Monday, September 29, 2008

Surgery as a Team Effort

In the mythology of our culture, the image of the heroic surgeon ranked right up there with Wyatt Earp and the Red Baron and outlasted both of them

But now it seems that even that last bastion of individualism is on the wane.

The September 22 issue of The Boston Globe carried an Op-Ed piece by Douglas Brown reciting the 2005 story of the temporary shutdown of the heart surgery program at the University of Massachusetts following the release of data showing that its mortality rate was twice that of the average of all hospitals in the state. The occasion for the column was the more recent (August 2008) release of data on heart attack survival rates showing U Mass to be ninth among 4300 hospitals surveyed.

Brown credited this turnaround to reforms implemented following the 2005 shutdown. New leadership was appointed, which “grouped all cardiac patients together so staff could develop expertise with their particular needs….[and] created a complete team approach to care, where everyone’s voice is encouraged and welcomed.”

A few days earlier, wife Marilyn and I were in the office of her orthopedist scheduling a knee arthroplasty to be performed at New England Baptist Hospital. We asked whether he was an enthusiastic participant in the hospital’s programs for preventing surgery-related infections and strokes, reminding him of Marilyn’s minor stroke last Christmas. He said he absolutely was. He said that Marilyn would be going to the Baptist for a pre-operative work-up, at which time all such matters would be identified and responsibility for their management assigned to the proper specialist. He said that at the Baptist surgery is a team effort.

We certainly wouldn’t have heard from a surgeon twenty-five years ago.

Thursday, September 18, 2008

Be Careful What You Wish For

Hospitals have good reason to be concerned about the nurse-staffed retail clinics showing up in places like Wal-Mart and chain pharmacies.

As mentioned in my previous posting, hospitals have long discriminated against patients who use their Emergency Room for what are seen to be non-emergency medical needs. In the prevailing view of the health care delivery establishment, those patients ought to be getting their care in scheduled clinics or the offices of private physicians.

One expression of the discrimination has been an ER fee structure that discourages ER use for non-emergencies by loading some of the cost of “true” emergencies into the charges for the non-emergency visits. For insurance companies, that makes the cost of visit to the ER higher than the cost of a clinic visit, giving rise to the popular view that money can be saved by getting patients to use clinics or doctors’ offices instead of ERs..

There is a good deal of mythology in that view. Hospitals operate ERs because people need a place that is always open to which they can go for emergency care. Strokes, heart attacks, injuries due to accidents and medical events of that type do not occur according to a schedule.

So hospitals are committed to the basic cost of operating an ER on a 24/7 basis whether anybody shows up for care or not. The added cost of treating a patient who shows up with a runny nose is trivial. Actually, hospitals ought to be thankful for that sort of case because it gives the ER something useful and remunerative to do in between “real” emergencies.

The commercial entrepreneurs who are creating retail clinics have figured out that they can charge less than hospital ERs do for taking care of these non-emergency cases and still make money. They can also improve on the less-than-sterling service hospital ERs typically provide.

If these retail clinics succeed in drawing significant numbers of patients away from ERs, hospitals are going to suffer financially because they are not going to be able to reduce their cost by anything like the amount of income they will be losing.

Hospitals have long encouraged patients to use clinics and physicians’ offices instead of the ER for non-emergency care.

Retail clinics provide another example of the need to be careful what you wish for.

Monday, September 15, 2008

It’s About Time

Hospital Emergency Rooms in Massachusetts are no longer allowed to declare “diversions.”

A diversion is when the hospital issues a notice that its ER is overcrowded and will no longer accept ambulance patients.

According to the September 13 issue of The Boston Globe, ER diversions have been prohibited by the state’s Department of Public Health with the only exceptions being a “code black” condition such as a major fire within the hospital. The reasons given for the prohibition were that the practice of diversions “has done nothing to solve the underlying problem…. [of] patients backing up in ER hallways because hospitals have no open beds” and that the practice has caused problems, “interfering with patient choice, increasing the time patients spend in ambulances, tying up the vehicles, and shifting crowding to other hospitals.”

What was not mentioned was that a hospital lacks open beds because it does not manage its admissions so as to provide adequately for ER patients, even though the need is predictable, particularly in the large hospitals that have declared diversions most frequently.

Also not mentioned were the long-established admitting practices that have the effect of giving priority to the private patients of the hospital’s medical staff over patients arriving by way of the ER.

The ER has long been seen as being in competition with private practice with the result that ER patients have been systematically discriminated against.

Now, it seems, hospitals are being called on it.

It’s about time.

Wednesday, September 03, 2008

Not Yet Serious about Health Care Reform

The American Hospital Association has a policy on health care reform.

According to the August 18, 2008 issue of AHA News, the Association’s weekly news bulletin, health care reform “should include….a focus on wellness and prevention; coverage for all, paid by all; high quality, cost effective care, with caregivers connected through state-of-the-art information systems; a restructured system that manages chronic disease, spends resources on care, not paperwork, and addresses the growing shortage of well-trained health care workers; and ensuring that hospitals receive the resources they need to provide critical services for their communities, particularly under the Medicare and Medicaid programs.”

Since hospital leaders are arguably the best informed and most experienced people in the provision and financing of health care, one might expect their association to have some suggestions as to actions that could be taken to achieve this desirable state of affairs.

But so far, not a word about that.

Obviously, we are not yet serious about health care reform. When we are, somebody will recommend how it should be provided and financed and who should make it happen.

This page is powered by Blogger. Isn't yours?

FREE counter and Web statistics from sitetracker.com