Friday, December 21, 2012

On Malpractice 

I have often observed that the problem with malpractice was that there was too much of it.   

Now I see that I am not alone in that opinion.   

The December 10 issue of Modern Healthcare included an article on infant mortality.  The article discussed the experience of a 14-hospital childbirth safety initiative.  The group is part of something known as the Premier healthcare alliance.  Premier led the initiative, which reportedly reduced by 25% the number of incidents that potentially cause brain damage.   

According to the article, Hospital Corporation of America, a national hospital chain that delivers more babies than any other organization, and New York-Presbyterian hospital/Weill Cornell Medical Center reported significant drops in malpractice claims after implementing obstetric safety programs. 

Midway in the article, Amy Romano, associate director for programs of a New York organization called Childbirth Connection, was quoted as saying that the solution to medical malpractice troubles lies not with legislatures but with clinical efforts such as Premier’s.  Referring to the Premier experience, she was also quoted as saying “These kind of patient safety initiatives are really the most promising intervention for tort reform – instead of capping damages.” 

I couldn’t have said it better myself.

Monday, December 10, 2012

On Accountability 

The Accountable Care Act (a.k.a. Obamacare) makes provision for something called Accountable Care Organizations (ACOs for short).  These organizations are to include enough of the major components of care, both professional and institutional, to allow them to be held accountable for outcomes, safety, and cost, something that has been difficult to do in our traditional provider system. 

The idea of accountability is a good one, but we have yet to figure out how these organizations will be held accountable and by whom. 

A lead editorial in the November 2012 issue of the AARP Bulletin was titled “Let’s Launch a War on Waste.”   It began by pointing out that the importance of hand washing by the providers of health care was first identified some 165 years ago and has been repeatedly confirmed since that time, but, according to a recent study by the highly regarded Institute of Medicine (IOM), something like half of all health professionals still do not follow proper hand washing technique. 

The IOM was further quoted regarding the avalanche of scientific and technological advances, which have stressed “the capabilities of the system to effectively generate and manage knowledge and apply it to regular care” resulting in the waste of some $766 billion per year. 

The editorial concluded by challenging patients to participate actively in their care and to be more observant about what providers do, even to the extent of reminding them to wash their hands.  The implication here is that it is patients who are responsible for holding providers accountable. 

I’m not sure that is enough.  I’m skeptical that providers will be much influenced by patients acting one at a time.   

I had hoped at one time that large employers would take on the role in evaluating provider performance, but they have shown no inclination to do so. 

Government can try, but the need to follow legal processes severely hobbles its effectiveness.

That leaves insurance companies.  The difficulty there is one of persuading subscribers that decisions are being made in their interest rather than in the interest of the insurance company’s stockholders.  Non-profit Blue Cross plans don’t have that problem, at least to the same extent. 

So the question remains.  How are ACO’s to be held accountable and who is to do it?




Tuesday, December 04, 2012

Mayo as Model 

In response to one of my postings about doctors becoming hospital employees, a reader who prefers to remain anonymous called my attention to the Mayo Clinic as a possible model for the delivery of health care.  Specific reference was made to a Commonwealth Foundation study called “Organizing the U.S. Health Care Delivery System for High Performance”  Mayo was one of 15 institutions studied and the report on that organization was titled  “Mayo Clinic: Multidisciplinary Teamwork, Physician-Led Governance, and Patient-Centered Culture Drive World-Class Health Care.” 

Under the heading “Lessons Learned,” the report included this statement:  “The success of Mayo Clinic’s model of integrated care flows from three primary and interrelated influences, according to Dr. Schwenk [a Mayo physician]. First, multidisciplinary practice with salary-based compensation fosters team-oriented patient care and peer accountability. Second, the supportive organizational and technologic infra­structure permits physicians and other caregivers to excel at the clinical work they were trained to do. And third, a physician-led governance structure inculcates a culture that filters all decisions through the lens of patients’ interests.” 

Mayo is one of several multi-specialty group practices that were formed early in the 20th century and which have become large, integrated, healthcare institutions consisting of group practices that operate their own hospitals.  Others that come to mind are Leahy, Ochsner, Geisinger, and Cleveland Clinic.   The question is whether they ought to serve as a model for the health care delivery system of the future. 

They very well might except for one thing:  they can’t be replicated.   

As a general rule, medical partnerships find it impossible to accumulate capital.  If the group is fortunate enough to accumulate cash in the bank, the desire of the partners to take it out for themselves proves too strong to resist.   

Mayo and the other groups like it were each founded by an entrepreneurial physician who ruled the group with an iron hand during its formative years.  They may have had some legal form of partnership but the founders retained enough power to hang onto the profits and use them to grow. 

That was possible in the culture of the time, but not in the culture of today.  There has been no repetition of these large, integrated groups in recent times and there is not likely to be in the future.

Monday, December 03, 2012

The Storm of Reform

The consolidation of the professional and institutional components of health care (notably physicians and hospitals) is an essential but very difficult part of health care reform.  There is not much hope for significant improvement in both quality and efficiency so long as the system lacks accountability due to their separation. 

But bringing them together raises new issues.  

Throughout history, the medical profession has been the dominant force in the provision of health care.  Hospitals were often referred to colloquially as doctors’ workshops.  In later years, that relationship has begun to change, with more and more doctors selling their practices to hospitals and becoming hospital employees.  According to the news article referenced below, only about 39 per cent of U.S. doctors are currently in independent practice, down from 57 per cent in 2000.  The executive head of the American Hospital Association has been heard to say that the number of doctors employed by the hospitals he represents is greater than the membership of the American Medical Association. 

A front page article in the December 1 issue of the New York Times deals with the matter.  Titled “A Hospital War Reflects a Bind for U.S. Doctors,” the story is about the competitive situation in Boise, Idaho where together, the two largest hospitals now employ about half the doctors in southwest Idaho.  According to the story, the doctors now complain that the hospitals “have too much power over every aspect of the medical pipeline, dictating which tests and procedures to perform, how much to charge and what patients to admit.” 

In addition, the government anti-trust people are getting interested in the situation.  The authority granted to doctors to order tests and treatments has economic consequences for the providers of those services and for the cost of health care.  Historically, doctors and hospitals were separate business entities, presumably operating at arm’s length.  Now that they are together, the question is whether they are colluding to increase the amount of service provided, thereby driving up the cost of care. 

So unifying the system is not such a simple thing after all and some stormy times can be expected along the way.

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