ accounting systems we actually had what it cost the hospitals to provide the care. That is unique.

It turns out hospital costs are not just what you do to a patient. What you do to a patient is the smallest percentage of hospital costs. One study found that fixed costs represent up to 70 or 80 percent of hospitalization: the cost of the building, heating, the physical structure of the hospital, and the cost of labor, the wages. You can imagine those fixed costs vary by a few things, including the region of the country you’re in. The cost of labor is much higher in New York than in Arkansas. It also depends on whether you just built a new hospital building — that’s an expensive endeavor and gets factored into the costs of care.

Then you have variable costs that include the cost of providing the care: things like doing the MRI, giving the necessary antibiotics and putting a patient on a ventilator. Bundled up in there is how much it costs hospitals to acquire the services or products they’re giving; for example, belonging to a purchasing group can bring prices down.

So hospital costs are extremely complex, but all that said, you also have the fact that some hospitals will then take a different approach to the way they treat patients with sepsis. This is what we were really trying to get at. Some aggressively pursue the source of infection. Other hospitals may do the basic bundle of treatment and then watch and wait to see what the cultures grow and how the patient presents. Some hospitals may provide high quality care and get patients more quickly in and out; other hospitals may provide lower quality care and the patients may have complications.

This is how you get into the question of how it can be that higher cost doesn’t equal better care. There are these possibilities:

1 – There’s some artifact in the spending that we can’t account for, one of the fixed costs or variable costs.
2 – Some hospitals are very aggressive about how many tests they do in attempting to diagnose the source of the problem. There’s no evidence to show that doing more tests is necessary, but it’s a style issue. You can’t say it’s not the right thing to do but you can’t say it is the right thing to do. We need more research on the right approach.
3 – Some hospitals provide lower quality care and their patients get more complications and their care thus gets more expensive. .
4 – Some hospitals may be more aggressive about pursuing end-of-life options than others; they may identify patients with poor prognoses and be aggressive about talking to them and their families about not being aggressive with care.

Those are four possible mechanisms that could lead to higher costs without showing better outcomes.

Q: So what do I do as a patient, if my stereotype of higher costs meaning better care is so wrong? Continue reading

With Sepsis, Higher Cost May Not Mean Living Longer

Just out online in the Archives of Internal Medicine: Yet more evidence that when it comes to hospital care, paying more may not mean getting more — or living longer.

Researchers based mainly at the Center for Quality of Care Research at Baystate Medical Center in Springfield and at Tufts University performed a sweeping, complex survey of records on nearly 167,000 patients with sepsis at more than 300 hospitals nationwide over two years. Sepsis is a dangerous immune response to infection that affects 750,000 Americans a year, with a death rate of nearly one-fifth. It costs the economy an estimated $17 billion a year, the authors note, putting it right up there with heart disease.

The researchers found that hospital cost varied quite a bit, as did mortality rates, but not in tandem. Their conclusion: “Higher hospital expenditures are not associated with better survival. Efforts to enhance the value of sepsis care could be modeled on hospitals that achieve lower-than-expected mortality and costs.”

Sepsis is interesting in part, the authors write, because it may serve as a test for hospital efficiency. It involves multiple organ systems and thus requires complex coordination of care; so “one of the potential drivers of the costs of care may be the quality of care coordination and the overall efficiency of the hospital environment.”

The findings jibe well, they write, with a 2009 study that found a similar lack of correlation between cost and longer life when it looked at Medicare cases of heart attack, congestive heart failure and pneumonia.

From the Archives of Internal Medicine press release:

Tara Lagu, M.D., M.P.H., of the Baystate Medical Center, Springfield, Mass., and Tufts University School of Medicine, Boston, and colleagues conducted a cross-sectional study of hospitals to determine whether higher levels of hospital spending were associated with better survival rates for patients with sepsis. Using the Perspective database, data were collected on 309 hospitals that cared for at least 100 patients with sepsis between June 1, 2004 and June 30, 2006. Continue reading