Monday, May 30, 2005

An Idea

Two articles appeared side by side on the front page of yesterday’s Sunday New York Times. There was no indication that the two were related, but they seemed so to me.

One described an effort by a group of health leaders that has been meeting secretly to find solutions for the problem of the uninsured. According to a spokesman for the National Association of Manufacturers, one of the participants, the group assumes that health care will continue to be provided through a mix of private insurers and public programs.

The adjacent article was about the John M. Olin Foundation, which has been supporting conservative right-wing intellectual activities. Explaining the approach taken by the foundation, its executive said that “….ideas have to be attended to. Only after that can you tend to the policies.”

Applying that philosophy to the issue of the uninsured, I have an idea to suggest. Government should be responsible for funding coverage for its own employees, the aged, the poor, the disabled, and their dependents. Absent single payer, coverage for everybody else should be funded in the private sector.

As a practical matter, that is the principle we are following and it seems to me that agreeing on it openly would greatly simplify the process of addressing the issue.

Saturday, May 28, 2005

More on Lay Interference

Neil Whipkey, a recent advocate of single payer in this space, weighs in on the subject of lay interference. What he says is not new to health care executives but he puts it succinctly and readers not so intimately involved in health care may find it informative.

For the most part, healthcare leaders are lay people. That may account, to a small extent, why some are reluctant to be more assertive in addressing clinical problems.

I believe there are other reasons which play a more significant role in the executive's decision to "look the other way". Two of the reasons are related to the fear factor(s). Fear factor #1 is: A totally disorganized medical staff can organize in a heartbeat, once they have determined the administrator needs to go. Reality is that all too often they can and do make this scenario happen, especially if they believe one of their colleagues is under the microscope for clinical shortcomings. Fear factor #1 results in fear of instant job loss. Fear factor #2 is: Any investigation into clinical issues may see your number one admitting physician pack up and go across town. This can play out along the same lines as fear factor #1 with the difference being that in fear factor #2 the "posse" will be the hospital board. In either case it can have the same result.

Factor #3 is: the Amoeba virus (instant loss of backbone). However, the Amoeba virus can often serve as an antidote for the previous two fear factors. The truth is those executives who resort to the Amoeba antidote will find themselves in the Jekyll/Hyde syndrome. Each use of the antidote will result in less and less protection. In the end the result is the same, one posse or the other will get the executive out of town.

There is a way for the health care executive to meet this challenge and his responsibility to the patients. Do your homework, enlist the support of some champions from the medical staff, and have a process that is consistent, fair, and objective. The process is the most important piece and it is the process that needs to be protected (not the administrator or physician). With that said the executive has to play the dual role of advocating both for the physician under review and the patient who got less than the acceptable standard of care. If your process is sound you (the administrator), the physician, and the patient will all be protected and the right thing will be done. Good luck.

Thursday, May 26, 2005

Hoffman on Lay Interference

Paul Hofmann, erstwhile health care executive and now senior ethicist to the health care management community provides the following in response to the recent posting Rethinking Lay Interference:

“One of the reasons too many health care executives are reluctant to be more assertive in addressing clinical problems is they view themselves as lay people who can and should defer to clinicians. I contend these executives, feeling intimidated, insecure and/or uncertain, sadly have abdicated one of their most important responsibilities - being a highly visible and effective patient advocate. Perhaps naively, I would still like to believe that the majority of health care executives have been attracted to the profession because it provides a wonderful opportunity to contribute to improving the quality of life for others. Consequently, I remain mystified and disappointed when I hear or read about executives who knew or should have known about significant clinical deficiencies and have managed to rationalize their non-involvement.”

Saturday, May 21, 2005

Single Payer and the Sales Tax

Clinical psychologist and long-time personal friend Gail Price had the following reaction to the Whipkey piece on single payer:

“The idea of funding health care through a national sales tax is interesting; these tax revenues would no doubt be diluted by all the other special interests, however. From my own experience, the huge costs of medical education are one of the reasons for the bits of corruption that exist and are dealt with not only by ordering tests that are unnecessary, but also by charging for tests not ordered. (I've had both, and by reputable physicians.) The other is the desire for status over service. I think physicians need both, but in balance. Also, the more research I do, the more I am convinced that various forms of pollution (air, water,food quality especially) are responsible for many more illnesses than we now acknowledge. Money needs to go to cleaning up these life essentials. A third cause of medical illnesses is over-medication.

I do not think anything will change until the profit motive is removed from medicine. We can see almost daily how tax revenues are being misused and purloined. Why would this be any different with health care funded by tax money?”
Cost and Reform

Below is Neil Whipkey’s response to my comments about the relationship between the cost and coverage issues:

“I believe cost is not an issue, at least with regard to reform. I am firmly convinced there is more than enough money in the system to provide universal coverage for preventive care, routine care, emergency care, and end of life care. The issue is not the cost, rather it is the money in the system, how it is generated, and how it is dispersed to providers.”

Friday, May 20, 2005

Rethinking Lay Interference

The April, 2005 issue of H&HN, the monthly journal of the American Hospital Association, featured an article titled 25 Things You Can Do to Save Lives Now.

As the title implies, the “things” listed tended to be of the common-sense variety, like washing hands and marking surgical sites accurately.

What struck me, however, was how many of them would have been seen not so long ago as interference in the practice of medicine. One had to do with handling risky medications. It reminded me that early in my career I learned that our outpatient pharmacy each day assigned a pharmacist full-time to the duty of clarifying prescriptions that were either erroneous or unclear. I thought we should perhaps do something about that but was quickly made aware that prescribing drugs was doctor business and I should stay out of it.

That seems to be changing. The introduction to the H&HN article notes that “hospital leaders worry about creating too many restrictions in clinical practice.” In response, Dr. Don Berwick, leading guru of quality in health care, is quoted as saying “That concern is misaligned because clinicians are looking to hospital executives and the board for direction.”

If by “hospital leaders” he means CEO's, most of them won’t be so sure about that. But Berwick’s willingness to say it publicly suggests that the epithet “lay interference” may be losing its punch. If so, progressive hospital leaders can be more assertive in promoting improvements in patient care by causing clinical practice standards to be laid down and enforced.

That would sure enough be a redesign of the system.

Wednesday, May 18, 2005

Another Plug for Single Payer

Dick Davidson, executive head of the American Hospital Association, has called to my attention a short, articulate, and pithy article titled A Plan for Universal Coverage that recently appeared in the on-line version of H&HN magazine. It was written by Neil Whipkey, administrator of Shands at Lake Shore Hospital in Lake City, Florida.

In brief, Whipkey’s plan is for national health insurance financed by a national sales tax. It includes a new method of paying physicians, patterned after the DRG (i.e., flat-sum-per-case) system used to pay hospitals.

The full article can be seen at the following address:


The three main issues in health care today are cost, quality, and coverage. Since expanding coverage would pump new money into the system, it seems to me unlikely to happen on any significant scale so long as the uninsured continue to receive basic care while the delivery system remains both grossly inefficient and financially stable.

Thus, I wish that when Whipkey and others advocate single payer, they would also address its connection with the cost issue.

Tuesday, May 03, 2005

Risky Business

This morning’s Boston Globe carried an article announcing the plan of the Massachusetts General Hospital to open a new orthopedics surgery center in the suburb of Waltham. The initial investment is estimated at about $10 million.

The article quoted MGH’s administrative director for orthopedics as saying that about 10 of its 30 orthopedic surgeons had agreed to move some of their cases to Waltham.

Can you imagine any other kind of business undertaking a new venture that depended for its success on the voluntary and continuing participation of 30 corporately and financially independent individuals?

And we wonder why our health care system is thought to be inefficient.

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