Monday, January 21, 2008

Unmanaged Care

For all the talk about managed care, it seems that managing care is something we have yet to do.

I’ve been vaguely aware of that for some time, but recent experience has brought it into sharper focus.

Last summer my father’s genes finally asserted themselves and I was diagnosed diabetic. Fortunately, it is a mild case, easily treated with diet and medication. I take a pill every morning and nstead of watching calories, I watch carbs.

My care has been provided by a primary care physician, a diet counselor and a nurse diabetic counselor. The dietician and the nurse know each other because they work out of the same office suite in South Shore Hospital. But neither of them knows my primary care physician and, to the best of my knowledge, has had any communication with her. Visits to the physician and the nurse counselor seem to deal with pretty much the same subject matter – weight, blood pressure, blood sugar levels, foot care, eye care, etc.

I read somewhere that there are 15 million diabetics in the U.S. That would be about five per cent of the population.

If the population served by South Shore Hospital and its medical staff is 100,000 (a conservative estimate, I think), then they would be serving 5,000 diabetics. That offers an opportunity, I think, for somebody to think about how the cost and outcomes of diabetic care might be optimized.

So far as I can tell, no one has done that. But, of course, even if they did, there would be the problem of implementing any conclusions reached. The medical staff consists mainly of private practice physicians who are effectively accountable to nobody for what they do in their offices, which is where diabetics get most of their care.

In theory, organizations like Kaiser, Mayo and Ford with their full-time medical staffs could do it, but they don’t impose the necessary discipline on their physicians, either.

If I’m wrong about that, I hope somebody will tell me. But if I’m not, we ought to be talking about unmanaged care rather than about managed care.

Friday, January 18, 2008

Steps along the Road to Reform

Earlier this month, wife Marilyn experienced a small stroke (from which, happily, she has had a great recovery).

It was late afternoon on Saturday when we realized what had happened and went to the emergency room of South Shore Hospital. Within a few minutes, she had been received, registered, and called by a triage nurse who carefully recorded her symptoms and their history and performed a simple examination. When it became clear that the symptoms had first appeared unrecognized on the previous day, the situation was no longer one of immediate emergency. Nevertheless, the nurse ordered a CAT scan (to rule out bleeding and tumors), some lab work, and an EKG, all of which were promptly performed and reported out.

Not so many years ago, nurses would not have been authorized to order these tests. Only a doctor would have been allowed to do it, which would have involved a potentially harmful delay – time usually being of the essence in the treatment of stroke patients. So having the nurse do it was a step along the road to reform.

Marilyn was then put in an exam room, where she was seen first by the ER nurse (who had by then received the results of the diagnostic work) and two hours later by the emergency physician who conducted her own examination and announced that Marilyn would be admitted to the hospital for monitoring (a small stroke is often followed shortly by a large one) and seen by a neurologist the next day.

Thinking about it later, I’m sure that having finished her work, the triage nurse knew exactly what was going to happen. She could have arranged the admission and notified the neurologist right there and then.

I predict that before long, she will be allowed to do so and still another step will have been taken on the road to reform.

Tuesday, January 08, 2008

A New Hurdle

As if health care reform didn’t already face enough hurdles, the federal Office for Human Research Protection (OHRP) has created a new one.

As was mentioned in an earlier posting, doctors at the renowned Johns Hopkins Hospital in Baltimore have been actively promoting the use of checklists in hospitals as a means of preventing infections and other adverse events that plague health care. A major program was mounted in Michigan with spectacular results. The rate of bloodstream infections from IV lines fell by two-thirds. The average ICU cut its infection rate from 4% to zero. Over 18 months, the program saved more than 1,500 lives and nearly $200 million.

Last month, OHRP shut the program down. It claimed that scientific ethics regulations had been violated by failing to obtain written, informed consents from every patient and health care provider involved in the use of the checklists.

All this was reported in an article by Dr. Atul Gawande that appeared on the Op-Ed page of the Sunday, December 30 issue of the New York Times. As reported by Gawande, OHRP justified its decision on the grounds that the use of checklists is an alteration in medical care (like the use of an experimental drug) that could put patients and doctors at risk – by exposing how poorly some of them follow basic infection-preventing procedures.

No doubt this ridiculous turn of events will be remedied. Getting the consents that OHRP says that current regulations require would be both useless and impractical. In the meantime, the OHRP decision stands out as an example of how difficult it can be to make changes in established ways of doing things.

Tuesday, January 01, 2008

Unraveling or Evolving?

The next time you use an emergency room and need a specialist, one may or may not be available.

In earlier days, providing on-call coverage for emergencies was considered an obligation that physicians accepted when they were admitted to the hospital’s medical staff and given the privilege of using its facilities in the care of their patients.

In addition, assuring that physician services were readily available whenever patients needed them was looked upon as a collective obligation of medicine as a profession.

It seems that neither is any longer the case. An article by Christopher Lee of the Washington Post, buried on page A12 of the December 23 issue of The Boston Globe, reported on the growing difficulty hospitals are experiencing in getting specialists to provide emergency on-call coverage. It suggested that the problem was due to “a fear of malpractice lawsuits, a reluctance to go without pay when seeing uninsured patients and a growing intolerance to the disruption in their personal lives and private practices.”

What the article did not mention is that instead of recognizing a professional or institutional obligation, a growing number of specialists are demanding that they be paid by hospitals for providing coverage.

Dr. Ann O’Malley, a physician who has studied this matter, was quoted in the article as saying that “The historic relationship between physicians and hospitals is unraveling.”

Alternately, she might have said that the relationship is evolving. It used to be that the medical profession had the lead role in health care with the support of hospitals. That day seems to be behind us with the mantle of leadership being passed to hospitals, which now have the burden of responsibility for making specialist services available to emergency patients. It is a responsibility that hospitals have resisted, but is now being forced upon them.

Completing this transition is a central element of health care reform.

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