Friday, July 24, 2009

Health Care Reform: What does it mean for me, my neighbor, and Ronnie? (written by Abby Lowe)

In retrospect, this was a perfect week to come to D.C. We talked to legislators, regulators and policy experts who are smack dab in the middle of negotiations on health care reform as we traveled around telling the CHRISTUS story. We pumped the journalists we talked to for information, and we exchanged ideas with national thought leaders. We inserted ourselves into the thick of things, provided our own expertise and learned a lot in the process.

We’ve learned that so far, there are few particulars on exactly what health care reform in the U.S. will look like. Lots of people have ideas about how things should go (some good, some not so much), and it can be difficult to pin down an exact position on anything. But we do understand that everyone—insured and uninsured, rich and poor, young and old, providers and patients--will have to give something up to make sure we come out on the other side with an equitable system that works for everyone.

One of the things I heard Dr. Royer say quite a bit this week was that reform needed to be patient-focused. “What’s best for the communities and the people we treat?” he’d ask.

And that got me to thinking of Ronnie.

Our Health Care System is Broken

I met Ronnie during a year I spent in inner-city Oakland, California. From the fall of 2004 to the fall of 2005, I lived in a tiny apartment with four other young women and spent half of my week volunteering in an elementary school and the other half providing foot care for homeless men in a clinic downtown.

Most people don’t realize that many folks who are homeless deal with extensive foot pain because they walk around all day and can’t take their shoes off at night (because they’ll get stolen) or when they get soaked in the rain (because they rarely have a pair to spare). So we trimmed their toenails, shaved their calluses, listened to their stories and sent them off with a clean pair of socks.

But one slow Tuesday, a guy in a wheelchair showed up at our clinic door with a bandage around the left side of his face and over his left eye. He was emaciated, weak and covered in dirt.

His name was Ronnie, he told us. A failed suicide attempt had left him paralyzed from the waist down, and skin cancer had eaten away at his face.

He took the bandage off to show one of the clinic nurses his wound, and I was shocked.

I don’t know if the wound actually was the result of skin cancer, but I know that it was so deep that I could see his cheekbone, and it had a horrible, rotting smell. (I did foot care two days a week for homeless guys, and yet I had never seen or smelled anything like it.)

Ronnie explained that he had slept in a park the night before, and had woken up to realize that there were ants crawling in and out of the huge gaping hole in his face. He just wanted some help, to be sure it was properly cleaned before he went on his way.

So the nurse, God bless her, cleaned his wound, gave him some more gauze and bandages and slipped him a sandwich or two before he left.

As he wheeled himself away, I felt somewhat defeated. Ronnie obviously needed much more care, a clean place to sleep and behavioral help than we could not provide.

Ronnie needed a health care system that worked for him. And while we had done what we could, we had ultimately let him down. He could not get or afford the long-term care he needed, and the care we provided him at our tiny clinic would never be enough.

I will never forget the first time I saw Ronnie’s scrawny frame dwarfed by his wheelchair, feeling my heart break at hearing his story. And I will certainly never forget the stench of his rotting flesh. I want health care reform for Ronnie.

And I want health care for a man we met yesterday, whose wife was diagnosed with breast cancer a little over two months into her second pregnancy. They had insurance, but couldn’t get clear advice on what to do, what was best for this woman and her baby. They visited many specialists and got many different answers. The male doctors said one thing, the female doctors said another. The oncologists said one thing, but the surgeons said another. Finally, they found a reconstructive plastic surgeon who helped them navigate their options and her care. Today, their child is a healthy four-year-old, and this man’s wife is still in remission. But the system did not work for them—in all its convoluted brokenness, it caused them pain, confusion and fear instead of assisting them in their time of need.

They deserve better.

The Truth Hurts

But I have to be honest. I’m a normal, everyday kind of person. And although I consider myself compassionate and informed and I care about what health care reform means for Ronnie, I also care about what it means for me, that insured gal who (thankfully) has mostly used her insurance coverage for preventive care, to treat small colds/sinus infections and to offset the cost of prescription medications.

I also want health care reform for me.

The New York Times reports that:
”Our health care system is engineered, deliberately or not, to resist change. The people who pay for it — you and I — often don’t realize that they’re paying for it. Money comes out of our paychecks, in withheld taxes and insurance premiums, before we ever see it. It then flows to doctors, hospitals and drug makers without our realizing that it was our money to begin with. . .”

”The United States now devotes one-sixth of its economy to medicine. Divvy that up, and health care will cost the typical household roughly $15,000 this year, including the often-invisible contributions by employers.”

Health care reform is important for all of us, and we’re in it together.

It was in our inner-city neighborhood in Oakland, walking past discarded drug paraphernalia that lined the streets, where loud music filled the air and our poverty-stricken neighbors reach out to us, fed us, protected us and invited us over to watch cable TV that I learned that everyone--no matter what kind of job they do, the level of education they’ve achieved or how much money they earn--is basically the same. We all deserve to chase the American dream as healthy, whole individuals.

Ronnie deserves it, wherever he is. And so do you.

Now’s the time. Dr. Royer started the CHRISTUS system on this journey this week in D.C. Will you join us? ~Abby

We did this all week long

Members of the CHRISTUS team meets with a senator’s Chief of Staff and other stakeholders in the Senate Reception Room to tell our story

Thursday, July 23, 2009

Day 3: Change is Hard, but our CHRISTUS Family Does it Well (written by Abby Lowe)

Once again today, we met with journalists, legislators, regulators and policy experts to tell the CHRISTUS story. We also got a chance to meet with a representative from the Mexican Embassy, which allowed us some time to fill him in on our operations in our CHRISTUS Muguerza region.

It seemed like we spent a little longer sitting down with folks today so we could really focus on building relationships. After all, Dr. Royer is here not only to tell the story of the CHRISTUS family, but also to make it clear that CHRISTUS has a different focus than many other health systems, is forward-looking, and would like to help with health reform or any other issue that they might want information, education or resources on.

One thing that struck me as I sat in these meetings was an overwhelming sense of pride in CHRISTUS and the work done by CHRISTUS Associates every day. Dr. Royer, Peter Maddox and Patti Harper have spent time telling our story to all sorts of groups, including the head of FEMA, the LA Times, the U.S. Department of Health and Human Services and even Mark McClellan (who served both as FDA Commissioner and head of the Centers for Medicare and Medicaid services).

They continue to focus on the unique things CHRISTUS Associates are doing across our diverse system. They talk about our futures planning (especially Futures Task Force I and II), and how those learnings have changed our system. They talk about our experiences with hurricanes, the great sacrifices of our Associates to care for patients and each other in affected regions and what can be done better in the future. They talk about the fact that we’re not building more inpatient beds, and even about the CHRISTUS Stehlin Foundation for Cancer Research in Houston, which we believe has made some advances that will revolutionize cancer care in the next 10 years.

I wish everyone could see the faces of the folks Dr. Royer meets with as he tells many parts of the CHRISTUS story.

They are surprised. They are impressed. They have lots of questions about what we’re doing.

They’re stunned to hear that we don’t agree with the American Hospital Association (AHA) and even our state hospital associations on every point of health care reform. We have been honest about the fact that we’ll need to make some concessions if reform is to pass. We won’t give away the whole shootin’ match—obviously, we must remain financially viable to continue to serve the members of our community—but CHRISTUS is not willing to let perfect be the enemy of good.

We’ve heard that we will see some kind of reform legislation this year, but it might not be as sweeping as the changes being considered now. And I’m sure many of you heard today that these reform discussions will not be done by Congress’ August recess.

But we’ll also be in touch with representatives while they are at home over this break. It will be another great chance to explain what we’ve been saying about health care reform: it’s necessary, it’s urgent, and it must be done correctly now.

Dr. Royer often reiterates the fact that most of the excess cost in health care is from overuse and misuse, not under-use by uninsured populations. (If you’re really interested in this topic, I’d suggest you read an article written for the New Yorker about McAllen, Texas. You can access it here. It’s a lengthy write-up, but it really clarified the health care reform discussions for me.)

It’s become clearer to me that people are people, wherever they live and whatever they do. These health care reform discussions may seem scary for many Americans who are concerned about cost containment. They are scary for those who have insurance that they like. And they are scary for many health care providers, who are worried about what these changes will mean for them.

That’s understandable. And it’s one of the reasons that Dr. Royer is here telling your story, explaining about the progress that the members of the CHRISTUS family have made in our 4 directions on our Journey to Excellence. These improvements prove that high quality care can be provided at a low cost, one of the main focuses of health care reform.

Change is hard, and almost no one likes it. In many ways, the known evil seems less threatening than the unknown. But in this case, the known evil is 46 million Americans without adequate access to care, rampant overuse and costs in the provision of care all across the country, reimbursement that doesn’t make sense (and should fairly include preventive care) and no end in sight to these issues.

Now’s the time, so we continue with meetings tomorrow. Once again, we’ll keep you in the loop. ~Abby

Wednesday, July 22, 2009

Day 2: CHRISTUS is Unusual (Written by Abby Lowe)

Today I’ve been as sponge-like as possible. I sat in on meetings with Republicans, Democrats, Senators and Representatives. And while today’s discussions really focused on health care reform, Dr. Royer and Peter Maddox did speak about hurricane/disaster preparedness once again.

We had our first meetings with journalists today, where we answered their questions about our opinions on specific reform bills. We also spent an extensive amount of time introducing CHRISTUS, telling them about our Journey to Excellence, our experiences with tort reform, our portfolio realignment (to 1/3 acute care, 1/3 non-acute care and 1/3 international care), our partnerships in Mexico and our experiences caring for patients in some of the states with the highest uninsured rates in the U.S.

And through all of these meetings, I came to understand one important fact about CHRISTUS Health: we are weird.

I think all the legislators we met with today were shocked that we did not come to ask for more money, or to complain about health care reform. No, we came to express our support, to tell them our views about what we thought should be included, and to ask what we could do to help them in their negotiations.

And it was clear that the fact that we came in to listen as much as we came to talk and that we weren’t carrying a “No, no, no” message meant that the legislators and their staffs were much more open to sharing openly with us and hearing what we had to say.

Dr. Royer says the same things to all of them about health care reform. We support reform, and believe it should, at the most basic level, be:
• Available and accessible to everyone, paying special attention to the poor and vulnerable.
• Prevention-oriented, with the goal of enhancing the health status of communities.
• Sufficiently and fairly financed.
• Transparent and consensus-driven in allocation of resources, and organized for cost-effective care and administration.
• Patient-centered and designed to address health needs at all stages of life, from conception to natural death.
• Safe, effective and designed to deliver the greatest possible quality.

It should also include tort/medical malpractice reform, which has been a winning formula for CHRISTUS in Texas. Tort reform caps medical malpractice awards for noneconomic damages at $250,000. This means that patients who are injured by negligent medical care retain the right to full recovery for their economic damages. The people of Texas reap the rewards of tort reform as they see doctors returning to high risk locations and high risk areas of practice and as they see hospitals providing new resources for more and better medical care. Texas has become a role model for a fair, practical and lasting approach to medical malpractice reform. You can read more about the CHRISTUS experience with tort reform here.

Health care reform, Dr. Royer says, should also align physicians and hospitals, standardize care based on evidence-based principles across the country and provide quality-based incentives.

Everyone we’ve met with so far has seemed to be very open to these suggestions and interested in our experiences.

Tomorrow we meet with the Mexican Embassy, regulators and journalists. I’ll do my best to keep you up to date with all the news that’s fit to print! ~Abby

One stop on our whirlwind tour

One visit we made today was to check in with the staff of Rep. Matheson (D-UT). I thought I'd let Dr. Royer fill you in on the visit. (Seems like the right thing to do since this is still his blog. . .)

Tuesday, July 21, 2009

Day 1: Disaster Preparedness, Health Care Reform and Health Care IT (written by Abby Lowe)

Wow. I obviously should’ve worn more sensible shoes today.

I’m exhausted, but Dr. Royer just keeps moving right along. (“I’m not tired until the work is done,” he says. And even though I’m 30 years younger and even though he probably woke up around 4:30 or 5 this morning, I seem to be the one dragging.)

It was a great first day of meetings, though. We met with the staffs of 2 senators and 1 congressman, an expert in health care IT who is charged with helping HHS regulate recent funding requirements and some of our friends at the Catholic Health Association who are very involved in health care reform and have attended quite a few meetings at the White House.

We talked some health care reform today, but mostly carried messages about disaster preparedness—how state and local governments could work better with us and with FEMA to help us be more effective during hurricane evacuations and help us better care for our patients, and the legislative changes we’d suggest to help that process along. Obviously we talked about health care IT--the American Recovery and Reinvestment Act of 2009 (ARRA) provided approximately $19 billion for Medicare and Medicaid Health IT incentives over five years, so we and other health systems want to stay engaged in those discussions.

I might take some time later in the week to delve into health care IT and disaster preparedness, but I learned quite a bit about health care reform today that I think you’ll find interesting.

My head is still spinning, and I can say that even though I do my best to keep up with the health care reform discussions, I have trouble keeping up with who said what, what’s included in a suggested bill, what’s not, what’s been thrown out, who’s working with whom, who feels like they haven’t been invited to the table, etc. It’s a dizzying mix of conversations, negotiations, he said/she said, and it all feels like it’s moving very, very quickly.

But we met today--and will continue to meet--with legislators on both sides of the aisle—Democrats and Republicans, conservatives and liberals. We also heard from some of our colleagues at the Catholic Health Association who speak on our behalf. Here are some things I learned:

1. You can’t let perfect be the enemy of good. The bills being bandied about on the hill aren’t perfect. No bill of any kind on any subject ever will be, but the 46 million Americans without insurance can’t wait. A recently released report by the Institute of Medicine makes clear that Americans without health insurance live sicker and die sooner. And they can’t afford to wait 15 more years for real health care reform.

I also learned that 28 million of the uninsured are small business owners and employers. And it sounds like many of them would be happy about being able to afford insurance coverage.

2. A solution crafted this year won’t be a permanent fix. The bill that is crafted now may work for the next 10 years or so. But given the advances we expect to see in medicine and technology, it may not be appropriate for the 10 years after that.

3. We aren’t here asking for no cuts to Medicare/Medicaid, but we have drawn some lines very firmly about what we will not accept. Hospitals have agreed to $155 billion in cuts over the next 10 years. It sounds like we will be able to cover these costs, provided that the majority of Americans emerge with health insurance coverage. However, we would never stand for cuts in dollar amounts that we could not manage. (We could not shoulder cuts that reached as high as $300 billion, for instance. And after all, what good is insurance if no hospitals can afford to stay open to provide care?)

As a Catholic system, CHRISTUS would not support any kind of reform efforts that included threats to life like abortion. From what we heard today, it does not sound like the current discussions will form a bill that addresses abortions in any way.

4. I heard someone say today that health care reform will cost $2 trillion. $2 trillion is a whole lot of money. It sounds like WAY too much to pay for anything, no matter how it is financed. (Including health care reform.) But the insured of our nation are already carrying that kind of burden. Did your insurance costs go up this year? Mine did. Apparently our costs have been rising for years and CHRISTUS has been carrying that cost, but it got too large for CHRISTUS to carry anymore. So some of that cost was shifted to me and the rest of our Associates on the CHRISTUS plan. Insurance premiums will continue to rise, because insured patients carry much of the burden of health care costs. They don’t carry it all by any means, but many people treated in hospitals cannot pay for their care, and that cost is passed on to those who can.

I also understand that $2 trillion is probably not the most correct cost. I believe the Congressional Budget Office estimated the cost closer to $1 trillion, which does not at all include new accounting rules or the concessions made by industries like hospitals. Legislators are also still working on the final plan, and I believe more cuts in that nunmber will be made. For more information on this, I suggest this article.

5.Being here obviously brings back some Schoolhouse Rock! memories. I have “I'm just a bill / Yes, I'm only a bill / And I'm sitting here on Capitol Hill” stuck in my head.

But we have three more days of jam-packed agendas to get to, and I’m exhausted but excited to see what comes next. Stay tuned! ~Abby

Blog: Hijacked!

Hi there. As you might have noticed, I’m not Dr. Royer.

I’m Abby Lowe, Communications Specialist for CHRISTUS Health. I’ve hijacked Dr. Royer’s blog during his visit to Washington, D.C. to meet with legislators, regulators and journalists. He’ll be there talking about all sorts of things that matter to the CHRISTUS family, from health reform to our experiences with disaster/hurricane preparedness and what we’ve learned from our relationships in Mexico and time spent in the Futures Task Force.

I’m going to do my best to ensure that you’re fully informed about what he’s doing while he’s in D.C. because, after all, it’s the story of the CHRISTUS Associates that he’s here telling.

I’ll be your tour guide on this journey, and I know we’re in store for some tweeting, video blogging. . .and no telling what else! Just keep your arms and legs inside the cart at all times, and we’ll be just fine.

Wednesday, July 15, 2009

What Happened to Physician Diagnosis?

In recent posts, I’ve addressed the high cost of health care often associated with lesser quality when overuse or misuse of treatment and procedures are undertaken and when more emphasis is placed on treatment instead of prevention.

Clearly, another reason for these costly and often ineffective practices is that some older physicians may not be using the important tools associated with physical diagnosis, and some younger physicians may not be learning them.

When I was in medical school over 40 years ago, much time was spent on learning and then relying on four processes to make a diagnosis of our patient:
1. Inspection – Look at the patient and tell me what you see and what you think it indicates. Is the skin pale? It could indicate anemia. Yellow? Liver disease. Puffy? Hyperthyroidism.
2. Palpation (putting your hands on the body) – Do you feel breast mass, thyroid nodule, hernia, abdominal mass or abdominal aneurysm?
3. Percussion (beating on the chest & abdomen with a two-finger/drum stick technique) – Have you identified a solid lung lesion, or air or fluid in the pleural or abdominal cavity?
4. Auscultation (listening with a stethoscope to the heart, lung and bowel sounds) – Do you hear pneumonia, mitral valve disease, aortic regurgitation, or an obstructed, non-functioning bowel?

In addition, smell and a good history can be added to the four tools described above as inexpensive but often reliable adjuncts to reach the right diagnosis. I quickly learned that you can smell a pseudomonas infection on a burn patient, and that a person with acute appendicitis is never hungry.

These are important tools that cost little or nothing, but could focus the diagnosis with fewer lab and radiological tests. Unfortunately, however, the first line of approach by many providers as they begin the diagnostic journey is to start with an MRI or the CAT scan. And because we have far too many of these machines in the U.S., they, too, are overused.

I worry that the skills of physical diagnosis are rapidly being forgotten, and I worry more that if we do not enhance their uses in the future, the costs of health care may never decline.

Wednesday, July 8, 2009

Why More is not Necessarily Better

In a recent post, I addressed the problems associated with the overuse of medical procedures and studies made available by less invasive and safer technology.

Clearly, these are cases where more treatment is not better treatment. There are numerous examples proving that the focus on more medicines, procedures, lab studies, etc. as part of the treatment plan to control a disease rather than a strong emphasis on prevention to create wellness and health substantiate my belief that more is not necessarily better, but in fact is often far worse.

Although there are many scenarios that could be described to support this hypothesis, the most obvious are smoking, obesity and excessive drug and alcohol use.

Although we have known for years that smoking leads to disorders ranging from mild shortness of breath to virulent emphysema and lung cancer, we continue to provide misaligned incentives that do not inspire true change, as reimbursement is still provided for the treatment of the diseases rather than rewarded for removing the cause. If working with a patient on smoking cessation therapies including medication support was reimbursed at even 10 percent of what a cancer treatment plan costs, I am sure there would be significantly less smokers in the world, particularly if the patient and provider were both reimbursed an additional amount of money for every year the patient continues to not smoke.

We are also all familiar with the myriad illnesses that are caused or exacerbated by obesity, the number one health malady in the world. (I’m sure many of you heard of a study by the Trust for America's Health and the Robert Wood Johnson Foundation last week that reported that in 31 states, more than one in four adults are obese.) But rather than seriously encouraging both the patient and provider to focus on fixing an obesity problem, we provide more and more medicines and therapies to treat the resultant pedal edema, congestive heart failure and uncontrollable diabetes. We use more and more supply and labor, spending more and more money with little benefit. Again, what if the rewards for removing the cause were greater than those for stabilizing the resulting chronic disease?

Trauma, which was the leading cause of death in children 7-years-old and younger 25 years ago to the leading cause of death in people 52 years and younger today. I believe this statistic will reach 60 years by 2020. Trauma care is among the most complex and expensive to provide, and is often poorly reimbursed. We know that drug and alcohol usage accounts for the majority of traumatic events we treat in our Emergency Departments. Again, if some of the resources we applied to each trauma victim could be shifted to alcohol and drug prevention programs (which are much less costly), and like smoking, rewarded annually if relapses to do not occur, would we not have a better, less traumatic world in which to live?!

Yes, these are clear examples where we apply more and more of our resources daily which have no long-term benefit. To be successful, health care reform must realign incentives so that “less” at times will be embraced as better!

Wednesday, July 1, 2009

The Dark Side of Technology

If I was forced to pick the most important driver of the improvement in the quality of health care in the U.S. in the last 40 years, it would be the advances we’ve seen in technology. Clearly, these advances have created much safer procedures and processes for patients and their families, many less-intensive and less complicated techniques for physicians and their teams and significant reduction in poor clinical outcomes.

Some of the more obvious examples of these improvements include:
•Better eye sutures so cataract surgery can be performed in 10- 20 minutes as an outpatient procedure as compared to the three-week mainly bedfast hospital stay with sand bags placed on both sides of the patient’s neck to minimize movement. A major complication of that kind of surgery and recovery included strokes in elderly patients.
•Use of laparoscopic surgery for gallbladder removal resulting in a short outpatient procedure and return to work and normal activities in four to seven days. This compares to a week-long hospital stay after an open right subcostal incision procedure, four days of which the patient had severe pain and nausea with the inability to return to work for four to six weeks.
• Proctoscopies done with a hard metal scope, which had to be carried out only by surgeons because 1 in 1,000 cases resulted in a perforated bowel. Now these bowel examinations are done with flexible scopes with little chance of a significant complication.
• Arteriograms done through the femoral artery as compared to those done through the carotid artery, causing numerous vascular compromise incidents.

Based on these few examples—and I believe there are many more--I have always said the “good old days” were not so good. Clearly, technological advances have created much brighter and better days from many perspectives. But, unfortunately, there is a dark side to technology.

As the equipment became safer to use, the ability for more providers to do more procedures in less acute locations has occurred. Procedures once done only in a hospital can now be done in doctors’ offices, ambulatory surgery centers, specialty hospitals and even convenient clinics. This increased availability in multiple settings by multiple providers has resulted in an overuse of these procedures often driven by revenue enhancement (What’s best for me?) vs. quality care (What’s best for the patient?). In addition, many of the highly-reimbursed procedures have been moved out of hospitals, resulting in extremely low income levels and making the survival of some hospitals almost impossible.

Because of this knowledge, Obama and Congress, who are driving health care reform, believe if the revenue overuse was replaced with evidence-based quality guidelines for use, billions of dollars could be saved while simultaneously improving quality. They are right. The question is, do we as health care leaders have what it takes to eliminate this dark side of technology and replace it with only the best use of this technology for the right patient and the right time at the right cost?