When the Affordable Care Act (ACA) was passed in 2010, the most contentious provisions – which are still the subject of challenges in federal courts – were the establishment of state-wide insurance exchanges, the “individual mandate” that compels eligible citizens to buy insurance, and the expansion of state Medicaid programs. Less well appreciated, but arguably more important, were a wide range of reforms to the Medicare program. Summarized here, they touch on almost all aspects of the program, but I want to concentrate on just one.
The law directed CMS to move Medicare from a strictly fee-for-service (FFS) payment model (“paying for volume”) to one in which the quality of care was factored into the payment received by hospitals and physicians (“paying for value”). As I have written previously I believe this is the right move. There are just too many challenges to improving care and lowering costs that derive from “straight” FFS that is disconnected from any assessment of quality. And while you may not have known that they grew out of the ACA, the payment reforms themselves have gotten a lot of attention. Penalties for readmissions, requirements for physician quality reporting, pilot programs for bundled payments and accountable care organizations are just of few of the Medicare reforms. Even though they currently influence a small percentage of overall Medicare spending, these changes may already be having a big impact on how care is delivered.
Continue reading Not Your Father’s Medicare
Steven Brill made a name for himself with an article in Time magazine back in 2013 entitled “Bitter Pill,” in which he harshly criticized how health care providers (especially hospitals) inflate the costs of their services. The piece created a lot of buzz, and some backlash from hospital groups and others. Now it seems that Mr. Brill has had a bit of a “sick-bed conversion.”
He has a new piece in the January 19th issue of Time called “What I learned from my $190,000 open-heart surgery: the surprising solution for fixing our health care system.” Since Time won’t let you read the article without subscribing or paying, I will save you the trouble. It seems that what he learned is that health care providers – the same ones he vilified in 2013 – were pretty great when they were taking care of his heart in 2015. In fact, he now believes that the way to “fix” healthcare is to “let the foxes run the henhouse” by allowing large integrated health systems become insurance companies and compete on price and “brand” and regulate their profits to assure that they are acting in the public interest. Yeah, well, no kidding.
Continue reading So What Else is New?
Every so often I come across a research paper that leaves me feeling as if I am glimpsing the future. I had that experience when I came across the work of Cingolani and colleagues in the December 23 issue of the Journal of the American College of Cardiology (volume 64, no. 24). The paper, entitled “Engineered electrical conduction tract restores conduction in complete heart block: from in vitro to in vivo proof of concept” details a new approach to an old problem.
Here’s the problem. Many people develop serious disturbances of the heart rhythm based on deterioration or destruction of specialized “conduction tissue” within the heart. This tissue is responsible for transmitting the electrical impulses that govern the beating of the heart. In the case of the dysfunction of conduction tissue between the atria and ventricles, the chambers become electrically and mechanically dissociated – a condition termed complete heart block, and generally treated with an implanted pacemaker.
Continue reading Department of Really Cool Ideas
I wrote recently about the need to take into account patient characteristics when using patient outcomes to compare the quality of care provided by different physicians. That is a well-accepted principle, and the need for so-called “risk-adjustment” applies not only to evaluating physicians, but also to evaluating hospitals and larger care delivery systems. There has been a smoldering controversy, however, about which patient characteristics to consider and, in particular, the implications of including socioeconomic factors in such comparisons. This controversy played out again in a recent issue of the Annals of Internal Medicine.
Here is the core of the issue.
Continue reading Adjusting Outcomes
I took advantage of the holiday slow-down in routine meetings to visit our Health System’s new serious transmittable disease unit – the “Ebola Unit” – at Glen Cove Hospital. Wow!
I had the good fortune to have Darlene Parmentier, the nurse manager of the unit, tour me around and explain how patients will be cared for. Darlene is an experienced clinician and had a ready answer for every one of my questions. In fact, she had answers for lots of questions I never thought to ask! Despite the fact that the physical space had been transformed from an unoccupied “regular” hospital inpatient unit into a highly specialized containment and care facility in just days, I was amazed at the thoughtfulness of the design. Here are just a few of the salient features:
- A dedicated pathway (including a dedicated elevator) from an external ambulance bay directly into the patient care area
- Ample living space for care givers who may choose to stay on the unit between shifts, complete with thoughtful touches like a ping pong table and an X-box
- Designated training areas, recognizing that continuous simulation and drilling are integral to the effectiveness of the unit
- Well marked “zones” that correspond with the risk of contact or exposure to infectious agents, and dictate the different the levels of personal protective equipment that must be worn
- The pervasive evidence of planning, not just for the range of clinical challenges that may arise, but also for the needs of patients’ families, the impact on caregivers and the reaction of the community and news media
Overall, I came away incredibly impressed. Once again, our Health System has stepped up to do the right thing for our patients and our staff, and I am confident that any patient who needs treatment there will get great care.
Let’s hope it never happens. Continue reading System Readiness
A few years ago, the United States Navy launched a new recruiting and marketing campaign using the slogan: “America’s Navy – a global force for good.” The line was apparently a flop, and the Navy threw it overboard for “protecting America the world over,” but I liked it. I thought it captured a deep truth about the Navy, which is that it is undoubtedly a “global force” and that the force exists for a good purpose, but I guess most people thought that it made the Navy sound too much like a bunch of social workers.
I was reminded of the phrase, and of an experience I had while serving in the Navy Medical Corps, when I read a recent article in the Annals of Internal Medicine. A Navy physician retold the story of a mission he was on to a remote village in Honduras. He and his team were flown into small villages, where they would “see dozens of patients each day and dispense an assortment of symptomatic medications” and where “the most practical health benefit that we provided villagers consisted of hundreds of tooth extractions.” He further noted that “although advertised as humanitarian missions, these exercises provided US military personnel with experience working with military and civil authorities from host nations.”
Continue reading A Global Force for Good
There are plenty of good reasons why thoughtful physicians are often unhappy with the current approach to measuring the quality of care they provide. Some, of course, object to the whole notion of quality measurement, but I believe they are in a shrinking minority clinging to an anachronistic mental model in which each physician defines for himself what constitutes high quality care. I have addressed this previously. But even those, who like me, believe it is essential (and possible) to measure quality, can point to legitimate shortcomings in the way it is done.
Among these shortcomings is the imperfect process by which individual physicians’ “results” are “adjusted” to account for differences in the patients they care for. In the simplest case, when the quality of care is judged by looking at patient outcomes, this risk-adjustment is meant to reflect the fact that clinical outcomes reflect both the baseline characteristics of the patients being treated and the treatment they get. For example, if one were to use in-hospital mortality rates to assess the quality of care for acute myocardial infarction, it would be essential to know “how sick” the patients, on average, were on presentation. A 50 year-old man with a small inferior wall MI is likely to live even in the absence of good care (or any care for that matter), whereas a 90 year-old woman with cardiogenic shock from an anterior wall MI is likely to die even with state-of-the art care. Any attempt to assess the quality of care for a population of MI patients must take this into consideration.
Continue reading Shared Accountability
I have been a big proponent of seeking the feedback of our patients regarding their experiences with our care, and of pushing our organization to be more transparent about the results. I believe that sharing performance motivates everyone to raise his game, and that we should embrace valid ratings on specific measures. On the other hand, I have always thought that global “rankings” divorced from specific performance measures make little sense.
As Malcolm Gladwell pointed out in the New Yorker a few years ago rankings of complex, multidimensional things like cars or colleges are inevitably flawed, because they don’t account for the fact that different people will value various attributes in different ways. There is no “best car” since I may value handling and acceleration, and you may value styling and safety. Likewise, there is no “best college” because one student may value class size or athletic facilities while another values research opportunities and proximity to a large city.
Continue reading Residency Ratings
I was listening to the news on my way to work last week, and heard a story about the review conducted after the well-publicized security breach at the White House. Like many people, I was shocked when the story of the fence-jumper first broke. How was it possible that some guy with a knife managed to get over the fence, cross the lawn, enter the White House and get deep into the building before he was stopped? The answer, according to NPR’s reporting of the Department of Homeland Security investigation is that a whole sequence of events made it possible:
It turns out that the top part of the fence that he climbed over was broken, and it didn’t have that kind of ornamental spike that might have slowed him down. Gonzalez then set off alarms when he got over the fence, and an officer assigned to the alarm board announced over the Secret Service radio there was a jumper. But they didn’t know the radio couldn’t override other normal radio traffic. Other officers said they didn’t see Gonzalez because of a construction project along the fence line itself. And in one of the most perhaps striking breaches, a K-9 officer was in his Secret Service van on the White House driveway. But he was talking on his personal cell phone when this happened. He didn’t have his radio earpiece in his ear. His backup radio was in his locker. Officers did pursue Gonzalez, but they didn’t fire because they didn’t think he was armed. He did have a knife. He went through some bushes that officers thought were impenetrable, but he was able to get through them and to the front door. And then an alarm that would’ve alerted an officer inside the front door was muted, and she was overpowered by Gonzales when he burst through the door. So just a string of miscues.
The explanation rang true. Of course it was no “one thing” that went wrong; it was a series of events, no one of which in isolation was sufficient to cause a problem but, when strung together, led to a catastrophic system failure. The explanation also sounded familiar. It is a perfect example of the “swiss cheese” conceptual model of patient safety.
Continue reading Patient Safety, Swiss Cheese and the Secret Service
In my administrative role, I have the great pleasure of signing thank you letters to patients and family members who have acknowledged the great care they have received by one of our physicians or other caregivers. It is a nice way to tell the patient “we got your note” and to simultaneously recognize the provider by copying her or him. The best part is that I get to read the patients’ letters, which are filled with gratitude, and remind me of the great privilege we have to make a positive difference in the lives of our patients.
Sadly, I also have to deal with the occasional patient complaint. Although these are clearly a lot less fun to address, they also point out the impact that we have on the lives of the patients and families that we serve.
Continue reading Sometimes “Sorry” is all it Takes