Friday, June 29, 2007

Cuba’s Cure

“The Cuban health system is producing a population that is as healthy as those of the world’s wealthiest countries at a fraction of the cost.”

That statement is taken from an article that appeared in the Summer 2007 issue of a magazine called Yes! and was called to my attention by long-time friend and fellow amateur philosopher Bill Busby.

The article went on to point out that Cuba offers universal coverage and in recent years has been exporting doctors to other countries.

Bill asks: Any truth to this?

Having never been to Cuba, I don’t know any more about the facts than Bill does. However, I’m willing to venture a guess that there is some truth to it but not the whole truth.

For example, evaluations of health systems often cite infant mortality statistics. We in the U.S. tend to classify any fetus that shows signs of life as a live birth. Every effort is made to save it, but sometimes the baby dies. Other societies follow a less strict definition. Without the staff or equipment needed to try to save a marginally viable baby, they would consider it to be stillborn, not an infant death.

I have also long believed that our system of health care is based as much on our culture and standard of living as on technical and scientific factors. We want to get our care from highly trained people in modern, well-equipped facilities. When we sense something not quite right with our bodies, we want something to be done about it and we want it done now.

Other cultures are more willing to take these things in stride and give nature time to take its course. And nature does take care of a lot of it, particularly if people adhere to preventive measures like immunizations, sanitation, and sensible eating.

The result is that there is probably less difference between the two systems in terms of actual clinical outcomes than we would prefer to believe. The odds of suffering actual harm because of a more spare system of care may well be lower than we think. Even so, we would probably not accept the store-front clinics and limited access to specialists that I suspect are common in Cuba.

What the comparison may tell us, however, is that getting a less expensive system will require a change in the way we think about health care; i.e., a change in our culture. It doesn’t mean that we have to think like Cubans, but we may need to make other changes, like being willing to accept restrictions on choice of physician. Our political leaders may sense as much and, realizing that culture change is always painful, tend to deal with the matter in vague generalities and avoid specifics.

Anyone interested in reading the article will find it at


Friday, June 15, 2007

A No to Institutional Oversight of Professionals

My recent posting on this subject elicited the below spirited response from good friend and fellow parishioner Kathryn Earle.

I am writing to respond briefly to your recent article, "What Happened to Professionalism?" and particularly to your conclusion: "I think it means that health care professionals have to be brought under the institutional oversight of institutions, such as hospitals or group practices, that are held accountable for the performance of the professionals they supervise. It means that we have to learn to put our confidence in institutions rather than in individuals." The major reason healthcare professionals are no longer as purely motivated by "doing the right thing" by each patient, as they once were, is that now, our basic system encourages inefficiency and distortion at best, corruption at worst. The insurance companies have become like many unions; the value they add is not commensurate to the price we pay for their services because the institutions themselves have become ends. Their own success is more important than the overall health of the system. Health professionals have as strong ethics and ideals as ever, but the system has absolutely beaten out of them their ability - and also, after prolonged abuse, their willingness - to deliver the very best care. Unless the public insists that the institutions change so that the major players in the system must interact in ways calculated to elicit quality of care and the satisfaction of patients and professionals, first, and value to stockholders and their satisfaction, second, I would argue that bringing health care professionals any further "under the oversight of institutions" would be disastrous. People naturally will do the right thing, but our systems are now set up to protect money-making rather than the people and the processes that serve them. Very few institutions will protect people incorruptibly past the point of their maturity, because most if not all institutions take on lives of their own, after a while, and lose sight of their original values. We, the people, must never entrust our safety and wellbeing to institutions for any length of time without periodically, vigilantly, monitoring and improving those institutions' service of the common, public good. If consumers do not insist on radical changes to the health care system, quality of care and nearly everyone's satisfaction with it will continue to erode.

And P.S., the same is true of our national government and the American people as a whole! But that's another subject.

Tuesday, June 12, 2007

Almost Lean

One of the current approaches to improving hospital operations has been imported from Toyota, the Japanese car company, and is called Lean. As the word implies, Lean aims to remove waste, unintended variation, and complexity.

Long-time friend and retired Land Court Judge Peter Kilborn has been good enough to send me a write-up on the Lean program at Children’s Hospital in Minneapolis. It included a picture of the hospital’s three-person Lean Resource Office, one of whom is Kilborn’s daughter-in-law.

As I read the material, I was curious about the extent to which the Lean program at Children’s included physicians. Physicians play a key role in patient care at all levels and it would seem imperative that they be an integral part of any hospital’s effort to improve performance.

I found little about physicians in the material Kilborn sent, and so I went to the hospital’s web page to look for more. There was material about projects in nursing and one in the lab. The only reference to physicians I found was in a project to standardize the contents of the hospital’s “crash carts” – the supply carts used in responses to emergencies.

My investigation was admittedly limited, but what I found did not surprise me. The wall of professional independence that separates physicians from hospitals continues in too many cases to exclude doctors from efforts to improve patient care processes.

So long as that continues to be so, the ability to improve efficiency and control cost in health care will be severely limited.

Wednesday, June 06, 2007

What Happened to Professionalism?

I have long believed that a change in the culture of medicine would be a difficult but essential part of health care reform.

For that reason, I was encouraged to read an opinion piece in the May 7, 2007 issue of Modern Healthcare as authored by Chalmers Nunn, M.D., President of the American College of Physician Executives and Medical Director of Clinical Informatics at Centra Health in Virginia.

Nunn bemoaned the slow pace at which progress is being made in the improvement of safety and quality. He said that physicians had to accept standardized care. He called for increased personal and professional development of physician leaders. He pointed out that clinicians needed to “learn a new way of thinking, a new way of approaching care and a new way of being doctors.” He talked about the need for physicians to develop the ability to “listen, negotiate and partner with others.”

But I was then brought up short by this statement: “Whether it’s additional pay for improving safety, or additional benefits such as more time off, physicians, nurses and others need tangible incentives to help them engage in quality initiatives.”

I have always thought that professionalism meant putting client interest ahead of personal interest. I’ve assumed that professionals were granted independence of action because they could be counted on to do the right thing.

Nunn seems to be saying that these understandings no longer apply and that health professionals can’t be counted on to serve the best interests of patients unless they are given some tangible incentive to do so.

Does that mean that in order to have confidence in my physician, I need to be sure that my insurance company or her employer is giving her extra pay or time off in return for doing what is best for me?

Sadly, I think there is something in what Nunn is saying. I can no longer count on my doctor to do the right thing because she is a professional. In my own case I am sure she will, but Nunn suggests that I can’t count on it.

I think it means that health care professionals have to be brought under the institutional oversight of institutions, such as hospitals or group practices, that are held accountable for the performance of the professionals they supervise. It means that we have to learn to put our confidence in institutions rather than in individuals.

Tuesday, June 05, 2007

More on Business vs. Ministry

Responding to the posting about whether health care is a business or a ministry, the below comes in from social worker and periodic responder Cindy Mugglie:

I can't remember the details, but a couple months ago I heard about a case where a group of doctors got together and started their own inpatient medical facility. It seemed that the public believed it was comparable to any hospital, but evidently it was not. A patient began having trouble breathing and as the situation became worse the staff realized they did not have the equipment needed to respond and finally had to call 911. I cannot imagine being in what you think is a hospital and having to call 911 to take you to another hospital. I must have seen this one on Court TV. The patient died and his wife is suing the doctors who owned the facility, I think it was in Texas. Anyway, whether a hospital is a business or a ministry, I want one where the people running things are trained and experienced at doing just that.

Sunday, June 03, 2007

Welcome Responses

As a blogger, it is always gratifying to receive responses of any kind (it means someone is reading) but particularly from people you hold in high esteem.

The recent posting A Step towards Reform dealt with the breaking down of the bifurcation of health care into its institutional and professional components.

The first came from John Casey, twice retired from a career in health care management and now board chairman of MedCath, Inc.

I found your comment about the need for physicians and institutions to be one to be particularly interesting. Given my history in recent years of having physician investor/partners involved in two different companies, I am more convinced than ever that we have to find new and better ways to have physicians meaningfully involved ( a la "skin in the game") if we are to truly expect them to act in concert with institutional or corporate interests. I think there is evidence, (despite the controversies over physician ownership) that some enlightened not-for-profits have come to that conclusion as well. There will very probably need to be some tax reform to enable that to fully blossom, but I believe that it has significant implications for clinical quality and patient safety as well as the economic well being of our healthcare system.

Later in that same day, Tom Sawyer, a recovering hospital administrator now associated with the investment bank Shattuck Hammond Partners LLC. had this to say:

I agree with your assessment that at some time we have to address the flaws in the model through a new organizational vehicle that incorporates the physician and the hospital into a common unit that can focus on improving the delivery of care. The system is still too fractured for anything but some type of reimbursement control model and that is not how you improve the health of the masses.

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