I recently wrote about the wonderfully inspirational documentary Rx: The Quiet Revolution, which tells the story of how four different groups are transforming health care for the better. Each group has some pretty amazing physicians who are committed to putting the patient at the center of the system, and they all have a lot to teach the rest of us about truly caring for patients as we “deliver care.” That got me thinking about physicians in our own Health System who are role-models for great care, and also about assuring that future physicians are just as caring and empathetic.
Well, as far as role-models go, it is hard to imagine a better group than the winners of this year’s Patients’ Choice Awards, given to those members of our Medical Group who achieved the highest scores on their patient experience surveys. They are:
Continue reading Great Doctors of Today and Tomorrow
A recent piece in the New York Times profiled a young man with a remarkable medical history, and an equally remarkable approach to sharing it. I think it raises some profound issues regarding the self-monitoring movement and the “ownership” of patients’ health information, both of which have the potential to change our traditional practices in a big way.
The guy – Steven Keating – is not your average Joe. He is a graduate student at MIT who trained as a mechanical engineer and is working in the cutting-edge MIT Media Lab. He also had a brain tumor the size of a tennis ball. His website hosts all of his medical records, including his pre- and post-op brain scans and, believe it or not, a video of his tumor resection surgery.
Continue reading Whose Record Is It?
I had the good fortune last week to see a screening of excerpts from an extraordinary documentary film that will be shown on PBS television stations in April. The film is called Rx: the quiet revolution and highlights four case studies. Each is an inspiring example of new models of health care delivery that are advancing the “triple aim” of better care for individuals, better health outcomes for communities, and lower costs. Our own remarkable Dr. Jennifer Mieres is the film’s executive producer.
The screening left me inspired and in awe of the great work being done by front line professionals all across the country. It also introduced me to a fabulous metaphor for the importance of engaging patients in their own care.
Continue reading There is Good News Out There
It has been known for a long time that “healthcare” – all the stuff that we do, prescribe and provide – is a minor determinant of how “healthy” any of us is. Overall health, or more technically, the variability in health outcomes, is much more dependent on the combination of genetics, personal behavior (think smoking and seat belts), environmental factors and socioeconomic status than it is on healthcare.
I was thinking about that when I read in the New York Times about how some healthcare provider systems, driven by the need to cut costs, are starting to address some of the non-medical social needs of their patients. These kinds of innovative community-based interventions started to get traction after they were highlighted by an influential profile by Atul Gawande in the The New Yorker. Their diffusion has been driven by the expansion of novel payment models that have started to reward providers for reducing utilization of services like ER visits and hospitalizations, the very services that they have traditionally been paid for.
Continue reading Health and Healthcare
No, this is not about getting a heart attack from shoveling snow (though that is a real phenomenon). It’s about how the rising cost of health care is eroding the ability of state and local governments to fund investments in infrastructure. This becomes most apparent when that infrastructure is stressed, as it is, say, during a snow storm. Case in point: Boston.
As a former resident of “beantown” I can attest to the fact that snow is a constant part of the winter landscape there. We could always count on the first snowfall to come before Thanksgiving (and could never count on being done before April. I recall one depressing year where it snowed in May! So I was not surprised, and was even a little nostalgic, when I witnessed Boston’s second major snowstorm of the year last week. I was, however, surprised at how much the city struggled to cope with the snow, and in particular, how poorly the public transportation system held up under the circumstances. With another snowstorm this week, the system failed completely. I was in town taking an executive education course at the Kennedy School of Government about healthcare delivery, which got me thinking about the connection between a failing transit system and healthcare.
Continue reading Snow Storms and Healthcare
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