Thursday, January 26, 2006

Medical Auxiliaries and Overbooking

Postings on the subject of medical auxiliaries prompted the following comment from social worker Cindy Mugglie:

Re the rise in use of physician assistants, nurse practitioners and the like, while working at nursing homes in a large city, I noticed that many doctors seemed to take on a wide variety of responsibilities that they could never manage on their own. There were times that I thought they couldn't manage it, even with all the helpers. For example, the medical director of a nursing home was also the medical director of 3 other nursing homes and saw patients in 3 clinics. I think that God and Santa Claus are the only beings able to multi-task that well.

Wednesday, January 25, 2006

Healthcare Costs? Who Cares?

It is hard to pick up a newspaper these days without reading something about the public’s concern over the high and rising cost of health care, which many believe threatens our economic competitiveness in the global economy and which alarmists claim is bankrupting the nation.

But if you read only the healthcare literature, you might not know anything about it at all.

The January 9, 2006 issue of Modern Healthcare reported the top eleven issues of concern to hospital CEO’s. Cost didn’t make the list.

On that same day, AHA Today, the weekly newsletter of the American Hospital Association, carried two companion articles summarizing the major issues faced by the Association during the past year and to be addressed in 2006. Cost didn’t make either of those lists, either.

So it seems that everybody is concerned about the cost of health care except those in a position to do something about it.

I noted long ago that no hospital administrator ever got his portrait in the lobby for saving money.

If progress is to be made in addressing the cost problem in health care, that will have to change.

Tuesday, January 24, 2006

A Request

The below is a request from Dan Ford - healthcare executive head-hunter, fellow alumnus and long time colleague - whose personal life has been greatly affected by the issue of medical safety.

1) I would be interested in hearing about hospitals that involve the patient/family in Root Cause Analysis of sentinel events. I am a member of the Quality Committee of the Board of Directors of Carondelet Health Network in Tucson, AZ. CHN is a three hospital, faith-based system, and a member of Ascension Health in St. Louis. I asked the question at the November meeting and was asked to give a presentation at the December meeting. We are now exploring this, including research across the country. The answer so far is not many.

For a variety of positive reasons, the patient and/or family member should be in the room. Denying this participation is wrong and offensive from a human standpoint and short-sighted. We can learn from each other. I understand the reticence and barriers, including tradition, change, legal considerations, role behaviors, egos and other human behavior. We have many fears and need to learn to communicate.....even if awkward and hurtful and even if Legal Counsel suggests differently. Am willing to share my power point presentation, and would be interested in ideas from my blog colleagues....to dford@furstgroup.com and/or through Dick's blog.

2) Am giving a talk in Geneva, Switzerland in May on the role of patients in their own safety. Ideas are invited and appreciated about this as well.....30,000 foot ideas as well as ground level. The audience will be 250 CEO's of members of the World Health Professions Alliance. WHPA is comprised of physician, nurse, pharmacist and dental associations/professional societies.

Thank you!

We are all consumers.

Friday, January 20, 2006

An End of Life Story

On the general subject of physician power, friend and former co-worker in the vineyards of hospital administration Peter Geilich provides the following:

My mother-in-law recently died after living more than 90 years. She has been in a nursing facility near us for two years and did quite well until 3 weeks before her death. Then she sort of 'fell off the table.' Her capable internist MD wanted to move her to the hospital and do brain scan and intensive Rx. Stupid. We fired him and brought in a palliative care MD (also an internist) who eased her down in a dignified manner and she died surrounded by people she knew and who cared about her. Therein lies some of the problem of high health costs and unnecessary Rx. I spoke about this with a doctor I knew well in another town - he said his protocol is to give the family a choice about intensity of care. Unfortunately, he says, many families choose intensive care and all that goes with it. He is stuck - afraid of being sued. So, the legal system is another factor - although in more than 150 expert witness cases I have never come across that sort of thing.

Thursday, January 19, 2006

More Income for Massachusetts Hospitals?

Massachusetts is considering legislation to reduce the portion of the population without health insurance. Mitt Romney, the Republican governor, proposes a “carrot” approach involving savings and tax incentives. The Democratic legislature is more inclined to the “stick,” with one proposal requiring any company with 11 or more employees to either offer coverage or pay a special payroll tax in the range of 5%-7%.

In the January 18 issue of the Boston Globe, reporter Christopher Rowland summarized a study by Families USA claiming that one version of the plan would “reduce pressure on health insurance premiums by at least $500 million a year.”

There being no such thing as a free lunch, it is recognized that patients who don’t pay are paid for by patients who do. If more people have health insurance, hospitals will have fewer patients who can’t pay. The question is whether hospitals will then reduce their charges accordingly or whether they will just enjoy some additional income.

I have long believed that some kind of mandatory coverage would have to be a part of health care reform. I have also believed that unless it was done as part of an overall reform strategy, the main financial effect would be increased income for hospitals, thus further fueling the health care cost inflation that is already out of control.

I’m not familiar with the details, but from what I read, I’m betting that is exactly what will happen in Massachusetts.

Saturday, January 14, 2006

My Letter Published in Health Affairs

Last September, I posted a copy of a letter I had written to the journal Health Affairs, commenting on an article titled Can Electronic Medical Records Transform Health Care? Briefly, the letter said that the answer to that question was no – that only people could transform health care.

The letter was published in the January/February 2006 issue of the journal, which has just come out. It was accompanied by a response from the paper’s authors, who said that they agreed and that the purpose of the article was to provide “evidence [health care leaders] will need to persuade their peers that an investment in change is worth the effort.”

I think the exchange was useful and I am pleased to have been a part of it.

Thursday, January 12, 2006

Consumer Driven Health Care Goes Too Far

The January 10, 2006 issue of the Omaha World Herald carried a column by Wayne A. Sensor, CEO of the Alegent Health hospital system, on the subject of consumer-driven health care.

For the benefit of the uninitiated, consumer-driven health care is the term used to describe the plan of having the patient pay directly for health care rather than have the health insurance company do it.

In his column, Sensor says that consumer-driven health care is “A new approach to health insurance that emphasizes choice, control, and responsibility.” He believes that it will “….embolden leaders in the health care industry to offer quality, innovation, and better value in health care and health insurance coverage.”

I’m not convinced. While I believe that patients should take a larger role in their health care than was thought proper thirty years ago, I am not in favor of letting health care providers as far off the hook as Sensor’s proposal would allow them to be.

For one thing, I don’t have that much confidence in my own judgment when it comes to picking a provider, even though I have spent my entire working life in the health care business. I want my provider to be publicly accountable for performance – not just accountable to me.

Second, I want my provider to be answering to a standard higher than keeping me happy. I still believe there is a place for professionalism in this business.

And finally, as an individual purchaser of health care services, I don’t think I would have much economic clout when it comes to bargaining. An insurer representing me and a few tens of thousands others would be much more effective.

I agree that market forces have a role to play in bringing our system of health care under control, but consumer-driven health care as recommended by Sensor goes too far.

Friday, January 06, 2006

A Question to Ponder

Recent postings on the subject What are Doctors For reminds me that the practice of medicine has always been a combination of art and science. The science part deals with facts. The art part involves judgment.

Physicians make use of science (or should), but it is the judgment part that makes them doctors. One’s blood sugar level is a fact that can be determined by a machine. But what if anything should be done about it is a matter of judgment, which is where the doctor comes in.

As the years have gone by, the science of medicine has expanded enormously. For a long time, it dealt mainly with the development of better diagnostic tools and more effective treatments. More recently, there has been research to identify the most effective approaches to treatment. One result has been the emergence of protocols; i.e., formalized treatment plans based on the results of these studies.

In other words, the science part of medicine has expanded while the art component has contracted.

Does it therefore follow that we should need fewer doctors?

Wednesday, January 04, 2006

Arnwine on What Doctors Are For

The following is just in from Don Arnwine, long a well-known figure in healthcare management – now retired – relative to the recent posting on the subject.

I think [your daughter-in-law’s mother] has it right. I've long felt that this business of "choice" concerning doctors is as much political as medical. In my experience [including my own] what most people want and need in most situations is "information and attention." This can very often be provided by a "physician extender" who is more readily available and willing to help. I have had the same internist for over 20 years. I talk more with his nurse than with him and if I get the information and help I need why wait for him to call me back? Sometime back I went through a series of visits and treatments with an orthopedist. He had a Nurse Practitioner who possessed about 90% of the information and savvy that I needed. If that talent could be organized as "levels of care" rather than 'physician extenders" we might improve things.

Monday, January 02, 2006

On What Physicians are For

Commenting on the similarly named posting, Patricia Keith of Ocala, Florida (with whom I share two above-average grandsons) suggests that some costly health services we receive might alternatively be available from sources that are less expensive and perhaps even superior.

Here’s what she has to say:

I wonder if the rise in the use of physician's assistants, nurse practitioners and midwives is merely a cost-cutting, time-saving measure or if it could be a response to our increasing understanding that many needs may appropriately be met by different levels of medical care? In my experience, professional and personal, people in these positions tend to educate as they treat, spending time teaching patients how to care for themselves.

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