Friday, November 28, 2003

“Vot iss ze effidence?”

My early days at the University of Chicago coincided with the waning years of Anton J. Carlson, who had within living memory been its renowned Professor and Chairman of Physiology. Known by his friends as Ajax, this Swedish immigrant who never quite mastered spoken English was said to have commonly responded to scientific claims made by his students with the question “Vot iss ze effidence?”

I was reminded of that the other day while watching a PBS documentary. One of the individuals being featured was reported as having been diagnosed with leukemia. He was being treated at the Sloan-Kettering hospital in New York, referred to in passing as “one of the best cancer hospitals in the country.”

I immediately asked myself how the film narrator could possibly know that. How could anyone be certain that less-renowned cancer treatment centers in places like Hoboken and Omaha weren’t getting better results with leukemia than the people at Sloan-Kettering? I thought I heard the ghost of Ajax Carlson ask: “Vot iss ze effidence?”

It is not a frivolous question. For one thing, in this day of electronic communication, all of the information about leukemia that is available to Sloan-Kettering is also available everywhere else. In addition, it is generally believed that cancer care benefits from close cooperation among oncologists, radiologists, surgeons and other cancer-related specialties – something that can be difficult to achieve at famous hospitals, which tend to attract big names with correspondingly big egos.

The truth is that in the absence of outcomes data we don’t know that Sloan-Kettering is one of the best cancer hospitals in the country.

But the right information would give us a pretty good idea. And we ought to get it.

Sunday, November 23, 2003

Private Sector Health Care – Intellectual Orphan

This morning’s New York Times had three letters to the editor under the heading “Health Insurance for All Americans?” All favored national health insurance in one form or another. They were signed by three individuals who identified themselves, respectively, as

· Professor of Political Economy at Princeton
· Professor of Health Economics at George Washington University
· Professor of Health Care Management at Boston University.

Although health care in the U.S. is provided predominantly in the private sector, and although it appears that we will have a pluralistic system of financing for the foreseeable future (one letter writer opined that we “probably never will” have comprehensive national financing), one is hard put to find anyone in the intellectual community carrying out thoughtful analysis of how it works and how it might be made to work better.

Those of us who are interested in the redesign of the health care system would benefit greatly from some help from the intellectual community.

But it looks like we will have to wing it.

Friday, November 21, 2003

More on Sloppy Healthcare

No sooner had I posted A Good Report from the Hisles (see below) than the following came in from Holly Raymond, a cytotechnologist who works in the Boston area and who claims 35 years of experience in hospital laboratories.

I had some medical tests this past spring and summer, and was absolutely shocked at the way things have changed for the worse. Luckily I am in the medical field and know how to talk to doctors, and I was able to stand up for myself and actually scolded a radiologist for the gaffes he made. For starters he entered the radiology suite where I was in the middle of a lower GI series, (another MD did the first half of the test, then had a meeting to attend); the second rad doc came and said to me "we're going to be doing a barium enema on you". I quickly corrected him and he proceeded with the planned test. At the end of the procedure he told me I had a completely normal intestine. Well, I knew I didn't, as I've had multiple surgeries for Crohn's Disease including temporary colostomy, and removal of the ileocecal valve. Evidently no one had been interested enough to get a medical history on me.

When I had a colonoscopy under anesthesia this summer, I announced that I would not be having the procedure until I had spoken with the GI doc, myself, whom I had never met. When I told him of my history, he was glued to attention to what I was telling him. What if I had been unable to tell him, orally, my history, all at the last minute?

A Good Report

With all the carping about what is wrong with our health care system, we need to be reminded from time to time that there is also a lot about it that is good. The following comes from Betty Jean and Leon Hisle, friends and hospital administration colleagues from Kentucky days. The Hisles are now retired and winter in Ocala.


Since good reports on health care issues are rare, we would like to commend The Central Florida Heart Institute in Ocala, FL on its extremely efficient service. The practice is made up of several Cardiologists and two Internists many of which are Asian Indians.

Dr. Ferns, Leon's Cardiologist, who trained at Jewish in Louisville, is a warm friendly man who cares enough to telephone with questions and suggestions.

Their Lab, X-Ray and other diagnostic services are located in the principal office building. Today Leon had an appointment for a routine follow up EKG. He was taken into the EKG room at the exact time of the appointment and before I was half way through the latest issue of Architectural Digest, he emerged. Both of us have been in for lab work and, in contrast to the phlebotomist at the UK clinic, the cheerful technicians at CFHI are always prompt and have yet to cause either of us the slightest haematoma.

The billing office staff is equally friendly and efficient.

Wednesday, November 19, 2003

Public Attitudes and Medical Errors

The other day, I learned from my friend John (not his real name) that our mutual friend Paul (not his real name either) was in the hospital. It seems that Paul had been admitted for angioplasty but something hadn’t gone quite right so he had stayed in the hospital longer than originally expected.

In the course of conversation, I let it be known that in my view we were too complacent about such things. When medical treatment goes awry, we tend to shrug our shoulders and say “well, these things happen.” I said that things that happen happen for a reason and that when bad things happen red flags ought to go up and urgent steps ought to be taken to find out why and to prevent them from happening again.

John’s response was that we ought to be grateful for all the marvelous things doctors can do nowadays.

That struck me as a non sequitur. Angioplasty is now a common procedure and the fact that it would have been thought a miracle fifty years ago shouldn’t excuse its being performed sloppily today – at least not in my judgment.

But I suspect more people agree with John than agree with me.

If so, it could say a lot about why doing something about medical errors is so difficult. Doctors who resist the discipline needed to prevent them may still find the public on their side.

The Dark Side of National Health Insurance

In its November 17, 2003 Internet publication, the Center for American Progress discussed the efforts being made to line up support for the Medicare bill now being debated in Congress. In discussing the attempts to recruit lobbyists to the cause, it stated that “One such group is the AMA. The new legislation will give doctors a 1.5% increase in Medicare fees next year instead of the 4.5% cut under current law. Thus, the lobby has said it will blitz Capitol Hill with an advertising and grassroots campaign."

In other words, the support of the AMA had been “bought.” In a previous posting, I suggested that revoking the 4.5% cut might well be justified. But using it as leverage to gain support for another cause is something else again.

The Center for American Progress is a Democratic think tank and its partisanship may at times lead it to see cause and effect where none exists. But if the statement it makes is true, it would not be the first time such a thing happened. At the time Medicare was enacted, it was commonly said that House Ways and Means Chairman Wilbur Mills “bought off” the AMA by slipping in Medicaid at the last minute – thus providing the profession with some relief in its age-old obligation to care for the poor. I recall reading that during the final days of the debate on the Clinton Health Care Reform proposals, the chiropractors were told that if they came out in support, Medicare would pay them for x-rays – something Medicare had steadfastly refused to do previously.

No one can argue against National Health Insurance as a remedy for the problem of the uninsured. But neither should anyone overlook the certainty that it would be used for political purposes as well as for the purpose of financing health care for the people.

Thursday, November 13, 2003

Is Malpractice Immune from Prevention?

This morning’s Boston Globe carried a long article on medical malpractice. It reported that the Massachusetts governor’s office and the Harvard School of Public Health are “….working on a sweeping proposal to move malpractice claims out of state courts and into a new administrative framework much like the state’s workers’ compensation system.”

The article ran about one and a half columns the full length of a newspaper page. It pointed out, among other things, that medical malpractice insurance premiums have risen 77% in Massachusetts since 1998.

In all of that, there was not a single mention of prevention. It seems never to have occurred to anybody that one way to reduce the cost of malpractice would be to have less of it. Patients would benefit, too.

The justice system considers that malpractice is due to human negligence. Everybody else seems to assume that it is an act of God.

The comparison with workers’ compensation calls to mind the signs in industrial establishments that show the number of days since the last worker injury.

Do you suppose hospitals will ever put signs in doctors’ lounges showing the number of days since the last malpractice claim?

Tuesday, November 11, 2003

David Drake on Employer-Financed Health Insurance

The following just in from erstwhile AHA bigwig David Drake:

In cleaning up my files to move them to Key West, I found an extremely interesting piece that I had clipped from the November 2nd New York Times by Daniel Akst entitled, "Why Do Employers Pay for Health Insurance, Anyway?". Akst starts out by listing some of the reasons for hating the employer-financed insurance system: It reduces employee mobility by creating job lock; it suppresses the creation of new businesses by raising the start up costs of new enterprises; it raises the operating costs of mature companies who incur huge costs for the benefits of retired workers; it is inequitable by unfairly excluding the unemployed, the self-employed and low-skilled workers and by shortchanging single workers to the benefit of married workers; and, worst of all, it totally disrupts the use of marketplace cost controls by obfuscating from consumers the real costs of health care. Akst concludes that "The status quo [in health care] is untenable," which is akin to my conclusion that the health care system can only be reformed by systematic overhaul, tinkering won't work. In economics, any system built on the premise that you can get something for nothing undermines the most fundamental of economic truths: scare resources have alternative uses. Akst and I concur that the only possible solution is the passage of universal health insurance, but, alas, we fail to agree on the type of UHI. He favors a voucher for basic coverage with high deductibles and co-pays, while I support income-related catastrophic coverage (see my Reforming the Health Care Market, Georgetown University Press, 1994). Except for this disagreement, I highly commend Mr. Akst's analysis.

Public Tolerance of Sloppy Performance in Health Care

In a release of November 9, 2003 under an Orlando, FL dateline (there must have been a medical meeting at Disneyland), Associated Press Medical Editor Daniel Q. Haney reported the sobering results of a study conducted by Dr. Greg Fonarow of UCLA.

The study measured compliance with four standard kinds of care for patients hospitalized for congestive heart failure. Reported results are as follows:

- 31% left without prescriptions for ACE inhibitors
- 72% left without complete discharge instructions according to recommended guidelines
- 69% of smokers had not been told to quit
- 18% had not had the pumping power of their left ventricles measured.

Lest someone conclude that these failures occurred only in backwater institutions, the study revealed that in “elite teaching hospitals” more than a quarter of the patients left without ACE inhibitors.

According to Haney, “Just why doctors do not give patients the treatments experts universally agree work best is not always clear, although those who study the situation say the reasons probably range from forgetfulness and haste to simple ignorance.”

The article also quotes Dr. Richard Pasternak, head of preventive cardiology at Massachusetts General Hospital as saying that he believes doctors are actually more likely to follow standard procedures than they once were.

Some comfort!!!

If a situation like this arose in any other line of work, there would be a cry to find out who was responsible for such an inexcusable lapse and an insistence that something be done about it.

But not in the case of health care, where the public is amazingly tolerant of sloppy performance.

One wonders how long it will last.

Thursday, November 06, 2003

National Health Insurance – Starvation Diet for Health Care

I have the impression that more than a few of our leaders assume that the current difficulties in health care will ultimately be resolved by adopting some form of national health insurance.

They had better think twice about that.

On October 30, CMS announced its physician fee schedule for 2004. In classic bureaucratese it said that there had been “an update for 2004 of negative 4.5%.” In English, that means that physician fees paid by Medicare – already about half of regular charges – will be cut another 4.5%.

The reduction resulted from the application of a pernicious formula enacted in legislation to control the Medicare expenditure budget. Rather than take the politically hazardous course of requiring that the health care delivery system reduce cost by reforming itself and becoming more efficient, the politicians devise a complicated calculation that cuts fees in ways that the public will not understand.

I have observed on occasion that national health insurance could reasonably be characterized as a method of freezing in place the existing and outdated system of health care delivery and then slowly starving it to death.

Great Britain and Canada have been my favorite examples. Medicare is joining the list.

More on the ER

No sooner had I commented on tendency of hospitals to discourage the use of the ER, despite the popularity of the service (See the posting just below) than did Baptist Health System in Memphis announce its “public awareness campaign” in response to ER overcrowding. The stated purpose of the campaign is to “educate the public about the problem and encourage patients to seek more appropriate care settings for non-emergent conditions.” (AHA News Now, November 5, 2003)

In other words, Baptist announces (and funds) a campaign to convince the customers beating on its doors to go elsewhere.

It seems that redesign of health care has to deal with attitudes as well as with structure.

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