U.S. Rumor and Hospital Report

Introduction: Below a post by Paul Levy, the former President and CEO of Beth Israel Deaconess Medical Center in Boston. For the past five years he kept an online journal, Running a Hospital. He now writes as an advocate for patient-centered care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement at one of my favorite blogs: Not Running a Hospital.

Levy’s post originally appeared on The Health Care Blog (THCB).  

I should add that, as a journalist, I have watched lists like this one being compiled at various magazines: “The Best Colleges in the U.S.”  “New York’s Best Doctors,”  “The Best Motels in America”. . ..  Who puts them together?  Young journalists who know no more than the rest of us about which universities, hospitals, or motels offer a better education, safer surgery –or a nicer swimming pool.   (I recall reporting a “best motels” piece for Money Magazine many years ago. I didn’t visit the motels. I talked to their owners on the phone.)  

These are not investigative pieces. This goal is not to warn consumers; the goal is to advertise.As for the physicians surveyed, Levy is not blaming them for offering opinions rather than in-depth information about outcomes and patient safety.  Most hospitals don’t make hard data about medical errors or infection rates available.  In fact, many hospitals don’t keep detailed data about medical mistakes.  They may well count the number of “adverse events,” but they don’t discuss and analyze them, even internally. Hospital CEOs have other priorities.  This, I think, takes us to the crux of the problem. (See my companion post below)

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It has been almost four years since I commented on the annual hospital ranking prepared by US News and World Report.  I have to confess now that I was relatively gentle on the magazine back then.  After all, when you run a hospital, there is little be gained by critiquing someone who publishes a ranking that is read by millions.  But now it is time to take off the gloves. All I can say is, are you guys serious?  Let’s look at the methodology used for the 2011-12 rankings:

In 12 of the 16 [specialty] areas, whether and how high a hospital is ranked depended largely on hard data, much of which comes from the federal government. Many categories of data went into the rankings. Some are self-evident, such as death rates. Others, such as the number of patients and the balance of nurses and patients, are less obvious. A survey of physicians, who are asked to name hospitals they consider tops in their specialty, produces a reputation score that is also factored in.

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Hospital CEOs Reveal Their Top Priorities

While reading Paul Levy’s post on hospital rankings, I couldn’t help recall an  American College of Health Care Executives (ACHE) survey that he discussed onNot Running a Hospitalback in March of 2010.  The ACHE asked hospital CEO’s about their top concerns. Below, a table shows the results: “Patient Safety” and “Quality of Care” ranked at the bottom of their list of priorities.

Granted, from 2004 to 2007 these issues moved up in the rankings, but CEOs still were more likely to worry about “financial challenges,” “the cost of caring for the uninsured,” and “Doctor/hospital relations.”  They might as well have been the CEOs of auto companies, who worry about  first about profits, then costs, then labor relations, roughly in that order.  

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Even worse, by 2009, Levy notes, “there was a major disappointment.”   The two issues most important to patients appear to have fallen off the chart.   “We can't blame just the CEOs for missing the boat on elevating safety and quality,” Levy commented. “It is the governing bodies of the hospitals, behind and above the CEOs, who should hold them accountable on this front.”

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“Slow Medicine”

Below, Kent Bottles, M.D. reflects on the difference between “slow medicine” and what he calls “UCLA medicine.” (For the full post, see “Kent Bottles’ Private Views” )

“I have been thinking about the difference between slow medicine and UCLA medicine. It has made me realize how complex and difficult it is to transform American health care so that we lower per-capita cost and increase the quality of our lives. And yet we must achieve these two goals.

“Slow medicine is practiced by a small, but growing subculture whose pioneer and spokesperson is Dr. Dennis McCullough, author of the book My Mother, Your Mother: Embracing ‘Slow Medicine,’ The Compassionate Approach to Caring for Your Aging Loved Ones. Slow medicine is a philosophy and set of practices that believes in a conservative medical approach to both acute and chronic care.

“McCullough describes slow medicine as ‘care that is more measured and reflective, and that actually stands back from rushed, in-hospital interventions and slows down to balance thoughtfully the separate, multiple and complex issues of late life.’ Shared decision-making, community and family involvement, and sophisticated knowledge of the American health care system are some of the slow medicine practices that sharply contrast with UCLA medicine.

“UCLA medicine is the status quo where the hospital is the center of the medical universe; where care is often uncoordinated and hurried, and where cure is the only acceptable outcome for both patient and physician. I call it UCLA medicine because the CEO of that well-regarded medical center was quoted in a New York Times Sunday Magazine article as saying, ‘If you come into this hospital, we’re not going to let you die.’   This is a statement that puzzles me as an old time anatomic pathologist.”

I would add that I find the UCLA CEO’s statement more than puzzling; I find it frightening.

I can’t help but think of the doctor who explained: “Once you’re in the hospital, you’re in ‘the system.’”  I imagine a prison door closing behind me. I am now in a place where people no longer ask me what I want.  Instead, they tell me:  “This is what we’re going to do.”

Of course, Bottles goes on to acknowledge that “there are times (serious acute illness correctly diagnosed where there is an evidence-based treatment that has a good chance of success) when I hope I am treated in UCLA’s ICU or operating room by UCLA specialists. However, there are also times as I get older that I hope I end up living in the Kendal-at-Hanover retirement community cared for by a wise and experienced geriatrician like Dennis McCullough and the community’s nurse practitioner; I want my providers to take things slowly and listen to what I want out of life.”

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Putting a Lid on HealthCare Inflation Is Possible

Summary:  Could we bring our nation’s health care bill down from 17% of GDP to 12%? An intriguing study from Milliman, the independent consulting and actuarial firm, says”yes.” Looking at actuarial date from some of our best and most efficient health care plans, Milliman’s analysts conclude that, in theory, it would be possible to trim our bloated health care system by 25%.

Before you dismiss the idea, consider this: not that long ago, we brought health care inflation down to less than 3% a year for six years running (1994-1999). During that time, the nation’s health care bill remained flat as a percentage of GDP.

And Milliman points out that today, our most efficient , high quality health plans are achieving similar savings by “reducing unnecessary inpatient stays” and “inappropriate imaging  The site of service also changes to emphasize lower cost settings—for example, home care instead of nursing-home care, or office-based primary care instead of emergency room care..

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Pilots Use Checklists. Doctors Don’t. Why Not?

This is a question Dr. Atul Gawande explores in the December 10 issue of The New Yorker. “The Checklist” is a shocking story, it’s an important story—and it’s also very long. I, of course, would be the last person on earth to criticize someone for “writing long” but it occurs to me that many of HealthBeat’s readers may not have the time to peruse the full nine-page story, so I decided to offer a capsule summary here. (To read the story in its entirety, click here).

Gawande is the author of one of my favorite healthcare books, Complications: A Surgeon’s Notes on an Imperfect Science, and he writes wonderfully well. This piece begins with a riveting tale of a three-year-old who falls into in icy fishpond in a small Austrian town in the Alps. “She is lost beneath the surface for 30 minutes before her parents find her on the bottom of the pond and pull her up.” By then “she has a body temperature of 68 degrees—and no pulse.” A helicopter takes her to a near-by hospital. 
There a surgical team puts her on a heart-lung bypass machine. She now has been lifeless for an hour and a half. Gradually, the machine begins to work. After six hours, her core temperature reaches 98.6 degrees, but she is hardly out of the woods. Her lungs are too badly damaged to function, so the surgeons use a power saw to open her chest down the middle and sew lines to and from an artificial lung system into her aorta and beating heart. “Over the next two days, all of her organs recover except her brain. When a CT scan shows global brain swelling, the team drills a hole into her skull, threads in a probe to monitor cerebral pressure, and adjusts fluids and medications to keep her stable. “

Slowly, over two weeks, she comes back to life. “Her right leg and left arm [are] partially paralyzed.  Her speech [is] thick and slurry.  But by age five, after extensive outpatient therapy, she has recovered her faculties completely. She [is] like any little girl again.” 

“What makes her recovery astounding,” Gawande writes, is “the idea that a group of people in an ordinary hospital could do something so enormously complex. To save this one child, scores of people had to carry out thousands of step correctly; placing the heart-pump tubing into her without letting in air bubbles, maintaining the sterility of her lines, her open chest, the burr hole in her skull; keeping a temperamental battery of machines up and running” all the while “orchestrating each of these steps in the right sequence, with nothing dropped . . .”

This, Gawande says, is what happens in intensive care units, every day of the year, all across the country. “Intensive care medicine has become the art of managing extreme complexity—and a test of whether such complexity can, in fact, be humanly mastered.”

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Doctors Who Know Better—But Do the Wrong Thing

On Health Care Renewal , Dr. Roy Poses reports on a disturbing new study just published in The Annals of Internal Medicine contrasting physicians’ attitudes toward professional norms with their self reports of whether they acted in conformity with these norms.

Poses does an excellent job of summarizing, so I’m re-posting his piece in full below:

“In brief, the authors developed a survey which asked physicians whether they agreed with various professional norms organized according to the 2002 ABIM/ ACP/ ESIM Physician Charter. They also asked them about whether they acted in conformity with these principles in terms of their recent actions, or in responses to scenarios. Physicians surveyed were primary care practitioners (family medicine, general internal medicine, and pediatrics), cardiologists, anesthesiologists, and general surgeons. The overall response rate was 52%.

“In general, large majorities of physicians agreed with the ethical norms. How often they reported acting in agreement with these norms varied. In particular, nearly all physicians reported treating patients honestly (less than 1% reported telling a patient’s family member something untrue in the last 3 years, 3% reported withholding information from a patient or a family member.) However, although 96% agreed that "physicians should put the patient’s welfare above the physician’s financial interests," 24% would refer a patient to an imaging facility in which the physician was an investor, without revealing this conflict of interest.

“Some commentators suggested that external pressures may prevent
physicians living up to the standards they themselves have endorsed.
For example, physicians interviewed in a Washington Post article
suggested that the current emphasis on patient satisfaction may
conflict with the physician’s ethical obligation to avoid wasting
resources when a patient demands an unnecessary but not clearly harmful
test. The Congressional Quarterly reported
quoted the CEO of the Federation of State Medical Boards saying that
physicians "were penned in by the American the health care system,
fighting giant bureaucracies while fearing legal action if they make a
mistake."

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Health Care Spending: The Basics

 

JUST HOW MUCH DO PRIVATE INSURERS ADD TO THE NATION’S HEALTH CARE BILL?

As a nation, we are spending well over $2 trillion a year on health care. This includes: all of the money that you and I pay out-of pocket to cover co-pays, deductibles and drugs; the dollars that you and I (and our employers) fork over for private insurance; the money Medicare, Medicaid and SCHIP lay out to reimburse doctors, hospitals and patients; the billions taxpayers chip in to fund veterans’ health programs, public hospitals, school programs, and health insurance for government employees as well as the money private charities contribute to health care.

What exactly are we paying for? How much of that money is used to pay the CEOs of drug companies salaries that read like telephone numbers? How much do hospitals eat up?  How much is spent on insurance company ads? How much is used to provide healthcare for the poor?

I’ve decided to do a series of posts spelling out exactly where the money goes. Today, I’m going to start with private insurance.

Many people believe that if we just eliminated the private insurance industry, healthcare would become much more affordable. There is a general sense that the “administrative costs” of private insurance are siphoning off a sizable share of our health care dollars.

There is some truth to that: because we  have  multiple insurers—not to mention so many solo practitioners, small hospitals, clinics, and individuals filing for reimbursement—the paperwork is enormous. If we had only one big insurance company that used just one set of forms we could simplify the paperwork greatly. People who want a “single payer” system, with the government paying all of the bills,  point out that the savings would be enormous.

And we could cut costs even more if, instead of having tens of thousands of health care providers filing for separate reimbursements, doctors, hospitals and clinics joined together into, say, eight our ten large organizations like Kaiser Permanente, each with its own back office.  The doctors would be on salary, so rather than filing for payment for each service they performed, they would receive a monthly check for taking care of their patients, just as they do at Kaiser Permanent or the Mayo Clinic (where doctors are on salary).

In other words, it is not only a fragmented multi-payer insurance industry that generates so much paperwork; on the other side of the transaction a fractured network of separate providers adds to a mind-boggling stack of paper. Unlike most other developed countries, we have turned healthcare into a  cottage industry. This gives us lots of choices: we can select from a Chinese menu of insurance plans and proviers. But it also means higher administrative costs. In this post I would like to focus first on just on how much our huge private insurance industry is costing us. (In a later post, we’ll look at the price we pay for a fee-for-service system of independent providers.)

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New CDC Report: The Nail in the Coffin for Health Care Myths

On Monday the CDC released a landmark, and in many ways devastating, report on health care in the U.S. The report contains a wealth of data that, while not surprising to some, should help silence the dwindling few who insist that America’s health care system is doing just fine. As a public service, I thought it’d be helpful to list some of the myths that the report demolishes (with some help from other sources as needed).

Myth: If people don’t have health insurance or get medical care, it’s because they don’t want it.

Reality: Actually, the big issue with access is cost. According to the CDC report, more than 40 million Americans—almost one in five Americans over the age of 18—have foregone one of the following in the past year because they couldn’t afford it: medical care, prescription medicines, mental health care, dental care, or eyeglasses.

It’s not that uninsured people don’t understand the value of coverage. Last year a study from the Urban Institute found that less than 3 percent of uninsured adults and children have never had insurance or report having no need for insurance. That same report also found that the high cost of coverage alone explained over 50 percent of those cases where people are uninsured 

And even when the uninsured cite job-related difficulties as the reason why they can’t access employer sponsored coverage, the problem isn’t just that they can’t get it through work—it’s also that they can’t afford individual policies. (Individual policies are much more expensive than group policies, and in many states private insurers can charge individuals astronomical premiums if individuals have any “pre-existing conditions.)  According to the Urban Institute, for 79 percent of adults and 74 percent of children who are uninsured because of job-related problems, the high cost of individual insurance is a major problem.

Myth: The American system relies mostly, if not exclusively, on private enterprise to support health care.

Reality: Yes and no. While the U.S. does have the biggest private sector share of health expenditures in the world, making up 55 percent of our funding, personal health care expenditures (i.e. spending on actual patient care) is mostly public. The CDC reports that in 2005 the federal government and state and local governments combined paid 45 percent of personal health care expenditures; private insurers only paid 36 percent, with 15 percent coming from out-of-pocket payments. So much for the libertarian utopia.

There’s also a bigger public sector coverage presence than many would like to admit. Though two-thirds of insurance policyholders have private coverage, a Census bureau report from earlier this year noted that more than one quarter of Americans (about 27 percent) are covered by government insurance. The American model is much more of a private-public mix than some pundits—and candidates—are willing to admit.

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The FDA: What Happens When You Starve the Beast

In October, I talked to a source inside the FDA who suggested that the agency was having a hard time keeping up with work-flow.  I quoted him on this blog as explaining that since the FDA has committed to reviewing applications for approval of a new drug within 10 months, drug-makers have been submitting “shabbier” applications that contain less evidence about risks and benefits.

“For the drug-maker it’s a gamble. The company is betting that, because we want to make the 10-month deadline, we won’t send the application back,” said the source. And often, he acknowledged, the drug-maker is right. “If you find a problem or there is something missing and it doesn’t seem terribly material, there is a tendency to overlook it. Because if you don’t it will just delay the whole process.”

In the past, he added, a company submitting an application knew that if the application wasn’t up to snuff, the FDA would send it back. But those standards have fallen: “Now we send it back [only] if it’s really crappy.”

Yesterday the FDA Science Board dropped a bombshell in the form of a report which suggests that standards at the FDA haven’t just fallen—they’ve fallen off a cliff. The title of the report says it all: FDA: Science and Mission At Risk.
The problem, according to the report: a lack of funding. The Coalition for a Stronger FDA,  co-chaired by the last three secretaries of Health and Human Services (the department that oversees the FDA), says the FDA needs a 15 percent boost in funding per year for the next five years. 

Here are just a few highlights from the report:

  • “The Information Technology situation is problematic at best—and at worst it is dangerous.”
  • “The FDA has substantial recruitment and retention issues”.
  • “Critical data…including valuable clinical trial data…are sequestered in piles and piles of paper documents in large warehouses."
  • “The FDA has an inadequate and ineffective program for scientist performance."
  • "The FDA has inadequate funding for professional development to ensure that staff maintain scientific competence."

William Hubbard, a former FDA associate commissioner who supports the Coalition for a Stronger FDA, told ABC News that the report stands out because of the "intensity of the feelings" expressed by the subcommittee.

"These people were horrified by what they found," he added.

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