Monday, November 21, 2005

Managing Care

Bill Busby, a long-time friend and fellow philosopher, is a less than enthusiastic patron of his local HMO in Albuquerque, AZ. He is also now old and a little bit crotchety, but the below-copied humor he sent along to me has a point.

Trying to manage the details of care with the details of payment is clumsy at best and infuriating (if not outright dangerous) at worst.

In the health care system of the future, care ought to be managed by doctors and hospitals. Unfortunately, their unwillingness up to now to do so has left the job in the hands of insurance companies.

Mr. Smith goes to the doctor's office to collect his wife's test results.

The lab tech says to him, "I'm sorry, sir, but there has been a bit of a mix-up and we have a problem. When we sent the samples from your wife to the lab, the samples from another Mrs. Smith were sent at the same time and we are now uncertain which one is your wife's. Frankly, it is either bad or terrible!"

"What do you mean?"

"Well, one Mrs. Smith tested positive for Alzheimer's and the other Mrs. Smith has tested positive for AIDS. We can't tell which is your wife."

"That's terrible! Can we do the test over?"

"Normally, yes. But you have an HMO and they won't pay for these expensive tests more than once in a year, so we can't repeat the test until next year."

"Well, what am I supposed to do now?"

"The HMO recommends that you drop your wife off on the outskirts of town........ If she remembers the way home, don't have sex with her.

Friday, November 18, 2005

Slowly, Slowly

Possibly because it thinks itself the pinnacle of all things medical, health care stories seem always to be of more interest in Boston than elsewhere. Prodded by Governor and would-be-President Mitt Romney’s current initiative to do something about the uninsured, the November 11, 2005 issue of the Boston Globe devoted its entire Op-Ed page to what it headed “The healthcare debate.”

The page included six presentations, representing

- an advocacy group favoring an employer mandate
- a health care provider organization
- the state hospital association
- an advocacy group opposing an employer mandate
- a professor of health policy and management
- an employer favoring an employer mandate

As can be seen from these headings, much of the debate was about an employer mandate; i.e., a requirement that employers of a certain size or larger either provide a health care plan for their employers or pay a special tax.

I found two things interesting:

- Support for an employer mandate continues to grow. More than one writer pointed out that since payments to providers are covering the cost of unreimbursed services provided to the uninsured, employers who provide health care plans are subsidizing those who don’t.

- Three writers mentioned the importance of getting the cost of providing care under control. Charles Baker, head of Harvard Pilgrim Health Care (the provider organization) made that his first and most important point.

An employer mandate can be legislated. Cost control is not so easy. The professor (Joseph P. Newhouse) said it was possible but an issue for another day. Baker thought the will to deal with it existed but awaited better information. He also remarked that affordability will drive sustainability.

There seems to be a growing realization that an employer mandate is necessary but its achievement depends in part on bringing cost under control.

Slowly, slowly, health care reform is happening, even if the pace is agonizing.

Wednesday, November 16, 2005

More on Evidence Based Medicine

The below comes in from long-time friend and clinical psychologist Gail Price in response to the posting on Evidence Based Medicine. As you will see, she is not encouraged by the direction health care is taking.

Excellent discussion of evidence-based medicine.

A major problem would seem to be the same as with "evidence based psychotherapy." Evidence means measure in this model (as I understand it). In fact, evidence in human response to medical and social psychological care is not measurable, but a manifestation of a combination of immeasurable factors like one's spirit--it is very difficult to measure the healing of a depressed or frightened spirit.

As the health care system increases the number of chronically ill children and adults because of its chronically inadequate care, the ability of individuals to engage in the innovative discoveries and the creative persistent diligent work will decline as our education system has declined. It takes healthy people with healthy bodies and spirits to build and maintain a healthy nation.

All forms of health care are best delivered by independent practitioners. The HMO's have cost enormous amounts of money that the independent system did not. It is unlikely that more than ten percent of independent practitioners acted in a way that undermined the integrity of the system. Now, the fears of physicians and practitioners voiced when this new system came into power have come true. We are being paid to harm and kill patients, not to heal them.

Monday, November 14, 2005

More on Universal Coverage

The below comes in from Neil Whipkey, whose thoughtful comments I have posted on several occasions. As he knows, I do not share his enthusiasm for national health insurance, but I suspect that among health care leaders, more agree with him than with me.

The first bullet in your October 6 posting (Universal Coverage) is right on target. The second bullet is inaccurate to the extent that while many players in the health care system are financially healthy, there are certainly many players who do not share in this financial prosperity. I strongly disagree with the third bullet. There is, in my opinion, more than enough money in the system. What has to change is not the amount of money in the system, rather how the money is collected and distributed. Universal coverage, one payer (government), along with a national tax for funding can address and resolve the issues you raise.

Your last bullet, "...infuse large amounts of additional money into a...system that is undisciplined, unaccountable, and grossly inefficient" is half right. The system is undisciplined, unaccountable, and inefficient. However, as stated above I am convinced no new money is needed and quite possibly less.

All of the issues that managed to get discussed are nothing more than symptoms of what is wrong with the system. Medicare crisis, Medicaid crisis, pharmaceutical cost, uninsured and under insured, rising insurance cost for businesses, governments, and individuals, IT, malpractice cost, trial lawyers and whatever issue might come up are not the problem. The problem is how the money in the system is collected and how it is distributed. Fix the problem and the symptoms will take care of themselves.

Here is how we can make this happen. What we have to do is get the heavy hitters involved. I do not mean the big players in medicine. I mean the automobile makers, GM, Ford, Honda, Nissan and the entire industry, IBM, Microsoft, Google, Time Warner/ComCast, Wal Mart, National and State Chamber of Commerce Associations, U.S. Governors Association, National Association of Mayors and on and on. Involve those who are most adversely impacted (in their finances) by the undisciplined, unaccountable, and inefficient Gordian Knot that we call our health care system.

Make it an economic issue and keep all of the health care players in the background in the effort. We, the health care players, can advise and assist the business leaders in this effort. Get business to lead the charge and significant positive reform will happen quickly. Universal coverage, one payer, and a national tax to pay for it will resolve the symptoms that we spend so much time addressing.

Thursday, November 10, 2005

Reason for Taking Heart

Those who may be discouraged about the prospects for health care reform can take heart from a story that appeared in the November 9, 2005 issue of the Boston Globe.

The story was about a surgical episode that occurred a year ago. A surgeon at Mount Auburn Hospital in Cambridge was suspended after five of his patients developed post-operative staph infections during a ten-week period – infections ultimately traced to the surgeon himself, who was identified as the carrier. Four patients recovered and one died.

According to the story, Mount Auburn was on top of the situation from the beginning. Its “infection control manager” picked up on the first three cases, at which time the surgeon’s operating privileges were temporarily suspended. Tests were inconclusive, however, and his privileges were restored. The other two cases quickly ensued (including the one who died), at which point the suspension was reinstated. The surgeon refused the three rounds of antibiotic treatment insisted upon by the hospital and in January of this year resigned from the Mount Auburn staff.

While under suspension at Mount Auburn, the surgeon began operating on patients at Beth Israel Deaconess Hospital in Boston, where he also had privileges. However, that hospital soon learned of the situation at Mount Auburn and imposed its own suspension.

At present, the surgeon is not practicing.

The encouraging point here is that while both hospitals properly reported their actions to the appropriate state authority, they accepted their responsibilities and took the initiative without waiting for regulators to make them do it.

It probably wouldn’t have happened that way ten years ago, and for sure not twenty years ago.

So health care reform is under way, sure enough. If only it could move faster!!!!

Sunday, November 06, 2005

The Threat of Evidence-Based Medicine

While catching up on my reading, I noticed that the September, 2005 issue of the American Hospital Association’s journal H&HN (Hospitals & Health Networks) included a special article on Evidence-Based Medicine (EBM).

EBM was defined as the “conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”

That sounds about as wholesome as motherhood and apple pie and might lead one to conclude that there was nothing controversial about it.

Not so. After listing a number of arguments in favor of EBM, the article presented the views of critics within the medical profession who believe that EBM standards:

- introduce disincentives for individual innovations in care and healthy competition among practitioners

- threaten to bring about stagnation and bland uniformity in care

- may create a lower level of safety by diminishing practitioner’s skills

- encourage providers to treat all patients as interchangeable

- poorly equip doctors to contend with the variations they will encounter in actual clinical settings

- may lead to the replacement of traditional health care professionals by less expensive, less skilled workers, who may be incapable of operating effectively in diverse situations

It’s an indication of what health care reform is up against.

Thursday, November 03, 2005

Notes from Dan Ford

From time to time my postings stimulate responses and observations from long-time friend, fellow alum, and health care executive head hunter Dan Ford. Some may remember the tragic story of the medical error that changed his life and that of his ex-wife.

Herewith his most recent message:

1) Go to www.themedform.org. A medication listing form for consumers (meaning every one of us, elderly parents, children, other family, friends), to keep organized, and for those periodic visits to the doctor and hospital. A good step to help prevent one aspect of medication errors. I was the last speaker at the press conference in Phoenix on Sept. 1 when this was announced, and the first consumer to complete The Med Form. A nice, symbolic gesture.

2) Our AzHHA Patient Safety Steering Committee visited the Palo Verde Nuclear Power Plant, west of Phoenix, on October 20, receiving a safety focused tour. Is the largest electricity producing plant in the country, servicing parts of CA, AZ, NM and TX. The plant re-opened the next day, after being shut-down for about two weeks. It had received a communication from another power plant about the potential for a serious safety issue. The problem never materialized at either plant, but Palo Verde was morally/legally obligated to shut itself down, while it examined the issue, which was potentially real because they could not find anything in their manuals that said it couldn't happen. They finally resolved it, got permission to re-open. Would hospitals do the same, e.g., an operating room, or are there too many political, fiscal, ego and role behavior issues that get in the way, even though there may be a serious potential safety issue?

Every leader at the plant carries a little "Leadership Observations" note pad. Each day he/she is expected to jot down two safety ideas, including input from other employees. They are assembled periodically, discussed, evaluated, used. They have a huge, conference-sized room devoted entirely to show and tell demonstration type safety training procedures, equipment, etc, in addition to classrooms for training. Their safety program oversight is divvied up between two executives. Roles are affectionately described as one being to protect the people from the facilities and the other to protect facilities from the people.

3) Your recent article on "Accountability in Health Care" was superb, Dick. I complimented you. We exchanged emails about the subject and you expressed an interest in finding the hospital trustee who asks how many of the 90,000-plus annual deaths identified by the IOM occurred in his hospital and insisted that steps be taken to prevent them in the future. I volunteered to help you find that one trustee. I am seeking that entire board and CEO who are so angry and livid about patient safety and the continued loss of lives and serious injuries, even with remarkable steps being taken with resources like IHI and others, that they are demanding and modeling the accountability. It is why I give patient safety presentations to provider audiences, to light such a fire.

4) For the last year, I have served on the Quality Committee of the Board of Directors of an Arizona health care system and recently joined its Patient Safety and Quality Council. The former is policy and the latter operations focused/action oriented. It is a great learning experience. I am able to contribute in a substantive way. I remind them that I am not a clinician. They remind me that they have plenty of clinical experts around the table and wanted someone what had experienced a medical error, who was passionate, objective, caring, candid, not shy, would ask the dumb and the dumb like a fox questions. I make the CEO's a little nervous when I suggest stretch versus conservative patient safety goals. The worst that can happen is that we do not meet the goals, while too many unexpected outcomes continue to happen. In spite of the fact that I am a "safe" consumer as an industry insider, this would seem to be one model for hospitals to involve consumers in their patient safety and quality endeavors.

Wednesday, November 02, 2005

Rearranging the Deck Chairs on the Titanic

is an aphorism people use to describe an activity that seems rather pointless in light of other, more important things that are going on.

I was reminded of that aphorism by several recent stories in the newspapers. The first was about an agreement between General Motors and the United Auto Workers under which company-paid health care benefits will be reduced for both GM employees and retirees.

Then a few days later there were reports of retail giant Wal Mart trying to rein in health insurance costs by, among other things, hiring more part-time people, hiring healthier people, charging more for dependent coverage, etc.

Last week while I was in Iowa the Omaha World Herald carried an editorial about ideas being explored by the Nebraska government to reduce the financial burden of Medicaid. One proposal was to give Medicaid beneficiaries vouchers of fixed dollar value that they could use to buy health care.

In these and other similar cases, employers and governments are responding to the high and escalating cost of health care by passing the financial burden on to somebody else – in most cases to patients.

I think it remarkable that in all these situations there is almost no discussion of the larger problem, which is that the cost of providing health care is too high and rising too fast.

The obvious remedy is to get cost down. But the prevailing assumption seems to be that providing health care costs what it costs and there is nothing that can be done about it.

One doesn’t have to think about it very long to realize the falsity of that assumption. There is nothing being done that can’t be done less expensively if imaginative people put their minds to it and want to do it bad enough.

While our health care system is not about to sink like the Titanic, it is clearly heading for some kind of crisis. In the meantime, it seems that we will keep rearranging the deck chairs.

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