Wednesday, June 25, 2008

Changing Attitudes

Copied below is an e-mail message I recently received from long-time friend Bill Busby, who now lives in Albuquerque.

Discounting the iconoclasm for which he has long been known, I take Bill’s comments to be another sign of changing public attitudes towards the health care establishment.

Take, for example, his statement that the administrator “gave orders” on where children arriving at the emergency room would be cared for. In my day, no administrator would presume to “give orders” on any matter involving the care of patients. Although I doubt it happened exactly that way at Presbyterian either (I suspect the matter was negotiated with the doctors and nurses), I find it interesting that Bill – and, quite possibly, others - thinks it did.

The same holds true of his remarks about getting hospitalists to sign discharge orders in a more timely way. If you were to ask Presbyterian’s hospitalists to describe the chain of command over them, I’d be surprised if any of them named the administrator. However, Bill – and, again, I suspect others – thinks that the executive head of the hospital ought to be able to define and require certain standards of performance from the hospital’s professional employees.

While I agree that ought to be the case, it hasn’t been and to a considerable extent still isn’t.

But things are changing.

Here is Bill’s message:

“Our Saturday morning Albuquerque Journal had an article about Presbyterian Hospital's efforts to reduce the wait times in their emergency rooms. The administrator made a quick survey which showed that their Albuquerque hospitals (two) ranked second in the state ("losing out" only to the New Mexico University Hospital which is the state-designated trauma center).

When analysis showed that a large percentage of the admissions were children, he gave orders for them to be sent to the new pediatric wing upon arrival. A large percentage of the adults shouldn't be in the hospital at all -- people with colds, for example. The real emergencies, he determined, were dealt with within minutes of entry into the hospital.

The larger problem was finding a bed to put them in. The problem, it seems, is that doctors (hospitalists all) want to wait until the end of the day to sign the dismissal orders. The administrator's problem, it seems, is to get them to spend a few minutes at the beginning of their shifts to sign the papers, thus making rooms available for new patients. Well, duh, aren't they employed to take care of their patients? One way to do that is to see that a bed is ready for them on entry and that they can get out of the hospital on a timely basis when they leave.”

Saturday, June 21, 2008

Managed Care Redux?

Working through my accumulated reading pile, I came upon a column in Modern Healthcare (May 19, 2008) by Mike Leavitt, U.S. Secretary of Health and Human Services. In it, he suggested that the competitive forces that exist in Medicare’s Part D (prescription drug) program should be applied to Parts A and B. He suggested that “A physician practice would be far more likely to invest resources in monitoring and tracking patients with chronic conditions if beneficiaries were provided with information on the quality of care and dollar savings available through more effective providers.”

That may be so, but I think he neglected to mention a central point. As a beneficiary of Part D, my basic relationship is with the insurance company (Humana in my case) – not with providers. The “competitive forces” involved are, on the one hand, among the insurance companies as they vie for my business and, on the other, between insurance companies and the pharmacies and pharmaceutical companies from which they “buy” drugs.

Applying that arrangement to Parts A and B would result in something very much like the HMO/Managed Care plans of the 1990’s. Those succeeded in restraining the cost of health care but proved unpopular and were largely abandoned.

I happen to believe that some form of the HMO/managed care approach is the best way to introduce “competitive forces” into the health care system and to that extent agree with Secretary Leavitt. But if that is what he has in mind, he should say so and suggest means for overcoming the objections that caused its demise.

Friday, June 20, 2008

More on Culture and Reform

Yesterday’s Boston Globe reported that Massachusetts Medicaid and Massachusetts Blue Cross Blue Shield will stop paying doctors and hospitals for care and treatment resulting from medical errors.

This decision seems so logical that it is easy to overlook how remarkable it is. During almost all of the 80 years since the invention of health insurance, we have believed that doctors did the best they could but sometimes things turned out badly. We weren’t convinced of that by any objective evidence. It was just something that seemed to explain the way things were and so we believed it.

With the notable exception of the malpractice courts, we haven’t believed that hospitals were responsible for bad outcomes, either. Try to think of a case in which a board of trustees and a CEO were publicly criticized for a medical mishap occurring in their hospital.

Then in 1999, the Institute of Medicine (IOM) reported that tens of thousands of people were dying every year as a result of preventable medical errors. That conclusion was supposedly based on objective evidence, but the credibility of IOM was such that few were interested in examining it critically. Also, I suspect that by that time a goodly number of people had known personally of bad outcomes that they suspected were avoidable.

So our beliefs changed and as a result Massachusetts insurers are able without apparent objection to reach a decision that a few years ago would have raised a storm of protest. No positioning by politicians or legislative debates were required.

This should teach us the importance of the relationship between culture and health care reform.

Wednesday, June 18, 2008

Somebody Do Something!!!

Last week we got a mailing from AARP soliciting donations in support of its campaign opposing an increase in Medicare premiums. We were also urged to contact our Senator, urging him to “find a better way to deal with the rising costs.” The suggestions offered were standardized and easily available health information, understandable medical bills, preventive care, and better options for long-term care.

Those are all good ideas, but nobody who thinks about it very long will be persuaded that they are enough to make a serious dent in the cost problem.

Then yesterday’s Boston Globe carried an article reporting that Federal Reserve chairman Ben Bernanke had characterized the performance of the healthcare system as “one of the biggest challenges facing the country.”

However, according to the article, “Bernanke didn’t recommend specific solutions, saying the choices involved with improving access and quality and controlling costs were best left to policy makers in Congress, the White House, and elsewhere.”

I find it remarkable that so many people are sure something should be done, but nobody is willing to make a serious suggestion.

It is safe to assume, I think, that so long as that condition continues, the process of health care reform will continue to move at a snail’s pace.

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