A Med School Teaches Science And Data Mining

Medicine, meet Big Data.

For generations, physicians have been trained in basic science and human anatomy to diagnose and treat the individual patient.

But now, massive stores of data about what works for which patients are literally changing the way medicine is practiced. “That’s how we make decisions; we make them based on the truth and the evidence that are present in those data,” says Marc Triola, an associate dean at New York University School of Medicine.

Figuring out how to access and interpret all that data is not a skill that most physicians learned in medical school. In fact, it’s not even been taught in medical school, but that’s changing.

“If you don’t have these skills, you could really be at a disadvantage,” says Triola, “in terms of the way you understand the quality and the efficiency of the care you’re delivering.”

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That’s why every first and second year student at NYU Medical School is required to do what’s called a “health care by the numbers” project. Students are given access to a database with more than 5 million anonymous records — information on every hospital patient in the state for the past two years. “Their age, their race and ethnicity, what zip code they came from,” Triola lists, as well as their diagnosis, procedures and the bills paid on their behalf.

The project, funded in part by an effort of the American Medical Association to update what and how medical students are taught, also includes a companion database for roughly 50,000 outpatients. It’s called the Lacidem Care Group. (Lacidem? That’s “medical,” backwards). It contains data from NYU’s own faculty practices — scrubbed to ensure that neither the patients nor the doctors can be identified. Students can use tools provided by the project to “look at quality measures for things like heart failure, diabetes, smoking, and high blood pressure,” says Triola. “And drill down and look at the performance of the practice as a whole and individual doctors.”

(Left to right) Christine Schindler, Mary Quien and Micah Timen hold a study session. Timen worked as an accountant before medical school; his database project tracked the relative costs of a hip replacement throughout New York compared to the relative costs of a fast-food hamburger. (Photo by Cindy Carpien for KHN/NPR)

Some students have taken to the assignment with relish. Second-year student Micah Timen is one. Timen likes numbers. A lot. A former accountant before applying to med school, he keeps a spreadsheet to track his study hours before a test. An upcoming test is on the digestive system. “So I know I have 18 hours and 40 minutes left to make sure I feel comfortable walking into my exam,” he says.

For his project, Timen wanted to know if the cost to patients of hip replacement surgery around the state vary as much as the cost of a fast-food hamburger. Timen says they tried comparing hip replacement costs using The Economist magazine’s famous Big Mac Index, which measures purchasing power between currencies. “But when you call McDonald’s, they don’t give you prices over the phone,” he said. So he tried Plan B: “Burger King gave it to me.”

Using his “Whopper Index” instead, Timen found, not surprisingly, that the price of a giant burger sandwich is higher in New York City than, say, Albany. So, too was the amount patients paid for their hip replacements. But the margin was much wider for health care than for hamburgers, meaning patients are paying more in some places than simple geography would suggest. Timen says he’d like to explore why that might be, “but unfortunately med school is a little bit time-consuming,” so that may have to wait.

Still, it turns out the classes appeal not just to data “junkies,” like Timen, but also to those who were not already steeped in crunching data.

“I really have no statistical background,” says Justin Feit, also a second year student. “I don’t even know how to use Excel well.”

So Feit was partnered with Jessica Lynch, who already has a PhD — in physics. She says that if medicine wasn’t moving in the direction of more data interpretation, “I don’t know if I would have gone into medicine.”

Together Feit and Lynch looked at the rates of cesarean births around the state – and, like the cost of hip replacements, found that C-section rates varied widely. But their project will get more than just a grade. A faculty member at NYU is using it as part of a bigger research project headed for publication.

Triola says he hopes that will happen more and more.

“With literally millions of records, these in-class student projects often involved more patients than the published literature. It’s incredible,” he said.

And the concept of having students learn to use health data is catching on quickly. Triola says NYU is offering its database and program to other medical schools; seven are already incorporating it into their curriculum.

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Fewer Black Men Apply To Medical School Than In 1978

Oviea Akpotaire and Jeffrey Okonye put in long days working with patients at the veterans’ hospital in south Dallas as fourth-year medical students at the University of Texas Southwestern.

In a class of 237 people, they are two of only five black men.

“I knew the ones above us, below us,” Okonye says. “We all kind of know each other. It’s comforting to see another person that looks like you.”

Jeffrey Okonye, left, and Oviea Akpotaire are both fourth-year medical students at the University of Texas, Southwestern. (Photo by Lauren Silverman/KERA)

While more black men than before have graduated from college over the past few decades, the number applying to med school has dropped: From 1,410 in 1978 to 1,337 in 2014. Enrollment statistics are similar:  542 black male students enrolled in 1978, compared to 515 in med school in 2014.

That’s according to a report from the Association of American Medical Colleges. Every other minority group — including Asians and Hispanics — saw growth in the number of applicants. And black women also saw an uptick in applications.

Enrollment statistics for 2015 are just out and they show a modest gain of 8 percent more black men in medical school over the year before.

“This is a positive sign,” says Marc Nivet, AAMC’s chief diversity officer, “but it does not change the fact that for 35 years the number has been trending poorly.”

“I was really surprised,” says Akpotaire, who is studying internal medicine. “I sent [the study] to my mom and dad immediately.”

The total number of applicants to U.S. medical schools was close to 50,000 in 2014, with about 20,000 enrolling, according to the AAMC.

Not Just A Numbers Problem

Increasing ethnic and gender diversity among doctors is important for patient health. Studies show people are more likely to follow doctors’ directions on things like medication or exercise if they can relate to them.

This story is part of a partnership that includes KERA, NPR and Kaiser Health News. It can be republished for free. (details)

Dr. Dale Okorodudu, a third-year pulmonary and critical care fellow at UT Southwestern, says making cultural connections can make a big difference.

“If you can relate to [patients], it’s a lot easier for them to feel at home and comfortable with you,” he says.

Okorodudu wrote a blog post about an experience at Parkland Hospital that stuck with him. He was walking down the hallway on the 10th floor when a black man stopped him:

“It’s good to see you brother!” I had never met this man, but I knew exactly what he was talking about. With a large smile on his face and a look of pride, he extended his arm to give me a handshake. “There aren’t too many of us doing what you do. I’m glad we got some representation in here.”

What’s Missing?

For years, Okorodudu has been trying to figure out why so few black men go into medicine. His conclusion: The lack of role models.

“If you’re a black male, let’s say you’re growing up in an inner-city neighborhood,” he says. “There’s so many things directly in front of you that you have the option to go into.”

From music and sports to small business and church, Okorodudu says those professions are visible and present in the lives of young African American boys. “But when you talk about the medical workforce, none of us are directly there in front of them,” he said.

Okorodudu decided to become a doctor when he was 18. A year from now, when he’s done with his fellowship, he’ll be 32.

Med student Jeffrey Okonye points out that for students like him who embraced math and science, there are much faster ways to “make it.”

“A lot of friends of mine, black males, are engineers,” Okonye says. “They go to school for four years. They have a job, great pay, even had internships in undergrad, I was highly jealous of. Whereas my route, four years undergrad, then another four years of school, and then another X amount of  training after that.”

So why did he take the longer route?

“It’s hard to describe the feeling you get when you make someone actually feel better,” Okonye says. “When you can see them go from one state to another and recognize that you were a part of literally changing this person’s life.”

Tools To Fix The Pipeline

A desire to care for others isn’t the only thing that Okonye, Akpotaire and Okorodudu have in common. All three have had role models of doctors or nurses in their families. And all three are the children of immigrants — from Nigeria. Okorodudu says that means the group of 1,337 black men who applied to med school last year is very different from the group in 1978.

“In 1978, those people we’re looking at, a lot of them were probably black American males” whose families had been in this country for generations, he says. Today’s black medical school students may be more recent immigrants from Africa or the Caribbean. “So if we broke it down that way, that factoid is actually even more alarming.”

That study by the AAMC has some suggestions on how to rebuild the doctor pipeline. Among them: create more mentoring programs, invest in education at K-12 public schools, increase financial aid options, and convince medical schools to put less emphasis on standardized tests scores like the MCATs.

Okorodudu is trying to help with an online service called DiverseMedicine. Users connect with mentors on chat or video.

Sometimes, he says, the key to getting kids interested is simply seeing a black man in a white coat.

This story is part of a reporting partnership that includes KERA, NPR, and Kaiser Health News.

In L.A., Community Health Workers Are Part Of The Medical Team

Month after month, Natalia Pedroza showed up at the doctor’s office with uncontrolled diabetes and high blood pressure. Her medications never seemed to work, and she kept returning to the emergency room in crisis.

Walfred Lopez, a Los Angeles County community health worker, was determined to figure out why.

Lopez spoke to her in her native Spanish and, little by little, gained her trust. Pedroza, a street vendor living in downtown Los Angeles, shared with him that she was depressed. She didn’t have immigration papers, she told him, and her children still lived in Mexico.

Then she mentioned something she hadn’t told her doctors: She was nearly blind.

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Pedroza’s doctor, Janina Morrison, was stunned. For years, Morrison said, “people have been changing her medications and changing her insulin doses, not really realizing that she can’t read the bottles.”

Health officials across the country face a vexing quandary – how do you help the sickest and neediest patients get healthier and prevent their costly visits to emergency rooms? Los Angeles County is testing whether community health workers like Lopez may be one part of the answer.

Lopez is among 25 workers employed by the county to do everything possible to remove obstacles standing in the way of patients’ health. That may mean coaching them about their diseases, ensuring they take their medications or scheduling medical appointments. Their help can extend beyond the clinic walls, too, to such things as finding housing or getting food stamps.

(L) The Los Angeles County-USC Medical Center is the county’s biggest and busiest public hospital. (R) Walfred Lopez, a community health worker at the Los Angeles County-USC Medical Center, sits in small cubicle in the clinic looking over a patient’s health record on Oct. 14, 2015. (Photo by Heidi de Marco/KHN)

The workers don’t necessarily have a medical background.  They get several months of county-sponsored training, which includes instruction on different diseases and medications, as well as tips on how to help patients change behavior. They are chosen for their ability to relate to both patients and providers. Many have been doing this job for friends and family for years – just without pay.

“By being from the community, by speaking their language, by having these shared life experiences, they are able to break through and engage patients in ways that we as providers often can’t,” said Dr. Clemens Hong, who is heading the program for the county. “That helps break down barriers.”

For now, they work with about 150 patients, many of whom have mental health issues, substance abuse problems and multiple chronic diseases. The patients haven’t always had the best experience with the county’s massive health care system.

Walfred Lopez, a community health worker at the Los Angeles County-USC Medical Center, visits patient Maria Rivera, 48, at her home in La Puente, Calif., on Oct. 9, 2015. Rivera says she depends on Lopez to understand what is happening with her health. (Photo by Heidi de Marco/KHN)

“They tell us, ‘I am just a number on this list,’” Lopez said. “When you call them by name and when you know them one-on-one … they receive that message that I care for you. You are not a number.”

By spring, Hong said he hopes to have hundreds more patients in the program.

Community health workers have been used for decades in the U.S. and even longer in other countries.  But now officials in various counties and states — including Massachusetts, Pennsylvania and Oregon —  are relying on them more as pressure grows to improve health outcomes and reduce Medicaid and other public costs, experts said.

“They are finding a resurgence because of the Affordable Care Act and because health care providers are being held financially accountable for factors that occur outside the clinical walls,” said Dr. Shreya Kangovi, assistant professor of medicine at the University of Pennsylvania and director of the Penn Center for Community Health Workers.

Community health worker Walfred Lopez checks the patient’s medicine to make sure she is up-to-date during a home visit in La Puente, Calif., on Oct. 9, 2015 (Photo by Heidi de Marco/KHN)

Kangovi said community health worker programs, however, are likely to fail if they don’t hire the right people, focus too narrowly on certain diseases or operate outside of the medical system. They also need to be guided by the best scientific evidence on what works.

“A lot of people think… they can sort of make it up as they go along, but the reality is that it is really hard,” she said.

Hong, who designed the program based on lessons learned from other models, said Los Angeles County is taking a rigorous approach. It is conducting a study comparing the costs and outcomes of patients in the program against similar patients without assigned workers.

The patients are chosen based on their illnesses, how often they end up in the hospital and whether doctors believe they would benefit.

To Lopez, 43, the work is personal. A former accountant from Guatemala, Lopez has a genetic condition that led to a kidney transplant. Like some of his patients, including Pedroza, he is now on dialysis.

He tries to use his experience and education to get what patients need. But even he runs into snags, he said. One time, he had to argue with a clerk who turned away his patient at an appointment because she didn’t have identification.

“The hardest part is the system,” Lopez said. “Trying to navigate it is sometimes even hard for us.”

Walfred Lopez informs patient Maria Rivera that she is a candidate for bariatric surgery, but needs to lose some weight before the procedure. (Photo by Heidi de Marco/KHN)

Lopez and his fellow community health worker, Jessie Cho, sit in small cubicles in the clinic at Los Angeles County-USC Medical Center, the county’s biggest and busiest public hospital. Throughout the day, they accompany patients to visits and meet with them before and after the doctor does. They also visit patients at home and in the hospital, and give out their cell phone numbers so patients can reach them quickly.

Cho said the patients often can’t believe that somebody is willing to listen to them. “Nobody else on the medical team has it as their job to provide empathy and compassion,” she said.

Morrison, the clinic physician, said both workers have become an essential part of the health team.

“There is just a limited amount I can accomplish in 15 or 20 minutes,” Morrison said. “There are all these mysteries of my patients’ lives that I know are getting in the way of taking care of their chronic medical problems. I either don’t have time to get to the bottom of it or they are never going to really feel that comfortable talking to me about it.”

Natalia Pedroza, who wears a colorful scarf around her head and speaks only Spanish, is a perfect example.  Morrison said before Lopez came on board, “I wasn’t getting anywhere with her.”

Initially, Lopez had a hard time helping her understand her health conditions and overcoming her distrust of the system. When they first met, Pedroza believed the dialysis that kept her kidneys functioning was the cause of her health problems. And she didn’t get why Lopez was always around.

But he helped her — by getting her appointments, for instance, and helping arrange for Pedroza to get pre-packaged medications so she wouldn’t have to read the directions. Now Pedroza thinks Lopez is helping her to get better.

On a recent afternoon, Lopez sat down with Pedroza before her medical appointment.

“How are you feeling?” he asked in Spanish.

Pedroza responded that her hair was still falling out and that she still felt sick. She also said she hadn’t been checking her blood sugar because she didn’t know how to use the machine. Lopez calmly demonstrated how the machine worked, and then the two spent several minutes chatting about her job and her neighborhood.

Patient Maria Rivera, 48, at her home in La Puente, Calif., on Oct. 9, 2015. Rivera is diabetic, dealing with high blood pressure and recently had a tracheotomy. (Photo by Heidi de Marco/KHN)

Lopez said he believes he has a made a difference for other patients as well. On a recent Sunday, a 43-year-old patient with chronic pain who initially refused his help texted that he planned to go to the emergency room because of a headache. Lopez reached Morrison, who agreed to squeeze him into the schedule a few days later. And the patient didn’t go to the ER.

Lopez persuaded another patient, a 56-year-old woman, to take her blood pressure medication before her appointments so that when she arrived, the doctors wouldn’t get worried about her numbers and send her to the hospital.

In one case, his ability to bond with a patient almost undermined his goal of getting the man the help he needed. The patient, who was depressed, said he didn’t want to go see a mental health counselor because he was more comfortable talking to Lopez.

“It was touching,” Lopez said. “I was about to cry.”

Blue Shield of California Foundation helps fund KHN coverage in California.

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Suing A Nursing Home Could Get Easier Under Proposed Federal Rules

As Dean Cole’s dementia worsened, he began wandering at night. He’d even forgotten how to drink water. His wife, Virginia, could no longer manage him at home. So after much agonizing, his family checked him into a Minnesota nursing home.

“Within a little over two weeks he’d lost 20 pounds and went into a coma,” says Mark Kosieradzki, who was the Cole family’s attorney. Dean Cole was rushed to the hospital, says Kosieradzki, “and what was discovered was that he’d become totally dehydrated. They did get his fluid level up, but he was never, ever able to recover from it and died within the month.”

Kosieradzki says that Virginia Cole had signed a stack of papers when her husband was admitted to the nursing home. As is often the case, one of the forms was a binding agreement to go to arbitration if she ever had a claim against the facility. So instead of taking the nursing home to court, her claim for wrongful death was heard by three private arbitrators. They charge for their services.

“The arbitration bill for the judges was $60,750. That was split in half between the two parties,” says Kosieradzki.

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Virginia Cole won her claim, but after paying the arbitrators, expert witnesses and attorney’s fees, she was left with less than $20,000.

The federal government is now considering safeguards that would regulate the way nursing homes present arbitration agreements when residents are admitted.

But more than 50 labor, legal, medical and consumer organizations have told the government that’s not enough. They want these pre-dispute arbitration agreements banned entirely. Thirty-four U.S. senators and attorneys general from 15 states and the District of Columbia also have called for banning the agreements.

“No one should be forced to accept denial of justice as a price for the care their loved ones deserve,” says Henry Waxman, a former congressman from California. Arbitration agreements keep the neglect and abuse of nursing home residents secret, Waxman says, because the cases aren’t tried in open court and resolutions sometimes have gag rules.

“None of the systemic health and safety problems that cause the harm will ever see the light of day,” he says.

The proposed federal regulation would require nursing homes to explain these arbitration agreements so that residents or their families understand what they’re signing. It would also make sure that agreeing to arbitration is not a requirement for nursing home admission.

The American Health Care Association, which represents most nursing homes, is against this proposed change in the rules. Clifton Porter II, the AHCA’s senior vice president for government relations, says that’s because “they’re prescribing us to do things that we, frankly, already do.” Porter acknowledges, however, that practices vary from facility to facility, depending on state law.

Arbitration agreements, he says, are common throughout the health care industry — in hospitals, surgery centers and doctors’ offices. “Why aren’t rules being promulgated to eliminate arbitration in those settings?” he asks.

In any case, Porter says arbitration is more efficient for both sides than going to court would be.

“It actually allows consumers to get an expedited award,” he says. “And you have the benefit of not having to use the courts and go through the entire process.”

But that expedited award is about 35 percent lower than if the plaintiff had gone to court. That’s one conclusion of a study commissioned by Porter’s organization in 2009.

If the federal government does regulate or ban the signing of arbitration agreements for new nursing home residents, Porter says the American Health Care Association will probably fight the move in court.

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The North Carolina Experiment: How One State Is Trying To Reshape Medicaid

North Carolina is in the process of overhauling its Medicaid program. The governor and state lawmakers are using a mixture of health care models to put the major players — doctors, hospitals and insurers — all on the hook to keep rising costs in check.

For many of the Republicans who control the state legislature, the reason for the change is simple: budget predictability.

“For years and years and years, Medicaid has been considered the budget Pac-Man that eats up all the dollars that people in this chamber would like to see spent on many, many other things,” Rep. Bert Jones said during the North Carolina House’s debate of the bill last month. Gov. Pat McCrory signed the overhaul into law on Sept. 23.

The state, which has not expanded Medicaid under the health law, struggled with huge Medicaid cost overruns from 2010 through 2013. That sent lawmakers looking for a better way to manage it, even though a signature part of the program has won national awards for quality and cost.

The lawmakers settled into two camps: One camp wanted to use a managed care model, which basically means paying large insurance companies a specific amount per person covered and relying on the companies to contain costs.

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“The alternative idea was to contract with what are called accountable care organizations,” said Wake Forest Professor Mark Hall, “which is a newly emerging idea both at the state level and the federal level to organize systems of health care finance and delivery that are led by doctors and hospitals.”

The federal government is pushing that model for Medicare, the government insurance program for the elderly. The idea is to put the doctors and hospitals in charge of the health of a certain population of people. If they can provide care that keeps people healthy and saves money, doctors and hospitals can share some of that savings.

Some state lawmakers worried that the doctor-and-hospital model wouldn’t save enough money. Others worried the insurance company model would skimp on care. So they settled on a mixture of both.

Will that create “a Frankenstein’s monster?” That’s the question Hall, the Wake Forest professor, asked earlier this year.

“We proposed the thought that hybridizing these two separate ideas might be freakish, but in fact, I don’t think it is,” he said. “I think it’s actually a very sound and carefully thought-out use of the best of both models.”

Outside of North Carolina, Oregon is also contracting with both MCOs and ACOs, and a few other states are exploring how to encourage provider organizations to play a bigger role in Medicaid managed care.

In the meantime, North Carolina is drawing from the managed care/insurance company model to change how it pays for Medicaid.

As of now, doctors bill Medicaid after they provide services, so the incentive is to provide more services. In the new system, the state will set budgets up front for whomever it puts in charge of managing care. If those managers go over budget, they’re on the hook – not the state.

That’s becoming the standard approach to payment, says Dan Mendelson, CEO of consulting firm Avalere Health.

“Most states contract for Medicaid through managed care because states don’t want open-ended financial liability,” Mendelson said.

Normally, those states contract with insurance companies. But here’s where the doctor-and-hospital model comes in. North Carolina will open up its bids to insurance companies and doctor-and-hospital systems. It will also set up quality metrics to track how they do.

Game on, says Julie Henry of the N.C. Hospital Association.

“We’re moving in this direction in other arenas in health care, not just for the Medicaid population, but for commercially insured patients and for Medicare patients,” she said.

Henry points out some doctor-and-hospital systems in North Carolina are already meeting quality metric standards and saving money under Medicare. Some insurance companies are posting similar results.

Patient advocates say one system isn’t necessarily better than the other.

“We think it’s important to focus on not just who we hand a big bucket of money to, but what are the rules for spending that money,” said Corye Dunn of Disability Rights North Carolina.

She says making sure the quality metrics are effective will be a crucial part of the overhaul process.

Also, lawmakers set a cap of 12 percent for how much money can go toward administrative costs and profits.

“The challenge lies in the fact that Medicaid is already a very lean program, and there’s just not a lot of fat to cut out there,” said Joan Alker of the Georgetown University Center for Children and Families. “The concern is, will the managed care company save money the right way or the wrong way?”

Some worry the risks of the overhaul outweigh the benefits. Cost overruns have not been a problem the past two years. And many in North Carolina’s medical community take pride in effective parts of the old program.

A Republican legislative leader on health care policy, Rep. Nelson Dollar, voted against the overhaul. And Democratic Rep. Gale Adcock, a nurse practitioner from Wake County, told other lawmakers to consider a guiding principle in health care.

“First, do no harm,” she said on the House floor. “I’m very fearful that if we pass this bill, we will do harm.”

The version that passed will change the award-winning part of the program, called Community Care of North Carolina. Community Care is a network of doctors, nurses and pharmacists who coordinate care for roughly 80 percent of Medicaid patients. A recent state audit found that Community Care has been saving the state money and improving patient outcomes.

As insurers and hospital systems take over those functions, Community Care President Dr. Allen Dobson says his organization will look to partner with them.

“We expect we’ll play a fairly significant role,” Dobson said. “It will be different. We may move from having one customer, which has been the state, to having multiple customers.”

One of the Republicans who led the overhaul effort, Rep. Donny Lambeth, says Medicaid is not broken in North Carolina. But he says as health care evolves, the state needs to keep up.

“Fact is, we can actually do better in North Carolina for these Medicaid beneficiaries,” Lambeth said on the House floor. “Do you think quality in North Carolina across all the providers is equal and good? I can tell you it is not.”

Lambeth says the new quality metrics will make it easier to track that. He says it’ll take three to four years to get federal approval and implement the changes.

This story is part of a reporting partnership that includes WFAE, NPR and Kaiser Health News.

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