Here are a few things that have happened since Ebola arrived in the United States:
- CNN and other cable news outlets seem to have become “all Ebola all the time” with breathless reports about the latest twists and turns
- A grade school banned a teacher from the classroom because she had visited Dallas
- A photojournalist who had travelled to the affected area (and was well) was denied the opportunity to give a talk to a University audience
Parents in Mississippi kept their children home from school because the principal had visited Zambia
People all across the country seem to be in a growing frenzy about the virus. On one hand, I get it. The disease is awful, the CDC seems to have fumbled in its management of the situation and in its messaging, and the disease rages on in a few countries in West Africa. On the other hand, a lot of this is just, well, nuts.
I had a recent conversation with an old friend about her elderly father that encapsulates a lot of what is both great and terribly wrong with healthcare in America today.
Here are the basic facts: the man is in his mid-80s, retired from teaching school, and is active and vigorous, living in the community; he is cognitively intact. He has a history of coronary disease and had an intracoronary stent placed some years back. He is asymptomatic on a typical “cocktail” of meds including aspirin, a statin, and an ACE inhibitor. Over the summer, he had a routine follow-up visit with his cardiologist, who detected a carotid bruit. After a duplex sonogram and a CT angio, a high-grade unilateral internal carotid stenosis was identified, and carotid endarterectomy surgery was recommended. My friend called me to see if I could recommend a surgeon in the city where she and her father both live.
I highly recommend a provocative essay by Ezekial Emanuel that appears in the October 2014 issue of the Atlantic. Dr. Emanuel is a prominent academic who has also held important positions in government, including as a Special Advisor on Health Policy to the Director of the Office of Management and Budget and National Economic Council. He is also the eldest of the three impressive “Emanuel Brothers” that also includes Rahm (former White House chief of staff and now mayor of Chicago) and Ari (a prominent Hollywood agent). His piece is entitled “Why I Hope to Die at 75.”
OK, so the title is a bit over the top and meant to shock, and it is not even entirely accurate. But the message is really worth thinking about. Emanuel sets out why he wants to avoid the typical American approach to aging and progressive infirmity; he does not want to join the ranks of what he refers to as “American immortals.” Instead, he says that when he hits the admittedly arbitrary age of 75, he will no longer actively seek to prolong his life. No more doctor visits, no more “preventive” measures, no more diagnostic tests, no more interventions. Done. Whatever happens after that, well, so be it.
About a year ago, I shared details of my own out of pocket medical expenses and concluded that we have to have to be more transparent with our patients (and potential patients) about the costs they will face for our services. The urgency of price transparency as a business imperative and a professional responsibility has only increased since then.
Consider that we are now a year in to the implementation of the Affordable Care Act. Everything that I have read suggests that consumers were intensely price sensitive when it came to choosing which plans they elected. Well, duh! The benefits are defined by “metal” levels (e.g., Bronze, Silver, etc.), and there is almost no way for people to compare the quality of competing narrow networks or individual providers, so price differences drove decision-making. Likewise, the healthy people who bought insurance because they were compelled to by the individual mandate generally chose high deductible plans to minimize their monthly payments. This, in turn, makes them much more price sensitive at the point of care. That means that patients may resist recommended treatment. It also means that physician offices will face more challenges in collecting fees from patients who have not yet met their deductible for the year. At the very least, patients will be more interested in learning what costs they will be exposed to.
Patient satisfaction is hot. Major payers, including the federal government have linked hospital payment to institutional performance on patient surveys of their experience with care, and are poised to do the same with physician payments. There is a proliferation of commercial websites for patients to offer up their reviews of physicians and to check out the ratings already there. An entire industry of consultants has appeared to help institutions improve how patients experience the care they provide. Hospitals and health systems, including our own, have hired Chief Experience Officers. Continue reading
There is a growing awareness of the importance of health literacy – the extent to which patients and their families are able to understand words we speak and the written materials we provide. This is a good thing, since there is very good evidence that patients who have a better understanding of their condition and recommended treatment feel better, adhere better to recommendations, enjoy better health outcomes and rate the experience of their care higher. Oh, and they also sue for malpractice less frequently. The problem for providers is that it is not easy to get this right. Continue reading
The New York Times reported last week on a ballot initiative in California that would mandate random routine drug and alcohol testing of physicians, and targeted testing after major adverse patient events. The full text of the proposal is available here.
Proponents of the measure (Proposition 46) highlight the danger posed by impaired physicians and the ubiquity of drug testing for other professionals such as airline pilots and public safety officers. Continue reading
I was recently on a commercial airline flight when I noticed a bit of a commotion across the aisle. Two flight attendants were responding to the situation, which was triggered when one of the passengers in that trio of seats reached over and started eating the food of her fellow traveler. They quickly moved “the victim” out of the way, and were struggling to manage “the perpetrator.” I overheard them agree that they were concerned about the medical condition of the passenger, and moments later, one of the flight attendants used the public address system to ask if there was a doctor on board. Continue reading
I was traveling recently and, as I typically do, I bought a copy of Fast Company magazine to read on the plane. I don’t subscribe, but I find that it often has interesting articles on the intersection of technology and business. In the July/August issue, there was an article about GE and its CEO Jeff Immelt that I think has important parallels with the current transformation of healthcare delivery. Continue reading
Last week, inspired by the Independence Day holiday, I wrote about the important distinction between independence and autonomy. I made the case that professional autonomy is not about each doctor doing as he pleases, but about physicians as a group taking responsibility for shaping medical practice.
I was pleasantly surprised over the holiday weekend when I came across a recent paper in Health Affairs that illustrates how effective physician leadership (autonomy) can reduce unnecessary practice variation (independence) and improve clinical care. The paper also reinforced some of my earlier thoughts about the central role that physicians must play in redesigning systems of care. Continue reading