Wednesday, September 30, 2009

The Cost of Care, Part 2

The second part of the Dallas Morning News’ five part series called “The Cost of Care” tackled the doctor-owned hospital dilemma. You can access the series here.

The article does a fantastic job of examining physician-owned hospitals from a variety of angles, admitting that it is a complex issue and that not all physician-owned facilities are created equal. We know that some physician/system partnerships provide much-needed services in a community in an efficient manner. However, we have also seen physician-owned facilities that duplicate services in order to cherry-pick paying patients from the community. These facilities have an Emergency Room in name only—usually a 10 x 10 space—in order to meet legal guidelines, but their main focus is making money, not caring for those in the community who may need it most.

What, then, are we to make of physician-owned hospitals? It is clear that this is an issue where we must tread lightly, examining all the facts before making judgments. While not all physician-owned hospitals exist solely to make money, we must be mindful of the conflict of interest self-referring may involve. It is sometimes hard to distinguish profit motives from patient motives when you are in the thick of things.

As the article points out, data on physician owned hospitals is hard to come by, but my anecdotal experiences with them run the gamut I expressed above. While I believe that all healers have as their highest goal the good of their patients, we have seen some of these hospitals that have positioned themselves to provide only “profitable” care for a small number of patients. We know that physicians must make a living, but doing so in a way that is not in the best interest of a community is immediately suspect.

So we move forward, aware of the pitfalls of and great services provided by physician-owned hospitals. We realize that they, like anything else in health care or life, must be approached with a healthy level of curiosity and—at times—skepticism. Above all, we must do what is best for those we treat, and ensure that our integrity can in no way be maligned as we go about our sacred work.

Wednesday, September 23, 2009

The Cost of Care, Part I

The Dallas Morning News began a five part series called “The Cost of Care” on the cost of medical care in Dallas in this Sunday’s paper. The news outlet has devoted a section of their Website to this series, which you can access here. It contains polls, interactive maps and links to the online versions of the stories from the series which appeared in print. I would like to take the next few weeks to examine the articles in this series, many of which confirm the positions CHRISTUS has taken for years past.

As health care reform discussions once again overwhelm the news we hear from Capitol Hill, this series is timely and frames the debate well. The articles and vignettes from part 1 of the series, which debuted on Sunday, cover a wide variety of topics, and tell the stories of many local people who can’t afford insurance or struggle to, only to find out in times of crisis that it did not cover their treatment needs. Many of these stories can be accessed online, and I suggest you take a few moments to read them, because they remind us all that the cost of having no or too little insurance is a human one. It is imperative for all of us—health care providers, legislators and regulators—to remember that we exist to serve people, in this case people who are sick and need healing or need preventive care to keep them healthy.

The main article in Sunday’s section aims to answer why Dallas spends more for health care than almost any other big city in America. You may recall this sounds similar to Atul Gawande’s question in his article “The Cost Conundrum, What a Texas town can teach us about health care,” which I have mentioned several times on this blog. The Morning News points out that
In 1992, Dallas was well below the national average in Medicare spending – much less than Fort Worth, Houston, San Diego and 121 other hospital regions across the country. By 2006, spending in Dallas had soared. The Dartmouth Atlas on Health Care now ranks Dallas 13th in the nation, well ahead of Fort Worth and Houston.

The article offers some reasons why this may be occurring, which I have often suggested are the reasons for skyrocketing medical costs. These include
Overuse and over-prescription of tests and technology. The Morning News says that “Area doctors are seeing patients more often, ordering more tests and doing more procedures.” As I mentioned last week, overuse of diagnostic tests on patients is rampant in the U.S. health care system, and very rarely accomplishes much more than increasing costs.
Competition causes duplication of costly services, and does not therefore result in reduced costs. The author states that “In other businesses, competition tends to drive prices lower as companies jostle for customers. Not in health care, and not in Dallas. Competition drives up spending.” We have long been in agreement with this statement, which is why we perform a thorough needs evaluation before entering any community. One such evaluation of the Dallas community proved to us that it was over-bedded, which is one reason why the CHRISTUS system has its headquarters in the Dallas area, but is not an acute care provider in this market. We determined long ago that Dallas already had more than enough acute care providers.
• The uninsured and underinsured often delay treatment, ending up in our Emergency Departments—the most expensive place to receive care—when their malady has progressed into something much worse than if we had treated it in its early stages. As a result of this and a gap in government reimbursement, costs for treatment can be shifted to insured patients. The article quotes Gary Brock, chief operating officer of Baylor Health Care System, who said that “ ‘the government reimburses Baylor just 80 percent of its costs for Medicare patients. To make up the difference, Baylor charges privately insured patients 150 percent of its costs.’ “
Care that is coordinated is best for the patient. The Morning News says that, “A broken market also helps explain a second cost culprit in Dallas. Patient care is not well-coordinated. Once a patient enters a hospital, family doctors say they are left out of the loop. Lots of doctors start duplicating one another's tests, ordering drugs that may interact in dangerous ways and leaving the physician who best knows the patient in the dark.” In fact, family doctors and Emergency Departments or specialists also duplicate tests, driving up the cost of care.
The U.S. health care system rewards quantity, not quality, and provides perverse incentives for physicians and hospitals to provide more, not necessarily better, care. While we were in Washington, D.C. at the end of July, we had a chance to meet with Mark McClellan, who heads the Engelberg Center for Health Care Reform at Washington's Brookings Institution. We discussed the many proposals coming out of Capitol Hill, and he said much the same thing to us that he said to the Morning News: creating accountable care organizations that pay providers extra for quality and efficiency instead of volume will drive down the cost of care.

The stories told by the Dallas Morning News in this informative series highlight problems with the health care system that are national, not just specific to the state of Texas. Nest week we will examine the second part of the Cost of Care series.

Wednesday, September 16, 2009

Why all the "to do" about physician integration?

Physicians and their role in the delivery and cost of health care have been in the spotlight recently as the health care debate rages on. Much of these early discussions seemed to result from Atul Gawande’s article in the New Yorker called “The The Cost Conundrum, What a Texas town can teach us about health care” and his follow-up, “The Cost Conundrum Redux.” Gawande suggested that physician overuse and the lack of integration in the care continuum are to blame for the fact that McAllen, Texas has the highest per person Medicare costs in the country. This led to explosive debates around the country about physician liability and integration.

But health systems, clinics and other organizations dedicated to delivering care have long understood that physicians and hospitals, while sharing the same goals, may seem pitted against each other. It is for this reason that physician integration is key to success for health systems and the joint delivery of high quality, low cost care.

The following graphic shows how this integration occurs, but the boxes about the differences show why achieving that it so hard.

How might we bring hospitals and physicians together? We may implement the following strategies for change:
• Set expectations for team process
• Train and educate the team together
• Plan together
• Implement and operate together
• Performance goal setting
• A performance appraisal process
• Shared incentive for financial gain

Ultimately, however, I believe we must gather both groups around the common goal of providing high quality, low cost care using evidence-based protocols. Both groups understand that they have a sacred responsibility to care for human life, and most view this as their definitive purpose. This must be what brings us together.

Wednesday, September 9, 2009

Remembering the Human Touch

One of our Associates recently sent me this story, written by a physician who urges doctors to return to the healing power of touch, and cautions that the rush to use the latest high-tech diagnostic tools often ignores the intrinsic value of a physical exam.

As I have often said, one of the reasons for the skyrocketing cost of health care is not misuse, but overuse. The author of the article avoided costly tests (ultrasounds, CAT scans, MRIs) to diagnose the patient’s condition by merely touching her, but this was not her first line of thought.

It also impresses upon me the importance of family practice physicians and physician extenders, who—it seems to me—generally have a much greater tendency to rely on their diagnostic skills.

We constantly hear the excuse that physicians are worried about liability, and therefore utilize more technology both in lab and radiology to, in essence, protect themselves from unmerited malpractice suits. This is why we have been so clear that tort reform must be included in national health care reform. I will not rehash the CHRISTUS experience with tort reform in Texas in this post, but feel free to visit a previous post on tort reform to learn how successful we believe it has been thus far.

If we as physicians could return to utilizing more physical diagnosis and not worry about liability before jumping to the use of technology, we would go far in reducing overuse and misuse in the health care industry.

The case Dr. Castro described in her article demonstrates that hypoglycemia is the most common cause for diabetic confusion (which is quickly diagnosed from confused dialogue with a sweaty patient). This patient could have been sent for a CAT scan or MRI, during which she could’ve suffered ongoing and probably permanent brain damage from her persistent low blood sugar.

Wednesday, September 2, 2009

Learnings from Comparing and Contrasting the British & U.S. Health Systems

As the U.S. health care debate accelerates, it continues to be important to compare and contrast the U.S. health system with those of other countries as part of our learning journey.

Our travels for our Futures Task Force II work provided us with an opportunity to grow some knowledge of the health care delivery systems in both Canada and England.

The National Health System (NHS) in Britain is celebrating its 61st birthday in 2009. At face value, comparisons between the U.S. health care system and the NHS are stark and have caused quite a debate.

The NHS has a “socialized system.” Socialized medicine is a term more commonly used in the U.S. and usually refers to publicly financed and/or government-administered health care. It has taken on a pejorative meaning and evokes negative sentiment toward public control of a health care system. Ultimately, each system around the world, regardless of what it’s called, aims to find a solution that best meets the needs of its country’s population. One could argue that the U.S. has aspects of a socialized system with its Veterans Administration and Medicare and Medicaid programs.

Understanding the origins and evolution of the NHS helps to contextualize changes in U.S. health care and to highlight strengths and weaknesses in both systems. The NHS was established by the Labour Party in 1948 against considerable opposition as a small component of a wave of postwar nationalization. Before its creation, patients were generally required to pay for their health care. The founding principles of the NHS called for health care services to be:
• Provided free at the point of use,
• Accessed by all people (even those temporarily resident or visiting the country) and
• Financed from central taxation and not through national insurance.

The NHS has changed considerably in the intervening years. Organizational restructuring in the 1960s integrated NHS primary and secondary services under single regional bodies, a process which has continued. An end to economic optimism in the 1970s and 1980s led to the introduction of modern management processes, which still dominate the Service. Sustained investment by Prime Minister Tony Blair’s government during the 1990s aimed to modernize and streamline the Service through the introduction of internal and external competition, closure of surplus facilities and introduction of efficiencies (including the elimination of long waiting lists). In recent years, the achievement of efficiency in the NHS has placed a renewed focus on quality and innovation.

The NHS provides a vast array of services. An annual budget of £90 billion (U.S. $135 billion) has produced some impressive results compared with other health systems, and the NHS consistently ranks higher than the U.S. in several global health surveys. In 2007, the Commonwealth Fund compared the performance of five nations—Austria, Canada, Germany, New Zealand, The U.S. and the UK—on five dimensions of a high-performance health system: access, efficiency, equity and healthy lives. Overall, the UK ranked the highest across these metrics, and the U.S. the lowest.

What has probably been most surprising is the unique sense of ownership and social responsibility people have for the health service. Major initiatives, such as the closure of an NHS hospital, are presented to the community for public consideration. In another example, the board of a pediatric hospital in the North of England actively sought feedback from community children on what they value most in their experience at a hospital.

At the same time, there is the National Institute for Health and Clinical Excellence (NICE), which plays a unique and valuable role in prioritizing new technologies and drugs. But NICE also creates a culture of conservatism that results in slow adoption and sometimes limited patient choice for very innovative practices and technologies.

As the NHS continues to evolve its system of care (I.e., the entire care continuum of inpatient and outpatient services), NHS chief executives and managers are looking to the U.S. for leading practice approaches to more systematic and collaborative care that have been achieved by such organizations as Kaiser Permanente and Geisinger health. As the NHS has shaped its model over the last 61 years, it has done a good job learning from the past and from the experiences of others around the world while finding the best available evidence to support its planning.

An NHS model would be a radical cultural shift for U.S. health care. But ultimately, we will find a solution that makes sense for us just as other countries have managed to do.