EPtalk by Dr. Jayne 11/29/18

Recent data from Case Western Reserve University shows that hospitals meeting EHR Meaningful Use standards had average patient stays that were shorter than their non-MU-compliant counterparts. Digging deeper into the data, they looked at four years of information and found that the length of stay was about four hours shorter. In various industry publications, there are plenty of quotes floating around from hospital administrator types talking about how MU-compliant EHRs improve compliance with treatment pathways and improve communication. As a physician, I’m wondering whether that four-hour length of stay is clinically significant. I’m also questioning the quotes from people talking about it generating “significant savings” for large health systems. To do that analysis, you can’t just look at the length of stay – you’d have to look at all the costs and factors contributing to that length of stay, including the cost of the EHR and the payroll costs associated with all the clicks mandated for Meaningful Use; as well as the costs to purchase, implement, and maintain the EHR at the MU-ready level above and beyond clinically-necessary EHR functionality. Nurses and staff can move faster caring for patients when they’re not performing clinically-irrelevant screenings or documenting unnecessary data.

The study, published in the Journal of Operations Management, only looked at hospitals in California and categorized hospitals three ways – those who had “meaningful assimilation” of EHRs, those with full adoption, and those with partial adoption. Comments from the authors note that “results from this study indicate that meaningful assimilation of technology is likely to help free-up clinicians and other valuable resources – this approach is preferable to making additional investments in facilities or hiring additional employees as more people seek hospital services.” This oversimplifies a complex problem. Speaking from experience, length of stay can also be shortened by having more care coordinators with smaller patient loads and greater ability to orchestrate hospital discharges in an efficient manner, making sure the family, the patient, the hospital, home health, and any receiving facilities are all on the same page. That requires hiring human beings, which cost money.

My last hospital stay was four hours longer than it needed to be because the surgeon’s PA rounded over lunch rather than before office hours, and there had to be a physical exam documented prior to discharge despite the fact that I had met all discharge criteria and practically had a car running in the parking lot trying to get out of there. Still, we had to check the boxes for people to get paid, prolonging the stay. The study also doesn’t show causation, merely correlation. It’s likely that hospitals that are fully compliant with Meaningful Use are also participating in other initiatives such as quality improvement projects, promotion of clinical best practices, etc. on a higher level than other hospitals. In order for the study to truly show causation, the authors would have needed to control for those factors as well.

Atlanta-based Sharecare was named to the Deloitte Technology Fast 500 for the second consecutive year. Sharecare promotes itself as a “digital health company that helps people manage all their health in one place,” including helping them calculate and track their “real age” versus their actual chronological one. These kinds of rankings are based on revenue growth rather than clinical or quality factors, although health plans are engaging with Sharecare so there must be clinical data in there somewhere. I’m skeptical about their involvement with Dr. Oz and also their website lead-ins on taking “the first step to growing younger.” We would be better served as a society if we promoted people getting the best health at any given point in time rather than focusing on being younger, etc. There’s something to be said for growing old with grace and not trying to fight the clock with various surgeries, injections, and products. They have a whole section on their site for advertisers titled “Drive measurable results for brands,” including talk of “precision targeting fueled by the largest database of first-party, self-reported health information” including the ability to drive “awareness, engagement, and proven conversion for brand partners.” That kind of calls into question their other motivations, at least in my book.

On that same note, in the news earlier this week, Mr. H asked about private equity in healthcare – specifically, whether the “slash-and-burn, flip-focused” methods were appropriate in healthcare. The Washington Post story he references looks specifically about PE in a nursing home situation. I’ve not personally experienced that, but I have seen plenty of private practices sell to PE organizations, particularly in dermatology and ophthalmology. Providers in those specialties have remained independent for a long time while their lower-paid primary care counterparts have already given up independence for the security of hospital employment. Still, running a practice is daunting, and with the changes in reimbursement and contracting and managing people it’s enticing to want to sell to someone who promises to take care of all the perceived hassles.

However, nearly everyone I’ve encountered who has sold their practices has very quickly found that it becomes all about profitability. The fact that the PE firms are only going after high-profit practices should have been a tip-off – they’re not snapping up general internal medicine or family medicine practices. Physicians gave up having to make human resources decisions only to find their staffs slashed and longstanding employees laid off. Administrators with MBAs but little healthcare experience are making decisions about patient care including what services to offer and whether providers can see uninsured patients. Not all the decisions are correct about profitability in the healthcare context – a colleague recently was forced to institute a policy where uninsured patients were turned away, because his PE overseer didn’t realize that self-pay patients can be profitable due to low billing costs. The 24 year-old administrator saw “uninsured” and thought “indigent,” causing the loss of some longstanding patients who had always paid their bills at the time of check-out. The physician would love to leave, but a 30-mile non-compete radius has him trapped unless he truly wants to start from scratch.

What are your thoughts about private equity organizations in the healthcare space? Leave a comment or email me.

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