Quality

QUALITY: Dying Well Beats Dying Badly. And Expensively

Joanne Kenen — Fri, 20 Nov 2009 14:01:00 -0500

As we've written a lot on end of life care, we notice when others do the same. NPR's Joseph Shapiro this week reported on La Crosse, WI where 96 percent of the adults who die have an advanced directive. That extraordinarily high figure arises from the innovations and commitment from Gundersen Lutheran hospital. Careful, sensitive discussions by trained doctors and nurses -- they use a 12 page guide -- is time consuming. Medicare doesn't reimburse them for that time, A provision in the House health care bill would change that -- the provision that was caricaturized as a "death panel." The Senate bill doesn't contain it.

Shapiro's thoughtful piece shows many aspects of end of life decision-making, but one element we liked in particular was that it shows these decisions are not static. People can reflect, and can change. That's the beauty of advanced directives or advanced care planning. Joe Hauser, one of the patients profiled in the NPR piece, initially declined dialysis for his failing kidneys. His wife Janice begged him to reconsider. So he gathered more information and spoke to a nurse. He and his wife were trying to decide whether to visit a dialysis center, and a support group. He learned that if he tried dialysis, he would always have the option of stopping. When Shapiro last spoke to him, Hauser was still leaning against dialysis. But he wasn't sure:

There's a surprise. He extends his left arm across the kitchen table. He wants to show what he calls his "buzzer." It's a spot at his wrist where you can feel the vibration from an artery and a vein that a surgeon has joined together.

It turns out that Joe Hauser's decided to be ready, if he changes his mind. And if he decides he wants dialysis, then the needle of the dialysis machine can slip right in to that spot -- the fistula -- that the surgeon has prepared at his wrist.

We should point out that the Washington Post.'s Alec MacGillis also had a fine story about LaCrosse earlier this fall. Don't think we linked to it at the time. MacGillis looked at both the economics of end of life care, and some of the local cultural traits of La Crosse. The population is full of people of German or Scandinavian descent who seem to have a pretty pragmatic view of aging and dying. And the local doctors and nurses have a culture, too, that values communicating with patients, and respecting their wishes. People in LaCrosse spend far fewer days in the hospital in their final weeks and months of life than people elsewhere in the country. Not because the Wisconsin community doesn't want to spend the money, but because that's what the people who live there, and die there, choose.

This coming Sunday (Nov 22) 60 Minutes will do a piece on end of life, featuring our occasional guest blogger Dr. Ira Byock (read his posts here and here). The short preview on the CBS website focuses a lot on costs; we suspect the televised segment will tell a moving story about quality of care, and patient choice. Because we too have accompanied Dr. Byock in that ICU, and sat in on his team meetings, and we know that quality -- and care -- is what motivates them.

One last relevant link -- Oregon Democrat Rep. Earl Blumenauer, who authored the House provision on end of life conversations, wrote an op-ed in the New York Times this week, describing how a measure that had long and deep bipartisan roots turned into political poison: "The battle lines were being drawn. Little did I know how deep the trenches would be dug, nor how truth would be one of the first, and most obvious, casualties." Live and learn.

WORLDVIEW: Assume There's Morality

Joanne Kenen — Thu, 19 Nov 2009 21:16:00 -0500

Not many health writers -- not many writers of any ilk, for that matter -- can match T.R. Reid's ability to bring a light, witty touch to really serious topics. Like health policy around the globe.

Tom (that's what the "T" in "T.R." stands for) was the featured speaker at the Peterson Institute of International Economics today. Not the usual venue for the book tour for his best-seller, "Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care." Before his talk, he told me he was planning to stress the moral case for covering everyone. Not the approach, perhaps, that this particular crowd was used to hearing. Go ahead, I told him. It is, after all, a roomful of economists eating a free lunch.

And that's what he did.

Every rich western democracy (and a few of the not so rich and not so democratic ones), he said, covers everyone. We don't.

None of their systems are perfect. Like us, they wrestle with the rising price of pharmaceuticals and medical technology, and with the needs of an aging population. But they all cover everyone. It's time, he said, for us to do the same. It's been time for a long time.

Reid argued that health care is a basic human right -- a controversial notion in the United States, but received wisdom elsewhere. He threw in some economic lingo as well. Covering everyone (and everyone, he said, means everyone) also brings about efficiencie that make the system work better. He talked about "distributional ethics." Every American -- both Bill Gates and the guy who mows his lawn -- each have one vote. But they don't each have one yacht. Health care, he said, should be more like a vote than a yacht.

Nor does he believe (as some Americans seem to, judging from decibel level of our national health reform debate) that expanding coverage is a zero sum game. I get more, you get less. He argues that we can all get more. More efficiency. More morality. If we find the will, other wealthy industrialized countries can show us a plethora of ways.

Two New America colleagues have reviewed his book. Phil Longman in the Washington Post called the book " a service to his nation," Shannon Brownlee in the Washington Monthly wished he had written more on the lack of evidence behind some of the treatments widely used in the U.S. We liked the film Reid did for Frontline last year, "Sick Around the World" and we liked the book, a readable account of different national health systems interspersed with his own amusing but enlightening global search for a fix for his bum shoulder. How can you not like a book that has sentences like:

France [is] a mirror image of the United States when it comes to health care: Americans strongly dislike their national health care system but haven't found the political will to change it; the French are highly satisfied with theirs but change it all the time."

Or, after having his shoulder treated (quite successfully) by traditional healers in India, when he wrote:

When the front office at the Arya Vaidya Chikitsalayam handed me a detailed accounting -- dozens and dozens of pages listing every navarakizhi, every poojah, and ever ancient herbal medication I had experienced -- I realized instantly that my U.S. insurance company was never going to pay this bill.

He didn't care. His shoulder was better -- and he had lost nine pounds.

Reid's message is not always wry or witty. Far from it. At the beginning of his book, and again near the end, he writes about Nikki White. She died of lupus at age 32. Not because her disease was so severe or untreatable. But because once she became too sick to work, she lost her insurance. And once she lost her insurance, she got sicker. She could not get the treatment she needed until she was so sick that it was too late.

"No other rich country would have tolerated the inequality that left Nikki White dead," he wrote. Designing a health system is an economic question, a medical question, a political question, he acknowledged. But in the end, he concluded, " the primary decision to be made is a moral one."

COVERAGE: Accidental Costs of Being Uninsured in the USA

Allison Levy — Wed, 18 Nov 2009 21:05:00 -0500

Here is more evidence that the uninsured fare worse than the insured. Including trauma patients in the emergency room.

The AP's Carla Johnson reported on a troubling study published in Archives of Surgery, Downwardly Mobile: The Accidental Cost of Being Uninsured. She writes that "uninsured [adult] patients with traumatic injuries, such as car crashes, falls and gunshot wounds, were almost twice as likely to die in the hospital as similarly injured patients with health insurance."

Under a 1986 law known as EMTALA (Emergency Medical Treatment and Active Labor Law), anyone who shows up in an emergency room needing emergency treatment will receive treatment to stabilize him or her. That statute is intended to "prevent hospitals from rejecting patients, refusing to treat them, or transferring them to ‘charity hospitals' or ‘county hospitals' because they are unable to pay or are covered under Medicare or Medicaid."

Despite adjusting for race, gender and age, the researchers concluded that the uninsured still have an 80 percent greater chance of dying than those with insurance. Even in a setting where equitable treatment is mandated by federal law, the uninsured still experience significantly worse health care outcomes.

What gives?

The researchers offer several possible explanations for this glaring disparity:

Uninsured patients may experience treatment delay. (A separate study published in the Journal of Pediatric Orthopaedics demonstrates that children with private insurance receive more timely care than children with public insurance or no coverage at all.)
Uninsured trauma patients are less likely to be admitted to the hospital and receive fewer services during their admission when compared to insured trauma patients.
Institutions treating a higher proportion of uninsured patients may have fewer available resources.
Lower health literacy, and less ease and skill in communicating with ER physicians or other health care providers, may play a role. (In 2008, 88 percent of all uninsured adults in America did not have a college degree.)

"I'm really surprised," Dr. Eric Lavonas of the American College of Emergency Physicians and a doctor at Denver Health Medical Center told the AP, "It's well known that people without health insurance don't get the same quality of health care in this country, but I would have thought that this group of patients would be the least vulnerable."

This leads us to the "accidental" part of the disparity question.

The researchers do acknowledge the limits of their study and that some of their explanations for the gap are speculative. They note that "treatment is often initiated before payer status is recognized; thus, this provokes the question of whether differences exist in processes of care during the hospital stay." (Meaning not the first encounter with the ER but the ongoing care.)

But even in a setting where equitable care is "not only expected but mandated by law" and providers may be unaware of their patients' insurance status -- health outcomes of the uninsured are significantly worse. There must be some other explanation. Or might it just be an "accidental cost" of being uninsured in the United States?

"This is another drop in a sea of evidence that the uninsured fare much worse in their health in the United States," explains senior author Dr. Atul Gawande. As the study concludes, these unintended consequences that the uninsured pay may just be "too high to continue to overlook."

QUALITY: The Bottom Line is Still Patient Safety. And We're Still Waiting

Joanne Kenen — Tue, 17 Nov 2009 19:05:00 -0500

With all the talk of financing and mandates and public options, it's important to make sure the essentials -- that patients are helped, not harmed, by health care -- don't get overlooked. Consumers Union's Safe Patient Project held a daylong event here in DC today to help us keep that in mind.

Roughly 100,000 patients die a year from medical errors and about another 100,000 die of infections acquired in health care settings. "The status quo is not acceptable," Art Levin, director of the Center for Medical Consumers, told the forum.

Consumers Union last May marked the 10th anniversary of the Institute of Medicine's landmark "To Err is Human Report" with a report of its own called "To Err is Human - To Delay is Deadly" (Here's what we wrote about it at the time). The bottom line: not a lot of progress.

The event today highlighted some achievements; the health reform legislation does take some important steps to improve safety and quality. It also sheds a rather depressing light on how much remains to be done.

On the plus side, the House bill has new requirements for hospitals and ambulatory surgical centers to report infections, and the infection rates will be made public. The Medicare policy of not paying hospitals for treating certain avoidable infections will be extended to Medicaid. Both the House and Senate bills start to address high hospital readmissions (often avoidable when care is optimal), and both include an array of test programs and studies designed to improve care quality.

But safety advocates have set the bar higher for transparency -- they want public reporting of medical errors, not just infections, publicly accessible quality data banks, more safety training for doctors and nurses. And they are still waiting.

The CU event also showcased some excellent reporting on patient safety. The Pro Publica series by Charlie Ornstein and Tracy Weber on incompetent -- make that dangerous, nurses -- staying on the job in California got a fair amount of attention, but if you missed it, here's your chance. (Read the follow up reports too.) And the Hearst papers have an ambitious national reporting project called Dead by Mistake, and it's pretty shocking. Among the conclusions: in the decade since the IoM report, as many as two million Americans have died of preventable medical mistakes. And too often, health care providers have responded with secrecy, not transparency. And that in many ways, the problems are just getting worse.

HEALTH REFORM: Necessary Nurses

Allison Levy — Fri, 13 Nov 2009 19:26:00 -0500

If all goes well, and we have a new and improved health care system -- which will have to absorb millions of newly insured people, many of whom have been putting off needed care -- one thing we're going to need is more nurses. And once we have them, we need to use them well.

As the AARP's John Rother and RWJF's Risa Lavizzo-Mourey reminded us earlier this year in Health Affairs:

It is nurses -- of every stripe -- who will deliver, coordinate, and direct care in hospitals, clinics, and physicians' offices, and it is these same most necessary nurses who are in short supply...

Nursing has developed and implemented innovative models of care that promote the goals of policymakers for health reform: expanding access, improving quality and safety, and reducing costs, (but) extending these models of care to the general public will be difficult without action to bolster the future nurse workforce.

A nurse's primary job, as the nurse-of-all-nurses Florence Nightingale once said, is to take "charge of somebody's health." The Institute of Medicine found that nurses are more likely than any other health care professional to both catch medication errors and prevent hospital-acquired pneumonia (which can raise treatment costs by $28,000 and increase hospital length of stay by 5 days.) Research demonstrates that higher levels of hospital nurse staffing is directly associated with nearly 25 percent fewer adverse outcomes. Yet studies have also found that nurses spend perhaps only 30 to 35 percent of their time actually at a patient's bedside. The Institute for Healthcare Improvement would like to see this number double.

The Institute of Medicine and the Robert Wood Johnson Foundation are working on a joint initiative, The Future of Nursing, to develop a "clear agenda and blueprint for action."

We got a sneak preview of some of what they are thinking about through an IHI audio program. Taking part was the chair of the IoM panel Donna Shalala, PhD, former U.S. Secretary of Health and Human Services who is now president of the University of Miami; Sue Hassmiller, PhD, RN, FAAN, director of the RWJF Initiative on the Future of Nursing; and IHI vice president Pat Rutherford, RN, MS. (Listen to the program here.)

What changes can be made to address the nursing shortage (which some estimate could reach half a million by 2025), increase nurse retention rates (turnover is highest in hospital surgical units, and each time a nurse leaves, it costs the hospital $50,000 to $65,000 to replace her), and enable nurses to do what they do best -- provide quality direct patient care?

Among the problems and solutions the experts noted:

Stress and disruptive behavior is often reported within health care settings. Conflicts amongst nurses, and between doctors and nurses, lead to unsafe and stressful working conditions. Work environments should reduce waste and inefficiencies, improve communication and decrease the time nurses spend "hunting and gathering" for supplies and information etc.
As we have written before, the widespread (and smart) adoption of health information technology will help improve the safety, efficiency and effectiveness of the U.S. health care system. Nurses should be involved in the design, and be thoroughly trained in using the technology.
All nurses should go through quality improvement training with a focus on patient care.
Health reform includes an emphasis on primary, preventive and patient-centered care -- and nurses should be central to this. Rutherford argued that it is wrong to think that we can substitute nurses for primary care physicians -- but we can utilize nurses' skills to improve and expand the scope of primary care.
Nurses need to be more involved in transitional care; patients have better outcomes (and reduced rates of rehospitalization) when they have good transitional care following hospitalization. Hospitals, as an example, could establish nursing "SWAT teams." Nurses would go into a patient's home and ensure that it is adequate for the patient's post-hospitalization return. (Will the patient be able to easily get to the bathroom? Will the patient trip on throw rugs? Are the medications right?) Hospital nurses should also be encouraged to communicate more with community providers so they have appropriate information for successful patient "hand offs."
Nurses should have a bigger voice in the boardrooms of organizations that oversee the health care quality agenda in the United States. Nurses learn quite a bit about quality and safety -- and they know "what works" on the ground, not just in theory. (Right now, only two percent of all health care company board slots are occupied by nurses.)
One way to address the nursing school faculty shortage (which perpetuates the nursing shortage) may be to have top national nurse educators record lectures, webcasts and podcasts for widespread use, and have the local faculty focus on teaching students how to apply these classroom lessons directly in a patient care environment.
Clinical practice and education need to be more closely tied together. Hospitals should encourage mentorship amongst experienced and newly-minted nurses -- a bit like young doctors have internships. (Studies demonstrate that on-the-job-training lowers turnover rates of nurses.)
Nurses need more training in geriatrics because of the aging population.
Health care settings need to permit flexible working schedules to encourage older nurses to remain in the workforce longer. (We don't recall hearing this on the audio, but flexibility might help more nurses with young children remain on the job at least part time.)

Several hospitals and states are already making efforts to improve the "future of nursing." For example:

The Coalition to Protect Massachusetts Patients would like to restrict the number of patients that a nurse can care for at any time and ban mandatory overtime.
The New Jersey Hospital Association's Institute for Quality and Patient Safety received a $732,000 grant from the Robert Wood Johnson Foundation to help New Jersey hospitals implement RWJF's Transforming Care at the Bedside program. This program will "provide education and training in performance improvement for front line staff nurses so that they can identify, test and implement improvements on their units."
Mississippi and South Carolina have increased faculty salaries.
As we wrote last year, in 2004, the Childrens Hospital in Los Angeles started a program to help train new nurses and combat the high turnover rates. The Versant RN Residency, which has now spread to more than 70 hospitals across the U.S., pairs up new nurses with more experienced nurses who guide them as they acquire more complex skills.

Too soon to know which of these the IoM group will consider to be top priority, or how quickly we can act on them. But if we're going to fix our health care system and give people the care they need, we're going to need more nurses and we're going to have to use them more wisely.

IN THE STATES: How Health Reform Can Stimulate Colorado Economy, Create Jobs

Len Nichols — Fri, 13 Nov 2009 14:05:00 -0500

Talking about health care reform all over the country, I have the opportunity to see many states' health systems up close. In particular, we spend a lot of time in Colorado -- as evidenced by our study on Grand Junction. In the context of current reform discussions, I began focusing on the state in earnest in 2006 when the Colorado Blue Ribbon Commission for Health Care Reform began trying to identify a sustainable future for the state's health care system. It was a privilege to be consulted by the Commission -- a true bipartisan and multi-stakeholder effort -- about choices they could make to cover more Coloradans, improve the quality of care while reducing health care cost growth, and make the health system economically viable in the long run. At the end of a long and impressive (but surely exhausting) process, the Commission's recommendations look prescient, in that they are structurally and conceptually consistent with the federal health reform proposals under consideration today.

At the time, the Lewin Group evaluated the Commission's recommendations to quantify the number of people who would be covered, how much it would cost, and the potential savings to households.

This week we released a study that picks up where the Lewin Group analysis stopped. We wanted to evaluate whether, using Colorado-specific data about income, jobs and premium growth, health reform could actually help the Colorado economy. To an audience of local business leaders invited by the Denver Metro Chamber of Commerce, I explained that failing to fix the health system will only lead to higher costs and a more unsustainable system, and make the coverage crisis worse. Reform done right, i.e., along the lines of the Commission's recommendations, in contrast, will on balance create jobs and stimulate spending that will benefit the Colorado economy as a whole.

It is no secret that health care costs place increasing strain on households, employers and governments. So the first thing we did in our report was demonstrate, with original and secondary state-specific data, that the economic consequences of maintaining Colorado's current health system are not good. Without reform in Colorado:

Health care and premium costs will grow at more than twice the rate of economy-wide productivity.
More Coloradoans will be uninsured, fewer will be covered by employer-sponsored insurance, and more will rely on Medicaid coverage.
Employer health care contributions will continue to rise.

Still, at a time when Colorado faces a two-year budget deficit of more than $2 billion, our task was to answer one fundamental question: will the economic benefits of coverage expansion and improvements to the delivery system outweigh the cost of financing health reform? We found that while significant state investment is required to finance reform, the resulting economic benefits will exceed the costs.

Specifically, our study found that expanding health insurance coverage in Colorado will (in 2019):

Lead to $3.8 billion in new economic output, with nearly 60 percent of new economic activity occurring outside of the health care sector.
Create 23,319 jobs, with 40 percent of job growth occurring outside of the health sector.

We also found that in addition to the benefits of coverage expansion, delivery system reforms alone could (in 2019):

Yield between $11 and $38 billion in additional savings.
Lower premiums by 5.5 to 17 percent

Finally, delivery system reform could have significant benefits for employers. In particular, health care reform will (in 2019):

Reduce uncompensated care costs and increase Medicaid payment rates, thereby reducing costs that are shifted to the privately insured
Establish a more efficient, high-quality delivery system
Lower premiums compared to what they would otherwise be by between 9.7 and 24.8 percent

The good news is that Colorado has already made progress toward health care reform. In particular, Colorado is leading the way to a more sustainable health system through innovative multi-stakeholder partnerships, integrated systems of care like Denver Health, and innovative communities like Grand Junction. Health reform is certainly a shared responsibility -- households, governments, and employers have a role to play. Colorado is poised to lead the way, if its leaders are willing to invest in the most effective ways.

IN THE STATES: Comparative Effectiveness in Minnesota

Meredith Hughes — Thu, 12 Nov 2009 19:49:00 -0500

What is comparative effectiveness research? If you need a reminder: comparative effectiveness means comparing two or more treatments for the same health problem to see which one works best for patients. The question has popped up quite a bit since comparative effectiveness research showed up in the economic stimulus package alongside other common sense health reforms, such as health IT adoption. Comparative effectiveness is about giving doctors and patients more information and facts for decision-making, not about taking away their autonomy.

Here's a real world example that's worth noting. The Institute for Clinical Systems Improvement (ICSI) in Minnesota is an example of an independent (private), non-profit organization that works to assemble and disseminate comparative effectiveness research. Clinicians in ICSI review medical literature and make recommendations about the most cost effective treatments based on the best available evidence. HealthPartners Medical Group, the Mayo Clinic, and Park Nicollet Health Services jointly founded ICSI in 1993. ICSI is made up of 57 member organizations and is funded by seven Minnesota and Wisconsin health plans. (The research funded by the federal stimulus bill looks at effectiveness, and doesn't make recommendations based on cost.)

ICSI maintains a list of evidence-based health care guidelines to encourage member organization to adhere to the best clinical practices. When better evidence comes along, previous guidelines get retired to make way for higher standards of care. For example, the most recent ICSI report updated care guidelines in several categories:

Obesity Guidelines. Because obesity presents such significant health concerns for the U.S., the Prevention and Management of Obesity in Mature Adolescents and Adults Guideline workgroup revised this document in 2008 to provide a more multi-faceted approach. It updated information on body mass index (BMI) and co-morbid conditions to include approaches to weight loss for each BMI category. Content and clarifying language were added to the waist circumference annotation. Conclusion grading worksheets on physical activity and low carbohydrate diet were incorporated into the related annotations, and one on surgical approaches to weight loss was added to the guideline.

Preventing Chronic Disease Through Primary Care. The guideline defines strategies and programs providers, communities, payers and employers can offer to support patients to make essential changes in four behaviors that contribute to roughly 40 percent of all deaths in the U.S. -- poor nutrition, physical inactivity, smoking and hazardous alcohol consumption. As a result, its recommendations are being used to address conditions like prediabetes, and are seen as a preventive component of care in health care homes.

Surgical Protocol: Before, During, and After an Operation. ICSI significantly revamped this protocol to describe all the steps performed throughout the pre-, intra- and post-operative periods of surgery. The protocol outlines the processes involved in obtaining patient consent, and verifying and marking the surgical site. It addresses the prevention of site infection for numerous surgical procedures, starting with the preoperative evaluation and surgical planning and proceeding through the perioperative period.

Guidelines and protocols describing the best standards of care are the primary goal of ICSI, though they also provide support for member institutions through strategic initiatives such as DIAMOND (Depression Improvement Across Minnesota, Offering a New Direction). DIAMOND is a collaborative care model that emphasizes depression detection and treatment. The program has six components:

A checklist that helps the care team detect and monitor symptoms of depression (ICSI discovered that most primary care physicians only pick up about half the cases of major depression in their patients)
A way for the care team to monitor the depressed patient
A proven medical guide to know how best to change or intensify treatment
Tools to keep a patient who is getting better from falling back into major depression
A care manager to educate and help the patient reduce depression symptoms and improve functioning
A psychiatrist to review patient cases with the care manager and consult with the primary care physician on any recommended changes in treatment

ICSI member organizations Community-University Health Care Center, Family HealthServices Minnesota, HealthPartners, Mayo, and SuperiorHealth Center launched the DIAMOND program in just 10 primary care clinics in early 2008, and by September, the program had spread to approximately 30 clinics serving 1,000 patients. According to ICSI, after six months in the program 47 percent of depression patients were in remission, and an additional 12 percent showed significant improvement.

ICSI's experience in Minnesota shows us that comparative effectiveness research can be a great tool for health care quality improvement. By working together and committing themselves to the most up-to-date, evidence based treatment guidelines, ICSI member organizations are able to provide high-quality, patient-centered care.

QUALITY: Seven Percent of Premier Hospitals Increase Lives Saved -- Can the Other 93% Follow Suit?

Tom Emswiler — Thu, 12 Nov 2009 17:08:00 -0500

We're always on the lookout for health care success stories. (Even if they are smaller scale than we'd like -- but we'll get to that.) Premier, Inc., a quality improvement alliance and group purchasing organization, just reported excellent quality results from a year-long initiative. It's called QUEST, which stands for Quality, Efficiency, Safety, and Transparency.

After sharing data, adopting measures such as aspirin and beta blockers for heart attack patients (inspired by CMS's Hospital Compare), rapid response teams (inspired by IHI, a QUEST collaborator -- and written about by our program in our Baylor case study), and giving clear instructions to patients at discharge so they are less of a readmission risk (a cost containment target for numerous reformers), the 157 participating hospitals calculated that they saved 8,043 lives and $577 million. That's an absolute real achievement.

Premier also performed a little back-of-the-envelope math: if all 5,000 acute community hospitals made the same progress, 52,000 additional lives would have been saved. Don Berwick and others would argue that these lives SHOULD be saved: it is not an achievement to save these lives, it is a necessity because all that is required is to implement evidence-based medicine. The professionals that work to deliver health care should offer no less.

Well -- how should that happen? As Premier CEO Susan De Vore wrote on the RWJF blog, these results were achieved via a voluntary effort. This is great for two reasons. One, we know what is achievable -- real lives and real money saved. Two, these aren't just academic medical centers in Boston or the Mayo Clinic in Minnesota. It included hospitals like Indian Path Medical Center near my in-laws' house in rural Tennessee.

But I performed a little back-of-the-envelope math of my own. 157 participating hospitals represent 7.1% of all of Premier's 2,200 hospitals. 157 participating hospitals represent 3.1% of all acute community hospitals. These data tell us that this is a pilot project: good hospitals working on being great. Yet it was quite limited in scope.

How can we get other hospitals engaged? It cannot be via voluntary effort. The literature tells us that voluntary efforts fail. Not just kind of fail - really, really fail.

The Premier data show that these reforms can take place. Their press release notes that the participating hospitals were from 31 states and included urban and rural, large and small, and teaching and non-teaching facilities. No one type of hospital was successful in implementing these quality improvements. That's important. If there is a hospital in America that wants to put these reforms into action, chances are there is a Premier facility that would be willing to collaborate to help that hospital save lives and money.

To be sure, Premier has done an excellent job engaging hospitals that want to improve quality. This summer, I posted on year four of their seminal P4P demonstration with CMS. That initiative, like QUEST, shows us what can be accomplished.

Patients and taxpayers, though, deserve a country full of these hospitals, not a single digit smattering of hospitals. To turn such voluntary efforts into mandatory ones, we need increased transparency and robust payment reform. It will save hundreds of thousands of lives over several years and billions of taxpayer dollars. The American people deserve no less.

WORLDVIEW: U.S. Lags In Primary Care

Meredith Hughes — Mon, 09 Nov 2009 20:40:00 -0500

The U.S. lags behind other leading industrial democraties in primary care, according to a new study from the Commonwealth Fund. The report, A Survey of Primary Care Physicians in 11 Countries, 2009: Perspectives on Care, Costs, and Experiences, surveyed doctors in Australia, Canada, France, Germany, Italy, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom, and the United States. It found the U.S. falls behind significantly in access to care, the use of payment incentives to improve health care quality, and utilization of health information technology.

Health IT. The U.S. lags behind every surveyed country except for Canada in health IT adoption. In the Netherlands, New Zealand, Norway, the U.K., Australia, Italy, and Sweden, over 90 percent of doctors use health IT, while in the U.S., only 46 percent of doctors use health IT. (It's worth noting that the U.S. has prioritized funding for health IT through economic stimulus package, and approximately $1.2 billion in grants has gone out to health IT development and implementation since data collection for this study concluded in July 2009.)

Cost. About half of U.S. doctors reported insurance restrictions were an obstacle to obtaining the treatment and medication their patients needed. More than half of U.S. doctors said their patients had difficulty paying for medication and care, more than any other surveyed country. Patients who struggle to pay for medical care are less likely to comply with treatment recommendations, and more likely to stay sick or get sicker. Millions of Americans go bankrupt every year because of medical debt.

Access. Only 29 percent of U.S. physician practices had arrangements to get patients reliable after-hours care -- which means many patients rely on costly visits to a hospital emergency room. In the Netherlands, New Zealand, the U.K., France, and Italy, more than 75 percent of physician practices had alternative arrangements. (Some examples of after-hours care arrangements include on-call clinicians and after-hours clinics.)

Financial incentives. The report found that other countries rely predominately on general practitioners or family practice physicians, in conjunction with primary care nurses. Primary care nurses counsel patients about healthy lifestyle choices, and help coordinate care of chronic conditions. In some countries, such as the Netherlands and the U.K., primary care doctors serve as gatekeepers for referrals to specialists. Elsewhere, patients and providers have financial incentives to rely on primary care. The U.S. offers few financial incentives to primary care doctors. Compared to 89 percent in the U.K. and 70 percent Italy, only 36 percent of U.S. doctors report receiving financial incentives. In many ways our payment system is geared to favor specialists with higher pay, and it discourages medical students with huge debts to go into the lower paying medical fields associated with primary care. We're facing a shortage of primary care physicians. On the other hand, one area the U.S. prevailed in was the wait time to see a specialist -- only 28 percent of doctors reported long waiting times for their patients to see a specialist, compared to more than 75 percent in Canada and Italy. However, the U.K. reported an even lower level of wait times to see a specialist -- only 22 percent.

Good primary care is the foundation for good health care. Research into primary care shows that good primary care leads to healthier populations, better health outcomes and lower costs. The U.S. has examples of both excellent and woefully inadequate primary care. The lack of a "strong primary care backbone" is the main difference between the U.S. and other countries, notes the Health Populi blog. Our reliance on internal medicine and pediatrics for primary care, coupled with very decentralized referral systems, makes the United States system of primary care uniquely different from the other surveyed countries. But as the study shows, that isn't necessarily a good thing.

QUALITY: A Good Beginning for Better Endings

Joanne Kenen — Fri, 06 Nov 2009 16:02:00 -0500

After all the sound and fury of last August, we're pleasantly surprised that the right hasn't risen again with all sorts of horror stories about the resurrection, so to speak, of the "death panels." Maybe because all that fear-mongering was finally discredited. Maybe we are finally getting just a little bit smarter.

The inevitable focus on the politics of health reform, and the disproportionate amount of attention paid to the public plan, sometimes obscures the many ways that the House and the Senate health plans are ambitious. Not perfect. Ambitious. I've heard experts, people I like and respect, say the legislation does "nothing" to advance the cause of quality of end of life care in America. They are wrong. The House and Senate bill each contain measures that would advance that cause -- not fix it completely, far from it, but they will take us important steps in the right direction. It's too soon to know which of these measures - if any -- will survive a final melding of House and Senate legislation. But let's look at them here because, except for the end of life consults which got way too much of the wrong kind of attention, they haven't gotten adequate attention. In an accompanying guest post. Dr. Ira Byock, director of palliative medicine at Dartmouth-Hitchcock Medical Center in New Hampshire, talks about what these changes can mean for his patients and their families.

One of the most damaging myths, or at least misunderstandings, in what passes for our national discourse about health policy is that our culture (and too often our doctors) have trouble talking about end of life care. And when we do talk about it, we don't always know what we're talking about. That confusion in turn fueled the "death panel" chaos of last summer.

An advanced directive -- whether a "living will," a health care proxy or a Physician Order for Life Sustaining Treatment -- does not mean "pull the plug." It does not constitute a license for rationing. It does not obligate you to "give up." It is not irrevocable.

An advanced directive is a tool. Properly used, it is a tool that helps you decide how you want to live out your final days, weeks or maybe even months. It is a tool that helps your doctors know what your wishes are so they can respect them. It is a tool that lets your family know what you want, so they too can respect your values and wishes, and avoid the anguished second-guessing and potential family conflict that ensues when people don't know or can't agree on what is best for an incapacitated loved one. If you want aggressive high tech care, a ventilator and a feeding tube and all that is offered in an advanced ICU, you can state that. If you want a DNR you can state that. And if you want something in between those options, you can say that too. (And we do so wish that the move to change the terminology eventually catches on, so that instead of Do Not Resuscitate, or DNR, we talk about Allow a Natural Death, or AND).

The House kept in its bill the VOLUNTARY advanced directive consult provision.(The word VOLUNTARY appears at least five times.) Basically, this means that Medicare will reimburse doctors for taking the time to talk to an elderly patient about what he or she may face medically and how he or she wants to confront it. Right now, there are all sorts of built-in disincentives -- cultural, emotional, legal and yes financial -- against having that conversation. The incentives lie in the other direction: Doctors, and ERS and ICUs are all reimbursed for giving you the aggressive care, and aggressive care is often the default form of care. Maybe our system should make sure you want it.

In addition, the House bill (Section 240) requires health plans in the new insurance exchanges make available to beneficiaries information about end of life planning and the option (Repeat after me: The Option. Not the requirement. The Option) to complete an advance directive or, in accordance with state law, a Physician-Order for Life-Sustaining Treatment (Not Life Terminating Treatment. You can repeat that a few times too.) The bill explicitly states this "shall not promote suicide, assisted suicide, euthanasia, or mercy killing." It also explicitly states that the provision "shall not presume the withdrawal of treatment and shall include end-of-life of life planning information that includes options to maintain all or most medical interventions."

The Senate left that out of the Finance bill. But the Senate bill does incorporate some -- not all -- of what's been on the wish list of hospice and palliative care doctors and nurses and social workers and chaplains for years. For instance, a number of states have been individually seeking Medicaid waivers so that seriously ill children can get hospice for 12 months instead of six -- and that they can also get concurrent, curative care. In other words, as a parent, you don't have to choose between say, chemotherapy, and all the support and symptom management and family assistance of hospice. The Finance bill would wipe out that lengthy, cumbersome, bureaucrat, financially-restrictive waiver process. All seriously ill children in Medicaid in any state could get concurrent curative and hospice care. It isn't that expensive, and it is so badly needed.

And it's not only kids who benefit. The Finance bill sets up a 26-site hospice concurrent care demonstration project in Medicare, so adults too in these test programs can have both curative and hospice care. Some earlier tests and research suggests that this isn't just going to improve the quality of care for people with advanced and life-threatening illnesses, it's actually cost effective. Given a better and gentler continuum of care, without having to make the stark either/or choice of hospice, people often end up gradually shifting the balance as their disease progresses. It is their choice. But their choice is often less aggressive care toward the end.

The concurrent care model, says Jon Keyserling, vice president of public policy and communication at the National Hospice and Palliative Care Organization, "lets you meet patients where they are." The NHPCO and other trade and advocacy groups have a longer list of programs they'd like tested, but Keyserling noted that legislation can be monumental or incremental -- and in some ways, health reform 2009 is both. The sweep of the whole bill is monumental; some components are incremental. But they are a start, and they can be built upon.

The House and/or the two Senate bills do include numerous provisions that have the potential to improve care for seriously ill people (and even nibble around the edge of the long-term care crisis -- which isn't addressed head-on by the current health reform bills). This post is long enough, so we won't go into detail here. But the bills include things like advanced medical homes for people with chronic disease, iniatives to reduce hospital readmissions, bundled payments, transitional care benefits (paying hospitals to do a better job of moving a patient from one care setting to another), assorted quality measurements, pilot programs to improve home-based (as opposed to institutional) care, even a new research initiative on undertreatment of pain. All these steps, whether they survive in a final bill this year or become part of the "building on" agenda for the future, mean paying attention to, and talking about, and doing something about, the needs of the old, the frail, the seriously ill and the vulnerable among us. Our grandparents. Our parents. And someday, ourselves. It's the one thing we all have in common.