Thursday, April 28, 2005

Credit Where Credit is Due

Peter Bosomworth, friend, long-ago colleague, retired Chancellor of the University of Kentucky Medical Center and an anesthesiologist by training reminds me of the good work that the American Society of Anesthesiologist has done with safety in patient care. In his words: “They have published an article in the anesthesia newsletter every month focused on improving safety. When I started doing anesthesia the death rate from anesthesia was 1 in 20000 patients. Today it is 1 in 50000. The newsletter had a lot to do with this. They set safety standards which eventually became accreditation requirements. The ASA has a committee that constantly works on this. One of the standards was the required use of comprehensive monitoring system technology. Its presence has reduced insurance costs, deaths and other misadventures.”

In all of our carrying on about the problem of safety in patient care, we should never overlook the people who are working every day on doing something about it.

Saturday, April 23, 2005

A C+ on Patient Safety

John Kelly, fellow grad school alum and newly minted health care management consultant, has steered me to a thoughtful and illuminating paper that appeared last November 30 in the Health Affairs web page. Written by Robert M. Wac
hter, Professor of Medicine and Chief of the Medical Service, University of California San Francisco Medical Center, it marks the fifth anniversary of the now renowned To Err is Human report issued by the Institute of Medicine.

Dr. Wachter gives the system a C+ on progress made in improving patient safety during this five-year period. He is being kind. After reading the paper I would have given it a C- or even a D+.

Dr. Wachter notes that in the modern health care environment “A critically ill patient might be seen by a half-dozen physician-specialists and scores of nurses, respiratory therapists, pharmacists, social workers, clergy and others, and receive hundreds of medications and tests.” He goes on to point out that “It should come as no surprise, then, that without a culture, procedures, and technology focused on flawless execution, errors would become commonplace.”

He attributes the lack of progress in improving safety to (a) an outdated mental model for medical mistakes, (b) collective inattention to patient safety, (c) a reimbursement system that provides no incentives for safety, and (d) a fragmented organizational structure. The outdated mental model is the one that emphasizes the importance of individuals in the provision of care and overlooks the role of systems. The fragmented organizational structure is the one that “separates the physicians from the rest of the hospital enterprise.”

He identifies the most complex issues as being: “how to promote a no-blame culture for providers who make innocent slips or mistakes while holding persistent rule violators or incompetent providers accountable, how to compensate patients for harm without necessarily invoking the heavy hand of tort law, and how to hold institutions accountable for allowing unsafe conditions to persist without hammering them in the newspapers or the courts when they acknowledge their flaws.”

Dr. Wachter has less to say about solutions, but if defining the problem is the first step, I would say his contribution is significant.

The full article can be seen at


Monday, April 18, 2005

Carrot or Stick?

Companion articles in the April 4, 2005 issue of Modern Healthcare discuss two methods of using economic incentives to improve health care.

One, headlined “On the bandwagon,” reported that CareFirst Blue Cross and Blue Shield, a Maryland-based non-profit insurer, would be initiating a pay-for-performance plan – “a $3.6 million pilot program that will pay doctors $50 per patient – or up to $100,000 per medical group – if they meet the National Committee for Quality Assurance’s criteria for using information technology to improve safety and standardize care.” The program is being licensed from Bridges to Excellence, an employer coalition formed two years ago to promote quality improvement.

The other, headlined “Poor performance” described a new performance rating program being undertaken by United Health Group, a for-profit insurer, and piloted in 13 states. Under this program “network physicians who are determined by United Health to provide higher quality, lower-cost care than their peers receive stars next to their names on the company’s Web site. The insurer’s three partners in the pilot - General Motors Corp., Daimler Chrysler AG, and United Parcel Service – then push their employees toward the ‘stars’ by demanding higher copayments for using non-designated doctors.”

Pay-for-performance might be described as a carrot in that offers rewards but not penalties. Performance rating is more like a stick since it uses penalties in the form of higher copays to steer patients away from doctors considered to be performing inadequately.

National employers are behind both approaches. No doubt they will all be watching the results carefully to see which works best.

The way economic incentives improve performance is by getting people to change their behavior. In my experience, getting people to change behavior takes a hard push. Gentle nudges don’t do it.

So I’m betting on the stick.

Sunday, April 17, 2005

A Bit of Cynical Speculation

In response to my posting about the Terri Schiavo story, the following comes in from Michael Pugh, one-time hospital CEO and now a highly regarded consultant:


“I was very disturbed by the Schiavo drama, as I am sure most others that read your blog were. What disturbed me most was not which side was right or wrong, or even the stupid posturing, misuse of facts and political interventions, but how the whole thing got to where it ended. I remember as a hospital CEO being involved in numerous tragic events in the 80’s where the players in the tragedy (the patient, doctors and family members) were at odds or unsure how to proceed, with very unclear or even contradictory legal advice thrown in for good measure. It was those types of cases that we as hospital leaders lost sleep over that eventually led to end-of-life care laws and the ethics guidelines that now exist in every state. My fear is that the politics surrounding this one media event case will undo much of what has been accomplished and disrupt an environment in which doctors and family members in the vast majority of cases come to an ethical and defendable decision, whatever it may be.

The malpractice angle to this drama leads one to other musings. I never read or heard this in the media coverage, but I can speculate that during the early years of the tragedy and before the malpractice claim was settled, the lawyers for the family encouraged measures to keep her alive because the financial settlement for long term incapacitation would likely be much greater than for a wrongful death suit. Perhaps just a bit of cynical speculation…”

Tuesday, April 12, 2005

Krugman on Ailing Health Care

My thanks go to Ed Parkhurst, Chuck Kleber, and Milton Hinshaw, each of whom called to my attention Paul Krugman’s column of April 11, 2005 entitled Ailing Health Care. Krugman is a liberal economist whose columns appear regularly in the New York Times.

The column dealt with rising costs, the uninsured, the reluctance of politicians to raise taxes, and the “wildly inefficient” U.S. health care system.

Krugman predictably leans towards governmental solutions and suggested that we need to shed “….the ideologically driven belief that government is always the problem and market competition is always the solution.”

I (together, no doubt, with a few thousand others) sent him an e-mail. This is what I said:

“Effective reform involves a lot more than shedding preconceptions about public versus private solutions.

In our system of providing health care services, nobody is in charge. Until that is fixed, reform will be slow and difficult.

The health care professions are organized according to a sort of medieval guild system. That inhibits the efficient utilization of manpower and needs to be diluted.

Systems – as contrasted with individuals - play an ever-increasing role in modern health care. The excessive independence we grant to health care professionals stands in the way of improving systems and, therefore, needs to be markedly reduced.

And those are just for starters.”

Sunday, April 10, 2005

More on HSA’s

Responding to the 3-25-05 posting titled “What Is It About HSA’s That I Don’t Understand?” Kevin Flynn has this to say:

“The way I always understood HSA's is that it is not about getting the best price. It is about the patient having to decide if he/she really wants to spend his/her own money for the care. It is a natural anti-selection process because if the patient will not pay the first $1,000, then the patient will not seek additional care that costs more money. In the end, utilization of health care resources will lessen and insurance payouts will decrease.”

(Kevin is founder and President of Health Care Advocates, which describes itself as the “auto club of health care.” For more information, see www.healthcareadvocates.com.)

In other words, the intent is to reduce utilization, not to put economic pressure on providers to reduce cost.

Are there other thoughts?

Wednesday, April 06, 2005

The Need for Something In Between

During the recent Terri Schiavo case, more than a few people complained about government getting involved in private matters.

While I can easily agree that the federal government should have stayed out of it, I don’t see that it was simply a “private” matter, either.

For one thing, the public was paying for Ms. Schiavo’s care and therefore has a legitimate interest in how the money is spent.

For another, the issue was seen as one of extinguishing a human life and society clearly has a stake in defining the circumstances under which that can be done.

Which poses the question of who should be involved in resolving such matters and how they should go about doing so.

Certainly the patient (to the extent able to participate) and the patient’s family should have the main say, as long as they stay within the bounds of the law. When this group finds itself in dispute, the courts will have to decide.

But I think there is also a role for the health care establishment. In the case of Ms. Schiavo, I am somewhat disappointed in retrospect that the hospice that was caring for her (including its medical staff) didn’t speak up. Who better knew Ms. Schiavo in her debilitated state and who was better qualified to reach a judgment that took all of the competing considerations into account and to represent the community’s point of view? As a remote but interested observer of the case, I would have placed a good deal of stock in what the hospice had to say about it.

We like to say that health care decisions should be left to the doctor and the patient but that is no longer realistic. The community has too much of a role and too large an interest in what happens. So there is a need for a representative agency that reaches informed judgments from a community perspective that is broader than that of the necessarily self-interested individuals involved but more local and flexible than is permitted by the impersonal legalities of government.

Private, community-based health care institutions are ideally suited to play that role and we ought to insist that they do so.

Saturday, April 02, 2005

Central Planning or Competitive Market for Health Care?

We have yet to decide whether our health care economy is to be based on central planning or on a competitive market.

Under central planning, a public agency decides what services should be provided where and in what amounts. The idea is to make sure that services are available where they are needed while avoiding excess capacity and unnecessary duplication.

In a competitive market, the purchasers of care buy services where they can get the best value for their money. The providers of services, responding to market demands, determine the availability and location of services.

Forces are operating both directions. A clear example is reported in the March 25, 2005 issue of AHA News Now. (AHA News Now is the e-mail newsletter of the American Hospital Association.)

I refer to the story about the proposed settlement of an anti-trust lawsuit brought by the US Department of Justice (DOJ) against Bluefield Regional Medical Center (BRMC) and Princeton Community Hospital (PCH), both in West Virginia.

In its March 24 summary of the case, the law firm Vinson and Elkins traced the origins of the case to a certificate of need application for a cardiac surgery program that BRMC filed with the West Virginia Health Care Authority (WVHCA). The application was turned down, partly because WVHCA doubted that BRMC could attract sufficient numbers of patients without working with other hospitals. Apparently, WVHCA feared that both hospitals would try to do cardiac surgery and wanted them to do it together. Instead, the hospitals decided that one would do heart and the other one would do cancer and entered into an agreement to that effect.

The anti-trust branch of the DOJ took exception and filed suit to nullify the agreement in order to “restore competition.” AHA News Now reports that the hospitals have agreed to do so.

So there you have it: two public agencies, both carrying out their legal mandates, trying to pull the health care economy in opposite directions. WVHCA wanted a joint program based on central planning considerations while the DOJ insisted on a competitive market.

(Sometimes states can shield market-dividing arrangements against anti-trust under a legal doctrine called State Action. In this case, however, West Virginia hadn’t dotted all the i’s and crossed all the t’s and so the DOJ said it didn’t apply.)

We cannot get on with redesigning the health care system without resolving this. The issue is too complex to discuss here, but my own view is that market competition (conducted under proper rules) is the only force strong enough to bring about needed changes in the health care system. But lots of people with louder voices than mine disagree.

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