Thursday, October 30, 2003

The Hospital ED – Captive of Myths

It has often occurred to me that if any other form of enterprise offered a service that was as popular as the hospital Emergency Department (ED) it would promote it to a fare-thee-well.

The reason hospitals haven’t done so is because in times past doctors haven’t wanted them to. They saw every paying emergency room patient who could have waited until the next day as a lost office visit fee. Even worse, a doctor’s patient who goes to the ED might get referred to another physician who is on call that day and never return.

But, of course, none of that could be said, and so we devised other reasons, none of which, as it turns out, holds water.

Three of these reasons appear in the report of a recent study (Insured Americans Drive Surge in Emergency Department Visits,” Issue Brief No. 70, Peter J. Cunningham and Jessica H. May, October 2003, Issue Brief No. 70, Center for Studying Health System Change (HSC), Washington, D.C., www.hschange.org ).

One is that that the ED is really for emergencies and so non-emergency patients who show up there are “abusing” the service. The HSC report puts it more gently, saying that “crowding could limit the ability of EDs to fulfill their community benefit function in responding to….emergencies.” That is a little specious since real emergencies are never neglected in favor of the non-emergency patients stacked up in the waiting room. Besides, there is an obvious way to deal with overcrowding. Expand!

A second is that ED care is episodic and thus suspect. As the study puts it, “….many health professionals and researchers have warned that because hospital EDs typically are not structured to ensure continuity of care and a strong patient-physician relationship, they are less-than-ideal regular sources of primary medical care.” What constitutes “less-than-ideal” is not specified. Researchers may be among those doing the warning, but their concern apparently does not extend to providing any data in support of it. Most likely there isn’t any.

The third is the most persistent and fallacious of all. Here is how the study puts it: “Because the cost of treating patients is higher in the ED than in other outpatient clinics and medical practices, privately insured persons’ increased use of the ED for many non-urgent health problems will contribute to higher health insurance costs…” There is no reason to believe that cost is higher. It only appears so because of the way books are kept. When the standby costs of being open on a 24/7 basis, the cost of major trauma cases, and the cost of treating a 9-year-old’s earache are averaged, it makes the cost of the latter look astronomical. But if the 9-year-old didn’t come, the cost avoided would be miniscule and the average cost of the other services would go up.

The study also points out that ED waiting times for patients are high and growing. From 1999 to 2001, the percentage of patients waiting more than a half hour grew from 36 to 45. Those familiar with EDs in major urban hospitals know that 3 and 4-hour waits are commonplace. Any other form of business lucky enough to have a constant supply of customers backlogged in the waiting room would be expected to be highly efficient.

In other words, a well-managed ED ought to be the least – not the most - costly way to provide ambulatory care.

Besides, it provides a service that the people want.

If the health care delivery system is to make progress in dealing with the problems of excessive cost and inadequate quality, these entrenched myths and prejudices must be overcome.

Friday, October 24, 2003

Do It Right! A Key to Quality

My mother always said that if a thing was worth doing, it was worth doing right.

I thought all mothers said that, but apparently not.

The October 8, 2003 issue of JAMA carried an article that got a modest splash in the media. Its title was “Excess Length of Stay, Charges, and Mortality Attributable to Medical Injuries During Hospitalization.”

My fifty-year-old knowledge of statistics proved insufficient to understand the methodology of the study. However, I could understand some of the conclusions, including the following

· “The most serious event appeared to be postoperative sepsis….”

· “….the 18 types of medical injuries [studied] may add to a total of 2.4 million extra days of hospitalization, $9.3 billion excess charges, and 32,591 attributable deaths in the United States annually.”

· “….our results clearly show that medical injuries in hospitals pose a significant threat to patients and incur substantial costs to society.”

At about that same time, I came upon an article in the July/August 2003 issue of Michigan Health and Hospitals Magazine authored by Dr. William A. Conway, Jr., a friend and colleague from Henry Ford Health System days. It seems that Henry Ford Hospital (where Conway is Chief Medical Officer) got picked in 2002 to participate in a demonstration project on surgical site infection prevention sponsored by the Centers for Medicare and Medicaid Services.

The prevention techniques employed were appropriate antibiotic management (i.e., giving the right antibiotic preoperatively, giving it at the right time, and terminating it at the right time), controlling blood glucose, clipping instead of shaving the surgical site, and monitoring and managing body temperature.

The results? To quote Conway, “For each group of patients in the pilot population, infection rates during the 12 months of the collaborative, compared with the previous 12 to 18 months, have dropped by nearly half or more.”

Providers often say that in order to address the quality problem we need national programs, standard definitions and criteria, better information systems, etc. etc.

The Ford people didn’t need any of that. They just put their minds to doing what they already knew was right.

My mother would have approved.

Tuesday, October 14, 2003

More on Whether California is Leading the Way

Herewith the response of Jeff Frommelt, long time colleague and personal friend, to my 9/16/03 posting making approving remarks about the California proposal (now law, I understand) requiring employers of a certain size to make health insurance available to their employees.


I hope California does not lead the way in many things. It has too many inane laws and voter initiatives that create impossible situations.

We already have laws, like OSHA, that govern firms in many ways once they reach a certain size. What they do is create work for those that help firms get around the laws. You will see more and more firms with "employees" made into "independent contractors."

On the Wonders of Fee-for-Service:

Last November, Marilyn (my wife) slipped on some wet tree leaves and broke a bone in her lower arm. The blow (described by the caregivers as a FOOSH; i.e., Fall On Out-Stretched Hand) also messed up her shoulder, which resulted in 24 physical therapy visits.

The flurry of financial transactions that ensued can be summarized as follows:

Number of charges processed: 104 (69 were for PT - whirlpool, exercise, and treatments).
Number of Medicare reports to the patient: 12
Number of reports from the Supplemental carrier: 10
Total charges: $5,168.80
Amount paid by Medicare: $1918.71
Amount paid by Supplementary carrier: $657.14
Amount paid by patient: $41.84
Total paid: $2,617.69
Amount of time it took for me to figure all this out: More hours than I want to admit.

In addition to that, goodness knows how much paper was exchanged by the providers and the third party payers.

There has to be a better way.

I recall my days at Henry Ford when Health Alliance Plan (HAP), Ford’s HMO, had a simple arrangement with the Henry Ford Medical Group (HFMG), Ford’s salaried doctors. For HAP patients enrolled with HFMG for care, HAP simply transferred to HFMG every month the bulk of the premium it had collected. From that amount, HFMG funded the physician care it provided and paid Ford’s hospitals for the hospital services it used.

While we were at Ford, Marilyn underwent arthroscopic repair of a knee she popped while skiing. As best we can recall, we paid nothing and got no financial notices.

Of course, that arrangement only works if providers take responsibility for managing care, something that they have been notably loath to do.

Oh. The broken bone healed nicely. The shoulder is much better and continues to improve.

Tuesday, October 07, 2003

Is the Gold Standard in Health Care Shifting?

On September 29, 2003, Modern Healthcare, in cooperation with Solucient and NEC (Information Technology Companies), published its annual list of the 100 top hospitals in the U.S. According to the publication, hospitals were ranked on eight measures of clinical and financial performance, of which the following six were mentioned:

Operating profitability
Expenses per discharge
Average length of stay
Mortality rate
Complications rate
Total asset turnover

In the category of major teaching hospitals (400 beds or more), what was remarkable was not so much who made the list as who didn’t. The list of no-shows included the venerated Massachusetts General and Brigham and Women’s, the two jewels in the crown of Harvard medicine. John’s Hopkins didn’t make it either, as didn’t other big-time places such as the University of Chicago and the University of Michigan. Summa Health System in Akron and Pitt County Memorial Hospital in Greenville, N.C. did make it.

Measurements used in these exercises are still pretty crude, but they are gradually getting better and it is my prediction that as they improve, there will be some surprises. Some places few have heard of may well show up better than the famous ones. Given the high costs that are common in the name institutions, payers are likely to wonder why they should pay more for poorer results.

That might cause quite a bit of system redesign all by itself.

Thursday, October 02, 2003

Who is in Charge?

Last May the 9th, while a patient at the renowned Boston Children’s Hospital, a 5-year-old boy suffering from epilepsy had a major seizure that wracked his entire body for an hour and a half, following which he stopped breathing. The boy was in the Medical ICU after having had electrodes implanted in his brain for the purpose of tracking his disease. Because of uncertainty about which doctor was in charge of the case (the neurosurgery resident, the ICU fellow, or the epilepsy fellow), the aggressive treatment usually applied in such cases was never ordered. The patient died two days later. There have been other such incidents at Boston Children’s. (Boston Globe, September 19, 2003)

In is interesting that in pursuing the case, neither the state authorities nor the press went after the Hospital’s medical staff, the Harvard Medical School with which the Hospital is affiliated, or a professional organization such as the American Academy of Pediatrics. Instead, they went for the Hospital, which made apologies and accepted full responsibility.

To the simple-minded, the obvious remedy would be for the Hospital to have on duty at all times a Physician-In-Charge with authority to resolve such matters on the spot. But, of course, that would compromise the absolute autonomy and authority of the Clinical Chiefs and so nobody was bold enough to suggest it.

Some day that will happen.

One only hopes that not too many more children will have to die first.

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