Friday, August 28, 2015
There are 168 hours in a week and illness or injury can strike during any one of them – not only in the 40-plus hours that physician offices are open for business.
There being no practical way for individual physicians to plan efficiently for the unplanned needs of their patients, they tend to fill their schedules ahead of time.
One result of scientific and technological advances is that a large and increasing portion of medical care can be adequately provided by people who are not physicians.
In light of all that, one might expect that the health care establishment would have some time ago made convenient provision for patients seeking out-of-hours care, much of which falls short of emergency status. But physicians in private practice would have seen that as competition and so it didn’t happen.
There being no alternative, patients got their out-of-hours care from hospital emergency rooms. The specter of competition prevented hospitals from making the service attractive. Hours of waiting for service became common but patients in droves sought it anyway.
As the health care economy grew, investors saw an opportunity and urgent care chains were developed and drug store chains began to offer health care services that could properly be offered by nurses.
Hospitals are finally beginning to become interested. Partners Health Care, the Boston Hospital behemoth, has announced that it will begin opening urgent care centers throughout the Boston area.
When Partners moves, everyone pays attention. So it seems that hospitals are finally responding to a need that they should have filled a long time ago.
Sunday, August 23, 2015
Doctors or Systems?
We used to think that the best way to be assured of good medical care was to put ourselves in the hands of the right physician.
It appears not to be that simple any more.
The July issue of H&HN, the journal of the American Hospital Association, included an article entitled When Stroke Care is a Statewide Effort. The article began by reciting the story of a stroke victim in Illinois who was taken to a 25-bed hospital in Taylorville rather than to a larger hospital in Springfield. The patient’s wife questioned that decision and was assured by the local doctor that it was the right thing to do. The patient got a quick CAT scan, followed by a dose of tPA, the clot-busting drug, and was then shipped off to the larger Memorial Medical Center in Springfield. By the time the patient arrived there, his previously paralyzed left side was working again.
The rest of the article discussed the Paul Coverdell National Acute Stroke Program. Coverdell was a U.S. Senator from Georgia who died of a stroke. The program named for him is operated by the Atlanta-based Centers for Disease Control and Prevention and sponsors stroke systems of care. These programs involve coordinating the activities of Emergency Medical Technicians and hospitals so that stroke victims receive appropriate treatment promptly – time being of the essence in this case.
So it seems that if, God forbid, you should suffer a stroke, the quality of the care you receive may depend more on the system that provides it than on the identity of the doctors who staff it.
Thursday, August 20, 2015
According to the August 10 issue of Modern Healthcare, the top ten compensation amounts for healthcare executives in 2013 ranged from 3.6 million to 8.4 million. Then the August 18 issue of The Boston Globe included an article about CEO salaries in Massachusetts teaching hospitals, all of which were well into seven figures, the highest quoted for the full year of 2013 being 2.6 million.
Spokespersons quoted attributed these salary levels to competition and market forces.
I don’t believe that. I have yet to read of a healthcare CEO being paid in the millions being attracted to another job by more pay.
I think what we are seeing is a social mechanism that has gone off the rails. I think what has happened is that compensation committees of boards of trustees started using consultants and that those consultants found that the way to become popular was to find ways to justify high compensation levels. Boards are populated in large part by CEOs of other organizations who are typically overpaid themselves and find it easy to adopt those consultants’ recommendations.
The thing has gotten out of hand and nobody as yet has found a way to bring it back under control. There are some indications of popular discontent over these exorbitant salary levels, but so far it doesn’t seem to be having much effect.
Friday, July 24, 2015
Some years ago I participated in a discussion of marketing strategy at New England Baptist Hospital in Boston. I mentioned that many patients came to that institution because they believed it offered the best chance for a good outcome. I asked if they were correct, suggesting that if they were, their belief could be an effective marketing theme.
After a rather embarrassed silence, one of the physicians said that they did not know, but that they should.
Well, they now know more than they did. I’ve received a document from the Hospital titled “A pledge from New England Baptist, your Orthopedic Hospital.” After some narrative describing the hospital’s dedication to quality care, there are three pages of quality-related statistics.
Some of it is a little opaque, including a number described as “Statistical Prediction of Infection” attributed to a Massachusetts CY2013 HA/Data Report and something called Post-op DVT, which is undefined. So there is room for improvement, but the accomplishment is real.
The hospital has good reason to be proud of its numbers. However, it has not gone so far as to include them in its advertising, so far as I know. Fifty years ago it was considered unethical for a hospital to advertise at all. That is no longer the case, but there seems still to be a reticence to make overt claims to clinical superiority.
Wednesday, July 01, 2015
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
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.