Canadian Telehealth

As I have written about previously, healthcare in Canada is certainly different than in the United States, from the physician component, to the sector’s funding, to the system as a whole.  The country’s desire to increase telehealth, however, is an appetite very similar to the U.S. as well as many other countries.  For Canadian healthcare, telehealth is an important factor already and still growing, with value for patients, communities and healthcare providers.  Telehealth is providing major contributions to care delivery in rural and remote areas in Canada, as well as patient and clinician education and training.  Various Canadian studies have demonstrated that access barriers of distance and time are virtually eliminated while maintaining quality of service.  A 2015 study shows some dramatic increases in the nation-wide adoption of telehealth.  Here are a few highlights:

  • Canada-wide, clinical telehealth sessions are up 46% from 2012 and 120% from 2010.
  • 89 services offered, from anesthesiology to wound management.
  • Mental health, neurology, oncology, pediatrics, and rehabilitation remain the most commonly delivered service in Canada.
  • There has been a 42% increase (from 2012 to 2014) in the expansion of telehealth endpoints.
  • Educational telehealth sessions have increased 78% since 2013.
  • There has been a 50% increase (since 2013) in patients enrolled in remote patient monitoring.

 “Telehealth continues to deliver on its traditional benefits of eliminating distance barriers while improving equity of access to services that often would otherwise not be available in remote and rural communities, along with reduced visits to the emergency rooms and enhanced healthcare provider-to-provider consultation.”

There has been a lot of discussion surrounding the integration of telehealth with electronic health records (EHRs) lately.  In a similar tune with U.S. complaints, Canadian physicians report the need for telehealth systems to integrate with their EHRs.  Platforms that successfully combine these systems could be the right compromise between patients and providers.

Canadian healthcare executives are also looking to increase remote patient monitoring in order to reduce hospital readmissions.  The theory is also that better chronic care management will keep costs down.  Through telehealth, you do not have to bring every patient into the office for small problems. You can “triage” them before they come in.  Once again, integration with EHRs will enable physicians to better understand the condition of these patients on an ongoing basis to better support them during office visits, or in the case of a future acute event.


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U.S. Healthcare Price—Quality Link

U.S. healthcare consumers are undoubtedly confused about the relationship between quality and price when evaluating healthcare services.  A recent study shows the inherent challenges in healthcare reform as the industry attempts to shift towards price transparency and value.  The research, based on over 2,000 adults, demonstrated that while most consumers do not see an association between price and quality, the framing of questions around the subject had a significant impact.

The researchers note that their analysis was based on “two pairs of questions about the association between price and quality.  One pair of questions referred to medical care in general, and the other referred to doctors, whose prices and quality can vary.  One question in each pair asked about high price and high quality, and the other asked about low price and low quality.  Survey respondents were asked one question from each pair.”

In short, a majority of consumers (58-71%) do not think health care cost and quality are associated, 21-24% perceive an association, and 8-16% are unsure.  The study’s authors found that consumers are more likely to say there’s no association between high price and high quality, and are less sure whether an association exists between low price and low quality.  Kathryn Phillips, one of the researchers, notes:

 “We know from other studies that people perceive information differently depending on how it is framed.  For example, they are more likely to buy ground beef that is labeled 75 percent lean versus labeled 25 percent fat.  Similarly, we found people perceive price and quality differently when described as high price/high quality versus low price/low quality.  We need to consider how people actually perceive price and quality information so we can design the right tools and policies.”

Race and ethnicity also plays a role in perception.  Apparently, Hispanics, Blacks, and those under the age of 30 are somewhat more likely than others to believe cost and quality are associated.

As information and data is increasingly being provided to healthcare consumers in an attempt to help them choose healthcare options, and while employers are steadily forcing their employees into high deductible health plans, the implications of this study’s findings are indeed significant.


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Pharmacy Interventions

Ask any physician about a key patient health issue as it pertains to medication and they will tell you it is patient compliance.  Simply put, many patients do a poor job at actually taking their medications as prescribed.  Community pharmacists have long been able to help reduce hospitalizations and total medical costs commonly associated with non–adherence to medications.  In the peer-reviewed journal Population Health Management, Walgreens has recently published a study examining just how these pharmacy interventions can lead to improved medication adherence.

The Walgreens research examined data from over 72,000 patients who initiated therapy within 16 drug classes used to treat common chronic conditions, over a six-month period in 2013.  The study, “Improving Medication Adherence and Health Care Outcomes in a Commercial Population Through a Community Pharmacy”, also compared Walgreens patients with those using other pharmacies.  The study’s author, Michael Taitel, PhD, noted:

“These findings clearly illustrate that the combination of pharmacist counseling, medication therapy management, refill reminders and telephonic and digital pharmacy interventions, tailored to patients’ needs, drive better adherence.  Further, this improvement in adherence results in fewer hospitalizations and emergency room visits, ultimately benefiting payers by lowering the overall cost of care.”

Here are some highlights of the study:

  • Patients eligible for Walgreens pharmacy interventions experienced a 3% greater medication adherence.
  • Walgreens community pharmacy patients had 1.8% fewer hospital admissions.
  • Overall, Walgreens new-to-therapy patients had 3% lower total healthcare costs then comparable non-Walgreens patients.
  • Walgreens community pharmacy patients had 2.7% fewer emergency room (ER) visits.
  • On a per patient basis, those in the Walgreens intervention group incurred lower total healthcare costs, including pharmacy (-$92), outpatient (-$120), ER expenditures (-$38), and total health care costs (-$226) over a 6-month period.

Walgreens states that their interventions include pharmacy-based patient counseling, medication therapy management (MTM), and online and digital refill reminders.  For new-to-therapy patients, these programs included pharmacist calls and consultations; and for those continuing therapy, included MTM consultations, automated reminders, pickup reminders, late-to-fill reminders and face-to-face consultations.

Another study in Progressive Cardiovascular Disease showed that only about 50 percent of patients with chronic conditions take their medications as prescribed by their physicians.

Walgreens Chief Medical Officer, Dr. Harry Leider, comments on the recent Walgreens research:

“Patients receiving a new chronic diagnosis and medication therapy are at very high risk for non-adherence to medication, and this important study demonstrates how a diverse set of pharmacy and digital interventions improves care while reducing total healthcare costs.”


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Rampant Malpractice?

The word “malpractice” often elicits anxiety in the medical community, especially for physicians.  Medical errors and adverse outcomes do happen.  However, the distribution of medical malpractice claims across the healthcare industry has not historically been well understood.  If claim-prone physicians account for a substantial share of all claims, and it is feasible to reliably identify those physicians at an early stage, there are clear implications for efforts to improve the quality and safety of care.  Liability insurers and healthcare organizations could use the information to address risks posed by claim-prone physicians.  Overall, very few physicians actually have claims; however, those physicians have increasing numbers of claims, which put the individuals at more risk regardless of their specialties.

A recent study analyzed malpractice claims paid against physicians between 2005 and 2014, calculated concentrations of claims among physicians, and sought to identify characteristics of physicians at high risk of “recurrent claims”.  Using data from the National Practitioner Data Bank, 66,426 claims paid against 54,099 physicians were analyzed from 2005 through 2014.  The study found that relatively few physicians account for a surprisingly large number of paid malpractice claims.  In fact, approximately 1% of all physicians accounted for 32% of paid claims.  The study’s findings also suggested that it may be feasible to predict who these physicians are before they accumulate troubling track records.

“Among physicians with paid claims, 84% incurred only one during the study period (accounting for 68% of all paid claims), 16% had at least two paid claims (accounting for 32% of the claims), and 4% had at least three paid claims (accounting for 12% of the claims).  Male physicians had a 38% higher risk of recurrence than female physicians and M.D.s had a lower risk than D.O.s.”

Specialties with the highest number of paid malpractice claims, include orthopedic, neurosurgery, plastic surgery, obstetrician-gynecologist, and general surgery.  Physicians in these specialties have twice the risk of recurrence compared with internal medicine physicians.  The lowest risks were among psychiatrists and pediatricians.  Again, physicians with multiple paid claims were at significantly increased risk of additional claims.

 “In an environment in which a small minority of physicians with multiple claims accounts for a substantial share of all claims, an ability to reliably predict who is at high risk for further claims could be very useful. . . . If reliable prediction proves to be feasible, our hope is that liability insurers and health care organizations would use the information constructively, by collaborating on interventions to address risks posed by claim-prone physicians (e.g., peer counseling, training, and supervision).”

Indeed, this study draws attention to an area of great interest in current risk litigation and management, and many healthcare institutions are embarking on aggressive strategies for behavioral modification.  However, the statement above about interventions implies that the physician is at fault and more data may be needed before administrators embark on such a campaign, especially given the potential “blood in the water” phenomenon as it relates to recurrence.

The study’s authors acknowledged some limitations of their analysis, including that not all paid malpractice claims are reported to the National Practitioner Data Base because doctors’ names are often not provided and instead replace with the institutions.  Additionally, the study didn’t take into account doctors’ patient volumes, hours worked or patient case mix when evaluating their risk of facing paid malpractice claims.  Lastly, the study did not include unpaid claims, which might still indicate problems in some situations.

The study (“Prevalence and Characteristics of Physicians Prone to Malpractice Claims“) can be found here.


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