Thursday, May 30, 2013
A Straw in the Wind
I have mentioned in previous postings my expectation that the large, prestigious teaching hospitals will experience some deflation of their reputation, once quality becomes quantified and people become aware of the data.
As a volunteer activity, I drive for a local organization in the
suburbs that provides medical transport for seniors. Boston South Shore
Last week I took a woman to a local physician. As we were leaving his office she commented on how competent the people there seemed to be and then out of the blue said that she was beginning to think that the big Boston hospitals might not be as good as people thought. She said that she had been going into town to see a cardiologist but was seriously considering switching to someone more local and saving the hassle of the long trip.
It is a sample of one, but it may be a straw in the wind. I don’t think anybody was talking that way ten years ago.
Tuesday, May 28, 2013
Guilds and Health Care
If you think the guild system went out in the middle ages, you have not noticed how health care and other professionals are organized.
The May 25 issue of the New York Times carried an article datelined
telling about the problems of one
Joyce Osborn Wilson. It seems that Ms.
Wilson invented a tooth whitener and has been selling it to salons and
spas. Recently, she received a letter from
a lawyer representing the state dental board accusing her of practicing dentistry
without a license and instructing her to cease and desist selling her product
in Guntersville, Alabama . She has filed a lawsuit in protest. Alabama
The article points out that our system of professional licensure now covers some 30% of workers and the issue is whether it is being abused by preventing competition.
Licensure creates what in effect are guilds that prevent unlicensed people from engaging in their trade. The entire professional component of health care is organized that way. The categories, such as medicine, nursing, pharmacy, laboratory technology, and physical therapy, were created when health care was very different than it is now. But each continues to jealously guard its “turf,” creating formidable barriers to any redistribution of functions that might reduce cost and improve quality.
There have been a few changes, such as allowing nurse practitioners to prescribe drugs, but they come slowly and with great difficulty.
Sunday, May 19, 2013
Silent Culture Change
Cultures can be said to change in one of two ways – noisily or silently.
The sexual revolution and other culture changes that occurred during the 1960’s were of the noisy variety.
The one currently going on in the health care delivery system is silent.
I happen to be on the mailing list of Doug Hawthorne, CEO of Texas Health Resources; a large hospital system headquartered in
. I recently received a letter from him
announcing the appointment of one Dr. Daniel Varga as Chief Clinical
Officer. That appointment was stated to
be in accordance with the strategy of “transforming Texas Health from a
hospital-centric organization to a patient-centered, fully integrated health
system.” Arlington, Texas
In my day, a hospital administrator engaging in that kind of talk would have been fired. The ideas of the “self-governing medical staff” and the independence of the medical profession that it implied were sacred. Any suggestion that it be compromised would have been perilous in the extreme.
Now, without any public discussion of the change that is under way, the institutionalization of the medical profession can be openly, if obliquely, discussed, using terms like Accountable Care Organizations and fully integrated health systems.
Perhaps it is easier to abandon a strongly held belief if nobody mentions it.
Saturday, May 18, 2013
Pardon Me While I Gloat
For years I have been making the argument that hospitals should be less concerned about the legal aspects of malpractice and more concerned about preventing it. So far as I could tell, I was a voice crying in the wilderness.
I now see that others are picking up the point.
The May 17 issue of the New York Times carries an op-ed piece by one Joanna C. Schwartz, an assistant professor of law at UCLA. She discussed a study she had conducted which found that hospital “risk managers and patient-safety personnel overwhelmingly report that lawsuit data have proved useful in efforts to identify and address error.”
The piece closed with this statement: “The Affordable Care Act pours millions into patient safety for research centers, demonstration projects and other programs. Proposed reforms and initiatives should not rely on conventional wisdom about the negative effects of malpractice litigation. Medical-malpractice lawsuits do not have the harmful effects on patient safety that they are imagined to have – and, in fact, they can do some good.”
I couldn’t have said it better myself.
Pardon me while I gloat.
Saturday, May 11, 2013
Several of the provisions of the Affordable Care Act, a.k.a. Obamacare, are commonly referred to as benefits. These include the higher age at which young people can be included in family health insurance policies, the prohibition against denying health insurance coverage on the basis of pre-existing conditions, and the abolition of ceilings on the dollar amount of health insurance benefits.
Calling these provisions benefits is accurate, but they also serve another purpose. They begin to provide a structure for a functioning market in the provision of health care.
If and when such a market emerges, competition should be based on safety, outcomes, patient satisfaction and cost, with market success being determined by performance in these areas. Insurance companies and providers should not be maneuvering for competitive advantage by lowering the age of children that can be covered under family policies, implementing a pre-existing condition exclusion, or setting dollar limits on benefits.
Whether we will ever have real market competition among health care providers remains to be seen, but by establishing some rules Obamacare is a step in the direction or making it a practical possibility.