Friday, May 30, 2008
The End of an Era
Health care in the western world has benefitted greatly over the years from the participation of the church. Almost all denominations have been active, but none more so than the Roman Catholic. Its orders of nuns have been particularly prolific in creating and operating hospitals. Nursing has been primarily a female occupation and during earlier times these Catholic orders provided a ready source of dedicated professionals to manage and staff Catholic hospitals.
Consistent with the mission of their founding orders, Catholic hospitals tended to be particularly dedicated to serving the poor, thereby making valuable contributions both to the communities in which they are located and also to medical education which, in its earlier days, depended on charity patients as the source of clinical experience for doctors in training.
But things change. Government has taken over responsibility for the financing of health care for the poor. Convent life has lost its appeal for Catholic girls. Medical education has adapted to paying patients. Hospitals have become large businesses no longer dependent on charitable financing.
Over the years, the Catholic hospitals in Boston have been consolidated into the Caritas Christi Health Care System (CCHCS), operated under the direct control of the Archdiocese of Boston. Periodic financial difficulties have brought CCHCS to the attention of Martha Coakely, the Attorney General of Massachusetts. Like most state attorney’s general, Coakely has general jurisdiction over non-profit organizations and is responsible for taking preventive action to avoid the adverse consequences of hospitals getting into financial trouble.
Attorney General Coakely concluded that the church’s control over CCHCS decisions was causing problems and asked that something be done about it.
In a brief article on the business page of its May 21, 2008 edition, The Boston Globe reported that CCHCS had been reorganized so that its board would be independent of church leadership, with the church retaining control of matters of medical ethics and sales of assets. It was further reported that Coakely had approved the changes.
It means, in essence, that the Catholic church has gone out of the hospital business in Boston.
It’s the end of an era.
Health care in the western world has benefitted greatly over the years from the participation of the church. Almost all denominations have been active, but none more so than the Roman Catholic. Its orders of nuns have been particularly prolific in creating and operating hospitals. Nursing has been primarily a female occupation and during earlier times these Catholic orders provided a ready source of dedicated professionals to manage and staff Catholic hospitals.
Consistent with the mission of their founding orders, Catholic hospitals tended to be particularly dedicated to serving the poor, thereby making valuable contributions both to the communities in which they are located and also to medical education which, in its earlier days, depended on charity patients as the source of clinical experience for doctors in training.
But things change. Government has taken over responsibility for the financing of health care for the poor. Convent life has lost its appeal for Catholic girls. Medical education has adapted to paying patients. Hospitals have become large businesses no longer dependent on charitable financing.
Over the years, the Catholic hospitals in Boston have been consolidated into the Caritas Christi Health Care System (CCHCS), operated under the direct control of the Archdiocese of Boston. Periodic financial difficulties have brought CCHCS to the attention of Martha Coakely, the Attorney General of Massachusetts. Like most state attorney’s general, Coakely has general jurisdiction over non-profit organizations and is responsible for taking preventive action to avoid the adverse consequences of hospitals getting into financial trouble.
Attorney General Coakely concluded that the church’s control over CCHCS decisions was causing problems and asked that something be done about it.
In a brief article on the business page of its May 21, 2008 edition, The Boston Globe reported that CCHCS had been reorganized so that its board would be independent of church leadership, with the church retaining control of matters of medical ethics and sales of assets. It was further reported that Coakely had approved the changes.
It means, in essence, that the Catholic church has gone out of the hospital business in Boston.
It’s the end of an era.
Monday, May 26, 2008
Micromanaging the System
We should have learned by now that trying to micromanage complex systems only leads to grief.
The May 22, 2008 issue of The Boston Globe reported that the Massachusetts Medical Society (MMS) had decided to file suit to derail “a two-year-old plan under which physicians are ranked for cost and quality measures by health plans associated with the Group Insurance Commission, the agency that oversees health insurance for thousands of public employees at state and local levels.”
MMS claims that the program has been unfairly ranking individual physicians using “inaccurate, unreliable and invalid tools and data.”
There are some 30,000 licensed physicians in Massachusetts. When you consider what would be involved in trying to rank that many doctors, given the wide variation in the way data is recorded and kept, the accusation should come as no surprise. My guess is that there is scant possibility of developing tools and data that are accurate, reliable, and valid enough to be both fair and credible.
In a separate article, that same issue of the Globe reported the intention of a US congressional panel to introduce legislation requiring health insurers to pay for a minimum 48-hour hospital stay after breast cancer treatment. Surgeon Kristen Zarfos had testified that thousands of patients undergoing mastectomy (one assumes not radical mastectomy) were being treated as day surgeries because their insurance companies would not pay for a longer stay. If there was evidence that this practice is harmful, it wasn’t mentioned in the article.
This is no way to run health care. What we ought to have is a system of health care institutions with responsibility for the full range of care provided in them, including the care provided by physicians. Those institutions ought to compete with other health care institutions for business. Purchasers of care would make their own evaluations, applying their judgment to whatever data they could collect. The tendency over time would be for business to gravitate to institutions that provide care of lower cost and higher quality.
That approach would be a lot more practical than somebody in Boston comparing the performance of surgeons in Plymouth with that of surgeons in Pittsfield, or than someone in Washington, D.C. deciding how long a mastectomy patient in Idaho should stay in the hospital.
We should have learned by now that trying to micromanage complex systems only leads to grief.
The May 22, 2008 issue of The Boston Globe reported that the Massachusetts Medical Society (MMS) had decided to file suit to derail “a two-year-old plan under which physicians are ranked for cost and quality measures by health plans associated with the Group Insurance Commission, the agency that oversees health insurance for thousands of public employees at state and local levels.”
MMS claims that the program has been unfairly ranking individual physicians using “inaccurate, unreliable and invalid tools and data.”
There are some 30,000 licensed physicians in Massachusetts. When you consider what would be involved in trying to rank that many doctors, given the wide variation in the way data is recorded and kept, the accusation should come as no surprise. My guess is that there is scant possibility of developing tools and data that are accurate, reliable, and valid enough to be both fair and credible.
In a separate article, that same issue of the Globe reported the intention of a US congressional panel to introduce legislation requiring health insurers to pay for a minimum 48-hour hospital stay after breast cancer treatment. Surgeon Kristen Zarfos had testified that thousands of patients undergoing mastectomy (one assumes not radical mastectomy) were being treated as day surgeries because their insurance companies would not pay for a longer stay. If there was evidence that this practice is harmful, it wasn’t mentioned in the article.
This is no way to run health care. What we ought to have is a system of health care institutions with responsibility for the full range of care provided in them, including the care provided by physicians. Those institutions ought to compete with other health care institutions for business. Purchasers of care would make their own evaluations, applying their judgment to whatever data they could collect. The tendency over time would be for business to gravitate to institutions that provide care of lower cost and higher quality.
That approach would be a lot more practical than somebody in Boston comparing the performance of surgeons in Plymouth with that of surgeons in Pittsfield, or than someone in Washington, D.C. deciding how long a mastectomy patient in Idaho should stay in the hospital.
Saturday, May 24, 2008
Changing the Culture of Health Care
Twenty years ago, no sober-minded hospital administrator would have risked being accused of committing “interference in the practice of medicine” by promoting the adoption of standard methods for treating particular kinds of medical cases. And yet that practice is rapidly becoming common. According to a report in the May 12, 2008 issue of Modern Healthcare, Baylor Health Care System in Dallas has such standards in place, is working actively on forty of them, and has plans for as many as 300.
That reflects a remarkable change in the culture of health care, which is deeply entrenched and resistant to change.
While there are few if any recognized methods for changing culture, the Baylor experience (like that of other health care institutions) might give us a clue.
Adoption of clinical standards by Baylor started with the now legendary 1999 report of the Institute of Medicine titled To Err is Human, which said that tens of thousands of patients in the U.S. were dying every year as a result of preventable medical errors and suggested some steps that might be taken to deal with the problem. The herd instinct is strong in health care and Baylor did not want to be seen as being behind the times. Its first step was to appoint a Chief Quality Officer and things proceeded from there.
The initial standard adopted by Baylor dealt with the treatment of pneumonia. The rate of adherence to recommended practice went from 10-20% to 70-80% and hospital mortality from pneumonia dropped by 35%. It would take a formidable culture indeed to resist numbers like that.
It is worthy of note, I think that Baylor neither criticized the practices of its physicians nor undertook to change the culture. Had it (or anyone else) done either one, the resistance almost certainly would have been fierce.
Whatever objections there were to Baylor’s initiatives, and there undoubtedly were some, they could not prevail in the face of the seriousness of the issue being addressed and the effectiveness of the remedy adopted. And so the culture changed.
Discussions of health care reform often mention the need to change the culture of health care. Perhaps the lesson here is that the way to do that is not by trying to do so directly, but by addressing its undesirable consequences.
Twenty years ago, no sober-minded hospital administrator would have risked being accused of committing “interference in the practice of medicine” by promoting the adoption of standard methods for treating particular kinds of medical cases. And yet that practice is rapidly becoming common. According to a report in the May 12, 2008 issue of Modern Healthcare, Baylor Health Care System in Dallas has such standards in place, is working actively on forty of them, and has plans for as many as 300.
That reflects a remarkable change in the culture of health care, which is deeply entrenched and resistant to change.
While there are few if any recognized methods for changing culture, the Baylor experience (like that of other health care institutions) might give us a clue.
Adoption of clinical standards by Baylor started with the now legendary 1999 report of the Institute of Medicine titled To Err is Human, which said that tens of thousands of patients in the U.S. were dying every year as a result of preventable medical errors and suggested some steps that might be taken to deal with the problem. The herd instinct is strong in health care and Baylor did not want to be seen as being behind the times. Its first step was to appoint a Chief Quality Officer and things proceeded from there.
The initial standard adopted by Baylor dealt with the treatment of pneumonia. The rate of adherence to recommended practice went from 10-20% to 70-80% and hospital mortality from pneumonia dropped by 35%. It would take a formidable culture indeed to resist numbers like that.
It is worthy of note, I think that Baylor neither criticized the practices of its physicians nor undertook to change the culture. Had it (or anyone else) done either one, the resistance almost certainly would have been fierce.
Whatever objections there were to Baylor’s initiatives, and there undoubtedly were some, they could not prevail in the face of the seriousness of the issue being addressed and the effectiveness of the remedy adopted. And so the culture changed.
Discussions of health care reform often mention the need to change the culture of health care. Perhaps the lesson here is that the way to do that is not by trying to do so directly, but by addressing its undesirable consequences.
Thursday, May 08, 2008
Does McCain Understand His Proposal?
I see in the papers that presidential candidate Senator John McCain is proposing a tax credit that would give individuals an incentive to purchase health insurance directly rather than through their employers. The stated goal is “to foster competition and drive down prices.”
I have tried to figure out what competition would be fostered and how it would drive down prices.
One way for insurance companies to get their premiums down would be by negotiating lower rates with providers. That can’t be it since insurance companies already compete at this level.
So McCain must think that the competition will be among companies competing to sell their health insurance policies to individual subscribers.
Those companies compete now in selling their policies to employers. But it is more costly to sell health insurance policies one at a time and to collect premiums on them individually than it is to sell them in large batches to employers who do the collecting.
So how is it that prices will be driven down? Unless insurance companies can somehow avoid insuring people who need lots of care, the only possibility I can see is for them to reduce benefits, such as by increasing the co-pays and deductibles.
At that point, the price of insurance may have gone down some, but overall costs will have gone up. That would be offset only if having consumers pay more of the cost causes them to reduce their use of health services by enough to cover the higher operating costs involved in insuring individuals rather than groups.
I doubt Senator McCain will be explaining that this is how his proposal will “drive down prices.”
Actually, I suspect he doesn’t understand it himself.
I see in the papers that presidential candidate Senator John McCain is proposing a tax credit that would give individuals an incentive to purchase health insurance directly rather than through their employers. The stated goal is “to foster competition and drive down prices.”
I have tried to figure out what competition would be fostered and how it would drive down prices.
One way for insurance companies to get their premiums down would be by negotiating lower rates with providers. That can’t be it since insurance companies already compete at this level.
So McCain must think that the competition will be among companies competing to sell their health insurance policies to individual subscribers.
Those companies compete now in selling their policies to employers. But it is more costly to sell health insurance policies one at a time and to collect premiums on them individually than it is to sell them in large batches to employers who do the collecting.
So how is it that prices will be driven down? Unless insurance companies can somehow avoid insuring people who need lots of care, the only possibility I can see is for them to reduce benefits, such as by increasing the co-pays and deductibles.
At that point, the price of insurance may have gone down some, but overall costs will have gone up. That would be offset only if having consumers pay more of the cost causes them to reduce their use of health services by enough to cover the higher operating costs involved in insuring individuals rather than groups.
I doubt Senator McCain will be explaining that this is how his proposal will “drive down prices.”
Actually, I suspect he doesn’t understand it himself.
