Sunday, April 25, 2004

Preventing Useless Cost in Health Care – Whose Job?

The following was composed some weeks ago but seems somehow not to have gotten posted. On re-reading, it still seems worthy so here it is:

The front page of the Sunday, March 21, 1004 New York Times carried an article about recently reported research that casts doubt on the value of artery-opening methods like bypass surgery and stents in preventing heart attacks.

The research found that heart attacks are not usually caused by a gradual buildup of plaque that eventually closes off the artery. Instead, what happens is that an area of plaque bursts, a clot forms over it, and blood flow is stopped. In 75 to 80 percent of cases, the plaque that erupts was not obstructing an artery. Since heart patients have hundreds of vulnerable plaques, there is no reason to believe that one selected for treatment is the one that will burst.

The research shows, in addition, that remedies like stopping smoking and reducing cholesterol levels are much more effective at preventing heart attacks than angioplasties and stents.

The three researchers cited were Dr. Greg Brown of the University of Washington in Seattle, Dr. Steven Nissen of the Cleveland Clinic, and Dr. David Waters of the University of California at San Francisco.

The article included data indicating that angioplasties and stents in the U.S. now total over 2 million per year. If it is true that the great majority of them are clinically useless, the amount of unnecessary cost being incurred is substantial.

The question I would ask is, who now is responsible for taking action in light of this new information? The NYT article didn’t deal with that, but did discuss at some lengths the difficulty in getting doctors to stop doing the procedure. For one thing, physician and hospital income is involved. For another, our culture is action oriented and when people are diagnosed with a life-threatening disease, they want something dramatic done.

In the redesigned health care system that I dream about, hospital boards all across the country would be addressing these new research findings during board meetings this spring, searching for a resolution of the dilemma of trying to protect income while being responsible about spending the public’s money.

As we Boston Red Sox fans have learned to say, maybe next year.


Saturday, April 24, 2004

Supervising Doctors Redux

No sooner had I completed the posting about medical misbehavior as reported by the Boston Globe last Sunday and Tuesday than another such story appeared in the Thursday (April 22) issue.

This time, the story reported that the Massachusetts Board of Registration in Medicine had suspended the licenses of five physicians.

· Dr. Donald J. Greely, Jr., a surgeon, was suspended for five instances of “substandard care,” two of which involved deaths.
· Dr. Lisa Lombard, an anesthesiologist, was suspended for practicing medicine while addicted to the painkiller Demerol.
· Dr. Lee Chartock, a psychiatrist, was suspended after repeated reports of alcohol impairment in his office and at public events.
· Dr. Christopher Simard, identified as a former anesthesiologist in New Hampshire who had a Massachusetts medical license, was suspended for abusing the addictive drug fentanyl.
· Dr. Beverly Greer, an obstetrician/gynecologist, was suspended after repeated arrests for alcohol-related motor vehicle offenses.

Hospitals involved in these cases were:

· South Shore Hospital in suburban Weymouth, where Dr. Greely had “agreed to stop booking patients.”
· Beth Israel Deaconess Medical Center in Boston, from which Dr. Lombard “has been on medical leave since March 18.”
· Mount Auburn Hospital in Cambridge, from which Dr. Greer “has been on a leave of absence….since last May.”

Apparently, these hospitals feel that their responsibility in such matters is limited to preventing obviously impaired doctors from practicing medicine on the premises.

And, again, there is no mention of the profession itself having a role to play (other than the operation of a substance abuse treatment program run by the Massachusetts Medical Society).

Considering the central role that medicine plays, both in the quality of life and in the economics of health care, this seems to me simply not good enough. Medical practice, like all other forms of human activity, needs to be supervised on an ongoing basis. Either hospitals should be charged with responsibility for doing it or some other, as yet undefined, mechanism needs to be created.


Wednesday, April 21, 2004

Who Should Supervise the Doctors?

The front page of last Sunday’s Boston Globe (April 18, 2004) had a long, front-page article about Dr. Douglas Wooldridge, a dermatologist practicing in suburban Wellesley who has taken up cosmetic surgery “….despite little formal training in the specialty.” The article reported on interviews with a number of dissatisfied patients, settled malpractice suits and drug abuse charges. It also recounted several actions taken in response to these complaints by the Massachusetts Board of Registration in Medicine, described as “the agency that oversees the state’s 26,000 doctors.” Dr. Wooldridge continues to practice, although the Board of Registration has restricted his right to perform surgery. (The article raised questions about the extent to which those restrictions are being honored.)

Then two days later (April 20, 2004) the Globe carried another article about officials of TAP Pharmaceutical Products who went on trial that day “….for allegedly defrauding the government of millions of dollars by bribing doctors and hospitals to buy and prescribe the company’s product instead of a less expensive rival drug.”

Medicine is considered to be a profession. According to my understanding, a profession is supposed to set its own standards of practice and of ethics and to regulate itself accordingly. Yet there was no reference in either article to action by a professional society or to any expectation of such. In fact, the article discussed at some length the unwillingness of physicians to report poor care that comes to their attention.

Hospitals are gradually coming to take responsibility for medical infractions when hospital patients are involved, but even there they have a ways to go. Several of them were themselves implicated in the alleged TAP scam. In the case of Dr. Wooldridge, the questionable practices occurred in his private office.

That leaves us heavily dependent, in the case of Massachusetts, on the Board of Registration – not an altogether comforting thought considering its limited staff, the number of physicians for which it is responsible (i.e., 26,000) plus the rules of evidence, due process requirements and other legal restrictions under which it must operate. As one of Dr. Woodridge’s unhappy patients put it, “I can’t imagine how many other Doug Wooldridges there are out there who are getting the benefit of the doubt just like he is.”

To deal effectively with this problem, what we need is not tougher regulation but, rather, a way of organizing medical practice that has every doctor practicing under the oversight of people responsible for spotting poor performance whenever and wherever it occurs and for taking steps to keep it from happening again.


Monday, April 19, 2004

No Vision Yet

Last Thursday I enjoyed a brief flush of hopefulness when the April 2004 issue of H&HN arrived in the mail. H&HN is the acronym for Hospitals and Health Networks, the monthly publication of the American Hospital Association (AHA).

What caught my eye was the title of the feature article as emblazoned on the front cover. It read: “How ready are we for reform?” Below that was the subtitle “Without a shared vision getting there will be difficult.”

I turned immediately to the article (authored by Terese Hudson Thrall) in the hope that it would at least suggest such a “vision,” at least in outline form.

Alas, it was not to be. As it turned out, the article dealt mostly with the uninsured. That is a worthy subject, but hospitals have a self-interest here (reducing the number of uninsured would increase hospital income) and, therefore, may not be the most effective advocate for a solution.

I also looked in vain for some reference to the connection between the problem of the uninsured and the cost problem. Insuring more people while costs remain out of control will just pump more money into a health care system that already spends too much.

To his credit, Dick Davidson, President of AHA, sees that reform involves more than the uninsured. He was quoted in a sidebar as saying “We must get to the objective of insuring all Americans, but that’s not what reform is all about. It also includes changing the way we deliver services and think about health. Providers and health plan leaders have a lot of work to do.”

But that doesn’t tell us how the way of delivering services and thinking about health should change, or what work it is that providers and health plan leaders should be doing. Nobody seems ready to speak to those points yet.

In other words, still no vision.

Would anyone care to offer one?

Tuesday, April 13, 2004

System Redesign – Still Too Hot to Handle?

The American Hospital Association is kind enough to keep old geezers like me on its e-mail lists and so the other day I got a notice of its 2004 Leadership Summit this coming July in San Diego.

I was curious about the subject matter, which was summarized as “a strategic overview of current and future hospital and health system issues and opportunities. The focus is on change, innovation, the evolving relationships within hospital systems and leadership.”

That sounded like it might have something to do with the theme of this blog, so I scanned further down to read the topics to be covered, which were listed as follows:

1. New Designs for Improving Organizational Performance
2. Planning for Financial and Capital Sustainability
3. Information Technology for Clinical Transformation
4. Advances and Challenges in Patient Safety
5. Managing Chronic Care for Healthy Communities
6. Meeting the Demands of Leading Complex Organizations

Needless to say, I was disappointed. Apparently the subject of redesigning the system is still too hot to handle.

I could be wrong, though. Item 1 might be hiding something. Now that I have to pay my own way to such things, I’ll not be going. But if someone who reads this attends the Summit and gleans any nuggets, please let me know.


Friday, April 09, 2004

Quality - Still Not Accepted as a Responsibility of Governance

In its March 22, 2004 issue, Modern Healthcare announced the winners of its annual Trustees of the Year award, which it cosponsors with the Witt/Keiffer, the health care executive search firm.

Two trustees were selected. One was Douglas Chamberlain, board chairman at Franciscan Children’s Hospital and Rehabilitation Center in Boston. Chamberlain was recognized for “….leading the hospital through two turnarounds, a name change, and a twelvefold increase in endowments.” He was also credited with expanding the hospital’s special education day school and its home-care program.

The other awardee was James Williams, the recently retired board chairman of the Robert Woodruff Health Sciences Center in Atlanta, part of Emory University. During his 30-year tenure as a trustee, achievements included “….creating Emory’s first healthcare system, affiliating the medical school with four more hospitals and two clinics…., starting Georgia’s first school of public health, obtaining funding for a cancer center, constructing or redeveloping four research buildings, and increasing the amount of annual research dollars….” He oversaw the conversion of Emory Clinic from for-profit to non-profit status and blocked a move to start an HMO.

All of this is laudable, but what struck me in the citations was the total absence of any reference to the quality or cost of care and to anything having to do with the practice of medicine. Apparently, we still believe that trustees are to focus on financial and legal matters and leave anything having to do with patient care to the doctors.

Small wonder that the quality issue in health care seems so intractable.

Thursday, April 08, 2004

A 21st Century Issue in a 19th Century Organization

In the March 22, 2004 issue of the AHA News (the biweekly newsletter of the American Hospital Association), Dr. Nancy Greengold of Wolters Kluwer Health, a Chicago-based consulting firm, discussed the process by which new research findings get incorporated into medical practice. She pointed out that “There seems to be a waiting period, which can last years, before people [i.e., doctors] are willing to modify their approaches, and sometimes not even then.” She mentioned a specific research project that found that “….there is a considerable lag (sometimes 10 or more years) between the publication of randomized controlled trials reporting new advances in medicine and the incorporation of these results into the practice recommendations of expert reviewers.”

She pointed out that this problem results, in part, from the flood of medical information (amounting to some 150,000 articles per month) that makes it difficult for any individual practitioner to keep up. She mentioned the role that the Internet and other electronic information technologies might play in sorting through this plethora of material to identifying the information pertinent to the practice of an individual physician.

She did not, however, identify another major source of the difficulty, which is the anachronistic way in which the practice of medicine is organized and managed. Faced with the problem she reviewed, any other branch of human activity would organize itself to deal with it. For example, someone might be assigned responsibility for keeping up with the pertinent literature, spotting new findings that seemed pertinent, and bringing them to the attention of the proper authorities. Those authorities would then cause a decision to be reached on whether standard practice should be modified and that decision, once reached, would be binding on all members of the organization.

Conceptually, there is nothing very complicated about that, however difficult it might be to implement in particular situations. If it were primarily a matter of system design, one would expect to find the large group practices doing it. But they don’t - at least not very effectively.

Which leads to the conclusion that it is first and foremost an issue of culture, and one that we ought to be facing.

This page is powered by Blogger. Isn't yours?

FREE counter and Web statistics from sitetracker.com