Sunday, July 31, 2005

Better Care for Animals than Humans?

The below comes in from daughter Eleanor who teaches philosophy at the University of the Pacific in Stockton, California.

She has asked me on occasion to explain the vast difference between animal health care and human health care and so far I haven’t come up with anything very convincing. Perhaps someone who reads this can help.

George is Eleanor’s ex-husband. Auggie is her cat.

“If I ever get seriously ill, I don't want to go to Stanford or any of the big (or little) hospitals, I want to get taken to U.C. Davis Vet hospital. I really think it would be informative if someone would study the differences in animal and human medical care. My animals get VASTLY better care than I do, and it costs pennies on the human health care dollar. Why? The science, surely, is no better. The instruments are the same. Ok, surgery on cats and dogs is easier because they have better immune systems than we do so don't need as much in the way of sterile environment. But surgery is the least of it.

I know I have told you the story of George's laceration and stitches (six inch gash, down to fascia, twenty or more stitches, nine hours in the ER waiting room, four more in a treatment room, bill totaling more than fifteen hundred dollars that took eight months to settle - even though we had perfectly adequate insurance and all the information was given twice at the emergency room.) vs. Barney (the horse)'s two inch gash, which from injury to treatment took 45 minutes, the doc came to us, brought the prescription, took payment and gave him treats and cost $120 which got paid right then. Oh and the Doc Lindstrom talked to me and was much more informative than the ER doc.

Auggie's experience at Davis convinces me that I am going to re-register as a non-specific primate. I am comparing it to George's experience at Stanford Hospital when he had the really bad migraine, or the urinary tract blockage, or the colonoscopy. First, the med students at Davis are much, much better. More respectful, better listeners, ask better questions, and are genuinely interested in your understanding what is going on. Second the Docs are also better in the same ways - and at Davis they seem less stressed, they seem to be able to take the time necessary to diagnose, treat and advise. Third - the treatment is just as high tech and based on cutting edge science.

Fourth, Davis vet hospital is WAY less expensive. Try getting in and out of Stanford medical center (and seeing someone with letters after their name) for less than $800. I'll bet no one has ever done it in this century. Oh, and the Davis doc has called me every day (except Sunday) since we were there to check on Auggie. My local vet calls every three days or so. Who was that guy at Stanford? We never heard from him again. We never heard from our GP either - and that was a small town operation and we were friendly with the doc. At Davis we did a biopsy and got test results within the hour. Try THAT at Stanford. When we asked a question the med student couldn't answer - she WENT AND GOT HER TEXTBOOK and a medical dictionary and helped us look up the info. I'm pretty sure no first year resident has ever done that. All in all the Veterinary medicine people are just more human, at the same time that they are more efficient.

What makes the difference? Surely the quality of person who goes into Vet medicine can't be that much better. I suspect that the root of the difference is cultural. Vet residents aren't chronically sleep deprived for years. They aren't socialized to view the patients as "the enemy." They learn to do all the basic stuff themselves, and aren't ever encouraged to think that they are "gods" or that they are above any of the routine tasks of medical care (drawing blood, looking at fecal samples, giving shots.) I suspect the hospitals are better managed too, maybe because the people are just more easy-going - having had enough sleep and normal egos. The Davis folks are also very conscious about being "slow" compared to their local counterparts ("Sorry it is taking so long (after an hour and a half) we have to do everything just right according to the protocols. And it takes some time to get everything set up and all the people in place"). I think they don't make very many mistakes.

Of course veterinary medicine is fee for service, and a lot of animals don't get the care we would expect to provide for people. But even "low end" vets WOULD do (and do well) more sophisticated treatment on a routine basis if their clients could or would pay for it. Maybe very little in the way of malpractice litigation has something to do with it - although I doubt it – horse people sue over stuff at the drop of a hat, and horse vets are still quite reasonable, and the Davis equine facility is just like the rest of the hospital. I can't help but suspect that the lack of insurance infrastructure decreases costs a whole heck of a lot though. And since the fact of the matter is that poor people DO get less and worse medical care than rich people, maybe we should stop pretending that everyone gets the same, establish an acceptable/affordable universal minimum and just resign ourselves to the fact that some people can afford to have more done for them when they are sick.

It would be great if someone would do a study to compare U.C.
Davis with some people-teaching hospital. Maybe they could compare that to hospice operations as another comparable operation (much more human...maybe due to the absence of doctors?) Who knows, we might learn something.

I'll tell you one thing, if I could count on getting care as good as Auggie's, the prospect of getting cancer, or some other horrible disease, wouldn't be nearly as scary. Remind me again, what is the purpose of human medicine? Everybody I've encountered seems pretty clear on the purpose of veterinary medicine. Maybe that's the difference.”

Thursday, July 28, 2005

Better Enjoy It While It Lasts

It was in 1965 that Ralph Nader published “Unsafe at Any Speed,” a book that nailed the automobile industry for not building enough safety into their vehicles. If memory serves, the general reaction of the public, and of government, was to tell the automobile manufacturers to shape up and fix it. And with some regulatory prodding that is pretty much what they did.

Some 36 years later, the Institute of Medicine issued a similar blockbuster, claiming that medical errors were killing over 90,000 people per year.

Remarkably, the reaction has been very different this time. The July 26, 2005 issue of AHA News Now (the daily e-mail news bulletin of the American Hospital Association) reported that the Centers for Medicare and Medicaid Services (the federal Medicare and Medicaid agency) had on the previous day provided congressional committees with a “roadmap” for improving the nation’s health care quality. The five point plan consisted of

· Close partnerships with federal agencies and private-sector groups.
· Widespread use of quality measures.
· Tying Medicare and Medicaid payment to quality.
· Promotion of adoption of health information technology.
· Efforts to speed access to new and better treatments and evidence.

Not a word about telling the providers of health care to shape up and fix it.

It surely cannot stay that way forever.

So health care leaders better enjoy it while it lasts.

Monday, July 25, 2005

Does the Devil Make Us Do It?

Some of us are old enough to remember a comedian named Flip Wilson. One of his characters was a spirited lady named Geraldine who, when caught in some misbehavior, liked to say “the devil made me do it.”

The July 21, 2005 issue of the Boston Globe carried a front-page article reporting on a study that ranked hospitals in 40 US cities on their treatment of heart attacks, congestive heart failure, and pneumonia. Boston was the top performer in heart attacks and congestive heart failure, but ranked 30th in pneumonia.

On the pneumonia front, Partners Health Care (Brigham and Women’s Hospital and Massachusetts General Hospital) had particularly dismal records. Dr. Elizabeth Mort, a Partners official involved in quality improvement, explained that emergency doctors were often distracted by more urgent cases. One component of pneumonia care is the administration of a vaccine and vaccination, she pointed out, is something that the specialists who see inpatients tended to leave to primary care physicians. She also said that cardiac care benefited from the existence of medical staff departments in that specialty, while pneumonia care did not.

As to what the hospital is doing about it, Dr. Mort said that it was developing a computer program to prompt physicians on the proper tests and treatments for pneumonia, as well as protocols to fast-track pneumonia patients in the Emergency Room.

She didn’t exactly say “the devil made us do it.”

But she came close.

Saturday, July 23, 2005

Whipkey on Progress by Indirection

Responding to the recent posting titled Progress by Indirection, Florida hospital CEO Neil Whipkey has this to say:

“Regarding the issue of ‘....the central difficulty is the reluctance of trustees to become involved in clinical matters, thus limiting greatly their ability to require cost reduction and quality improvement,’ I believe there is another very distinct explanation why trustees do not get involved. It falls upon the hospital leadership (Administrator, CEO, President or whatever) to lead our boards in the right direction. We need to not only encourage them but also to educate and assist them. Our theme should be quite simple. First, it is good for patient care and second, it is good for the well being and future financial success of the hospital.

It has been my great privilege to be involved in healthcare for over 25 years. I have known, personally, probably over a hundred top hospital officials. They have been, for the most part, intelligent, caring, ethical individuals who have wanted to do the right thing. For whatever reason(s) we (as a group) have come up short when it comes to dealing with quality issues and we have not aggressively chosen to pull our boards into this area.

I believe the lack of board involvement lies with us, the hospital leaders, rather than our boards. I do believe the tide is finally turning but it is still a struggle and we have a long ways to go.”

Tuesday, July 19, 2005

Progress by Indirection

My eye was caught by two items in the July 11, 2005 issue of AHA news, the weekly newsletter of the American Hospital Association.

One was about the AHA Information Technology Advisory Group, described as a “panel of experts on a wide range of IT issues” created to “get you [the reader] the help you need to implement systems that can enhance patient safety and improve operating efficiencies within your hospital.”

The other was about the AHA-sponsored Center for Healthcare Governance launched earlier this year and “designed as a full-service resource on health care governance education, research, and innovative practices.”

If there are other industries that have needed this sort of prodding and support, I don’t know about them.

On the IT issue, the problem is that health care management is not operationally oriented. Instead of conceiving operational improvements that can benefit from IT support, the pattern has been to buy an attractive-sounding or fashionable piece of software and hope that something good comes out of it.

As to governance, the central difficulty is the reluctance of trustees to become involved in clinical matters, thus limiting greatly their ability to require cost reduction and quality improvement.

These are sensitive cultural issues that few want to address directly. That probably explains the indirect approaches represented by the two items.

One would like to think that grown-ups could approach matters like this head-on but so far that has not been possible. So we have to accept progress by indirection.

It’s better than no progress at all.

Thursday, July 14, 2005

Early Retirement and Morality

Friend and fellow parishioner from Detroit days Chuck Kleber calls to my attention an editorial column by John Tierney titled The Old and the Rested that appeared in the June 14, 2005 issue of the New York Times.

Tierney’s main point is that people ought to work longer – a part of the Social Security debate that he refers to as the “elephant in the room,” something favored by liberals and conservatives alike, but that every politician is terrified to mention.

Tierney argues that there are lots of healthy and vigorous seniors and their working longer would be good for the economy, creating wealth and tax revenue.

He also quotes a 57-year old schoolteacher contemplating alternatives to retirement as saying “It's not healthy for you to stop working if you're still able.” My way of saying that is “Idleness is bad for your health.”

Implied but not mentioned in the column is that extending the retirement age to, say, 70 would fix both Social Security and Medicare for quite awhile.

I would mention a fourth reason, which has to do with the morality of spending long years of good health in retirement.

Regardless of how retirement is funded, retired people are supported by the employed population. The goods and services consumed during retirement, such as food, clothing, transportation, health care, and entertainment, are being produced by people who spend their days working.

My grandfather was a farmer before the time of modern farm equipment. When he reached the age of 65 his body was pretty well worn out. He had a right at that age to live off of the efforts of the working population as had his father at that age. As Tierney points out, most people nowadays are in no way worn out at that age and have lots of good working years left in them.

Tierney likes the concept of personal retirement accounts as it as been implemented in Chile. He claims it has induced people to work longer.

He may or may not be right about that. But, either way, the notion of working longer needs to be discussed. 65 as the pensionable age was conceived by Otto von Bismark more than a century ago. It is time – even past time – to re-evaluate it.

Thursday, July 07, 2005

Parkhurst on Health Insurance

Stimulated by the June 13, 2005 editorial on the subject of health insurance by New York Times columnist and single payer advocate Paul Krugman, health care consultant Ed Parkhurst weighs in with the following:

“I personally believe reform is best looked at in the following context........we should have a single payer system with a reasonable number of benefit plans thereby simplifying their administration, reducing administrative costs over that which is expended now, and then reinvesting administrative cost savings in care delivery. Private insurance companies could bid to administer with caps on administrative costs. I don't favor a single universal benefit package. Medicaid should be a national program for the disadvantaged with a basic benefit package funded by the States and the Feds on some type of formula basis. Medicare should be funded by both the Feds (not necessarily through SSA, which was set up for retirement and not medical benefits) and the beneficiaries on some type of a "means tested" basis which recognizes the disposable income in the elderly. There also may be "gaps" that have to be selectively filled. As to Medical Savings Accounts, I think them bad public policy in that care may be avoided thereby increasing morbidity and chronic conditions, over time. We need a delivery model that embraces first $ coverage, but not necessarily for physicians...physician extenders could enhance access and reduce costs overall.....consumer education programs to reduce unnecessary demands for care are necessary. Most don't know how to use the system wisely and we need to eliminate proprietary drug advertising which encourages over utilization and lower use of generics.”

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