Tuesday, September 08, 2015

Small May Be Efficient As Well As Beautiful

By completing a $30 million construction project, Fremont Health Medical Center in Fremont, Nebraska “intends to upgrade its quality and image by down-sizing its number of patient beds.”  The down-sizing is from 90 to 61 beds, not including 20 mental health beds being added.  Another $10 million is being spent to upgrade Dunklau Gardens, an attached nursing home.

That was the lead-in to a front page story in the September 5 issue of the Omaha World Herald.

Fremont is a town of about 25,000 people located on the Platte River, some 35 miles northwest of Omaha.

According to the article, Fremont Health operates about a dozen clinics throughout its service area.  It employs 30 physicians and has relationships with a hundred more – a number of which presumably are specialists who travel out periodically from Omaha.  Services include cancer care, labor and delivery, orthopedic surgery, cardiac catheterization, and psychiatry.

The article related the case of 87-year-old Loran Pfeiffer who recently had surgery in Fremont Health for a broken hip.  His daughter Peggy, a nurse practicing in a different hospital, was quoted as saying she was pleased with the care given to her father.

The story is indicative of what is happening in small hospitals all across the country.  While medical glamour has been associated with large teaching hospitals, these smaller institutions are showing that they can provide quality care in pleasant ways and at lower cost for a large portion of the patient population.

It causes one to wonder about the future of the large, prestigious institutions, particularly those located in relatively small communities like the Mayo Clinic in Rochester, Minnesota, the University of Michigan in Ann Arbor and the University of Iowa in Iowa City. 


Sunday, September 06, 2015

The Silent Evolution

Rich Umbdenstock having retired, the American Hospital Association has a new CEO, Rick Pollack.  The August issue of H&HN, the Associations journal, included an interview with him in which he summarized his plans, the issues facing hospitals, and so on.

The issues and strategies covered by Mr. Pollack were as might be expected.  I looked in vain, however, for mention of what seems to me to be a momentous development – the transfer of primacy in the delivery of health care from the medical profession to hospitals.

For all of history up until recently, medical doctors occupied the central role in the provision of health care services.  When my career in hospital administration began in the 1950’s, hospital medical staffs were “self-governing.”  County health departments were the creatures of county medical societies and state health departments and medical licensing boards were controlled by state medical associations.  The AMA accredited medical schools.  No legislature could adopt a law on a health care matter that was opposed by organized medicine.

The gradual change that has been going on in that for some time has been accelerated in recent years by a number of factors.  Except for a few large group practices like Mayo and Cleveland Clinic, the medical profession has not been organized in a way that would allow it to deal effectively with the emerging issues of cost and quality.  The complexity of the payment system has grown beyond the ability of individual practitioners or small groups to cope with it.  Doctors have become more interested in the quality of their lives and are avoiding the stresses and demands of individual and small group practices.

A result of all this is that the mantle of leadership in the provision of health care services has fallen on hospitals – the only entity with the culture, experience, resources, and organizational infrastructure to take it on.  Hospitals have not sought out that role but it has devolved upon them.

The culture of health care has conferred great respect – even adulation – on the medical profession and there is great reluctance even to talk about the demise of its primacy.

It is a silent evolution.

Friday, August 28, 2015

Urgent Care

There are 168 hours in a week and illness or injury can strike during any one of them – not only in the 40-plus hours that physician offices are open for business.

There being no practical way for individual physicians to plan efficiently for the unplanned needs of their patients, they tend to fill their schedules ahead of time.

One result of scientific and technological advances is that a large and increasing portion of medical care can be adequately provided by people who are not physicians.

In light of all that, one might expect that the health care establishment would have some time ago made convenient provision for patients seeking out-of-hours care, much of which falls short of emergency status.  But physicians in private practice would have seen that as competition and so it didn’t happen.

There being no alternative, patients got their out-of-hours care from hospital emergency rooms.  The specter of competition prevented hospitals from making the service attractive.  Hours of waiting for service became common but patients in droves sought it anyway. 

As the health care economy grew, investors saw an opportunity and urgent care chains were developed and drug store chains began to offer health care services that could properly be offered by nurses.

Hospitals are finally beginning to become interested.  Partners Health Care, the Boston Hospital behemoth, has announced that it will begin opening urgent care centers throughout the Boston area.

When Partners moves, everyone pays attention.  So it seems that hospitals are finally responding to a need that they should have filled a long time ago.

Sunday, August 23, 2015

Doctors or Systems?

We used to think that the best way to be assured of good medical care was to put ourselves in the hands of the right physician.

It appears not to be that simple any more.

The July issue of H&HN, the journal of the American Hospital Association, included an article entitled When Stroke Care is a Statewide Effort.  The article began by reciting the story of a stroke victim in Illinois who was taken to a 25-bed hospital in Taylorville rather than to a larger hospital in Springfield.  The patient’s wife questioned that decision and was assured by the local doctor that it was the right thing to do.  The patient got a quick CAT scan, followed by a dose of tPA, the clot-busting drug, and was then shipped off to the larger Memorial Medical Center in Springfield.  By the time the patient arrived there, his previously paralyzed left side was working again.

The rest of the article discussed the Paul Coverdell National Acute Stroke Program.  Coverdell was a U.S. Senator from Georgia who died of a stroke.  The program named for him is operated by the Atlanta-based Centers for Disease Control and Prevention and sponsors stroke systems of care.  These programs involve coordinating the activities of Emergency Medical Technicians and hospitals so that stroke victims receive appropriate treatment promptly – time being of the essence in this case. 

So it seems that if, God forbid, you should suffer a stroke, the quality of the care you receive may depend more on the system that provides it than on the identity of the doctors who staff it.

Thursday, August 20, 2015

Exorbitant Compensation

According to the August 10 issue of Modern Healthcare, the top ten compensation amounts for healthcare executives in 2013 ranged from 3.6 million to 8.4 million.  Then the August 18 issue of The Boston Globe included an article about CEO salaries in Massachusetts teaching hospitals, all of which were well into seven figures, the highest quoted for the full year of 2013 being 2.6 million.

Spokespersons quoted attributed these salary levels to competition and market forces.

I don’t believe that.  I have yet to read of a healthcare CEO being paid in the millions being attracted to another job by more pay. 

I think what we are seeing is a social mechanism that has gone off the rails.  I think what has happened is that compensation committees of boards of trustees started using consultants and that those consultants found that the way to become popular was to find ways to justify high compensation levels.  Boards are populated in large part by CEOs of other organizations who are typically overpaid themselves and find it easy to adopt those consultants’ recommendations.

The thing has gotten out of hand and nobody as yet has found a way to bring it back under control.  There are some indications of popular discontent over these exorbitant salary levels, but so far it doesn’t seem to be having much effect.

Friday, July 24, 2015

Hospital Advertising

Some years ago I participated in a discussion of marketing strategy at New England Baptist Hospital in Boston.  I mentioned that many patients came to that institution because they believed it offered the best chance for a good outcome.  I asked if they were correct, suggesting that if they were, their belief could be an effective marketing theme.

After a rather embarrassed silence, one of the physicians said that they did not know, but that they should.

Well, they now know more than they did.  I’ve received a document from the Hospital titled “A pledge from New England Baptist, your Orthopedic Hospital.”  After some narrative describing the hospital’s dedication to quality care, there are three pages of quality-related statistics.

Some of it is a little opaque, including a number described as “Statistical Prediction of Infection” attributed to a Massachusetts CY2013 HA/Data Report and something called Post-op DVT, which is undefined.  So there is room for improvement, but the accomplishment is real.

The hospital has good reason to be proud of its numbers.  However, it has not gone so far as to include them in its advertising, so far as I know.  Fifty years ago it was considered unethical for a hospital to advertise at all.  That is no longer the case, but there seems still to be a reticence to make overt claims to clinical superiority.

Wednesday, July 01, 2015

Primary Care

I haven’t said it for a long time, so I’ll say it again.  If medicine was a science, there would be no need for doctors.  If one could stick a finger a machine and learn the diagnosis and best treatment, there would be little or nothing for anybody else to do.  But no such machine exists yet so doctors learn what science and technology can tell them and then resolve uncertainties and choose among alternative courses of action.

It seems to me to follow that since science and technology can tell much more than they could in the past, there is less for doctors to do and we should need fewer of them.

The matter arises specifically in the case of primary care.  The June 23 issue of The Boston Globe carried a rather lengthy article on the subject, titled Precarious future for primary care.  The article discussed the difficulties of recruiting physicians into primary care, given that the specialties pay better and can be less demanding.

In my last two ER experiences (nothing serious, only bothersome complaints at inconvenient hours) I learned during the visit that I was being seen not by a doctor but in one case by a nurse practitioner and in the other by a physician’s assistant.  In both cases my concern was properly addressed and I was completely satisfied by the service. 

Adding to that a reflection on what goes on during my unexciting, periodically scheduled routine visits to my regular primary care physician causes me to wonder whether we really need physicians for most primary care at all. 

Primary care physicians graduate from college, go to medical school for four years and then undertake two or three years of residency.  According to the article, the average salary of a physician in family practice is $196,000 per year.  There may well be a goodly number of people who could be trained to carry out the function satisfactorily in a shorter period of time and who would be happy to work for a lower salary.

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