Wednesday, June 24, 2015

D to S time

If, God forbid, you should have a heart attack, the chances of your living or dying is determined more by door-to-stent (D to S) time than by the relative competence of the physicians who treat you.

There are probably not many Americans who believe that, but it is the clear implication of a long, front-page article that appeared in the June 21 Sunday New York Times.

A heart attack happens when one or more arteries feeding blood to the heart become blocked, denying the affected parts of the heart muscle the oxygen they need to function and survive.  The remedy is to thread a tiny balloon to the blockage through a leg or arm artery, open it up and maintain the opening with a metal-mesh tube called a stent.  If this now common procedure is completed in a timely manner, the patient has a good chance of recovery.  If not the patient either dies or is left with a badly damaged heart.

According to the article, the death rate from coronary heart disease dropped 38 per cent from 2003 to 2013.  Credit was given to better control of cholesterol and blood pressure, reduced smoking rates, improved medical treatments, and faster care of people in the throes of a heart attack.

The article then focused on the faster care factor.  Some years ago, the American College of Cardiologists set a goal of getting a stent planted in at least half of heart attack patients within 90 minutes of arrival at the hospital (door-to-stent or D to S time).  In the beginning that was thought unrealistic but now it is common for a hospital to achieve 61 minutes or less.

Several changes account for the bulk of the time reduction.  Rather than doing an EKG after the patient arrives at the hospital, the Emergency Technicians do it in the ambulance and send the results on ahead.  Rather than summoning the stent implant team members one at a time, a single phone call simultaneously activates the beepers of all.  On-call people are required to be no more than 30 minutes away from the hospital.  Consent form requirements are waived.  The Emergency Room physician is allowed to summon the stent implant team directly rather than being required to obtain confirmation of the diagnosis from a cardiologist.

The article makes no mention of the credentials or competence of the physicians.




Monday, June 22, 2015

Institutionalizing Medicine 

I think that the biggest challenge facing health care management today is the institutionalization of medicine – a profession that has historically defended itself vigorously against any loss of independence, a stand that has enjoyed general public support.  As evidence of that support, I frequently ask people whether they think their doctors should have bosses.  I have yet to get an unqualified “yes” as an answer. 

So it’s the brave healthcare executive who tries to incorporate the medical profession into a program for addressing the health care issues of the day. 

And yet there is little choice other than to try to do so.  Although they never say so in so many words, Obamacare, insurance companies, employers and other major health care players are adopting strategies and implementing programs that can only be responded to effectively by making the medical profession a part of the effort – in other words, by institutionalizing medicine. 

It is not easy.  The June issue of H&HN, the journal of the American Hospital Association, carries an article entitled The New Health Care CEO.  The article reports a survey on what health care CEO’s consider to be “the primary hurdle to achieving your organization’s strategic priorities”  The results are: 

Physician buy-in and engagement                            26%
Financial constraints                                                    15%
Organizational barriers to collaboration                  26%
Lack of talent or skill sets for key roles                     14%
Cultural impediments within the organization        14% 

I think it reasonable to suspect that every item listed, except for financial constraints, has to do with the institutionalization of medicine.





Monday, June 08, 2015

FFS Begone

There seems to be widespread agreement in health care that fee-for-service (FFS) has to go.

In the usual economic transaction there are two parties – buyer and seller.  Each has a financial interest in the deal.  Healthcare is different.  There, transactions commonly involve four parties – buyer, seller, consumer and payer, with the physician being the buyer, the pharmacy, lab, hospital, etc. being the seller, the patient being the consumer and the insurance company being the payer.   Only the seller and the payer are financially involved and historically the payer has had only an arms-length relationship with the buyer.

This unique arrangement is considered to increase costs because the incentives to order drugs, diagnostic tests and even treatments are stronger than the incentives to economize. 

 Saying that FFS has to go raises the question of what is to replace it.  So far, the main alternative that has been imagined involves some kind of “bundled” payment – either a flat sum for a defined treatment like hip replacement or a fixed annual amount per patient or per family – what in the managed care era was called capitation.  The other possibility is the payment of a bonus for achieving a cost level at or below target.

While FFS creates incentives to provide more service than a patient needs, bundled payments and bonuses do the opposite.  In those cases, a provider performing a hip replacement can make money by installing a cheaper artificial joint and by skimping on postoperative rehab.

That concern is being expressed these days in Massachusetts where, according to an article in the May 26 issue of the Boston Globe (Amendment incites a Medicaid fight), Steward Health Care System, a for-profit hospital chain, is promoting legislation that would allow it to be paid for Medicaid patients on a bundled (capitation) basis.  Steward was created and is owned by venture capitalists and a common view is that its goal is to become profitable enough to be sold at a profit. 

The proposal is being questioned by consumer advocates and insurers.  The stated objection is that the provider (Steward in this case) would be allowed to act as an insurance company without being regulated as such or being required to maintain reserves.  But I suspect the concern is that providers like Seward will withhold needed care in order to increase profits.

FFS may be an undesirable payment system but the alternatives have their issues, too.


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