Wednesday, January 31, 2007

Kudos to Levy

I have often commented on the inadequacy of hospital CEO involvement in efforts to improve the safety and quality of patient care. I understand the hazard of managers being accused of interfering in clinical matters. At the same time, I have been sympathetic with the observation of Paul O’Neill, President George W. Bush’s first Secretary of the Treasury, that until the hospital CEO takes personal responsibility for every medical error, progress in preventing them will be slow.

Well, we are still some distance from O’Neill’s ideal, but we are moving in that direction. Paul Levy, CEO of Beth Israel Deaconess Medical Center (BIDMC) in Boston now operates a blog. His January 23 posting dealt with catheter-associated blood stream infections. It indicated that the BIDMC record, when compared with that of other institutions, was not as good as it should be. The January 25 posting included similar information about Ventilator Associated Pneumonia. In both cases, Levy used his blog to urge his people to do better.

The postings can be seen at www.runningahospital.blogspot.com.

All of us wish that things would move faster, but we are thankful for progress made and to Paul Levy for doing his part.

Tuesday, January 30, 2007

A Persistent Issue

“In his ’52 State of the Union address, Truman vowed ‘to bring the cost of modern medical care within the reach of all the people” while Nixon, 22 years later, promised ‘a new system that makes high-quality health care available to every American.’ Not to be outdone, Mr. Bush offered a dead-on-arrival proposal that ‘all our citizens have affordable and available health care.’”

Those words are taken from a Frank Rich column that appeared on the Op-Ed page of the Sunday, January 28, 2007 issue of the New York Times. Although health care was not the main subject of the column, it seems to me that Rich’s observation is worthy of note.

If a political issue can last for more than 50 years, something about it must be more complicated than is being recognized. Perhaps the wrong question is being asked. Or perhaps there are aspects of the issue that are being ignored.

As readers of this blog will know, I have opinions on that subject. I believe that what prevents us from getting to the issue raised by Truman, Nixon, and Bush (among others) is the lack of discipline and accountability in the delivery of health care. Costs are too high, safety and quality are not what they should be and we don’t know who is supposed to do something about it. Right now nobody is in charge at the local level and until that is fixed, not much else is going to happen.

Perhaps there are better explanations. I’d be delighted to receive suggestions.

Thursday, January 25, 2007

Another Perspective on Colonoscopies

The following is the perspective of periodic contributor Cindy Muggli on colonoscopies:

In response to the article about the amount of time doctors spend doing colonoscopies; when the time comes for me to have one I'll be tempted to find a doctor who can get it done well in less than 6 minutes!

Monday, January 22, 2007

A Response to Cost? Who Cares?

Fellow alumnus and fellow blogger ( http://grindstonehc.blogspot.com ) John Kelly responds to my recent posting as follows:

The article on “Cost? Who Cares?” ends on the note….nobody cares enough to do anything about it.

On the contrary, I think folks are doing things about it…maybe not what we “desire” or is deemed good policy, but to say nothing is being done entirely misses the phenomenal change that some of us are experiencing.

To wit:

- I’ve spoken with a couple of banker friends…one of their fastest growing lines of business is to set up easy to administer Health Saving Account instruments that link to invested savings and back to employer funded medical savings accounts. This way, it is easier for businesses to “cost shift” some of the cost of first dollar health care to employees. Simultaneously, the feds have ushered in sweeping tax code changes (with the new congress hungry to do more) that allow for tax deductibility for these very same financial instruments.

- Walmart has seen a 300% increase in it’s generic prescription medication mail order business…much to the chagrin of retail, surgi-center and hospital sponsored retail pharmacies
‘brown-bagging’ for medications is not only encouraged, but required by several insurers as a means to bypass traditional provider mark-ups on medications administered in the providers facility.

- MedPAC is mid-stream in a major overhaul of the provider pay for performance system. Current discussions put the phase in on a 5 year timetable…sooner if congress gets a backbone and makes it legislative mandate versus regulatory reform snail-pace efforts.

- Employers shift more costs to employees every year, move jobs overseas to avoid paying health benefits and are demanding (not asking) narrow network insurance products with 20-30% discounts.

That’s just top of mind changes……..I could go on for pages.

Sunday, January 21, 2007

Cost? Who Cares?

Health Affairs is an inch-thick, highly regarded scholarly journal that comes out six times a year.

The January/February 2007 issue includes a review of a book titled Money-Driven Medicine: the Real Reason Health Care Costs So Much. According to the reviewer, the author identifies the culprit as corporate-based profit incentives.

The overall theme of this issue of the journal is Cardiovascular Disease & Society. By my count, sixteen articles are devoted to that subject.

What struck me was that none of the articles dealt with the cost of treating patients with cardiovascular disease and whether there might be less expensive ways to do it - except for a brief one about patients who go to places like India for their surgery (where the cost is a fraction of that of similar treatment in the U.S.).

So I would offer another Reason Health Care Costs So Much.

Nobody cares enough about what it costs to do anything about it.

Friday, January 19, 2007

No Pain No Gain

Anyone with management experience will know that there is seldom a painless way to reduce the cost of doing anything – particularly if it involves a number of functions performed by different people. Reducing cost requires changing the way the process is carried out. As a result some participants may gain a larger role, others a smaller one and some get eliminated altogether. Those who lose out will understandably not be happy about it; i.e., will feel the pain.
Some weeks ago friend and erstwhile colleague Peter Geilich mailed to me a copy of a long editorial on reforming health care (Washington Post, December 13, 2006), including restraining cost. The editorial reviewed the usual list of defects in the current system and commented on financing alternatives like single-payer and health savings accounts.

Its only recommendation was for the adoption of electronic (i.e., computerized) medical records. It suggested that doctors would order fewer tests if their computers told them which ones would be useful and which ones not, thereby saving money.

Would that the remedy could be so painless. More realistically, the article would have challenged the health care provider establishment to find and implement its own ways to improve efficiency, recognizing that some interests would be pinched in the process.

A common saying among those in training for athletic endeavor is “No Pain No Gain.” It applies to health care reform as well.

Wednesday, January 03, 2007

A Handicap to Overcome

Last summer two prominent hospital CEO’s in Chicago announced their retirements. One was Dr. Anthony Barbato of Loyola University Health System and the other Gary Mecklenberg of Northwestern Memorial Health Care. I do not know Barbato. Mecklenberg is a fellow alumnus whom I have known for many years and who in my judgment may well be the outstanding health care executive of his time.

Interviews with the two of them were published in the September, 2006 issue of Hospitals and Health Networks, which is the journal of the American Hospital Association.

If someone were to ask me what was the most significant change in hospital management that had occurred during my lifetime, I would without hesitation have said that it was the steady increase in the hospital’s responsibility for managing physicians and the way they practice medicine. Several articles in that same journal dealt with that topic indirectly. But neither Barbato nor Mecklenberg made direct mention of it.

I take that to be an indication of the unusual situation in which we find ourselves – which is that a subject central to the issue of health care reform and redesign remains so culturally sensitive that it can’t be discussed publicly.

Midway in the interview report Mecklenberg is quoted as saying “I suspect that Tony and I have done something right or we wouldn’t have the tenure we have.” Apparently one of the things they did right was to manage medical practice effectively without either mentioning it or being caught at it.

Unfortunately, most health care managers are not as capable as Barbato and Mecklenberg and so this “don’t ask don’t tell” approach to the management of medical practice is a handicap that needs to be overcome.

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