Friday, June 25, 2004

How About a Good Jacking Up?

My desk tends to pile up with items clipped for use as the basis for postings to this blog. Many never make the cut and end up in the proverbial File 13.

But today I came upon one such that still seemed worthy of comment. It was an article that appeared in the May 23 issue of Parade, the tabloid-type magazine that accompanies many Sunday papers.

The article was titled “How to Protect Yourself” and was in response to the now famous Institute of Medicine (IOM) report on deaths due to medical errors in hospitals.

As someone who spent his working life in hospital administration and who always believed, perhaps somewhat naively, that the central purpose of a hospital is to serve the best interests of its patients and its community, I confess to being bothered by the idea that the hospital has become something that patients have to protect themselves against.

The article listed the most common types of errors, all of which reflect sloppy practice and lack of discipline. It went on to suggest what patients might do to protect themselves. It also identified steps that health care agencies are taking to make things better.

However, the article ended with a quote from Arthur Levin of the Center for Medical Consumers and a participant in the IOM study. After acknowledging the efforts that are under way, he said, ”There is, however, a systemic lack of urgency about getting this job done quickly….There isn’t enough attention being paid to the fact that, as we speak, people are dying or being injured because we’re not doing enough.”

It makes one think that in addition to the need for redesign, our health care delivery system could use a good jacking up.

No One Tells Me S--T

I don’t have the habit of posting humor, but the following seemed to make a point as well as a joke. Thanks to Jeff Frommelt, who passed it along to me.

A sweet grandmother telephoned Mount Sinai Hospital. She timidly asked, "Is it possible to speak to someone who can tell me how a patient is doing?"

The operator said "I'll be glad to help, Dear. What's the name and room number?"

The grandmother in her weak tremulous voice said, "Holly Finkel in room 302."

The Operator replied, "Let me check. Oh, good news. Her records say that Holly is doing very well. Her blood pressure is fine; her blood work just came back as normal and her physician, Dr. Cohen, has scheduled her to be discharged Tuesday."

The Grandmother said, "Thank you. That's wonderful! I was so worried! God bless you for the good news."

The operator replied, "You're more than welcome. Is Holly your daughter?"

The Grandmother said, "No, I'm Holly Finkel in 302. No one tells me shit."

Wednesday, June 23, 2004

The Sky Is Still Up There

Yesterday’s newspapers reported that on Monday the US Supreme Court ruled unanimously that patients cannot use state courts to sue most health insurance plans for refusing to cover medical treatments. They have to use federal courts instead, where the permitted damage awards are much lower.

The ruling is based on the provisions of the federal Employee Retirement Income Security Act of 1974, generally known by the acronym ERISA.

Two cases were involved. In one, the patient had been readmitted for post-hysterectomy complications that she claimed were caused by being discharged from the hospital too early because the health plan wouldn’t authorize an additional day. The other patient claimed to have had a reaction to a generically equivalent drug that the health plan substituted for the one prescribed.

The court pointed out that under ERISA patients denied coverage have the right of quick appeal to an independent decision-maker, but neither plaintiff had done so.

What impresses me about all this is not so much the legalities involved, which I do not pretend to understand, but its implications for the structure of the health care delivery system.

The papers quote John Nelson, president of the American Medical Association, as saying “By reserving the right to decide what is – and what is not – medically necessary, managed care plans can now practice medicine without a license.”

Technically, of course, health plans do not deny services. They only deny payment. But everybody seems to think that is a distinction without a difference.

So it seems to me that Nelson is right, but if the losing attorneys made his argument (which surely they did), it didn’t seem to impress the Supremes.

It doesn’t seem to have impressed the Congress either, which after several attempts hasn’t been able to agree on a patient’s rights bill that addresses this issue.

If health plans can practice medicine without a license, does that mean that hospitals can, too?

If a judicial ruling like this had come down fifty years ago, one would have expected the sky to fall. But two days have now passed and the sky is still up there.

Tuesday, June 22, 2004

Something to Watch

The June 2004 issue of the Harvard Business Review includes an essay titled Redefining Competition in Health Care. The authors are Michael E. Porter of the Harvard Business School, one of 16 “University Professors” in Harvard University, and Elizabeth Olmsted Telsberg, an Associate Professor at the University of Virginia.

The essence of their idea is that competition in the health care market should be around particular diseases and treatments rather than at the level of health plans, networks, or hospital groups. It is expected that before long, the concept will be fleshed out and published in book form.

The article strikes me as being important for three reasons.

First, it offers hope that the needed redesign of our health care system may attract the interest of the intellectual community, which, up to now, it unfortunately has not.

Second, it deals with the design of the health care market itself, a topic that must be addressed if competition is to have the desired results.

Third, it urges that large employers take responsibility for redesigning the market, using their purchasing power to effect the necessary changes. This is probably the only way redesign will happen and Professor Porter is reputed to have the ear of the business community.

Although I think the Porter/Telsberg concept has serious flaws (it does not, for example, address the issue of utilization; i.e., assuring that patients get the services they need and no more), it perhaps will open a needed debate among the people that matter and is, therefore, something to watch.

Wednesday, June 09, 2004

Something More Good in Denmark

The following comes from Dr. Claus Curdt-Christiansen, a friend since Saudi Arabia days and currently Chief Medical Officer of the International Civil Aviation Organization, a UN agency based in Montreal.

I may have a fraction of an additional comment as to the supervision of doctors in private practice: no doctor wants to supervise other doctors and report on him/her to the authority - what happens in Denmark (where private practice is the rule) is to some extent solving the problem. More and more doctors get together in groups and operate "group clinics" thus sharing the cost of receptionists, secretaries, nurses and often very expensive equipment. When the doctors in such a group notice than one of their colleagues perform sub standard they either set him right or get rid of him. Doctors in "solo" practice are quite few nowadays - and mostly either old or odd. My advice to patients would be to avoid soloists and to go to a group clinic. We do (in Denmark) also have a "medical board for patients" where unhappy patients can complain about bad treatment. Their cases are printed in the Medical Journal which I read every week. By far the most frequent complaint is that the doctor was rude (!)

Saturday, June 05, 2004

Bill Robinson Comments

Periodically, I include in a posting a request for comments from readers. Bill Robinson – now retired after a distinguished career in hospital association work – was good enough to respond as below:

Well, friend Wittrup, I read your postings and wish you had more feed-back. So, here's one.

Way back (c. 1970) Dr. Leonard Cronkhite (brother of Walter), then General Director of the Boston Children's Hospital observed to me,

"Human need for health care is infinite.
This will require infinite resources.
We are not going to be granted infinite resources."

I think that's a succinct summary of the basics of the problem appearing in your many and interesting blogs about reform, delivery, finance, modern medicine, physician conduct, etc.

You described an earlier blog of mine as the "rantings of a grumpy old man".

Here's another rant.

Rationing should receive some gentle discussion. A place to begin might be with the very elderly (I know, you will say define elderly in a politically acceptable way). I remember a very distinguished and very famous hospital CEO - has to be both because he's a past chairman of (dear old) AHA – saying that he thought it wrong that an 88 year old woman could have both hips replaced so that she could resume her enjoyment of gardening. There's a starting point.

Cheers, Bill Robinson

Low Expectations Plaguing Health Care

This morning’s Boston Globe reports the case of a woman whose appendix burst during a six-hour wait for care in the Emergency Room of South Shore Hospital in the suburban town of Weymouth. According to the report, she had been transferred to the Hospital by ambulance from South Shore Medical Center in Norwell (an ambulatory clinic) where her appendicitis had been diagnosed.

Dr. John Benanti, the hospital’s director of emergency medicine, issued a written statement saying that the hospital “remains committed to patient care” and through a spokeswoman said that the case “did not meet our expectations of how care should be delivered.”

One would hope so.

He also said “as the second busiest emergency center in Eastern Massachusetts, there will be times when our care does not meet our patients’ expectations.”

Like waiting six hours to receive treatment for an already diagnosed appendix, one supposes.

The state Department of Public Health said that it would investigate the case. Spokeswoman Roseanne Pawelec said the investigation would try to determine whether anything was done wrong.

Sounds like a real challenge.

The article also mentioned an asthma patient in the hospital’s ER who was having trouble breathing and after two hours of waiting used her cell phone to call an ambulance, which transported her to nearby Quincy Medical Center where she was treated.

In any other kind of organization, such gross misfeasance would give rise to calls for heads to roll. But not in health care. At least not yet.


Friday, June 04, 2004

The Case of the Escrowed Skull

For the benefit of those who may not have seen it, I pass along the following, which was kindly forwarded to me by Jeff Frommelt.

After trying to think of something clever to say about it, I decided to let the story speak for itself.

By Alexandria Sage
Associated Press
Published May 14, 2004

MIDVALE, Utah -- After a lot of red tape, Briana Lane has her skull back in one piece.

The 22-year-old woman was injured in an auto accident in January, and doctors temporarily removed nearly half her skull to save her life.

For nearly four months afterward, however, the piece of bone lay in a hospital freezer across town because of a standoff with Medicaid and the hospital over who would cover the surgery to make her whole again.

The surgery finally came through after an excruciating wait, during which she suffered extreme pain just bending down and would wake up in the morning to find her brain had shifted to one side during the night.

"When you think of weird things happening to people you don't think of that," Lane said. "It's like taking out someone's heart--you need that."

Sonya Schwartz, a health-policy analyst for Families USA, a consumer health-care group, said insurance horror stories happen every day but "this particular story is outlandish."

On Jan. 10, Lane's car rolled over on an icy canyon road above Salt Lake City. Lane, who was not wearing a seat belt, was thrown through the windshield. She later was charged with driving under the influence and not having a driver's license.

Doctors at the University of Utah Health Sciences Center in Salt Lake City removed the left side of her skull to treat bleeding on her brain. Lane's doctor originally scheduled the replacement surgery for mid-March, a month after her release from the hospital, said her mother, Margaret McKinney, a nurse who works in another division of the medical center.

But the operation was canceled the night before because the hospital was waiting to see whether Medicaid would cover it--a process that can take at least 90 days.

Lane, a waitress with no insurance, was sent home from the hospital with a big dent in her head where the bone had been removed but the scalp had been sewn back into place. She stayed home, able to walk around but not go to work, and had to wear a plastic street-hockey helmet during the day.

During the wait for a decision from Medicaid, the hospital could have declared an emergency, moved ahead with the surgery and figured out afterward who would pay--the hospital, Medicaid or the patient. But the hospital did not do so.

Lane's mother said she argued with the hospital: "We just want what you've taken away. Can you just give us back the skull and we'll go on with our lives?"

After months of delay, Lane contacted a local television station, a move she thinks hastened the surgery. The operation took place April 30.

Exactly what broke the impasse is unclear.

The operation took place after Lane's mother's insurance decided to cover the surgery, as well as her nearly $200,000 in medical bills.

A hospital spokeswoman though refusing to comment on certain specifics of Lane's case because of federal privacy rules, said the medical center decided to go forward with the surgery before it learned the insurance would pay.

Utah's Medicaid program has yet to decide whether Lane qualifies.

Robert Knudson, director of eligibility services at the Utah Health Department, which oversees Medicaid, said the agency has not yet seen enough evidence to decide whether her injuries entitle her to benefits under the law.

He would not comment on whether her four-month wait was unreasonable. He said the decision over how fast Lane should have received treatment was up to the doctors, not Medicaid.

Dr. Ronald Young, a neurosurgeon at St. Vincent Indianapolis Hospital, said such surgery would not be considered an emergency but typically is performed within three to four weeks, after swelling has gone down, because the risks to the patient are high.

"There's no reason not to replace that as soon as you can," Young said. "I don't like to have people who are walking not have their skull."

He added: "For a person who is walking, who is ambulatory, to not have their skull is a problem because you get a lot of brain shift. A simple fall, hitting her head or something could be horrendous."

Today, Lane finds that performing simple tasks is no longer excruciatingly painful, but she said the experience has left her more cynical about the health-care system.

"Just because [patients] don't have money doesn't mean they should be treated differently from anyone else," she said. "I'm a good person. I just happen to be not as rich as some of them."

Copyright © 2004, Chicago Tribune

A Note of Pessimism

Below are comments received from Leo Greenawalt, who has had a long and illustrious career as a hospital association executive, most recently in the state of Washington. Contrary to what my rantings might suggest, I am less pessimistic than him.

What other views are out there?

As I approach the end of my career (nearly all as an association executive) I must say that the lack of "systemness" is very discouraging. One likes to think he has made a difference, but the evidence gets more and more sparse.

What I can say is that I have done an excellent job in getting hospitals and others an ever growing percentage of the gross domestic product. It is hard to show a link with markedly improved health outcomes.

I am finding much more of my own sympathies tied to a more centralized and planned approach to health care. I have lost all belief that the market approach will produce anything meaningful in terms of improving health.

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