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Thursday, February 18, 2010

reforming health care at the state level

This keeps coming back to me: federal level health care reform is stalled, related to massive dysfunction in the legislative branch of government in Washington D.C.  Add to that the fact that we have a huge and incredibly diverse country, and it is not too surprising that we haven’t come up with an acceptable health care reform bill.

But what about Massachusetts? They managed to pass health care reform, and though it is not perfect, it beats the heck out of what they have in Washington and Idaho, the states in which I practice medicine.
Just today I read an article in the New England Journal of Medicine about the way the medicaid system is administered in Oregon. They use cost effectiveness research to determine a basic health care package, and then budget to allow as many people as possible to be covered by the state Medicaid system.  This is the article: http://content.nejm.org/cgi/content/full/362/7/e18

I would very much like to see Idaho, where we spend 20% of our state budget on health care, combine intelligent “rationing” with creative payment schemes (prepaid health care aimed at encouraging appropriate health care utilization) to extend coverage to state residents who can’t afford to pay for private insurance.
In fact I would very much like to see every state design location appropriate health care reform to take care of citizens who don’t have access. The huge crisis of medicare costs still needs to be dealt with at a federal level because medicare is a federal program and is much of the federal budget. Much of the house health care bill focused on making medicare more efficient and more effective. Reciprocity would also be an issue if health care reform was done by the states, but that is hardly a deal breaker.

Monday, February 8, 2010

ideas for quality improvement that could be done at a community hospital

1. The return of the Morbidity and Mortality conference, but with a twist--When I was in medical school and residency, if any hospital admission went spectacularly wrong, we had an M and M conference.  The major players had to research the medical record, draw a timeline of what happened, and discuss their reasoning and actions with regard to the case.  Everyone came. It was like a gladiator show. There was blood. There were tears. And everybody at the conference thought about what they would have done differently to make the whole thing come out better.  There is nothing wrong with a traditional M and M conference, other than the fact that should there be a malpractice case it would potentially lead to embarrassment or successful prosecution. What I would propose would be C and Q conference which would explore the cost and quality of any spectacularly complex case. The bill would be projected on the wall, and the various actions would be evaluated and discussed in terms of their adherence to known effective practice, and their eventual contribution to the health or disease of the patient. We would all get to see exactly how much all of the things we ordered and did cost.

2. Suggestion boxes, possibly online, with rewards: This was effective in reducing costs in airlines, and might be helpful in hospitals. Airlines got rid of mandatory bags of peanuts and various other silliness that I don't remember. The scale of these companies made peanuts a big deal. Still. Community hospitals don't have the scale issue, but an individual aliquot of money in medicine is usually huge. Perhaps just the activity of thinking about cost savings would help focus us appropriately.

tort reform--the key to unlocking health care reform gridlock?

Democrats and Republicans are talking about health care reform. This is good.  Tort reform absolutely needs to be a part of this discussion.

I watched a brief snippet of Bill Reilly interviewing John Stewart, and Reilly asked Stewart why, if Obama wanted to compromise with Republicans on health care reform, did he not agree to make tort reform part of the package. This is, I would surmise, a big issue for Republicans.

According to John Stewart and other Democrats, the primary reason for not including tort reform in the health care reform bill is that the CBO (Congressional Budget Office) has estimated that tort reform would only save 11 billion dollars in a year, a measly 0.5% of the overall health care budget.  This is based on an estimated small effect on utilization of health care resources and a significant effect on the cost of malpractice insurance, taking into account also the savings seen in states where tort reform has occurred.

This vast underestimate of cost savings is an important reason why practicing physicians need to be part of crafting this bill.  11 billion dollars saved assumes that each of the more than half a million doctors (estimates of numbers of practicing physicians vary, probably there are around 800,000) in the US will save $20,000 each. I personally know that most of us could easily save $20,000 in a week if we didn't order excessive tests and consults due to the perceived risk of being sued.  Add to this the wasted time reviewing and explaining the results of these,  and the numbers get staggeringly higher.  Physicians in high cost areas of the country could save astronomical amounts of money.

Why is this not seen in the states with tort reform laws? I can speak to that.  I practice in Idaho, where a cap on non-economic damages passed several years ago.  This has reduced the numbers of suits and the level of damages, as well as malpractice insurance costs, but doctors' attitudes have not changed significantly because the specter of being sued continues to loom.  More substantial tort reform is necessary, to make recognition of error and compensation for it a regular part of practice. We need education in practices that are effective, and an open attitude toward improving performance and recognizing errors.

If real, substantial tort reform is something Republicans value in a health care reform bill, they should get it. The concept of tort reform is dear to most physicians and to a majority of Americans as well, and including it in this bill would probably put an important and realistic shine on its image.

Friday, February 5, 2010

reading the Internal Medicine News

Once a month I get a large journal in the mail which I don’t pay for.  It is called the Internal Medicine News.  Authors write about reports from meetings or new ideas posed by scientists, but without the scientific rigor of a real journal article. It is possible to review all sorts of topics in a short amount of time, and some of the information is even true.

Diabetics don’t necessarily have an increased risk of heart attacks: researchers looked at the results of a Cat scan of the arteries around the heart of over 800 diabetics and found that 40% of them were absolutely fine. Cool. This is something I have found too. Some diabetics who I think should really have heart disease are absolutely fine, with no narrowing of the coronary arteries at all. But the authors add that maybe we should do this Cat scan on all diabetics to see who is who, even though studies of this test show that it is close to useless and we know it exposes people to radiation at a level that does cause cancer. The authors don’t mention this.

Mammography experts rail at new reduced recommendations for mammogram screening in patients between 40 and 50 years of age: Mammography experts, who happen to be radiologists, and therefore do make their money through mammograms, deliberately misunderstand and spin the new recommendations to stop routine screening mammograms in the 5th decade of life. Ack. The medical profession seems completely unable to address the question of limited resources and the fact that more useless mammograms do take away money from the overall health care pie that is supposed to serve, but is not serving, everyone.

Fructose may be causing increase in heart disease: On average, each American eats 150 lbs of sugar a year, and a great deal of it is fructose, in the form of high fructose corn syrup.  This raises blood pressure, uric acid levels, reduces good cholesterol levels and increases bad cholesterol levels. The effect of all this fructose on blood pressure can be reduced by taking a drug that reduces the uric acid level. This is new and interesting, and explains why the study was sponsored by a drug company. Clearly the solution to this problem lies with reducing the use of high fructose corn syrup, though it was spun in the direction of treating gluttonous patients with the uric acid lowering drug.

Australian study shows that all of the so called warning signs for colon cancer don’t predict colon cancer at all: Patients who are encouraged to get colonoscopies to look for colon cancer because they have blood in their stool or change in bowel habits or abdominal pain are no more likely to have colon cancer than another random person their age.  This is interesting, but I’m afraid it can’t particularly influence my practice since people who have these symptoms, if they are significant, would like to know if their colons are the culprit. Still, it is nice every once in awhile, to find that something that I believed rather firmly is not true.

Bladder infections can be diagnosed and treated over the phone just as effectively as if the patient is seen in the office: This applies to what we call “uncomplicated urinary tract infections” which means that the person isn’t terribly sick and hasn’t been treated recently. Still, this saves tons of money and time for both patients and doctors. It raises the question of how to be reimbursed for phone medicine, since treating a bladder infection over the phone is not necessarily trivial.

Despite a “cost transparency” law in California, costs are not transparent: Researchers posing as uninsured patients asked for price information at various hospitals.  They got answers from fewer than 1/3 of the hospitals visited, and the information they did get was not standardized in a way that allowed them to compare different hospitals.

Monday, February 1, 2010

Documentation: another reason for radical tort reform

In medicine we always seem to use a word with many syllables where a couple of words that people can actually understand would do. Thus the word "documentation". In the practice of medicine, since I have been practicing it, we spend lots of time writing stuff down.  The amount of this writing or typing or dictating or computer point and clicking that we do has gradually increased, and is now eating up the time that we could use to do other important things, like take care of patients, for instance.

In my own practice I spend over half of my time creating some sort of record of what is going on with my patients' care.  Most of it is necessary, and if I were to reduce the time that I spent in documentation, it would be by streamlining the process, maybe by using a better computer system. Most of the words on paper or words on a screen are valid communication, though the detail in which I keep my records is primarily to satisfy insurance companies and the legal system should I be unlucky enough to be sued.

In the hospitals and the nursing homes, though, the situation has become much more dire.  One nurse I spoke to today said that she spends at least 4 hours of a 12 hour day record keeping, and of that she thinks that probably nobody reads any but a tiny fraction of it.  The nurses I work with in the intensive care unit say that anywhere from half to three quarters of their time is spent in documentation, and maybe 20% of that is ever useful. "The only one who is ever going to read this stuff is the lawyers," said one of them. In nursing homes the situation is the same, and with the ratios of staff to patients that nursing homes have, this results in hurried and inattentive care and unhappy harried staff.

I would propose that in reforming the tort system and insurance systems the whole system of documentation be revamped.  This would require the involvement of nurses, physicians and administrators to determine exactly what parts of the documentation we do actually benefit the process of taking care of patients.  Sometimes writing can be part of remembering, in the case of complex work routines. It would also require a cooperative interaction with whatever legal organization would deal with medical error and malpractice, since this will not entirely go away. If malpractice law is reformed in the way it should be, to make it a vehicle for compensation and quality improvement, we will need to have some way of tracing what happens in situations of medical injury. We will need to be able to look at the processes that lead to errors so we can change systems to work more efficiently.