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Tuesday, June 29, 2010

Community organizing for health care reform: what we have to do now

We had our 4th meeting of doctors and staff interested in improving access, cost and overall quality at our hospital. It was well attended, but mostly by staff and board members rather than physicians. I guess we doctors think we are too busy to talk about health care reform. We had me, an internist, a psychiatrist, a radiologist and and emergency doc. Thinking was clear and focused, and the meeting was productive, as much as talking can be. We came up with several items needing action, and discussed several items that are moving solidly in the right direction.

1. My Own Home: an organization is being born which provides all sorts of resources to older folks wanting to stay in their own houses rather than moving to retirement homes.  It will be supported by grants and will require membership payments. It will probably really start functioning in the next year. It is moving in the direction of getting up and running as fast as is practical.

2. Direct or prepaid medicine: there is quite a bit of interest by the hospital leadership in looking at some sort of community based prepaid health care.  This would involve using the money that is already being spent on health care, by individuals and insurance companies, to provide comprehensive health care for the whole community.  There are models for this elsewhere. Grand Junction, Colorado, has a system that provides affordable health care for the whole community, and we are a good size and makeup for that sort of thing.

3. Physical therapy--appropriate utilization and rapid transition to exercise programs: This is already happening.  There is room at the hospital wellness center and costs are low, so many people who go to physical therapy multiple times because that is the only exercise they every get can be transitioned into something much cheaper and more appropriate.

4. Information systems: The hospital just made the decision to buy an electronic medical record system, and will start using it, ever so gradually, in the next few months.  This will make monitoring of costs and outcomes much simpler.

5. Radiological testing--making it more appropriate to avoid excess radiation exposure and monetary costs: This will be aided a great deal by the computer ordering of tests. Criteria for appropriateness can be evaluated at the time the test is ordered, and duplication can be avoided.

6. ER use: There is still a great deal of money spent due to patients being seen in the emergency department when seeing a primary care doctor would be more appropriate. This involves excessive testing and insufficient followup, and is associated with higher costs than appropriate care would have generated. This will require a work group to figure out the best approaches. Some suggestions included diverting patients to primary care providers who indicate in some way that they are available and willing to work with these patients for a reasonable fee. Another helpful service would be 24 hour van transportation to get patients home after treatment and evaluation are completed. This kind of service would more than pay for itself, and the hospital CEO said he would move on that.

7. Cost-of-care clinical conferences: I would really like to present case conferences which look at the costs incurred at all stages of a patients hospital stay, along with the clinical outcomes. This can probably be done, with attention to confidentiality, and would really inform some of our choices. I will work on this.

8. Cost transparency for patients: the billing department is working on this, but the progress is slow.  They really need more staff to get an efficient interface working.

The hospital has been very receptive to ideas that involve streamlining care and costs, which initially surprised me. They are aware of a new climate of belt tightening, though, and would like to be involved in the process as much as possible.

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