Health Care Anew

The Responsible Thing to Do

Last January 19, I published a posting titled “More Income for Massachusetts Hospitals?” It was about the current effort in Massachusetts to achieve universal health care insurance coverage. It concluded that the main financial effect would be increased income for hospitals, thus further fueling the health care cost inflation that is already out of control.

Today’s Boston Globe carries an article headlined “Care bill may be a hospital bonanza.” It suggests that the latest version of the universal coverage legislation as proposed by the state’s House of Representatives would provide $270 million of new revenue to Massachusetts hospitals. The equivalent number for the Senate bill as passed last fall is $540 million.

The article goes on to point out that “A good chunk of that extra revenue will go to several of Boston’s prestigious teaching hospitals that have in recent years made huge profits.”

An obvious solution would be for hospitals and doctors to volunteer to lower their rates to offset their increased income.

It’s a lot to ask, but it would be the responsible thing to do.

Summers, Harvard, and Hospital Administration

Applying the Summers and Harvard story to hospitals, regular contributor Neil Whipkey offers the below words of wisdom.

I find these words interesting not only for what they say about the direct subject at hand, but also for what they say about the nature of the health care business and its problems. In what other form of enterprise would it be necessary for a senior corporate executive to secure “a goodly number of champions” before beginning “to champion quality?”
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Having been in the business for some years I [Whipkey] surmise that it is not infrequent for a CEO/Administrator to get out of town ahead of the posse, and sometimes not. It is an interesting process and can be quite an education for the CEO. To me the question of how the CEO navigates this minefield is not without answers. Granted it can be difficult but here are a few pointers, from my personal school of hard knocks:

* Issues need to be patient based (it is possible to make a financial issue; in fact, almost any issue, a patient care issue).

* Acquire some physician champions for your causes (take baby steps at first and remember the higher up the chain of influence your physician champion is the better your chances for success).

* When secure with a goodly number of champions, then begin to champion quality patient care/outcomes at the various committees.

* Present them with objective quality data on a regular basis. At this point do not go looking for any individual targets, just let the issues bubble up to the surface.

* When appropriate issues arise that demand immediate action (i.e., summary suspension), be prepared to take the necessary steps. WARNING: have a process in place that involves the Chief of Staff, Chairman of the Credentials Committee, and, if you wish, the appropriate Chief of Medicine or Surgery. Failure to do so will be the catalyst that gets the posse organized.

* Prior to initiating the process for a summary suspension, do your homework and have all of the facts laid out to present to the above referenced group. Enlist their support and try your best to get consensus for the action you are to take. Make it clear that this is an action you are authorized to take on your own. If you have done your homework and done it well you may be surprised at the support you get.

* Remember to keep it focused on patient care. All physicians wish to have it known that the facility they practice at cares about quality and deals with quality issues in a forthright manner.

* Keep your appropriate board members updated on what is taking place.

* Act and act decisively.

In almost 25 years in this business I have utilized the summary suspension twice. Neither time was easy but with the understanding and consent of the medical staff leadership I was able to avoid the posse doing their work. If we as administrators take patient care and quality outcomes seriously then we must be prepared to take some risk. Minimize those risks by building strong and positive relationships with your key players.

Hofmann on Medical Paternalism

Even in a computer it is possible to misfile things. I recently came across the following by accident, filed in the wrong place. It came in from friend, colleague, health care ethicist, and faithful blog reader Paul Hofmann. It was stimulated by a posting last December titled What Doctors are For.
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In conducting ethics rounds, I continue to see lamentable evidence that medical paternalism is alive and well. Too often, physicians assume their values are shared by patients and/or their surrogate decision-makers. And in some cases, when physicians have determined their values are not shared, they use their professional leverage to impose them on the patient. The basic ethical principle of autonomy is being violated when a patient "consents" to an invasive diagnostic or therapeutic procedure under these circumstances. For example, there are still physicians who insist on aggressive therapy for terminally ill patients despite their preference to the contrary. I am also aware of physicians who have written no-code orders without speaking to patients or their surrogates. What is needed here is not unquestioning deference to the physician's legitimate authority or the patient's legitimate right of self-determination. Instead, we should encourage a process that permits and facilitates an informed discussion of the patient's values and preferences. A physician colleague once told me that most doctors think communication happens when they're talking. Yes, remarkable advances in science and technology have occurred, but unless patients voluntarily and explicitly choose to have physicians make decisions on their behalf, patients should indeed be encouraged to ask the types of questions that permit them to be active rather than passive participants in the diagnostic and therapeutic process.

Medicare Part D – Part of the Muddle

Wife Marilyn and I have just enrolled in the much maligned Medicare Prescription Drug Plan (Part D). The decision to do so arose out of the decision to drop our Medicare Supplement Plan (another story). We thought that enrolling in Part D made sense for two reasons. One was that it seemed prudent to protect ourselves against catastrophic drug costs. The other was that we would benefit from the government subsidy and whatever discounts the insurance company had been able to negotiate with drug companies.

I did it via the Internet. The process took some time and focused attention, but was not as onerous as I had expected. The web pages of both the government and the insurance company were well designed and easy to navigate.

Without computers and the Internet, about the only thing you could do would be to find an insurance company that covers the drugs you are taking and has a relationship with a nearby pharmacy, sign up and pay the quoted rate.

With a computer and Internet access you can compare the alternatives. What you do is to go to Part D section of Medicare’s web site and enter your zip code and the drugs you are taking. You then get a list of the insurance companies that offer plans in your area and cover your drugs. In our case there were about four such plans. The list also shows the general features and monthly cost of the least expensive plan offered by that company.

I then went to the web site of the company that looked most promising and entered the drugs we are taking. The web page then computed an estimated annual out-of-pocket cost for each of that company's plans (I think there were four). Each plan has different co-pays and deductible. As it turned out for us, the least expensive plan also involved the lowest total out-of-pocket cost. So the decision was pretty easy.

I am now less negative about Part D than I was originally prepared to be. It is complicated, to be sure. But if given the job of designing a better way to go about it, I’m not sure what I would do. Medicare could have done it directly, but that would have required it to set the rates it would pay, as it does with its Parts A and B. Given the wealth and clout of the pharmaceutical industry, and its demonstrated willingness to use them, the politics of that would be horrendous.

It seems clear that we will not be redesigning our health care system according to some preconceived plan. Instead, we will muddle through. Part D is just one part of the muddle.

Managing Care - the Third Way

In going through the stacks that accumulate around my workplace, I came across a clipping sent to me a couple of months ago by Chuck Kleber, friend. fellow parishioner from Detroit days, and faithful blog reader. It was a column by Paul Krugman titled “Medicine: Who Decides?” as published in the December 26, 2005 issue of the New York Times. Its theme is encapsulated in a sentence found midway through the piece that reads “So if costs are to be controlled, someone has to act as a referee on doctors’ medical decisions.”

The Krugman column, like so many others, entertains only two alternatives. One is government, through publicly operated health insurance. The other is some sort of consumer-driven health care market.

But there is a third way, which might be called Managing Care and which is based on the principle of the HMO. In this alternative, health care institutions that employ doctors and operate their own hospitals – let us call them integrated systems - accept responsibility for managing the care of specific patients within a fixed amount of money set in advance. The Mayo Clinic, Kaiser Permanente, and Henry Ford Health System, are examples of integrated systems. They are properly organized to perform the role I describe. To some extent they already do.

Personally, I would rather have one of these non-profit institutions managing my care than either the government or myself.

It is true that there are at present relatively few integrated systems as I have defined the term. But it is also true that health care providers have been evolving in that direction for some time now and the movement could be encouraged.

Of course, if provider institutions are going to manage care, they also have to manage the clinical practice of their doctors. Getting used to this idea and learning how to do it is the hardest part of health care reform. Nobody can as yet claim to do it well. But it needs to happen and the sooner the better.

In Defense of the VA

Wade Mountz, long-time friend and colleague and for many years CEO of Norton Infirmary in Louisville, KY – rises to the defense of the VA in response to a recent contribution on that subject:
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I was appalled at the blanket description of the V.A. Healthcare system in your recent blog. I have been in the V.A. Medical Center in Louisville, Kentucky (outpatient only) two or three times a year for some time. No words in that description would come to my mind if I were describing the situation here. Certainly their medical record technology is light years ahead of most hospitals and doctors offices in this country. These facilities are old, but well maintained, are clean with no "stink to high heaven" and compare most favorably with community hospitals nationwide. A 30-40 minute wait for an appointment in a clinic is usually maximum. Every prescription is discussed with a pharmacist, but the queue is well organized and not that long. My drugs are usually mailed to me. The most remarkable (and perhaps surprising) thing that I witnessed from my first visit on has been the employee culture. Obviously my experience is limited, but by and large, the employee group here, from service workers through medical staff could not be more helpful or anxious to please. I am sure every VA institution is different, as is every community hospital. Somehow it would seem that the statement "every single VA hospital I've seen the inside of" etc.,etc. surely has to be a bit of a stretch - perhaps to justify the last sentence in the blog.

Mugglie on Care Management

Occasional contributor and social worker Cindy Mugglie has some comments that relate to efforts to manage care by means of payment:
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One would expect the ever changing state and federal regulations regarding patient/client care to result in better care for health care consumers, but in my experience the opposite is sometimes true. Extensive paperwork that must be completed within strict time frames often serves to reduce the amount of time spent in caring for patients/clients. This has an even greater impact when regulations are changed frequently because of the time it takes to constantly adjust to the changes and educate staff on their changing responsibilities. I understand that regulations are needed to protect consumers and control costs, but there must be some point where we realize that regulations can do more harm than good. At times they may even seem unethical.

I wonder if any research has been done on this issue and I have 2 examples.

First, I've worked with many nursing home residents who at some point received physical therapy under Medicare. When a resident reaches the maximum physical gain deemed possible, Medicare will no longer pay and the resident is dropped from physical therapy. Once dropped from physical therapy, the resident's physical abilities often decrease and at some point they are allowed more physical therapy. However, they may not see as much improvement as before, and over time their physical ability will show a marked decrease. Wouldn't it make more sense for Medicare to pay for some kind of maintenance physical therapy in order to keep people from losing so much ground over time? Wouldn't it cost less to provide maintenance care, especially when you consider the paperwork that must be completed each time a resident is discharged from physical therapy and each time a resident is re-admitted to physical therapy?

Second, there are instances where people with dementia are admitted to hospice care because of weight loss and other associated problems that, if continued, can at times result in death. Hospice provides the care needed to assist such a patient by increasing their intake of food and liquids. But after a certain amount of time, the weight loss and other problems that indicated a need for hospice care can be reduced so much that the patient will no longer qualify for hospice care under Medicare, and the patient must be discharged from hospice. Once off of hospice care, that patient's weight loss and other problems can re-occur, and the patient may be re-admitted to hospice. Here again, wouldn't it cost less to allow such a person to remain on hospice? More importantly, wouldn't it be better for the patient to prevent a recurrence of the weight loss and other problems associated with dementia?

Have the For-Profits Fled New Orleans?

Erstwhile colleague and now retired hospital administrator Peter Geilich poses a question about for-profit hospitals and New Orleans.
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I was recently in New Orleans giving an expert witness (You can fool . . .) deposition. I toured much of the city. It is as bad as or worse than you can imagine - I almost came to tears - seriously. I got the impression that the non-profit hospitals are hanging in there with what staff they have left and assisting with recovery efforts (via clinics and the like). The implication was that the for-profits (including Tenet who was the 'target' of the plaintiff attorney I was assisting) have closed up. Again, the implication is that when things get tough (read: not profitable) they flee. I wonder if this is so and would like to hear what more knowledgeable folks than I might have to say on this matter.

Lets Hear It for Cassy Horack!!

Health care providers under pressure to improve the safety and quality of care often cite the lack of consistent national criteria as a reason for not doing more.

That was the general subject of an article in the March 6, 2006 issue of Modern Healthcare. The first sentence of that article read “The effort to improve healthcare quality appears to be stagnating as the [healthcare] industry continues to sort out the details of how to organize the movement.”

Then a few paragraphs down, Cassy Horack was quoted as having opined that problems at the national level were no excuse and that the desire for self-improvement comes from within. She said, further, “If the literature and the evidence are there, you should be doing it anyway.”

Ms. Horack is director of quality and safety at 593-bed OSF St. Francis Medical Center in Peoria, Illinois.

The rest of the three-page article went on to elaborate on its basic theme, which was what was happening or not happening nationally on the quality front.

But we should all give a little hooray for Cassy Horack, who said what needed to be said. Hospitals have plenty of things that need improvement and most of them are easy to find. They need to get with it and do something about them. Having clear national guidance would be nice, but it isn’t necessary.