Wednesday, July 26, 2006

Unwritten Law

“No written law has ever been more binding than unwritten custom supported by popular opinion.”

That quotation, attributed to American feminist Carrie Chapman Catt (1859-1947), appeared as a filler in the Living Section of the July 19, 2006 issue of the Omaha World Herald. It neatly encapsulates what may well be the single most important barrier to the effective redesign of our health care system.

For example, take the unwritten law that gives people an unrestricted right to use whatever physician they might choose. Or the one against interfering in the doctor/patient relationship.

The result of those laws is that whoever undertakes to remedy what ails our health care system starts with one hand tied behind his back and the other in a boxing glove.

That was the experience of the so-called managed care era of the 1980’s and 90’s. Managed care companies negotiated with providers, and contracted only with those who offered the most acceptable terms. Their subscribers were fully covered only if they obtained care from the contracted providers. Beyond that, managed care companies refused to pay for services they determined to be unnecessary or inappropriate.

Cost escalation was effectively stopped in its tracks. Furthermore, no convincing evidence has ever been developed that demonstrated that subscribers were physically harmed to any significant extent by denied services. Since every medical procedure involves some risk, it may even be that subscribers benefited from being denied services that they did not need.

But the public rebelled at this infringement of unwritten laws. Managed care was largely abandoned and costs resumed their upward spiral.

The lesson to be learned from all this is that those who would redesign our health care system must first find a way to amend, repeal or replace the unwritten laws that keep it from happening.

Tuesday, July 18, 2006

Letting Hospitals Off Too Easy

In recent times, there has been a lot of discussion of community hospitals and community benefit. As indicated in a special report on this subject included in the July 3/10 issue of Modern Healthcare, the issue usually boils down to whether non-profit hospitals provide enough charity care to justify their tax exempt status.

I think that is a very short-sighted way to look at community benefit. To me, a non-profit hospital is owned by the community and everything it does ought to be for the community’s benefit. Charity care may be one of those things, but it is by no means the only one.

One source of confusion is the tendency to refer to non-profit hospitals as “charitable organizations.” It is true that non-profit hospitals have long been seen as an instrument of charity, but there are lots of non-profit organizations that are not involved in charity at all.

It may be that in the modern era, non-profit hospitals have become big and rich and powerful and have lost sight of the fact that they owe their allegiance to the communities that own them – not to their doctors, their high-paid executives, or anybody else. They may well need to be reminded of their basic purpose. But allowing them to get off the hook by providing some quota of charity care is letting them off too easy.

Sunday, July 16, 2006

Two Lessons from France

Bill Busby, friend of 50 years plus, was good enough to send me a clipping from the July 5, 2006 issue of the Albuquerque Journal – a column entitled Europe Makes Health Care Work by Steven Hill of the New America Foundation.

The article pointed out that several European countries have health care systems that seem to work well and cost a lot less than ours. It made specific reference to France, which has been rated by the World Health Organization as having the best system in the world.

The French system is financed partly by employers, partly by employees, and partly by the government, each of which contributes to a Sickness Insurance Fund (SIF). Most doctors are employed by private medical groups. Fees and cost control measures are negotiated annually between the SIFs and representatives of the doctors.

There are many similarities with the program recently adopted by the Commonwealth of Massachusetts, with one important exception – the Massachusetts program has no provisions for cost controls.

At its close, the column cited two important lessons to be learned from European plans. One is that universal coverage does not necessarily mean single payer. The other is that cost doesn’t control itself – somebody has to do it.

Tuesday, July 11, 2006

Whipkey on Ellwood

The posting On Gratification drew the following comments from Neil Whipkey, Administrator of Sands at Lake Shore Hospital in Lake City, Florida:

Your piece on Paul Ellwood and his comments was both powerful and interesting. Mr. Ellwood is somewhere up on the mountain top with the other gurus. I happen to toil down on the lower slopes. Regardless, there was much I liked but also some information that I question.

First: "....unaffordable, unaccountable, and inconsistent healthcare." I'll give Mr. Ellwood credit for two and a half out of three. For those who are the "haves" in this country the "unaffordable" part of healthcare is a non-issue. With regard to unaccountable and inconsistent he hit those nails squarely on the head.

"....if they're not doing the right thing, they shouldn't be getting paid." Bingo! What other line of work is so well rewarded for such less than stellar results? It is shameful. I hope Mr. Ellwood can come up with an answer. After over 25 years in healthcare I confess to knowing too much. The thought of going to a hospital, any hospital, is scary.

"....unless the parents of the next health policy give birth to a healthcare system made up of fully integrated groups....accountable..." Wow, too far up the mountain top for me. Parents? Give birth? Integrated groups? Who are the parents? What is going to be birthed? Who are the integrated groups and who are they accountable to?

"Instead we learned from HMOs that the U.S. needs a permanent entity that can follow and subtly gauge and influence the ability of a less fragmented healthcare system to cost-effectively produce health." That is the magic bullet that will significantly revamp and improve our current dysfunctional system. I want to officially volunteer my services to be one of the charter members of the "permanent entity."

Any other volunteers?

Monday, July 10, 2006

An ER Run Properly?

Friend and former colleague Jeff Ackerman is CEO at the San Jacinto Methodist Hospital in Baytown, Texas. He has this to say on the subject of running ER’s properly:

First, my experience is that most of our patients think we are doing well.

Second, we revised our process and no longer put every patient in a bed. Instead, a physician sees every patient in a triage room within 20 minutes of arrival. Some patients are treated immediately and sent home. Those patients who are not acute but need lab work or x-rays are sent to a waiting room where they are picked up for their procedure and returned after. They are then seen by the physician in the triage area and treated and discharged.

The result is a decrease of throughput time by 1 hour (3.5 hours to 2.5 hours) and a reduction of patients leaving without being examined from 3% to .5% - 1.0%.

However, offsetting these improvements is a growth in our ER volume year over year of 9%, which follows a 10% growth 2005 over 2004.

I don’t think the problem is how we run our ERs but rather how we manage healthcare.

P.S. Our ER volume this year is projected at 62,000 visits with 30% uninsured.

Sunday, July 09, 2006

Betting on Hospitals

Separation of its institutional and professional components has long been an established feature of our health care provider system. We recognize the distinction in the separate identities of a hospital and its medical staff. We see it in health insurance, with Blue Cross paying hospitals and Blue Shield paying physicians. Similarly, Medicare’s Part A covers hospital services and its Part B, physician services.

As health care has come to depend more on process and less on individuals, that historical bifurcation has become increasingly problematic and may now be the single most significant barrier to meaningful health care reform.

Actually, the boundary between the two components has been breaking down for some time now. The courts have long held hospitals financially accountable for the malpractice of physicians on their medical staffs. Employment of physicians by hospitals, once anathema to the medical profession, has become commonplace.

But we do not yet have agreement on who should end up in charge.

Historically, it has been assumed that health care ought to be under the control of the medical profession. Politicians love to carry on about how we have to get medical decisions back into the hands of doctors and their patients. A number of states have “corporate practice” laws designed to protect the profession from institutional control.

The cover story of the June 26, 2006 issue of Modern Healthcare was about an attempt by Carilion, a non-profit hospital system based in Roanoke, Virginia, to convert itself into a physician-run clinic along the lines of the Mayo Clinic, which operates its own hospitals. A later article in that same issue was about for-profit hospitals that invite their physicians to become owners by investing through syndications.

There has also been a growth in the number of physician-owned hospitals, particularly in specialties like orthopedics and heart surgery.

All these are consistent with the historical assumption.

But institutional jurisdiction over medical practice has been increasing, as well, with more and more physicians being employed by hospitals as mentioned above. Further, most of the recent quality improvement initiatives – all of which involve changes in medical practice, have been hospital-based.

So who will win out? I am betting on hospitals. Only hospitals have the structure, experience and qualification needed to carry out the role. Some, like Henry Ford in Detroit and the Shelby County Health System in my Iowa home town, have already done so. The medical profession is not organized to take it on, with the exception of places like Mayo which are likely to be the last of their breed since the circumstances that led to their creation cannot be duplicated.

Whichever way it goes, the issue needs to be settled so that we can get on with the process of redesigning the system.

Tuesday, July 04, 2006

On Gratification

It is always gratifying when a recognized authority expresses an opinion that matches your own.

Paul Ellwood was for years one of the gurus of health care. Among other things, he is considered the father of managed care and is given credit for inventing the term Health Maintenance Organization. He was influential during the Nixon years when HMOs were formally promoted as a matter of national policy.

In its cover story, the June 19, 2006 issue of Modern Healthcare featured four “Father Figures” of major movements in health care. Ellwood was one of them.

When asked about the future, here is what he said:

“The next president’s most compelling domestic problem will be unaffordable, unaccountable and inconsistent healthcare. The problem cannot be solved unless the parents of the next health policy give birth to a healthcare system made up of fully integrated groups that can be held accountable for their patients’ health.

One of the key missing elements remains the assurance that the medical care we’re buying actually works. The closest thing to that right now are the plans that pay providers something extra for doing the right thing, but that kind of tool is not sufficiently powerful. My feeling is, if they’re not doing the right thing, they shouldn’t be paid.

The government agencies that buy healthcare such as Medicare and Medicaid need to get out of the business of attempting to manage healthcare. Instead, we learned from HMOs that the U.S. needs a permanent entity that can follow and subtly gauge and influence the ability of a less fragmented healthcare system to cost-effectively produce health.”

I couldn’t have said it much better myself.

Sunday, July 02, 2006

Whipkey on Operating ERs Properly

Regular reader and contributor Neil Whipkey, Florida hospital CEO, has the following to say in response to the posting Time to Get Over It.

I may respond to his invitation to comment. Others are encouraged to do so, as well.

".....time to get over it and operate their ERs properly." Properly?
Very interesting choice of words. How might we operate our ERs properly? Let me make some guesses:

· Reduce wait time to 10 minutes?

· Staff with only Board Certified physicians?

· Provide life flight helicopters service for speedy transfer to major facilities?

· Provide only 16 slice, and above, CT scanners and same quality equipment for other services?

· Staff with only ACLS trained and Bachelor level trained RNs?

· Reduce charges to zero since charges are meaningless and we collect nearly zero anyhow?

· Provide Starbucks to go, upon prompt discharge?

Ok, I'm being somewhat facetious, but only somewhat. I believe our obligations are to:

· Provide as prompt as service as possible.

· Provide the highest quality level of care possible within the context of our abilities with regard to staffing and equipment.

· Treat all comers with respect, regardless of any ability to pay or the number of times they frequent our facility.

· Provide an environment that is safe and friendly for patients, visitors, and staff.

Rather simplistic, right? Still, I would like to hear what you, and your readers, think is "Proper(ly)"?

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