Monday, August 30, 2010

The Central Role of Hospitals in Health Care

Hospitals are taking on the central role in the provision of health services. It is not something they have sought and is something that we as a society have yet to acknowledge, but it is happening, and at a fairly rapid pace.

This was brought to my attention by the August 9 issue of Modern Healthcare, which listed the top 100 hospitals as determined by Thomson Reuters in its annual survey.

Here is what Thomson Reuters says about it in its web page:

“The Thomson Reuters 100 Top Hospitals®: National Benchmarks study evaluates performance in 10 areas: mortality, medical complications, patient safety, average length of stay, expenses, profitability, patient satisfaction, adherence to clinical standards of care, and post-discharge mortality and readmission rates for acute myocardial infarction, heart failure, and pneumonia. The study has been conducted annually since 1993.

To conduct the 100 Top Hospitals study, Thomson Reuters researchers evaluated 2,926 short-term, acute care, non-federal hospitals. They used public information — Medicare cost reports, Medicare Provider Analysis and Review (MedPAR) data, and core measures and patient satisfaction data from the Centers for Medicare and Medicaid Services (CMS) Hospital Compare data set.”

What I particularly noticed in that statement was the prominence of clinical criteria. Of the ten performance areas measured, all but three (expenses, profitability, and patient satisfaction) are purely clinical in nature

To hold hospitals accountable for these outcomes is to hold them accountable for the performance of the physician component of care as well as of the institutional.

For most of history, the leadership position in health care has been held by the medical profession. The transfer of that role to hospitals is a major event, the importance of which is in no way diminished by its having so far gone largely unremarked.

Monday, August 23, 2010

Bring on those Germs!!!

My grandmother immigrated to America by boat as an infant. She told me that she was sick the whole way and that her mother expected to find her dead every morning of the trip.

She then lived a healthy life. In the days of quarantine for things like scarlet fever, she was the one to deliver food and supplies to the isolated household because it was generally known that she never got anything. She died a few months short of her hundredth birthday.

I was reminded of that by an essay forwarded to me by David Keith of Ocala, Florida, with whom I share two grandsons. The author is his friend nurse Wendie Howland who wrote in response to a discussion that had appeared in the publication NurseNet.

The essay was in response to a discussion on the NurseNet about egregious sanitation practices some members had observed. Here it is as it originally appeared in NurseNet and in the Paradigm Bytes (http://paradigm97.blogspot.com:

You know, I hear you about the hospital vignettes, and we should always continue to do all we can to protect people who have indwelling lines, immune weakness, and other well-known risks for iatrogenic infection with the nasty bugs we warehouse in our hospitals.

However, the other vignettes give me pause. Assume for the most part that the writers have been buying food at those counters or restaurants for most of their adult lives, perhaps feeding children with those foodstuffs, and so on. Now, how many deadly illnesses did they contract in these seething slurries of germiness?
There are plenty of studies to show that children who grow up with pets have fewer illnesses and fewer allergies. In the developing world, the incidence of pediatric atopy and asthma skyrockets in one generation after pinworms are eradicated from schoolchildren-- but not in untreated adults or neighboring populations who still carry their normal commensals. Every first grade teacher can tell you which kids didn't go to preschool-- not because they don't know their numbers or letters, but because they spend their first year in a mixed population getting sick. In a recent cholera outbreak in a resort area in Indonesia, about 200 people were affected, and the only ones that died, that did not respond to ordinary IV fluids and support, were the Japanese, that notoriously germ-phobic culture, where every piece of clothing you can buy comes with embedded antimicrobials, where people wear masks on the subway, and doctors don't tell you what your diagnosis is. Many, many studies show that the majority of people, men and women, do not wash their hands after handling or wiping their genitals in the toilet. If so, since we are in constant contact with humans, how come we aren't all down for the count with GI disease ALL THE TIME? Don't even get me started on our favorite germ-swapping practices, all related to reproduction and all pleasurable. There's probably a reason for that.

More studies are indicating that the immense numbers of chemicals, including antimicrobials, we are exposed to are --gee, I know this will come as a shock-- BAD for us. The tremendous growth of resistant organisms-- heard of that? "Kills 99.5% of household germs!" What are those other ones doing? Multiplying, that's what.

So you ask for an extra napkin to put your silverware on after somebody wiped the table and the banquette with a rag? Who handled that napkin between the dryer and your table, and how? So you put your silverware on the edge of your plate instead of your table? Who handled the edge of that plate? Or the silverware, for that matter? So you think there are "butt germs" on the vinyl banquettes at the Country Buffet? Does your butt slide onto them, and then do you touch your pants, or your purse, or the car seat that your pants just sat on after your meal? Does your hand that helped you slide into your booth then touch the salt and pepper? Did the hands of the people who sat there before you arrived? Do you touch the rails on stairs, the buttons on elevators, try on clothes in department stores? Do you just get the sterile ones, or maybe did someone else touch them too? What did they do with their hands before that?

You can see where I'm going with this. Actual pathogens are bad. I'm not advocating that we should go back to wells on the street corners that dispense hepatitis and typhoid with every bucket. I'm not saying we take Semmelweiss and Pasteur out of the medical and nursing curricula. I'm not saying we shouldn't change enteral feeding bags really often, give up scrubbing before surgery, forget glutaraldehyde in the endoscopy suite, use linens from off a hospital floor, or save money in Surgicenters by making single-use vials and lancets multi-use.
But honest to god, this phobia about germs, all germs, is ridiculous. There's increasing evidence that your gut and skin bacteria (and BTW, how did they get there and from where, huh?) have beneficial effects. People evolved to live with commensals like pinworms; our immune systems are built and maintained to work with that. If you don't let them do what they are on guard to do, they are weakened when we need them, and they go looking for something else to do, and that's when the trouble starts.

Maybe we should start a campaign to have people STOP washing their hands so much, in the interest of the overall public health. Boost the collective immune system, and the whole population benefits. It's what immunization was before Jenner-- exposure to germs makes your immune system make antibodies. So get out there-- pick your nose, scratch before you make dinner for your family, stick your fingers in the batter to taste it, then do it again. Pat the dog, then form the meatballs and roll out the pie crust. Don't panic if your kid has a permanent snot-nose the first three years of her life-- she'll probably never be sick much again. Let your grandchild gnaw on your fingers even if you haven't just slathered them with alco-gel first (come to think about it, how good is alco-gel for a baby, anyway?). Go play in the dirt, swim in a pond. It's a big bacterial-laden world out there. If you want a decent, robust immune system, give it some exercise. Don't live in a bubble...or delude yourself that you can.”

Ms. Howland’s identity and location are as follows:

Wendie A. Howland RN MN CRRN CCM CNLCP
Principal, Howland Health Consulting, Inc.
Editor, Journal of Nurse Life Care Planning
Life Care Planning, Case Management
508-564-9556/866-604-9055 toll free
Fax 915-990-1367

Sunday, August 22, 2010

A Disagreement

Michael Dukakis thinks that the Massachusetts Certificate of Need (CON) law ought to be more vigorously enforced. I think it should be abolished. Dukakis has twice been governor of the state and in 1988 was the Democratic candidate for U.S. President

CON laws require providers of health services to get government approval for major capital expenditures or the initiation of new programs by demonstrating that there is a need for them. The idea is that unless existing facilities or programs are insufficient to meet the population’s need for services, adding to them is wasteful and increases cost. Generally speaking, need has been determined on the basis of whether existing facilities are adequate to provide the amount of services needed. Consideration is not given to the possibility that an applicant might provide better service at lower cost.

Over the years, there has been debate over whether CON contains cost or increases it. The possibility of increases is based on the monopolizing effect of CON, which assures providers that their capacity will be fully utilized by preventing the development of unused facilities.

My own belief is that, on balance, this protection against competition has worked to increase the cost of health care.

But apparently Michael Dukakis thinks differently.

A Steven Syre column in the Business section of the August 20 Boston Globe tells the story of his (Dukakis’) composing a statement on how to reduce the cost of health care and shopping it around to community leaders, including the governor.

The statement urged three main ideas: state regulation of health insurance premiums, allowing employers to organize into health insurance purchasing groups, and enforcing CON.

My experience has led me to the belief that competition that includes the ability of payers to move blocks of patients from one provider to another is the only force that will get providers to become serious about reducing cost. Health care providers find it difficult to adjust to reductions in the volume of care. Furthermore, so long as they are making a reasonable profit, non-profit hospitals do not respond vigorously to incentives that offer the possibility of making more. For them, the trauma involved in cost reduction is not worth it. But they will do so if faced with the threat of losing patients to a more efficient, competing provider.

However, in order for that sort of competition to work, there has to be unused capacity available. Payers cannot move blocks of patients unless there are empty beds to move them to.

During my years in Texas, which does not have CON, such a situation existed and it was effective.

By preventing the construction of surplus beds, CON becomes a barrier to the development of that sort of competition.

That is why I disagree with Dukakis

Thursday, August 19, 2010

Test for Alzheimer’s?

An e-mail from Health Care Anew follower Ed Ablard calls attention to the emergence of diagnostic methods (spinal tap and PET scans) that are highly accurate in diagnosing Alzheimers, but less so in predicting dementia.

It raises issues of who should have these tests and what should be done for those who come up with positive results.

In present circumstances it seems likely those decisions will for the most part be made by patients, patients’ families, and doctors and paid for by insurance – mostly Medicare. It may be that there are, or could be, evidence-based conditions in which reasonable people would agree that the benefits of doing the tests are not commensurate with the cost and other consequences. If so, those conditions won’t be known by most of those who make the decisions. The result is that cost will be incurred for tests of questionable value.

As a practical matter, there are two possible sources of guidelines that would address this issue.

One is the insurance company (in this case probably Medicare) which could prescribe the conditions that must be met if the tests are to be paid for.

The other is a local Accountable Care Organization, most likely a hospital, which is financed by means of global payments; i.e., capitation, and therefore has an incentive to avoid costs, particularly those that result in little or no benefit to the patient. That means some limitation on choice of physician.

Despite that limitation I personally would vote for the latter. I would have more confidence in the judgment of a local institution controlled by my friends and neighbors than in that of a national governmental agency subject to political pressures.

Others may disagree, but that is where I come down.

Tuesday, August 17, 2010

Medical Homes

There has been quite a bit of talk lately in health care circles about something called Medical Homes.

The American College of Physicians expands the term somewhat and defines it as follows:

“A Patient-Centered Medical Home is a team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient's lifetime to maximize health outcomes.”

The idea is to remedy the general absence within the health care system of provision for the management of care. Such management would be the responsibility of the personal physician as leader of the Medical Home team. The notion has seemed sensible to me but recent personal experience has raised in my mind some questions about it.

Like many men my age, I have prostate cancer. Various recent studies have posed the question of whether the approach to the treatment of that disease has been too aggressive, considering the expense and side effects and that many senior men with the disease die from something else before the prostate cancer becomes a problem.

Thus, once the disease is diagnosed, the issue of what, if anything, to do about it is not always clear and therefore becomes a matter of judgment.

I have an able and conscientious primary care physician who, as best I can tell, is knowledgeable about her field of medicine and exercises thoughtful and sober judgment in the care and treatment of her patients. But she has been of no help in decision making about my prostate cancer, other than to listen to my reasoning about it and agreeing that it seems logical.

When you think about it, that is about all she can and ought to do. Neither she nor the group to which she belongs has the time or resources to study such matters in the depth required to come up with evidence-based guidelines for use in advising their patients.

Only institutions like hospitals can do that.

So I think the Medical Home concept is a good one, but that it needs to be institution-based.

Friday, August 13, 2010

What not How

The hospital journals are full of talk about computerizing medical records, reflecting the scramble for the incentive money included in the recently enacted health care reform legislation.

It reminds me of a lesson I learned early in my administrative career.

My boss thought that the daily close-out procedure being used by the cafeteria cashiers was too cumbersome and asked me to design a better one, which I proceeded to do.

A couple of months later, he suggested that I go back and see how my procedure was working out. What I learned was that the cashiers were now carrying out both procedures; the one I designed because I told them to and the old one because they understood and trusted it.

The lesson was that in situations involving complexity, it is better to tell people what you want them to do and give them whatever help they need to figure out how to do it.

Our system of health care, infinitely complex and bound up in culture and tradition, follows many practices that are antiquated and inefficient. As was the case with me as a young administrator, the first impulse of politicians and experts is to prescribe the solution. The result is often the same as it was with me – instead of improving the situation, they make it worse.

What is going on is that hospitals and other health care institutions are implementing computer technology (at considerable expense) in order to get the federal money and the favorable publicity that goes with it, while continuing to do their work in the same old-fashioned, costly way.

The better course would be to put pressure on them to get their costs down and their quality up.

Then leave it to them to figure out how to do it.

Saturday, August 07, 2010

Is Boston Getting Serious about Healthcare Reform?

Some time during the early 1970’s I was in a meeting with the clinical chiefs of what is now Brigham and Women’s Hospital in Boston. Mention was made of a particular surgical procedure. Dr. Frances Moore, Chairman of Surgery at the Peter Bent Brigham Hospital, labeled it as experimental. Someone protested, saying that it had been done extensively in some city (St. Louis, as I recall). Dr. Moore’s response was that it had not been done in Boston and that until it was, it was experimental.

Boston medicine generally, and Harvard medicine in particular, has long been known for that sort of arrogance, and not altogether without justification. It is known for its collection of the most renowned minds in medicine.

So perhaps the movement to healthcare reform will not be serious until it is taken up by the medical establishment of Boston.

An early sign in that direction was the creation of the Institute for Healthcare Improvement (IHI) which is based in Boston and its founding executive head, Dr. Don Berwick (now head of Medicare and Medicaid), is a pediatrician with roots in the Harvard Medical School. IHI has had a profound influence in improving the safety and quality of health care.

Then Drs Thomas Lee and James Mongan came out with a book titled Chaos and Organization in Healthcare. Dr. Lee is a senior medical executive at Partners Healthcare – the organization created by the merger of Massachusetts General Hospital and Brigham and Women’s Hospital, both closely affiliated with Harvard Medical School. Dr. Mongan is the recently retied CEO of Partners. The book calls for remedying the lack of organization in health care.

More recently, the Boston Sunday Globe of June 13, 2010, carried an article in which Dr. Gary L. Gottlieb, currently CEO of Partners, said that slowing the rise of health care costs would be an important goal of Partners in the coming year.

So perhaps Boston medicine is beginning to take interest in health care reform. The evidence would be more convincing if it came from the chiefs of Medicine and Surgery in Partners hospitals (who wield the real power in those institutions) or from the Dean of the Harvard Medical School.

But perhaps the expressions of the nominal leaders is a sign that things are moving in that direction and that before too long serious efforts will begin to reform our system of health care.

Wednesday, August 04, 2010

Signs of Progress

The other night I happened upon a PBS television program about the historical development of surgery. One thing that struck me was the difficulty the profession has had in adapting to advances in practice. Hand washing before delivering babies and controls on the use of chloroform as anesthesia were offered as examples, both failing to be widely adopted for decades despite clear evidence that when practiced they saved many lives.

The story has its counterpart in the modern age, when the adoption of simple procedures for reducing surgically related infections has been so slow.

In thinking about that, it seemed to me that the only remedy would be some form of influence coming from outside the profession, such as market forces (e.g., insurance companies steering their patients to hospitals with low infection rates) or public opinion.

Those thoughts caused two items in the August 2 issue of The Boston Globe to catch my eye.

One was an article about laboratory mistakes. It told the stories of two patients, one of whom underwent an unnecessary removal of his prostate based on the biopsy of a different patient. The second had been mistakenly cleared of prostate cancer as a result of a similar error. His case was correctly diagnosed some eight months later.

According to the report, it is not clear that the delayed diagnosis adversely affected the second patient, but the first was experiencing incontinence and erectile dysfunction as a result of the surgery. Needless to say, both are suing.

The other item was an editorial urging doctors and hospitals to make greater use of the known methods for reducing surgically related infections.

Neither of those articles would have been published as recently as twenty-five years ago. Matters of that kind were considered to be the province of the medical profession and not suitable for consideration by non-physicians.

So while progress in health care reform seems slow, there are signs that it may be proceeding more rapidly than it has in earlier years.

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