Self-dealing between a health system and its insurance company

Just when you think you've seen the limits of market power, creativity emerges.  Julie Donnelly at the Boston Business Journal reports:

Partners HealthCare aims to drive new members to its newly acquired health insurer, Neighborhood Health Plan, by cutting off access to some doctors within new health plans offered under ObamaCare.

Neighborhood Health Plan is one of 10 insurers that has been certified to offer subsidized and un-subsidized ObamaCare plans through the state’s Health Connector.

But what Neighborhood Health Plan has is exclusive access to primary-care doctors at Brigham and Women’s Hospital and Massachusetts General Hospital.

Now that Partners, the parent organization of the Brigham and Mass General, owns a piece of the insurance pie, they have decided to offer access to their primary care doctors only to those members who choose Neighborhood Health Plan.

This is likely to drive new business to Neighborhood Health Plan from Boston-area patients who want to keep or begin a relationship with a primary-care doctor at one of the two most prestigious hospitals in the state.
 
This is a departure from Partners’ strategy in the past. Before its purchase of Neighborhood Health Plan, Partners’ offered access to its doctors to all of the health plans within the state-subsidized health plans that were launched under Massachusetts' own statewide health reform.

Dear GBIO, No need for your meeting

Sometimes, the concatenation of news stories on the same day is too compelling to pass by.

On Wednesday, the Boston Globe reported:

The next big movement in Massachusetts health care may come not from the state’s world-famous hospitals or its cutting-edge research labs, but from houses of worship. Stepping up pressure on the health care industry to control spiraling costs, which are crimping family and government budgets, the Greater Boston Interfaith Organization will host a forum next Tuesday at Temple Israel in Boston’s Longwood Medical Area to grill hospital and insurance leaders about the affordability of medical care.

On the same day, with no hint of irony, the same newspaper reported:

Public health officials on Wednesday approved Brigham and Women’s Hospital’s proposed $450 million research and outpatient center, deciding that the project will allow the hospital to better care for patients.

(See more about this in a post I published in December 2011.)

Meanwhile, over at the Boston Business Journal, we read:

Boston Children’s Hospital . . .  said net patient revenue totaled $236.9 million in the three months that ended June 30, a 5 percent year-over-year increase driven by greater demand for outpatient services as well as several initiatives to boost revenue through “enhancement initiatives.”

The Patriot Ledger brings this to the personal level by explaining how individuals can be hurt by the current Medicare rules, which allow hospitals very little discretion about defining admission versus observation status:

Ann Gillis of Milton, who is 83, is fighting the denial her appeal of a $7,000 bill she faced for follow-up rehab services after being hospitalized at Beth Israel Deaconess-Milton last winter. The problem: she was placed on observation status rather than admitted to the hospital, even though she was in the hospital four days. Not being admitted meant Medicare wouldn't cover her rehab at follow-up skilled nursing care in Westwood.

And when research might help produce savings, WBUR tells us:

The Framingham Heart Study is considered one of the most important research projects in medical history. Over the last 65 years, data from the study has been used to develop and test technologies and treatments that have saved millions of lives and hundreds of billions of dollars in health care costs. But now, the mandated across-the-board budget cuts, known as the sequester, are dramatically reducing federal funding for the research.

So, GBIO, what is it you hope to learn at your meeting that isn't being splayed out in the daily media?

Coach gets failing grade in concussion training

Our state youth soccer association now requires all coaches to take an on-line training session (like this one from the CDC) about concussions.  This is a good thing because concussions of boys and girls can be serious, especially if the child is prematurely permitted to play and experiences a second one.  Here's the policy:

The Massachusetts Youth Soccer policy on concussions is intended to be clear and unambiguous so as to accurately reflect the seriousness of concussion-related injuries and our unwavering commitment to keeping our children safe.

A player removed from participation as a result of a head injury or symptoms similar to those of a concussion shall not be permitted to return to play to any extent until they have provided their team coach with a written unconditional “Medical Clearance to Return to Play” from a licensed Medical Doctor.

It is our expectation that this policy will clarify protective measures for all involved in youth soccer in Massachusetts and simplify communication between coaches and parents when concussion related issues arise. 

The training and policy are supposed to make it easy for a coach.  If the child is disoriented or dizzy following a head injury, or experiences several other symptoms (see below), we pull them off the field for the duration of the game.  Referees are likewise instructed to enforce this policy.

Today, when refereeing an under-14 boys game, after a collision in front of the goal, the goalkeeper started to walk off the field complaining of a head injury and dizziness.  Imagine my surprise when the coach came out onto the field and started to try to convince the boy that it was "not a very hard hit."  I intervened and said that he would have to leave the field.

The replacement goalie was excellent and made some terrific saves.  Nonetheless, the coach tried to replace him 15 or 20 minutes later.  I was some distance away and didn't recognize it as the same boy who had been injured, but my assistant referee, a high school boy, did.  He came running out to inform me and to make the point that the boy was not permitted back on the field absent medical approval.  Of course, we sent him back to the sidelines.  Who knows what kind of persuasion the coach had used on the sidelines to encourage the boy to re-enter the field?

After the game, in front of the other AR, I praised my AR for his good judgment.  He said, "I've had a concussion, and I don't want anyone to go through what I did."

Indeed.  It's time for the coach to retake the course.

Having their cake and eating it: Perverse incentives

A friend made an excellent point the other day, upon reading my post about Consumers Union's advocacy for warranties on orthopaedic devices.

"The thing about CU and the warranty struck me hard as a revelation. We in the health care field are brainwashed into thinking these normal business practices shouldn't apply to medicine, while embracing the idea that the money-making business ideas (like ROI) should apply. But basically it adds up to doctors, administrators, and equipment suppliers having their cake and eating it, too: Getting to apply the positives from business, while avoiding the negatives which apply in all other industries, like guarantees of your work."

The big costly examples are obvious:  An alliance among the three groups (doctors, administrators, and equipment suppliers) to install a surgical robot or a proton beam machine to gain market share, but take no responsibility for determining clinical efficacy or adverse impacts or overall inflation of medical costs.

But as my friend points out, the small, ongoing ones are equally obvious.  Orthopaedic devices that regularly fail after installation in human bodies, with no recourse to the suppliers, and no adverse consequences for the hospitals or doctors that have used them without insisting on warranties.  Ditto for minimally invasive surgical equipment, which is notorious for failing after normal cleaning and sterilization processes.

You would think that the payers--Medicare, Medicaid, and private insurers--would step in, but they are complicit or oblivious.  You would think that the group purchasing organizations would step in, but they, too, are complicit or oblivious.  Maybe they are motivated by the implicit or explicit kick-backs they get by favoring certain suppliers.

On the road with WIHI

The next WIHI broadcast — On the (Virtual) Road with Mobile Clinics and Population Health — will take place on Thursday, September 12, from 2 to 3 PM ET.

Our guests will include:

• Nancy Oriol, MD, Dean of Students, Harvard Medical School; Co-Principal Investigator, Mobile Health Map; Co-Founder, Family Van, Boston, MA
• Leonel Lacayo, MD, Gastroenterologist, Glenwood Hospital; Co-Founder, Health Hut, Ruston, LA
• Anthony Vavasis, MD, Director of Medicine, Callen-Lorde Community Health Center, New York City, NY; Co-Principal Investigator, Mobile Health Map
• Jennifer Bennet, BA, Executive Director, Family Van and Mobile Health Map
• Niñon Lewis, MS, Director, Triple Aim Initiatives, Institute for Healthcare Improvement, Cambridge, MA

What’s the first thing that comes to mind when you spot a mobile health clinic? Good people, probably volunteering their time, traveling to underserved neighborhoods to offer screenings, health education, and some helpful, friendly guidance on where to go for anything more serious or chronic that should be checked out? If this is your impression, it’s fairly accurate. Except for one thing. Nowadays, more and more mobile health vans are an integral part of the health care system… especially in cities and communities where traditional bricks-and-mortar health care services are linking up with innovative community outreach programs that, together, can better manage population health. 

With that as a backdrop, we’re going to hit the (virtual) road on the September 12 WIHI with some of the leading innovators and researchers who are injecting new fuel and purpose into more than 2,000 mobile health clinics across the US. They’re doing this by mapping what’s taking place at a range of health clinics mounted on wheels, and also by carefully investigating health issues that can be impacted and maybe even better addressed by a mobile health van.

If we’re serious about improving population health, it’s critical to look hard at what’s already “out there” that’s working or helping, and then determine how to strengthen its role. Mobile health clinics are increasingly one such trusted and effective resource in many communities. WIHI host Madge Kaplan and IHI’s Niñon Lewis invite you to find out the latest on mobile clinics from an expert panel of clinicians and researchers on the forefront of the issue.

You can enroll for the broadcast here.

The winner's curse

As we look across the US and see large academic medical centers acquire community hospitals, we have to wonder whether they will someday regret their deals as they experience what's called "the winner's curse."  Here's the definition from Wikipedia:

The winner's curse is a phenomenon that may occur in common value auctions with incomplete information. In short, the winner's curse says that in such an auction, the winner will tend to overpay. The winner may overpay or be "cursed" in one of two ways: 1) the winning bid exceeds the value of the auctioned asset such that the winner is worse off in absolute terms; or 2) the value of the asset is less than the bidder anticipated, so the bidder may still have a net gain but will be worse off than anticipated.

How does this relate to the health care world? Well, let's say you are a community hospital in a locality that is strategically important for two or more competing academic medical centers who are doing their best to assemble properties to create Accountable Care Organizations. (Recall that the ACOs want scale to create a larger risk pool to deal with the introduction of risk-based payment regimes from insurers and government payers.  They also want to own medical facilities to treat patients across the spectrum of care. Finally, of course, they want a bigger guaranteed referral base to feed the beast, the academic medical center itself.)

If you are the normal community hospital, your earnings for many years have been substandard, and you have slowly been decapitalizing your plant and facilities.  You just can't earn enough of a margin to cover depreciation based on original cost, much less renew and replace capital equipment at its current price.  You also have trouble recruiting and retaining the best doctors to serve your patients because you cannot offer salaries that compete with those paid in the big city, just a few miles away.. You are, in short, looking for a sugar daddy to acquire you and be a source of capital and also cover your risk in those new risk-based contracts.

You let it be know that you are up for adoption, and the bidding war begins among the region's academic medical centers.  Since these are all non-profit organizations, there is not a "price" that gets paid from one party to another, but there are commitments that must be made to win the auction.  The mother ship must promise to invest a certain number of dollars in renewal and replacement of buildings and equipment; it becomes the guarantor of your outstanding debt and takes on the obligations of your retirement system; it promises to help with recruitment and retention of local primary care and specialty doctors; and it must permit you to have representation on the governing board of the ACO.  Your community hospital board of trustees sits in the catbird seat as the big players around town come a-courting.  The big hospitals may even bid against themselves to make a stronger case, fearful that the other guys are doing the same.

The acquisition is made. A lot of time and effort is devoted to clinical integration, business systems integration, and governance integration.  So much so that the administration of the academic medical center neglects the kind of process improvements that are necessary to increase quality, safety, and efficiency in the mother ship.

After a while the folks in the city come to realize that their acquisition is not a profit center.  It is a cost center.  Since this takes a few years, by then the CEO who negotiated the deal is off to another job, but the board of trustees remains, wondering how their new CEO is going to solve the problem of a steadily growing erosion of earnings.

Warranties for hip and knee implants?

A press release notes:

Consumers Union, the policy arm of Consumer Reports, is calling on the top manufacturers of hip and knee implants to provide warranties that would entitle patients to have defective devices replaced at no cost.

Consumers Union is pushing device makers to equip patients with warranties so they will have a better understanding of how long an implant is expected to last and a clear process to follow in the event that it fails prematurely.  Ultimately, warranties will encourage companies to make their devices safer and more durable, according to Consumers Union.

“Patients have a right to know how long medical device manufacturers are willing to stand by their products,” said Lisa McGiffert, director of Consumers Union’s Safe Patient Project (www.safepatientproject.org).  “While patients may be told by their surgeon how long a device can be expected to last, they rarely get a guarantee in writing since most hip and knee implants do not come with a warranty.”

A Consumers Union review of hip and knee implant recalls found that all major manufacturers have recalled a product or line of products for defects over the past decade.   These recalls underscore how devices can fail prematurely and harm patients.

In letters sent to Biomet, Inc., DePuy Synthes, Smith & Nephew, Stryker Corporation, Wright Medical Technology, Inc, and Zimmer Holdings Inc., earlier this summer, Consumers Union urged the companies to provide a 20 year warranty and outlined the terms of a model warranty. 

What a great idea.  Thus far, I have heard of  no overwhelming response from manufacturers.

What if we "helped" them along.  What if the American Academy of Orthopaedic Surgeons adopted a policy statement saying that its members would not insert any such implants unless the manufacturer provided such warranties?  What if the major orthopaedic hospitals announced that they would not purchase or insert any such implants unless the manufacturer provided such warranties?  What if CMS announced that it would not pay for any such implants for Medicare patients unless the manufacturer provided such warranties?

You judge. What's the right call?

Here's a video of a soccer game in which a Brazilian physiotherapist steps on the field and saves a goal from being scored--and then hightails it for a quick escape.

A question for you aficionados:  What's the correct call for the referee? Who gets the red card?

Answer from my colleague John: "The referee on the pitch got it right. Not much can be done when an outside agent interferes."

In our games, though, the outside agent is usually a dog running across the field.

Oh good. More expensive AND no benefit.

A story from Robert Langreth at Bloomburg, based on a scientific study. Excerpts:

Surgery to remove the uterus using a $1.5 million robot from Intuitive Surgical Inc. (ISRG) doesn’t reduce complications and may raise pneumonia risk compared with conventional less-invasive techniques, according to a second extensive study to find no added benefit from the devices. 

Researchers examined data from about 16,000 women who had hysterectomies for benign conditions in 2009 and 2010. The robot operations cost hospitals $2,489 more per procedure with a similar complication rate as the standard practice of removing the uterus with minimally invasive equipment, according to the study released in the journal Obstetrics & Gynecology. 

The results released yesterday are from the second large-scale research published this year to find higher costs with no added benefit for robotic hysterectomy.

In February, a study in the Journal of the American Medical Association found that robotic hysterectomies for benign conditions cost hospitals $2,189 more per procedure than the same surgery without the robot. That research, which looked at data from 441 hospitals from 2007 to 2010, showed complication rates were 5.5 percent for the robot surgery and 5.3 percent for a less invasive hysterectomy. 

The response from Intuitive.  Regular readers will recognize it as a variant on, "Our patients are sicker."

Intuitive Surgical, in an e-mail, said patients in the study getting robotic surgery tended to be older, heavier and had a higher rate of chronic conditions. 

Unimaginable: Lose their kidney and then seek to recover court costs

Doug Wojcieszak over at Sorry Works! retells the sad story of a hospital, University of Toledo Medical Center, that mistakenly disposed of a kidney being donated from one sibling to another.  He draws excellent conclusions about the nature of disclosure and apology.  The article is worth reading for Doug's insights alone.

But the article also contains an amazing tidbit.  Here goes:

According to the [Toledo] Blade article and a story by Good Morning America, the hospital was initially very open with the family and accommodating, including the assistance finding another kidney.  But, things broke down when the Ohio Attorney General's Office, which is representing this university hospital, thought the family's additional requests for assistance were unreasonable.  Now the AG's office is trying to dismiss a suit by the family by claiming the hospital was not negligent and seeking to recover costs.

The Blade article actually says something a bit different about the medical negligence portion of the case:

The medical center on Tuesday filed an answer to the Fudacz family lawsuit, in which it acknowledged the organ was discarded but denies some of the Fudacz claims. The document ends with a request to dismiss the Fudacz complaint in its entirety at the plaintiffs' cost. UTMC also on Tuesday filed a motion to dismiss the Fudacz complaint – specially two parts of the lawsuit that claim: “parental loss of consortium” and “sibling loss of consortium.” The motion to dismiss did not ask the court to dismiss the first count of the lawsuit, which claims medical negligence.

The UTMC motion to dismiss states the Fudacz family has “no right to compensation for parental loss of consortium of an adult." The medical center also said, “there is no right to compensation for sibling loss of consortium in a nondeath case.”

AG Mike DeWine

I'm not qualified to comment on the legal niceties of what kind of complaints are justified in this kind of case, but would you really want to be an elected Attorney General who seeks to recover court costs from a family that has gone through this kind of ordeal?  What possible negotiating advantage could be achieved in that regard, especially if you desire--as you clearly should--to settle the negligence portion of the case?

How not to conduct a rulemaking

A well done article in Modern Healthcare raises more questions about CMS' analysis and motivations than it answers with regard to the agency's proposal to change facility fees for outpatient services. 

Quick summary:

CMS has proposed tighter controls over facility fees as part of a plan to redirect billions of dollars Medicare spends annually on outpatient care. Its proposal, though preliminary, is already drawing fire.

I make no judgment about the appropriateness of the rule change, but I have to raise questions about the manner in which the proposal was made.  Specifically, there seems to be an aversion to transparency on the part of the agency as to the reasons for the change and the likely impacts.  Here are more excerpts from the article:

The CMS didn't estimate the financial impact of the coding change and declined a written request for any data indicating upcoding by hospitals. The agency also declined to provide any comment on the rationale for the draft rule.

In proposing the facility fees change, the CMS appears to be searching for a simple way to prevent hospitals from picking service codes at a higher level than they really deserve, an illegal practice known as upcoding. Hospitals deny they engage in upcoding.

Hospitals argue that they shouldn't be taken to task for any confusion over how to bill these charges properly. During the past decade, the industry repeatedly urged the CMS to set standards for billing emergency department facility fees. But in 2007, CMS officials wrote that the effort “was proving more challenging than we initially thought.” The proposed new rule states that national guidelines are “not feasible,” hence the decision to give up on them and adopt a flat-rate payment.

Jugna Shah, a hospital outpatient billing expert who is president of Washington-based Nimitt Consulting, said CMS officials in recent years haven't given any hint that they believe some hospitals game Medicare. “It caught me off guard,” she said of the proposed rule. The CMS could be searching for a “quick fix” to the controversy over alleged upcoding, she added.

Along the same lines, the American College of Emergency Physicians advised its members that the CMS “might be reacting to the media attention and speculation” about upcoding, noting the “harsh reprimand” from Holder and Sebelius.

If the CMS wants to be more persuasive that the direction of its proposal is sound, the agency should be more forthright about the thought process behind the proposed change. Otherwise, this just looks like a knee-jerk reaction at the behest of the Attorney General and the Secretary of Human Services.

The importance of being earnest and NICE

UK's National Institute for Health and Care Excellence is widely admired both in the country and abroad for the rigorous manner with which it develops guidance on the use of new and existing medicines, treatments and procedures within the NHS.  (We have no such body in the US.)

It is hard to imagine (not!) that some of its deliberations are controversial.  How wonderful then to see this language used in describing the qualifications desired for an analyst position the Institute is seeking to fill:

“Excellent oral and written communication skills, including the ability to communicate highly complex ideas to a range of audiences where there are significant barriers to acceptance which need to be overcome in a hostile, antagonistic or highly emotive atmosphere.”

(Thanks to Marco D. Huesch, MBBS, Ph.D., assistant professor at the USC Sol Price School of Public Policy, for this lead.)

Tom still reminds us of a Reason to Ride

One of my great pleasures when I was CEO of a hospital was to engage in philanthropic efforts by grateful patients who wanted to support the research or clinical activities of the doctor who had served them.  I would offer my personal involvement, and I would also make sure our development office provided planning and on-site support to the events. In my mind, these kinds of events were a symbol of the very human relationships between providers and patients, and I always felt them worthwhile even if they didn't bring in the kind of dollars that one might solicit from major donors.

A prime example of this was an event initiated by Tom DesFosses, a brain cancer survivor.  After finishing his treatment, Tom took a solo bike ride of several hundred miles throughout New England to celebrate.  Then he started up an annual fund-raising event--called A Reason to Ride--to raise money for Dr. Eric Wong's research program.

Back in 2009, I wrote about this ride and quoted Tom:

"For me, this ride will be very emotional, but in another way it will give me incredible joy. It will give me time to reflect on how blessed I am to be a cancer survivor, and to think of others who are not able to join me on this quest. I hope other cyclists will join me on this ride to help raise greatly needed funds for life-saving cancer research."

Each year, dozens of Tom's friends, cancer survivors, and friends of other cancer patients join the ride.  Now, Tom and his crew take total responsibility for planning and running the event.  A stalwart supporter has been Jim Boland, owner and operator of four New England-based Fuddruckers restaurants, seen above at right with Dr. Wong (left) and Tom (middle).

Today's ride was a great success.  We hope to see you next year!

There goes the random walk hypothesis!

My daughter recently mapped the path of her one-year-old son shortly after he learned to walk.  Here it is:

Wise words from my friend Boaz Tamir

On this eve of the New Jewish Year, the fog grows thicker and the horizon seems to be moving ever-further away: We face uncertainty, confusion and daily challenges to our assessments of what the morrow may bring. Once our slogan was, "Every plan serves as a basis for change;" but the in the current pace of change, we must adopt a slogan of, "Changes are the basis for never-ending planning."

The changes are multi-dimensional: technological innovations; global climate change, civil uprising and political unrest, drastic adjustments in public consciousness, consumer awareness and the political arena and the rearrangement of global and local systems are bringing about epic transformations. These are leading to a destabilization of the validity of established economic, political and managerial paradigms and their usefulness as a base for the development of economic-political polices and sustainable business strategies.

What should we wish for others and for ourselves as this New Year begins?

1. That we learn to adjust to reality, even if we have no theory to explain it.
2. That we learn to view chaos as a lever for creativity, disruption as an advantage and crisis as an opportunity.
3. That we are wise enough to create systems that blur hierarchical boundaries, whose stability stems from constant movement in fluid surroundings.
4. That we replace the paralyzing anxiety brought about by uncertainty with the ability to grow in a storm.
5. That we exchange pride with modesty, answers with questions and certainty with investigation.
6. That we succeed in integrating internal and external strengths as we enlist workers and managers to cope with an environment full of contradictions and disharmony.
7. And to those who have lost their way in the fog: We hope that they will be able to return to their foundations – to interpersonal relations, the foundations of culture, and to be willing to learn from organizational frameworks and cultures that have survived for thousands of years.

Happy New Jewish Year,
Boaz Tamir, Zicheron Yaakov, September 5th, 2013

I wasn't cynical enough about the proton beam industry

I've posted a number of stories about the manner in which the medical-financial complex has pushed through the construction of very high cost proton beam machines, creating a market for a service that has limited clinical support.  It turns out I wasn't cynical enough.

Here's a report from The Advisory Board Company entitled, "Achieving financial success in proton therapy in 2013." Here's the imperative laid out in the report:

This turns the scientific method on its head. Instead of conducting research to determine if proton beam therapy is clinically more efficacious that traditional radiotherapy, we are told to conduct trials designed to substantiate the superiority of this technology. Here's the advice:

Facing heavy payer scrutiny and patient recruitment challenges for large-scale randomized controlled clinical trials, proton centers will need to augment clinical trials while refining strategies for engaging private payers. For tumor sites facing scrutiny, proper patient selection, recent data, and messaging will be very important.

In other words, pick the patient sample to support the desired conclusions.

Meanwhile, another report sets forth marketing advice. Here it is:

As proton centers enter the market in 2013, administrators will need to adapt referral strategy to a new environment.   Changing market forces, including the proliferation of centers,  an expansion in clinical eligibility, trends in physician-hospital relationships, and healthcare reform create new marketing imperatives. 

Now, centers will focus not on a largely exclusive, trans-regional marketplace, but focus much more intensely on finding patients within their own backyards, raising the need to convert exploratory self-referrals.

Let's think about the meaning of: "Convert exploratory self-referrals."  We're going to take ordinary people suffering from cancer and persuade them that this technology is the answer to their problems.  So direct-to-consumer marketing will be applied to this patient population.

Well, it's worked before, e.g., with the da Vinci surgical robot.  Who can blame these guys for taking a leaf out of that book?

Are Surgibuns™ for you?

Not all health care innovations come out of NIH R01 grants.  Here's one developed by Lisa Corcoran, an OR nurse who was tired of wearing the bouffant caps that are popular in the medical field. Her Surgibun™ hair covers are disposable and latex free and the woven and non-woven materials meet the Standard for the Flammability of Textiles CPSC 16 CFR Part 1610.

She's trying to introduce them to the marketplace.  Check them out here. In addition to the healthcare world, they would be excellent in the food and restaurants sectors and in any area in need of hair caps and protectors.

There are protons in Europe, too

Speaking of proton beams, while they populate like rabbits in the US based on a financial model that includes overpayment for prostate irradiation, there are real debates going on in Europe about their efficacy.  Here are excerpts from an article from the British Medical Journal:

Critics say the NHS should not be spending so much money on a treatment that has not been subjected to randomised controlled trials and for which there is little evidence of long term efficacy or safety. In April, an article in the BMJ questioned whether the government’s £250m investment was premature. “For most indications,” reported a review of the evidence in February, no firm conclusions could be drawn about the superiority of protons over photons and it was “sobering to observe that no phase III trials have been performed.”

The debate has been clouded in the UK by a focus on the widespread use of proton therapy in America for the treatment of prostate cancer. This is a red herring, says Adrian Crellin, a consultant clinical oncologist at St James’s University Hospital, Leeds and the Department of Health’s national lead for proton beam therapy: “We have quite specifically excluded prostate cancer as a standard indication for treatment because there’s no evidence.”

In fact, the application of proton therapy in the UK is limited to just 15 rare cancers— three adult and 12 paediatric—that have the clearest evidence, including base of skull chordomas and chondrosarcomas and primary paraspinal tumours. Referrals to overseas treatment centres, which will continue until the NHS units are up and running in 2017, are subject to approval by a national clinical panel that takes account of a range of other factors, including the timing of radiotherapy in relation to other treatment and the stage and pathology of the cancer.

Meanwhile, we see some caution in the Netherlands:

Roelofs explained that the Netherlands takes a somewhat cautious approach when it comes to introducing new treatment regimes, as evidenced by its health insurance board, which will only reimburse proven technologies. For many years, there was concern about the lack of evidence for proton therapy, a situation that led to the instigation of ROCOCO - an ongoing international multicentric in silico trial comparing photons, protons and carbon ions. 

The idea is that before a patient is referred for proton therapy, simulated plan comparisons must reveal a significant dosimetric benefit of protons. This advantageous dose distribution then needs to be translated into clinical benefits, such as reduction of side effects, using proven complication prediction models. "This general in silico concept was picked up by the health insurance board to be enough evidence to reimburse," Roelofs said. The board has stated four model-based indications: head-and-neck, lung, prostate and breast cancer, where patients are eligible for reimbursement, as well as the standard indications: intraocular tumours, chordoma/chondrosarcoma and paediatric tumours. 

But they recognize that the jury is still out and so study is needed.

Another government requirement is that all patients treated with protons in the new centres are included in standardized clinical trials with uniform outcome measurement, requiring close collaboration between sites. "All four initiatives have been working on this proposal for years, so there's already good collaboration between them," Roelofs explained. "We're working together to set up one registry for protocols. When you have four centres treating in the same way, collecting the data in the same way, this will enable you to perform comparisons more easily. I think it will help create the evidence for proton therapy that is still needed." 

In the US, there is not a requirement that efficacy be demonstrated.  Only safety.  So the capital markets have leaped on the technology as a way to draw in the dollars.  Hospitals sign the mortgage to create a competitive advantage.  The medical arms race continues, enhanced by a national association!

September 13 deadline for HOPE Award nominations

 

Nominations for the MITSS HOPE Award are Due by Friday, September 13, 2013. 

 

Now that Labor Day has passed, it's time to get those nominations in for the 2013 HOPE Award.  Don't miss the opportunity to recognize someone who is making a difference.  Self-nominations are welcomed, and submissions from anywhere in the United States and Canada are encouraged.

Click here  or visit www.mitsshopeaward.org for eligibility criteria and submission requirements, to download a nomination form, check out past winners, and much, much more!

This prestigious award is being sponsored by RL Solutions, and the winner will receive a cash prize of $5,000 to continue their important work.

Learning from patients, made easy and effective

An article in The Guardian tells of a lovely and simple approach for really listening to patients and using their feedback, from Spiral Health's 40-bed rehab center in Blackpool (UK). Thanks to Samantha Riley, Director of Insight at NHS England, for the tip.  Excerpts:

A group of people representing all stakeholders in our hospital community – managers, healthcare assistants, therapists, nurses and patients – gather together to analyse patient feedback and decide on action points. Our staff and patients have loved being involved, and it is interesting to hear feedback on problematic issues from so many different perspectives.

Before we start, we collect patient views by conducting friendly bedside interviews. Each patient is asked to talk to us about two things that are working, two things that are not working and two things that people would like to see if they came back to the unit again. The interviews are more of a chat than a formal process and we work hard to make patients feel at ease. We also remind them that negative feedback is as important as glowing praise. Older generations sometimes don't like to make a fuss, even if something is troubling them.

As we are determined to be open and honest about the feedback we receive – negative and positive – we have a display in our reception area that highlights issues raised and what we are working on.

Some people have said we are brave to invite criticism, but we feel strongly that if we are going to be truly patient-centred we must listen hard to them and learn from them. If we were just content to ask tick-box questions of our patients, would the results really be worth the paper they were written on?

Calling the trustbusters!

The case for market concentration driving higher health care prices, which could be predicted by virtually any economist, is being proven over and over.  It happens in the UK.  It happens in the US.

A story in Modern Healthcare.com sets forth the latest study, by the Center for Studying Health System Change, documenting the phenomenon.  The lede:

Bargaining leverage, not the cost of providing complex care, is the main reason why some hospitals can demand prices twice as high as their competitors' and still get contracts to treat privately insured patients, according to a new study.

The analysis by the Center for Studying Health System Change of actual payments to hospitals and physicians by private insurers in 13 U.S. cities found that the most expensive hospitals got rates as much as 60% more than the lowest-priced competitor for inpatient care, and prices that were double the competition for outpatient care. 

And here's a familiar argument (one that our friends at Partners Healthcare habitually made about the Eastern Massachusetts market):

Expensive hospitals have long argued that providing medical education and the best equipment available drives their costs. But the study authors cast doubt on that because their research was based on how much each hospital's rates exceeded Medicare payments for the same services. Since Medicare rates are adjusted to reflect patient case-mix complexity and the cost of capital equipment, those factors shouldn't explain why some hospitals get more than others relative to Medicare's rates.

Let's recapitulate, citing a conclusion noted in a recent New York Times article:

If there is one thing that economists know, it is that market concentration drives prices up — and quality and innovation down.

 

The body politic has chosen to look the other way.  Will greater price and outcome transparency make an iota of difference when the largest provider group in a given metropolitan area dominates the landscape?  I doubt it, in our lifetimes.  The article cited above notes:

 

The entities with the most bargaining power, and thus the highest mark-ups, are the “must-have” hospitals—that boast good reputations, large numbers of services and desirable locations, the authors found. “Even in metropolitan areas with many competing hospitals and hospital systems, these must-have hospitals can command unusually high prices,” they wrote. 

Congratulations to Dr. Minter-Jordan

I missed this announcement earlier this summer but am very pleased to repeat it now.

Dr. Myechia Minter-Jordan took over as the new president and CEO of The Dimock Center on July 1. Dimock is a community health center serving the Roxbury section of Boston--the second largest health center in the city--offering a variety of important programs to people in that part of town. 

Myechia served as chief medical officer at the center since 2007.  I had the pleasure of getting to know her and working with her during my tenure as CEO of BIDMC.  She is a spectacular choice for the head of the center.  As the article in the Bay State Banner notes:

The 41-year-old Minter-Jordan is also dedicated to improving the community health-care model. And she wants to make sure The Dimock Center, already a recognized leader in community health care, will continue to lead the way.

“I relish the opportunity to talk … about issues that impact the Latino and black community,” she said. “I think it is important to me to bring the voice of community health centers to that discussion.

“We can’t stop there. We have to keep moving until it is recognized by all that community health centers are really the model … to create a place for patients and family where all their needs are met,” she added.

Still nothing from CMS, but Blue Shield of CA acts

One of the mysteries of the medical arms race is why the CMS administrators who have served in the Obama Administration (Don Berwick and Marilyn Taverner) never took action to eliminate the unjustified Medicare subsidy of high cost proton beam machines.

So, bravo to Blue Shield of California for doing just that, even in the face of inaction at the federal level.  Here's the story from the Los Angeles Times.  Excerpts:

As hospitals race to offer the latest in high-tech care, a major California health insurer is pushing back and refusing to pay for some of the more expensive and controversial cancer treatments.

Blue Shield of California is taking on this high-cost radiation treatment just as Scripps Health in San Diego prepares to open a gleaming, $230-million proton beam therapy center this fall, only the second one in California and the 12th nationwide.

This week, Blue Shield began notifying doctors statewide of its new policy for early-stage prostate cancer patients, effective in October. The San Francisco insurer says there's no scientific evidence to justify spending $30,000 more for proton beam treatment compared with the price it pays for other forms of radiation that deliver similar results.

"Proton beam is really the perfect example of all that is wrong with our healthcare system," said Cary Gross, a researcher at the Yale School of Medicine who recently compared outcomes for 30,000 Medicare patients who received proton beam or standard radiation. "The rush to adopt proton beam is far outpacing the amount of evidence to support its use."

In December, Gross and other Yale researchers published a study that analyzed 30,000 Medicare patients who received proton beam therapy or standard radiation for prostate cancer. Supporters of proton therapy say it helps those patients avoid common side effects from radiation such as incontinence and erectile dysfunction.

But the Yale researchers found that there was no difference in terms of side effects a year after treatment. Yet Medicare paid more than $32,000 for a course of proton beam treatment, compared with less than $19,000 for conventional radiation.

Survival of the fattest

Best quote of the day by Alan Sager, professor of health policy at Boston University, from an article in FierceHealthFinance:

"The most profitable hospitals are the ones that are able to command higher payments. We again see the survival of the fattest where profitability has more to do with their market leverage than with efficiency."

Indolentomas: What is and is not cancer?

Check out this recent article and accompanying video by George Lundberg on Medscape entitled, "What Is and Is Not Cancer?"  Dr. Lundberg reviews the tendency in medicine to label many types of lesions as cancer, and he notes that this is a form of over-diagnosis that can be harmful.  Here are some excerpts:

Cancer cells -- anaplastic, dedifferentiated, capable of autonomous growth, utterly out of control until destroying their host -- are, however, not just one thing. We are learning more every day that cancer is many different diseases, even thousands or tens of thousands of different diseases.

For a long time, it made sense to try to eradicate all cancers, as early and as completely as possible. Mass efforts were launched to find cancers wherever they were and destroy them. Since the earliest cancers seemed to evolve from some identifiable premalignant conditions, wouldn't it make sense to also nip those in the bud? Sounds logical.

But, as with many exuberant efforts, this one got out of control. Many lesions that were called "cancer" really were not cancers at all in behavior, and this fact began to be recognized in large numbers of patients. These unfortunate victims have experienced massive psychological and physical harm and costs without any clear benefits achieved by finding and treating their "noncancers."

Pathologists never can really predict how any one cancer will behave. But after many decades of matching histologic patterns with the natural history of diseases, we are actually pretty good at predicting which lesions will be really bad actors and which seem likely to lie around indolently.

Cure rates from aggressive therapy on those "indolentomas" are 100%. But, so would the outcomes have been of nondiscovery---100% cure of nondisease.

Ceasing to name lesions that are most likely indolentomas by that fearsome word "cancer" is the first step. Almost any patient who hears the word "cancer" applied to their pathologic findings experiences their hair catching on fire. Even if the word is cushioned by physicians with modifiers like "in situ," "early," "precancer," "on the way towards cancer," "caught it in time," and the like, the patent simply wants to get it out of their body. A surgical sell by a surgeon becomes really easy.

Will there be missteps? Certainly. Will there be resistance to change? You bet. Will there be unintended consequences? Most assuredly. Will some of those trial lawyers jump with glee at the possibility of underdiagnosis and new opportunities at lawsuits for "failure to diagnose"? Yes, but we must use our science and professionalism on behalf of the patient's best interests and collectively tell the lawyers and the hospital risk managers to take a flying leap.

Science marches on. Let's listen to it and lead from the front.

Dr. Lundberg cites a recent JAMA article by Laura Esserman and colleagues on this topic.  Entitled,  "Overdiagnosis and overtreatment in cancer: an opportunity for improvement." it is well worth reading.  Here's the abstract:

Over the past 30 years, awareness and screening have led to an emphasis on early diagnosis of cancer. Although the goals of these efforts were to reduce the rate of late-stage disease and decrease cancer mortality, secular trends and clinical trials suggest that these goals have not been met; national data demonstrate significant increases in early-stage disease, without a proportional decline in later-stage disease. What has emerged has been an appreciation of the complexity of the pathologic condition called cancer. The word “cancer” often invokes the specter of an inexorably lethal process; however, cancers are heterogeneous and can follow multiple paths, not all of which progress to metastases and death, and include indolent disease that causes no harm during the patient’s lifetime. Better biology alone can explain better outcomes. Although this complexity complicates the goal of early diagnosis, its recognition provides an opportunity to adapt cancer screening with a focus on identifying and treating those conditions most likely associated with morbidity and mortality.

Reducing hospital acquired infections to reduce costs

What's one of the best ways to reduce health care costs?  Stop hospital acquired infections.

JAMA posts an article outlining the costs of the most common such infections.  An excerpt:

On a per-case basis, central line–associated bloodstream infections were found to be the most costly HAIs at $45,814, followed by ventilator-associated pneumonia at $40,144, surgical site infections at $20,785, Clostridium difficile infection at $11,285, and catheter-associated urinary tract infections at $896. The total annual costs for the 5 major infections were $9.8 billion, with surgical site infections contributing the most to overall costs (33.7% of the total), followed by ventilator-associated pneumonia (31.6%), central line–associated bloodstream infections (18.9%), C difficile infections (15.4%), and catheter-associated urinary tract infections (<1%).

There is only one thing wrong about the article, the policy conclusion:

As hospitals realize savings from prevention of these complications under payment reforms, they may be more likely to invest in such strategies.

Here's where they are wrong on this point.  You do not have to institute so-called "payment reform" to incent hospitals to eliminate infections.  Even under a fee-for-service rate design regime, hospitals that engage in work flow redesign to eliminate infections find improvements in efficiency, reduction in length of stay, and higher utilization of high fixed cost facilities.  While there might be some revenue loss from a reduction in complications, that is more than offset by these other considerations.  There is a strong business case to be made regardless of rate design.  Many of the most dramatic improvements in elimination of hospital acquired infections have occurred in hospitals during a fee-for-service regime.

Labor Day 2013 -- Time to revisit the approach

The US Department of Labor notes:

Labor Day, the first Monday in September, is a creation of the labor movement and is dedicated to the social and economic achievements of American workers. It constitutes a yearly national tribute to the contributions workers have made to the strength, prosperity, and well-being of our country. 

The vital force of labor added materially to the highest standard of living and the greatest production the world has ever known and has brought us closer to the realization of our traditional ideals of economic and political democracy. It is appropriate, therefore, that the nation pay tribute on Labor Day to the creator of so much of the nation's strength, freedom, and leadership — the American worker. 

This is very much the case, but the day also should bring attention to how the labor movement can, under today's conditions, bring about continued progress for families in the country.  Unfortunately, in many respects, the movement has become as calcified in its beliefs and techniques as the very corporations with which it vies.  It often suffers from boards that do not engage in best governance practices, from a lack of transparency about its finances and other operations, and from the kind of political activism that is divisive rather than collaborative.

Labor in America has experienced a drop in membership, and one reason might be that the traditional approach to organizing--one based on getting to know and understand the concerns of potential members at a personal level--has given way to corporate campaigns and the use of big money that fail to engage individuals with a sense of purpose and identity.

Several years ago, I introduced Marshall Ganz at a speech he was giving, and I was struck at the disconnect between the exemplary words he was using in his talk and the practices of the SEIU, the largest union in the health care arena.  I noted:

[H]is impressive speech about the nature of community organizing and, in particular, the importance of having an underlying set of values to serve as the moral basis for a movement.

Having now watched the SEIU for several years, I was struck by the contrast between Marshall's prescriptions and this union's mode of operation. As I listened to his talk, I realized that the union has, in many ways, lost its soul as it has gained power and influence. It has become part of the "they" that is the target of community organizing. Instead of drawing on the resources available to it -- the courage, passion, creativity, and commitment of workers -- it relies on money and power to gain more money and power.

My book, How a Blog Held Off the Most Powerful Union in America, deals with one such example, when the SEIU conducted a multi-year corporate campaign against my former hospital--seeking to denigrate the reputation of the hospital and the people working in it to bypass the normal democratic approach to union certification.  David P. Boyd, Professor of Management at Northeastern University, wrote a foreword for the book.  He noted:

In this book, Paul Levy offers a compelling historical narrative of labor-management relationships over a tumultuous five-year period. While the story itself is riveting and the stakes compelling, it is more than simple case narrative; rather it is a morality play about an attempt at power dominance which, if realized, would have foreclosed employee engagement. Through such tactics as “neutrality agreements” and “card checks,” a powerful union sought to become hostage-taker of a hospital’s financial and reputational halo. Levy knew such an approach would usurp the primary goal of the hospital to preserve and enhance patient care. It would also deny employees the right to debate and determine the environmental parameters within which they worked. Thus the principles in play were no less than institutional purpose and individual prerogative.

As one of our nurses said at the time:

I believe in our practice, mission and values. I understand the concept of free speech, but it certainly hits a sensitive spot when people purposely set out to mar reputations through smear campaigns.

What an incredible waste of time, effort, and money by this union.  Let's hope that it and others will find a new focus for their efforts.

UK: Market concentration leads to higher prices

In what should be an implicit advisory to the United States as geographically powerful ACOs become the norm, the UK Competition Commission has found that most patients in UK private hospitals are paying more than they should for treatment because of a lack of local competition.

CC Chairman and Chairman of the Private Healthcare Inquiry Group, Roger Witcomb said:

‘The lack of competition in the healthcare market at a local level means that most private patients are paying more than they should either for private medical insurance or for self-funded treatment.

"The lack of available and comparable information, often less than is available to NHS patients, also makes informed choices—which could help drive competition—for these patients difficult."
 
The BBC News summarizes that the financial results of this market power are clear:

Hospital groups BMI, Spire and HCA had been "earning returns substantially and persistently in excess of the cost of capital", the commission said.

How much does this amount to?  The conservative estimate is £173 million to £193 million a year.

"No insurer has countervailing buyer power that can fully offset the market power of BMI, Spire and HCA," the commission's provisional findings said.

The commission recommended moves to make more information available about the quality of hospitals' services and the level of fees charged by consultants. [Note to US readers: "Consultants" = "doctors".]

It also suggested that operators owning a cluster of hospitals in one area should have to sell off some of them. 

Disruptive noises from Pennsylvania

I'm not sure how I missed this, but it is still timely and worth noting.  In June, a new Disruptive Health Technology Institute was created at Carnegie Mellon University, in collaboration with Allegheny Health Network and Highmark, Inc.  The insurance company, Highmark, will make its claims data available to DHTI researchers.  By mining that data, the researchers will make suggestions to CMU researchers as to fruitful areas that might benefit from new technologies.  The focus will be on accessibility of medical diagnostics, behavior change, chronic disease management, data mining, improved endoscopy, improved diagnostic ultrasound and infection prevention. The DHTI will then fund a small number of those ideas each year, eventually building a large library of research studies that might generate disruptive technologies in the field.

As the story notes,

Alan Russell, who will serve as the director of DHTI and as both executive VP and chief innovation officer for the Allegheny Health Network, says that healthcare is a field that needs to be shaken up.

For sure!

In July, Lynn M. Brusco was chosen to be executive director.  She is well qualified for the role, having served as vice president and chief relationship officer at the Pittsburgh Life Sciences Greenhouse (PLSG) and director of the PLSG Accelerator Fund.

We'll look forward to the results from this new institute.  I also see a potential for an alliance with our friends at the National Center for Human Factors in Healthcare.  I imagine they will have a lot to share over the coming years.

Doctors tweet about IWantGreatCare

My post about the IWantGreatCare patient evaluation program prompted some interesting conversation among UK doctors on Twitter.  I'm not suggesting this is a statistically valid sample of physician responses to the program--after all, these are doctors who feel comfortable talking about such matters on Twitter--but it is an indication that IWGC is adding some value to the doctor-patient relationship. The doctors also note a desire to get more participation from patients and steps they are taking along those lines. I conclude that this is a work in progress, and it will be good to get more updates over the coming months.

First, Clare Rees @doccmr (a pediatric surgeon) noted she was impressed with Oliver Warren @DrOliverWarren (surgeon) on his engagement with the patient in the example I posted.  He responded:

Thank you! Bit nerve wracking sometimes but right thing to do.

Then Dermot O'Riordan @dermotor (surgeon and medical director in Suffolk) led us to his blog post on the issue:

I must confess it was an anxious leap of faith to start asking patients to take cards home and rate me anonymously. I have read lots of stories about the pitfalls of unmediated review sites, e.g. TripAdvisor.

I have been giving them to every patient I have seen in clinic for three months. To start with nothing happened. A couple of weeks later I received my first review & it wasn't that flattering: I wondered if I was doing the right thing.

However I persevered and further reviews started to come in. Fortunately some were much more positive and it is always nice to hear good things. Most patients after all do trust, respect and value their doctor, in contrast to many other professions. In addition I have received constructive comments that I have tried to learn from.

Without this sort of feedback I might never know how I am perceived by patients. The response rate is still not high but I feel that it is an incredibly powerful rebalancing of the doctor-patient relationship for the patient to know that I have invited them to feedback. It does involve trusting the patient but it is important to remember that the patient is trusting me to operate on them!

I am convinced a system such as this can play a major role in changing the culture of medicine towards transparency and putting the patient in charge. It also plays a major role in providing patient feedback for doctors to support their revalidation. A number of clinicians whom I spoke to were highly positive.

Clare noted reactions and then asked:

Every single parent has been surprised to be asked - need to change #culture.  What's your response rate? I give them to everyone but very few give feedback.

Oliver answered:

Three packs of cards used 30 responses. Estimate about 1 in 20.

Dermot said:

Mine's bit lower but don't only do it for the response but cos change dynamic of consultation/trust.

Clare:

OK not just me then!

Dermot:  

But those that do respond do seem to like you.

Clare joked:

Guess I should look at the half full part of the glass more often!

I'd like to hand out iPad with link to improve response rate, but then it wouldn't be anonymous.

In a separate thread, Dermot has a conversation with Richard Bogle @RichardBogle (cardiologist), who notes:

The only thing we have to fear is fear itself.

Dermot replies:

Totally agree. The patient survey produced by @gmcuk was unhelpful. Using @iwgc changes consultation but accept is a big step.

Richard comments, too, on the previous system:

The 360 degree patient feedback is totally useless. It represents about 0.1% patients seen and is self selected.

Then they discuss how to get more responses from patients:

Dermot: Clinic nurse gives it to every patient I see.

Richard: I have the link to iwgc on my website and also a friends and family test on the site. I put the web address on all correspondence. The website gets lots if hits but no responses on iwgc. I think I will start using the cards.

Dermot: I too put my @iwgc URL in footer of all letters. Not sure if produces that many responses.

Communication Counts

Sign seen at the George Washington University Hospital:

Those are the basics!  Good for them to make it explicit. I'd love to hear from patients, families, and staff how it's working.

Badge buddy residents work together on adverse reporting

"Every resident should know how to make an adverse event report," says Nate Margolis, M.D., a fifth-year resident training in New York University's Radiology Residency Program.  (Nate is co-chair of the NYU School of Medicine’s House Staff Patient Safety Council.)

Nate's right, of course, and indeed this is now a requirement of the ACGME, the governing body of residency programs in America:

The Sponsoring Institution must ensure that residents/fellows have access to systems for reporting errors, adverse events, unsafe conditions, and near misses in a protected manner that is free from reprisal.

But this capability is often missing, the victim of a prejudice on the part of many hospitals against resident involvement in this kind of activity.  Often, too, residents feel cowed by a perception that their future career prospects will be damaged by honest reporting.  The situation is complicated, too, for residents who rotate through several hospitals.

Nate and his colleagues decided to help solve this problem using a “badge buddy”—a simple, effective tool to assist residents with the process of reporting events at the multiple hospitals in which they train.  Here's a video describing the initiative, which was strongly supported by the Committee of Interns and Residents (CIR), as well as the senior leaders at NYU.

IWantGreatCare

A group in the UK called iwantgreatcare.org has been running a consumer evaluation website about doctors and hospitals.  Analogous to TripAdvisor, people can post quantitative rankings as well as qualitative comments.  It covers 100% of the NHS hospitals and over 200,000 doctors.  All information is absolutely transparent to the public, the clinicians, and the hospitals.

I can already hear the complaints:  "Our patients are sicker."  "People don't understand enough about medicine to properly judge us." "This is just going to be a complaint board."

Taking the last objection first, well, no.  It turns out that the vast majority of people are actually pleased with their medical care and use the site to send a positive, thankful message to their caregivers.  Here is a touching example:

Everybody finds the GU clinic a bit scary. It just is. For me it's a bit more than scary. I was sexually assaulted 10 years ago and find the examinations difficult after my experiences. After the assault I was examined by a male doctor... it was traumatic to say the least. Just to add insult to injury I have also had cells removed from my cervix (bear with me I am trying to build up a scenario) so I have been examined by various doctors, nurses, blah blah. The point is this. Dr [Robin] Bell is extraordinary. His approach, helpful manner and wit are second to none. I have NEVER ever felt so at 'ease' (relatively speaking) when having said examination. Having seen him twice now I can honestly say I will not see any other GU doctor unless I really have to. I was nervous the first time I went to his clinic; nervous about the examination and (wrongly so) the fact, he is of course, a man! Pah! No female has ever treated me with such tenderness. I would like to thank Dr Bell and I meant to say it today but after my last visit I called my mum (confidant and aide) and cried (for quite some time) about the fact it was ok, that a man had dealt with me and it had gone well. I cried that my fear was over; believe me the police examination was horrific. I can't recommend Dr Bell highly enough. I never ever thought I'd get the chance to conquer the fear of a male examiner... but I did and he's the best :-) Who is in control? His patient :-) 

But sometimes, there are complaints.  Here's one, along with the response by the doctor, posted within 24 hours:

Saw my mother after an examination of her bowel because her GP was worried about something serious. Spent more time talking to student doctor than to my mum and kept asking me questions instead of my mum. She wears hearing aides but isn't stupid! She was still worried about her stomach pains but all he cared about saying was that it wasn't cancer. He is very professional and smart and probably very clever and not rude but he didn't address my mother's worries and talked down to us both a bit. Would ask for a different doctor next time.

Response from Mr Oliver Warren 

Thanks for your feedback. I'm very sorry that you feel I didn't live up to the high standards of care I expect from myself and that we all strive for at Chelsea and Westminster Hospital. I would never presume that someone who requires hearing aids is stupid, and would never wish to give the impression of talking down to a patient or a relative; it can sometimes be really difficult to get the balance right between explaining things in a way that people understand and aren't too complicated, and oversimplifying. Likewise with reassurance; many of our patients are very much focused on cancer, and ensuring they don't have it. On this occasion I read the concerns of your mother and you incorrectly. We try to ensure that the medical students are fully involved and seen as part of the team at our teaching hospital. Balancing their educational needs with the needs of patients can also sometimes be fraught with difficulty in a busy clinic. I would be delighted to organise a second opinion with a colleague if this would be of any help or benefit and am grateful for your feedback.

I don't know, but I bet the information collected here is more useful than the kind collected by Press Ganey and other such patient evaluation services.  Yes, this site suffers from a self-selection bias, but it would be difficult to know in which direction the bias acts.  As mentioned, lots of the comments are laudatory and appear to give people a chance to show gratitude.  If I were running a hospital, I would be sharing these results broadly among my staff, looking to see where trouble areas might be occurring.  As the site notes: "Quantitative and qualitative feedback for organisations, departments, wards and clinics gives real insight with data that actually allow continuous improvement and is proven to engage front-line clinical teams."  I would also celebrate the success of consistently fine reviews.

The site makes no representation that it is evaluating clinical decision-making and outcomes.  That's not the point. It collects reactions from patients in three categories:  Trust, Listening, and Recommend.  You don't have to be a genius to understand that these characterizations are going to be made anyway by patients to their families, friends, and associates.  Doesn't it make sense to hear them directly if you are running a hospital or physician practice?