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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.

Wednesday, June 24, 2015

D to S time

If, God forbid, you should have a heart attack, the chances of your living or dying is determined more by door-to-stent (D to S) time than by the relative competence of the physicians who treat you.

There are probably not many Americans who believe that, but it is the clear implication of a long, front-page article that appeared in the June 21 Sunday New York Times.

A heart attack happens when one or more arteries feeding blood to the heart become blocked, denying the affected parts of the heart muscle the oxygen they need to function and survive.  The remedy is to thread a tiny balloon to the blockage through a leg or arm artery, open it up and maintain the opening with a metal-mesh tube called a stent.  If this now common procedure is completed in a timely manner, the patient has a good chance of recovery.  If not the patient either dies or is left with a badly damaged heart.

According to the article, the death rate from coronary heart disease dropped 38 per cent from 2003 to 2013.  Credit was given to better control of cholesterol and blood pressure, reduced smoking rates, improved medical treatments, and faster care of people in the throes of a heart attack.

The article then focused on the faster care factor.  Some years ago, the American College of Cardiologists set a goal of getting a stent planted in at least half of heart attack patients within 90 minutes of arrival at the hospital (door-to-stent or D to S time).  In the beginning that was thought unrealistic but now it is common for a hospital to achieve 61 minutes or less.

Several changes account for the bulk of the time reduction.  Rather than doing an EKG after the patient arrives at the hospital, the Emergency Technicians do it in the ambulance and send the results on ahead.  Rather than summoning the stent implant team members one at a time, a single phone call simultaneously activates the beepers of all.  On-call people are required to be no more than 30 minutes away from the hospital.  Consent form requirements are waived.  The Emergency Room physician is allowed to summon the stent implant team directly rather than being required to obtain confirmation of the diagnosis from a cardiologist.

The article makes no mention of the credentials or competence of the physicians.

 

 

 

Monday, June 22, 2015

Institutionalizing Medicine 

I think that the biggest challenge facing health care management today is the institutionalization of medicine – a profession that has historically defended itself vigorously against any loss of independence, a stand that has enjoyed general public support.  As evidence of that support, I frequently ask people whether they think their doctors should have bosses.  I have yet to get an unqualified “yes” as an answer. 

So it’s the brave healthcare executive who tries to incorporate the medical profession into a program for addressing the health care issues of the day. 

And yet there is little choice other than to try to do so.  Although they never say so in so many words, Obamacare, insurance companies, employers and other major health care players are adopting strategies and implementing programs that can only be responded to effectively by making the medical profession a part of the effort – in other words, by institutionalizing medicine. 

It is not easy.  The June issue of H&HN, the journal of the American Hospital Association, carries an article entitled The New Health Care CEO.  The article reports a survey on what health care CEO’s consider to be “the primary hurdle to achieving your organization’s strategic priorities”  The results are: 

Physician buy-in and engagement                            26%
Financial constraints                                                    15%
Organizational barriers to collaboration                  26%
Lack of talent or skill sets for key roles                     14%
Cultural impediments within the organization        14% 

I think it reasonable to suspect that every item listed, except for financial constraints, has to do with the institutionalization of medicine.

 

 

 

 

Monday, June 08, 2015

FFS Begone

There seems to be widespread agreement in health care that fee-for-service (FFS) has to go.

In the usual economic transaction there are two parties – buyer and seller.  Each has a financial interest in the deal.  Healthcare is different.  There, transactions commonly involve four parties – buyer, seller, consumer and payer, with the physician being the buyer, the pharmacy, lab, hospital, etc. being the seller, the patient being the consumer and the insurance company being the payer.   Only the seller and the payer are financially involved and historically the payer has had only an arms-length relationship with the buyer.

This unique arrangement is considered to increase costs because the incentives to order drugs, diagnostic tests and even treatments are stronger than the incentives to economize. 

 Saying that FFS has to go raises the question of what is to replace it.  So far, the main alternative that has been imagined involves some kind of “bundled” payment – either a flat sum for a defined treatment like hip replacement or a fixed annual amount per patient or per family – what in the managed care era was called capitation.  The other possibility is the payment of a bonus for achieving a cost level at or below target.

While FFS creates incentives to provide more service than a patient needs, bundled payments and bonuses do the opposite.  In those cases, a provider performing a hip replacement can make money by installing a cheaper artificial joint and by skimping on postoperative rehab.

That concern is being expressed these days in Massachusetts where, according to an article in the May 26 issue of the Boston Globe (Amendment incites a Medicaid fight), Steward Health Care System, a for-profit hospital chain, is promoting legislation that would allow it to be paid for Medicaid patients on a bundled (capitation) basis.  Steward was created and is owned by venture capitalists and a common view is that its goal is to become profitable enough to be sold at a profit. 

The proposal is being questioned by consumer advocates and insurers.  The stated objection is that the provider (Steward in this case) would be allowed to act as an insurance company without being regulated as such or being required to maintain reserves.  But I suspect the concern is that providers like Seward will withhold needed care in order to increase profits.

FFS may be an undesirable payment system but the alternatives have their issues, too.

 

Tuesday, May 26, 2015


Cancer

I recently finished reading The Emperor of All Maladies by Siddhartha Mukherjee.   It is the story of the study and treatment of cancer – one of the most stubborn scientific puzzles ever faced. 

A part of the story that I found interesting was the intensive competition among the treatment modalities – surgery, radiation and chemotherapy – each controlled and represented by a different medical specialty.

I remember being told at one point that a study conducted in a major cancer hospital found that the treatment chosen was determined primarily by the specialty of the physician who first saw the patient.  If it was a surgeon, the patient would be operated on, if a radiation therapist, radiation would be used and chemotherapy in the case of a medical oncologist.

That seems to be changing.  The May issue of Modern Healthcare had an article about the cancer program at the University of Tennessee Medical Center, which claims that 60% of its cancer cases are treated according to an evidence-based protocol.  The article also said that “New cases are presented at weekly cancer conferences….and a multidisciplinary team develops patient treatment plans.”  I noted that it did not say “all new cases” and that there was no discussion of how disagreements were resolved.

I asked a medical oncologist friend about that.  He said that there are also weekly interdisciplinary conferences at his institution, at which new cases are presented.  Individual physicians decide which cases to bring and after a case is discussed, the physician who brings it makes the final decision on the course of treatment.  He remarked that while there are well established treatments for some types of cancer and that those treatments are almost universally applied, there are other types for which the best treatment is not yet scientifically agreed upon and that in those cases, the specialty of the patient’s physician still influences the selection of treatment.

I suspect it works somewhat the same way at the University of Tennessee.

So patients still cannot be assured that they will be treated according to institutionally adopted, evidence-based protocols, but the situation is better than it used to be.

 

 

Thursday, May 07, 2015

Non-profit vs For-profit

There is concern in Massachusetts about a reported decline in the quality of care following the purchase of ten nursing homes in the state by Synergy Health Centers, a for-profit nursing home chain (Woes follow nursing home chain’s arrival, The Boston Globe, May 5, 2015).   The article discusses similarly reported declines in nursing homes recently purchased by Genesis Health Care and Zenith Health Care Group, two other for-profit chains. 

It all poses the issue of what role for-profit enterprise should play in the provision of health care services.

Professionalism is a very important component of our health care culture.  We believe that those who provide diagnosis, treatment and care should put the patient’s interest over their own.  They should not behave in ways that are of financial or other benefit to them but are of no value or damaging to their patients.  The reason we don’t let doctors sell medicine is because we don’t want them to be tempted to make money by prescribing a drug the patient doesn’t need or might find harmful.

As our health care system moves towards financial mechanisms that incentivize providers to do less rather than more, we will see whether the for-profits can discipline themselves to resist the temptation to withhold needed services in order to increase profits for investors. 

To some extent that will also be an issue for non-profit providers but the absence of private investors looking for a return will reduce the intensity of the temptation and public ownership will provide a more effective means of redress if they succumb. 

 

Thursday, April 30, 2015

Cost and Culture

I like aphorisms and one of my favorites is this – no hospital administrator ever got his portrait in the lobby for saving money.

That one has been apt for a long time and still is, but things seem to be changing.  Here are a couple of quotes from an editorial that appeared in the March 16 issue of Modern Healthcare:

“Over the past two years, conventional wisdom presumed without offering much in the way of evidence that the lingering recession and the rise of high-deductible and narrow network plans explained the slowdown of healthcare spending, now in its fifth year.”

“Indeed, most economists and the media echo chamber repeatedly said rapid spending growth would resume once the economy picked up steam.”

“But now, finally, the Mr. Joneses at the Congressional Budget Office have come around to admitting that something is happening here, even if they don’t know what it is.”

One possibility is that there has been a shift in the culture.  Somehow, public concern about cost, the inclusion in Obamacare legislation of cost-reduction measures, more aggressive tactics by insurance companies, the growth of so-called value based payment mechanisms and other factors seems to have made it acceptable for management to be more aggressive in pursuing cost reduction measures, even when that gores somebody’s ox.

Culture is a powerful thing and may someday even get a cost-reducing administrator’s portrait in the lobby.

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