Thursday, February 23, 2006

Larry Summers and Health Care Reform

Those who want to understand why health care reform is so difficult can learn a great deal by studying the case of Larry Summers.

Mr. Summers is distinguished both as an economist and as a public servant, having served as Under Secretary of the Treasury in the Clinton Administration. After President Clinton left office, Mr. Summers was appointed President of Harvard University. It was reported at the time that the governing body of Harvard was looking for someone who could restore coherence to the University by rejuvenating its mission and reining in the excessively independent academic divisions.

Summers seemed to be the ideal candidate for the position with his impeccable academic credentials and demonstrated ability to be an effective administrator in a highly charged political environment.

It didn’t work. On February 21, 2006, Summers announced his resignation. Evidently, the President and Fellows of Harvard College, Harvard’s governing body, finally came to the conclusion that the cost of controversy within the faculty was outweighing the benefits.

The situation in many hospitals is almost precisely analogous. When Boards of Trustees undertake to recruit a CEO, they typically say they are looking for a strong leader who can capture control of the institution and enforce standards of performance. But the CEO who takes that literally and generates the inevitable medical staff resistance will find his Board opting in favor of peace, with career limiting consequences.

In both cases, the forces to which the governing body is reacting are mainly outside the institution. In a University, continued internal turmoil starts to hurt recruitment and, of perhaps even greater importance, to discourage donors. When it happens in a hospital, the community is likely to take the side of the doctors, who continue to enjoy high status and great public respect and whose professional independence is thought by most people to be something that should be preserved and defended.

Thus, those who would accelerate the pace of reform would be well advised to focus not only on the determination and vision of health care leaders, but also on the willingness of society at large to support reform in the face of the controversy that it inevitably will entail.

Tuesday, February 21, 2006

Comments from Kelly

Fellow alum John Kelly, long-time health care executive and now consultant, responds as follows to some recent postings:

On McNulty’s Comments: The thought that doctors would practice medicine without the threat of trial lawyers can/should only be considered when we also craft systems whereby the is no NEED for trial lawyers. More reflection on what Dan Ford is suggesting is in order – or – as Donald Berwick has said “nothing about you without you” and this should include investigations into errors of omission and commission. The patient (or representative) should be involved in a full disclosure process.

On the use of Non-physician practitioners: Let’s even take it a step further and create systems of care for which the individual patient/person can direct themselves to health. Here’s a practical example (as a father of little children yet): every parent should be instructed in the proper use of the otoscope before they can take their kid out of the nursery. This would allow the parent to evaluate almost every fever of more than 3 days duration to rule out ear infections and save thousands of visits to the doctor. Okay, perhaps a silly example, but you get the point. If we expect people to dial in to ‘troubleshoot’ their computer…why not for their healthcare? Put the tools in the hands of the patient in a true extension of the physician (or non-physician practitioner) practice.

Monday, February 20, 2006

More on Knowing Cost

Previous contributor Neil Whipkey, Florida hospital CEO, has this to say in response to the recently posted comments of Tom McNulty:

I find the comments of Tom McNulty both informative and interesting. It may very well be that we, as a collective business, have no clue as what our actual costs are. As the administrator of one hospital in a two hospital town I am continually amazed at the vast differences in the prices the two facilities charge for the same procedure. This has provided for some lively conversation among our local population.

Since my campaign for universal coverage, one payer, and a national tax to pay for health care seems to be on a very slow track to nowhere I have come up with another cost savings idea. It may not be original but I have not seen it get any press. Hospitals are essentially reimbursed a flat rate for a specific diagnosis. It seems that surgeons are paid a flat rate for a procedure performed in a hospital. The hospitals and the surgeons know going in what their reimbursement will be. Not so with medicine physicians as they get paid according to the amount of hospital visits they make on a given patient. They have no incentive, not financially anyway, to promote moving a patient to a level of care less than that offered by a hospital.

Change the payment structure for medicine physicians to a plan similar to how hospitals and surgeons are paid and you will see hospital overutilization go away in a proverbial heart beat. Savings would be huge and I am convinced patient care will improve. It is unhealthy for patients to stay in hospitals longer then necessary. Inappropriate extended stays are not good medicine.

Just think, less resources expended and better patient care. That sounds like something we all might be able to agree upon.

Sunday, February 19, 2006

An Inside View of the VA Hospital Success Story

Friend and faithful follower of this blog Chuck Kleber sends along the following comment on what has been referred to as the VA Hospital Success Story from his granddaughter, whom he identifies as “an experienced pharmaceutical and high tech medical equipment rep, and a doula.” Reportedly, VA hospitals have made notable progress is things like the computerized medical record and computerized physician order entry. For those like me who are often found behind the times, a doula is, in Chuck’s words, a highly trained midwife, a woman who attends a pregnant woman, and sometimes the father too, as an advisor, a confidant, hand holder, quasi-nurse and person of great support throughout the pregnancy and especially in the final weeks and days and, more especially, in the hospital and the delivery room. Also, for care and support after the birth.

Here is the comment:

I saw the headline about "the veteran's administration success story." I have no idea what they're talking about, but from the 12+ years I have been inside of VA hospitals, I would hardly call their health care delivery a success story. Veterans wait months for referrals to specialists. Every single VA hospital I've seen the inside of has been old, rundown, stunk to high heaven, crowded, dingy.... nowhere I would want to get health care for sure. The lines at the pharmacies there are long, every day, every time of day. The lines at the clinics are the same. There is so much red tape to cut through to get the type of appointment you need that it's a wonder any vet can see the right doctor.

I agree our health system is broken in America, but I don't see the answer being nationalized, subsidized health care.

Saturday, February 18, 2006

But What About the Cost of Care?

The February 7, 2006 issue of AHA News Now, the daily e-mail newsletter of the American Hospital Association contained an item titled “Houston hospital leader calls for overhaul of health care system.” It seems that in an speech of the same day at the National Press Club in Washington, President and CEO Dan Wolterman, CEO of Houston’s Memorial Hermann Healthcare System had called for comprehensive health care reform that focuses on prevention and wellness, personal accountability, liability reform, sufficient government reimbursement of Medicare and Medicaid services, and a mandate that all employers offer some form of health insurance for employees.

What about the cost of care, one might ask. His only reported reference to that was to say that hospitals could help effect change by working with physicians on shared goals and by improving quality, which often reduces costs.

In other words, we’ll try to do something about quality and, if we’re lucky, we might get some cost reduction as a side benefit.

One wonders how long the providers of health care will be able to get away with it.

Sunday, February 05, 2006

McNulty on Management and Health Care Costs

Recent postings on the high cost of health care and management’s responsibility for doing something about it brought the following comment from Tom McNulty, former colleague and CFO of Henry Ford Health System in Detroit, now retired:

I am somewhat concerned about the lack of understanding on the effect of the economics of health care expense on those that are charged with the stewardship of directing it (health care executives). You made two observations that beg for further discussion. One was about the decisions made by the palliative practicing MD who utilized his compassion and knowledge to allow the proper treatment for a person at the obvious end of life. The other physician wanted to continue to DX and Rx in order to prevent possible repercussions from family or peers. The second was the comment about insuring that everyone should have health care coverage as that would lower the cost.

I note that expanding coverage is nothing more than the cost shifting that has been going on for the last 40 years since Medicare was passed in 1965. It was then decided that the Federal Government should only pay cost for the program but it took almost 15 years before they could figure out what cost meant. By that time they had caused such a significant burden on the providers of the care, by deciding to pay considerable less that the average cost for the services, that the providers had to shift cost to the other payers( commercial insurance companies, individuals and self-insured companies ) who would then pass these on to the purchasers( individual, corporate or self-insured). It caused the whole method of allocating the real cost and controls to be a mess and impossible to decipher.

The real approach to how all of health care can be addressed rests with the approach that allows doctors to practice medicine without the fear of the trial lawyers and federal oversight personnel from financial, audit and regulatory agencies who do not contribute any value added to the process (but still need to maintain oversight on quality, appropriateness, malpractice)

The thought that the professional health care executive needs to be more concerned with the structure of the cost of the deliverable, the need for and responsible use of such services and the courage to address them, is laudable but I am afraid that the challenge will not be taken up. In that lies the real problem. We need the champions from industry to lead the real effort and not defer to the Political Policy Farce and federal pressures

Saturday, February 04, 2006

A Solution for the PCP Shortage

Friend and former fellow parishioner Chuck Kleber has referred me to a recent statement from the American College of Physicians (ACS) as reported in a Reuters article by reporter Maggie Fox. In unusually dire terms, ACS said that our system of primary care threatens to fall apart because fewer and fewer young physicians are going into that specialty.

The remedy proposed by ACS is to pay primary care physicians (PCPs) more and to give them a larger role in the organization and management of care.

I have an alternative suggestion: have physicians’ assistants and nurse practitioners take on most of what PCPs have been doing.

In a recent posting, Don Arnwine testified that in his own case, he was happy to get the information he needed from a nurse rather than wait for the doctor to return his call.

As it happens, Mrs. Wittrup is going through a course of care in which the primary care functions are being carried out by a nurse practitioner. She is convinced that she is getting more attention and, therefore, better care that way.

Friday, February 03, 2006

More on Involving Families in Sentinel Events

Dan Ford’s request for input about involving families in the investigation of sentinel events drew the following response from previous contributor Don Arnwine:

I found Dan Ford's comments provocative. I, too, have served and even chaired hospital Quality Assurance Committees. The idea of involving family in sentinel events never came up. If it had I think the first three questions would have been; "Will our attorney quit? and "Will our insurance company bail out? and "Will the attending physician have apoplexy?” I'm sure Dan has an answer for each. Seems to me the idea of involving family may not be absolute. There may be circumstances where it is appropriate and circumstances where it is not. If that makes sense then it would indicate that the first thing the QA Committee should do is to develop "Involvement Criteria" to recommend to the Board. I haven't seen Dan's presentation yet but I’m sure wouldn't do it without a policy from the board and hopefully also from the Medical Executive Committee. I would also like to know what the "Ethics" community would have to say. I would like to know if they consider it a "moral imperative." Thanks to Dan for raising the issue.

Thursday, February 02, 2006

George W and the Cost of Care

In his 2006 State of the Union address, President Bush put his finger on a central dilemma faced by those who would do something about the cost of health care.

Here is what he said:

“For all Americans, we must confront the rising cost of care, strengthen the doctor-patient relationship, and help people afford the insurance coverage they need.”

What the President seems not to realize is that the current strength of the doctor-patient relationship is prominent among the major barriers standing in the way of doing something about the cost of providing care.

Modern health care depends on systems. The way to get cost under control is to make those systems more efficient and the way to do that is to manage them.

For example, the evidence indicates that if patients with congestive heart failure are treated in accordance with a certain standard, outcomes will be better and costs will be lower. Health care managers are making efforts to get doctors to adhere to that standard. Those efforts are often resisted because they are seen as interfering in; i.e., weakening, the doctor-patient relationship.

So, Mr. President, you can either confront the rising cost of care or you can strengthen the doctor-patient relationship. But you can’t do both.

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