Wednesday, August 20, 2008

How Long Will It Take?

There is a squabble going on at the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) having to do with standard number MS 1.20 (Modern Healthcare, June 23, 2008). The disagreement has something to do with the authority of the Executive Committee of the hospital’s medical staff to resolve medical staff bylaws issues without the approval of the medical staff as a whole.

The dispute calls to mind a contradiction between organizational principles that has existed in modern hospitals since their inception. One principle holds that a hospital’s board of trustees has jurisdiction over everything that goes on in it. Another holds that the medical staff is “self-governing.”

The contradiction is this: The medical staff plays an essential role in hospital operations. If it is self-governing, then it is not governed by the hospital’s trustees, in which case the trustees do not have jurisdiction over everything that goes on in the hospital. So both principles cannot hold.

This unresolved conflict goes far to explain the absence of accountability in health care. As is well known, there are issues of cost, safety and quality in hospitals. The medical staff cannot deal effectively with those issues because it does not have jurisdiction over hospital operations. The trustees and administration are similarly handicapped because they lack adequate jurisdiction over the chief medical decision-makers; i.e., the physicians.

There is little public awareness of this contradiction. One assumes this will change as the public becomes increasingly concerned about cost, safety and quality in health care.

Over the years, the need to deal with the increased complexity of health care has caused a gradual shift in power from the medical staff to the hospital. The dispute at JCAHO probably represents an attempt by organized medicine to stem the tide.

Eventually, the contradiction will be resolved by abandoning self-government in favor of an appropriate form of hospital control.

The only question is how long it will take.

Sunday, August 17, 2008

Getting There

Iowa has adopted a plan for providing health care coverage to all of its children. While it will take some four years to fully implement the plan, a special commission created by the Iowa legislature is beginning to look at providing coverage for more of the state’s adults.

The commission is bipartisan and is co-chaired by two former governors; Terry Branstad, a Republican, and Tom Vilsack, a Democrat.

The August 12 issue of the Omaha World Herald reported that Governor Vilsack had characterized the problem as enormous and then said “Ultimately, we are going to have to confront the rising cost of healthcare.”

The article went on to say that the Iowa effort had the support of business groups “who are hurting the most.”

I have for some time wondered when concern about the rising cost of health care would reach the point at which there would be a willingness to do something about it.

If one can believe Governor Vilsack, we’re getting there.

Thursday, August 14, 2008

About All the Savings They Can Afford

During my career in health care management career, it seemed that anything we did to generate savings always ended up costing more money. On occasion, some time after undertaking such an effort, someone would suggest that "we've gotten about all the savings out of that program that we can afford.”

Apparently things in health care are still like that.

Massachusetts has for some years had a free-care fund financed by assessing all hospitals. Grants from the fund were then made to so-called safety-net hospitals; i.e., hospitals that cared for a lot of non-paying patients. A high proportion of the money went to two institutions in metropolitan Boston – the Boston Medical Center (which includes the old Boston City Hospital) and the Cambridge Health Alliance.

Massachusetts enacted what was called health care reform in 2006. Actually it was a program to reduce the number of uninsured. Health insurance for persons with low incomes would be subsidized. Since the newly insured would now be able to pay for care, the cost of the subsidy would be offset, in part, by lower grants from the free-care fund.

A larger number of the uninsured than originally projected took advantage of the program, the cost of which therefore increased beyond the amount budgeted. An op-ed piece in the July 22 Boston Globe (“Doing the math on health care” by Jim Stergios) suggested that since there were fewer uninsured than expected, safety net hospital grants could be reduced more rapidly than scheduled.

Well, you can imagine the reaction that got. The July 29 Globe carried a triad of letters under the heading “Paying for Health Care Reform” – one from each hospital and the other from the labor union that represents their employees. All recited the dire consequences of grant reductions larger than originally planned.

Massachusetts and its free care fund may be close to realizing all the savings from health care reform they can afford.

Saturday, August 09, 2008

Small Wonder

In recent news articles reporting the retirement of Bill Gates as CEO of Microsoft, it was mentioned that IBM introduced its first PC in 1981.

Of course, there were computers before there were PCs. But PCs were what made computers personal appliances available to everyone rather than esoteric devices usable only by a sophisticated few.

So I think it safe to say that except for computer science majors, students who graduated from college before 1980 did so without benefit of any significant exposure to computers. Those who went into management went to work for executives who had no experience in using computers as management tools.

It seems safe to assume that most of the senior executives of our health care institutions are at least 50 years old.

If the typical college graduate is 22 years old, then most people who graduated before 1980 are now at or above 50 years of age.

The result is that our health care delivery system is currently being led by a generation of executives whose experience with computers is limited to e-mail and perhaps some word processing and internet surfing. They have not during their careers personally used computers to improve the operations they were managing.

Add to that the fact that the health care managers of that generation are not as a rule operationally oriented. The basic operations of health care institutions is the care of patients – something that wise managers have stayed out of, deferring instead to the doctors, nurses, and other health professionals.

Small wonder, then, that the health care field has experienced so much difficulty in adopting computer technology.

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