Health Reform

QUALITY: Fessing Up to Serious Medical Errors

Joanne Kenen — Tue, 08 Jul 2008 18:16:00 -0400

A prominent Boston hospital made a big mistake (operating on the wrong side of the patient—who luckily should be fine) and then told the whole world—including the Boston Globe—about it in an email and a blog post from the hospital CEO in which he describes the circumstances and the hospital's response.

We like Beth Israel Deaconess CEO Paul Levy's Running a Hospital blog, and we link to it now and then. Beth Israel has a reputation for being a leader in both quality improvement and transparency, and Levy often writes about how even people on the lower rungs of the hospital hierarchy are encouraged to pipe up when they see something potentially unsafe or just inefficient. What really bothered us about this case was the hospital does have a "time out" policy—before the surgery, the team is suppose to call out, "Right patient, right procedure, right side." No one did, and no one spoke up. It bothered Levy too. As he said, the "culture of safety" hasn't permeated everywhere it needs to go.

Not only did Levy tell the Globe about it (yes, it's textbook PR crisis management, coming clean, as some of the more cynical commenters on his blog pointed out, but it's still the right thing to do), he then even provided a handy list of blogs that have been examining his actions. We liked this comment from the "New York Personal injury Law Blog," which we hadn't come across before, that said

This type of conduct is simply unheard of from my view in the medical malpractice world. I've taken testimony from hundreds of doctors. Exactly one has acknowledged that he made a mistake. .... If more hospitals and doctors acknowledged mistakes and sought to learn from them—as Beth Israel Deaconess is doing—it would probably go a long way to putting medical malpractice attorneys out of business.

Medicare, several states, and some health plans are moving toward a system where they don't pay for care stemming from preventable errors. That may be a powerful incentive in reducing them. But we like Levy's approach too. Develop safety systems. Talk about them. Address their failures. And fix them.

REFORM: IHI's Triple Aim Rolls into DC: Part II - Population Health

Tom Emswiler — Tue, 08 Jul 2008 14:38:00 -0400

Yesterday we focused on the who-what-why of the Institute for Healthcare Improvement's seminar titled "Achieving the Triple Aim: The Simultaneous Pursuit of Excellent Health, Ideal Care, and Controlled Costs." Now let's focus on the first aim: population health.

During the early part of the event, we were shown a pie chart titled "Determinants of Health and Their Contribution to Premature Death," with data adapted from this Health Affairs article by Michael McGinnis and colleagues (subscription required). Measured as "Proportional Contribution to Premature Death," behavioral patterns constitute 40%, genetic predisposition is 30%, social circumstances 15%, health care 10% (!), and environmental exposure 5%. It would normally be ambitious to say that a person's local health care provider influences both behavior and care, adding up to 50%—but as the seminar progressed we were encouraged to think (pardon the phrase) "outside the box"—what are the social circumstances? Why not partner with community leaders to reduce homicides, like one pediatric surgeon did when he helped found the Cincinnati Initiative to Reduce Violence (CIRV)?

This pediatric surgeon had become sick of seeing so many children become victims of gun violence. He decided to "go upstream" to stop the killing. He partnered with the city government, Procter & Gamble (based in Cincinnati), schools, Cincinnati Children's Hospital, and even ex-convicts willing to go back into their community to stop the violence. The city began fully prosecuting offenders, and at the same time a "Community Works" program began to help support job training, employment, education, and social services. Goals include reducing shootings, helping residents feel safe, decreasigng drug sales and helping residents train for and hold jobs. All these goals can be measured with crime and survey data. All have a health component.

The results? This initiative really got off the ground about halfway through 2007, and 2007 became the 2^nd lowest homicide year in the past six years. 2008 is also rather low thus far. This is not due to Cincinnati Children's investing in new technology or adding 100 new beds. Rather, they have worked with other organizations in the community to improve the health of the people of Cincinnati.

"Go upsteam" was spoken by Dr. Bonnie Zell of the Centers for Disease Control when she was describing the program in Cincinnati, but she was referencing a story told by a someone from Genesys Health System, where their CEO tells people to imagine themselves at Niagrara Falls. Let's say you see a person down at the bottom of the falls, struggling. You have the means to save them and you do so. But just as soon as you do, you notice a couple more people at the bottom of the falls. You're able to keep up rather well saving the many people in the water—but shouldn't you be asking yourself why so many people are going over the falls? Perhaps the answer isn't more life jackets, but a guardrail upstream.

I'll be back tomorrow to look at how to improve the patient care experience.

COST: Krugman and the Links Between Health Care and the Economy

Paul Testa — Mon, 07 Jul 2008 21:41:00 -0400

Health care is the Kevin Bacon of economic maladies. Name a problem facing the U.S. economy and, without too much effort, you can find a way link to the wealth of nations back to the health of nations. New York Times columnist Paul Krugman zeroes in on this connection in his column today, discussing the close link between health care, jobs, and the economy. He argues:

Most public discussion of health care focuses on the problems of the uninsured and underinsured. But insurance premiums are also a major business expense: auto makers famously spend more on health care than they do on steel. One of the underemphasized keys to the Clinton boom, I’d argue, was the way the cost disease of health care went into remission between 1993 and 2000. ... But premiums surged again after 2000, imposing huge new burdens on business. It's a good bet that this played an important role in weak job creation.

Krugman's point on the "huge new burdens" facing businesses echoes our recent policy paper regarding employer health costs in a global economy. We show how manufacturing firms in the U.S. pay more than twice as much in hourly health costs as their major trading partners—$2.38 per worker per hour versus $0.96. With similar trends in many U.S. industries, it's not surprising that, since 2000, the percentage of employers offering health benefits declined from 69 percent to 60 percent according to the 2007 Employer Health Benefits Surve y.

At $2.2 trillion a year, health care plays a major and complex role in the U.S. economy. Krugman simplifies the situation to make a political point about who's to blame for our current economic woes. But the long term relation between health care cost growth and job creation is hard to parse out with 15-variable econometric models let alone 25 inches of prime column space. And when it comes to the economy, the question should not be who is to blame but what is to blame. Here, Krugman is right to highlight the importance of health care to the overall economic welfare of the U.S. Our current economic problems are not an excuse to beat around the bush on health reform. America will recover from its current economic woes, and when it does, it will still be faced with a crumbling health care system in need of sustainable reform.

REFORM: IHI’s Triple Aim Rolls into DC: Part I – Introduction

Tom Emswiler — Mon, 07 Jul 2008 14:00:00 -0400

I had the pleasure recently of attending the Institute for Healthcare Improvement's seminar titled "Achieving the Triple Aim: The Simultaneous Pursuit of Excellent Health, Ideal Care, and Controlled Costs." IHI is a Massachusetts-based nonprofit that seeks to improve all aspects of health care: better quality, lower cost, more efficient. You might have heard of its current campaign to prevent five million incidents of medical harm. That's really just the tip of the iceberg; to find out more, visit them on the Web.

The conference was among the first at the fancy new National Harbor complex just south of Washington, D.C. (truly a sight) over two days. Conferences typically use classroom-style learning, lectures, panels, and powerpoints. This seminar featured a prominent role for small group exercises where we were able to reason out how to implement some of the solutions that were being discussed; how to make them go from theory to practice. Groups of about 10 sat around tables and shared stories. I was quite intrigued by a delegation from a Gulf Coast state that included both physicians and insurance officials who were able to engage in a real life, cross-organization workshop.

We used vignettes to describe different scenarios, and thought about how the health care system could address them. Examples: Darryl is an eight year old with asthma. His working mom has trouble getting him in for appointments. His father, whom he stays with on weekends, doesn't believe he has asthma despite multiple hospital admissions. Eleanor is a 79-year-old retired nurse with diabetes and mild congestive heart failure who has a stroke. Don is a 52-year-old who's been street homeless for four years, is in methadone therapy and drinks heavily; he has four hospitalizations in the last 18 months. During the course of the seminar, we learned different ways to improve the health of these individuals, improve their experience within the health system, and limit their financial cost. In subsequent posts this week I'll explore each of the three triple aims.

One more item of note: I was very surprised how international the attendees were. There were 125 American participants, 20 from Canada, eight from the United Kingdom, two from South America, one from continental Europe, and one from Africa. From talking with other participants, I can tell you that other nations, whether they insure all their people or not, face many of the same obstacles in care delivery. That's why the triple aim attracted them. I'll be back tomorrow with a look at population health.

IN THE STATES: San Francisco's Ride on the Health Reform Trolley

Paul Testa — Thu, 03 Jul 2008 16:54:00 -0400

Rice-A-Roni may be the San Francisco treat, but health reform has been the topic du jour of late for the Bay City. As the San Francisco Chronicle noted, yesterday marked the one-year anniversary of Healthy San Francisco—the city’s ambitious plan to make health care accessible and affordable to its uninsured residents.

Like a cable car descending Nob Hill, there have been a few bumps along the way—the growing pains health reform—as well as uncertaintity because of a pending decision from the Ninth Circuit regarding the legality of the city’s efforts. Still, the plan is an innovative effort from one of the cities described in a recent Families USA report as being on the front lines of America’s health care crisis.

The key elements of San Francisco’s plan are laid out nicely here, but we’d like to highlight two points from the initiative:

An emphasis on medical homes in which a participant chooses one of 27 participating clinics to coordinate their care.
Shared and individual responsibility represented by income-based cost-sharing on the part of individuals and an employer contribution for firms with more than 20 employees.

New America health policy program director Len Nichols provided a positive and realistic assessment of the plan for the Chronicle article:

For a city to try to do it at all is pretty amazing. Ultimately, we're going to need federal help to make health care access a reality in this nation, and it's impressive San Francisco is trying to do it in whatever patchwork way they can.

REFORM: Watch Out Harry and Louise, Here Comes Elizabeth

Joanne Kenen — Thu, 03 Jul 2008 16:38:00 -0400

Harry and Louise, watch out for Elizabeth Edwards.

The New York Times politics blog reports that Health Care for America Now, a coalition of labor, health care and liberal organizations pushing for comprehensive health reform, will roll out a new television commercial next Tuesday, part of what the group says is a $40 million planned campaign to promote affordable health care under the next administration. The idea is to have a pro-reform media message as powerful as the insurance industry's Harry and Louise ads were in fighting health reform when Bill Clinton was president.

Elizabeth Edwards, breast cancer patient, wife of former Democratic Sen. John Edwards, health policy blogger and visible proponent of health reform, will speak at the group's inaugural event in Washington next week.

The Times reported that after the initial buy of $1.5 million for national television, print and online advertisements, the coalition plans to pour $25 million into additional advertising. The first commercial will run in national newspapers, on CNN and MSNBC and online.

We expect to see lots of ads battling back and forth as the issue heats up. It's an election year, so we realize that things will get rather heated. Here at New America, we're still hoping that both sides don't get so caught up in the politics that, whoever is in the White House next January, they can't sit down and start working together for sustainable solutions that will help all Americans get the health care they need in a way our country can afford.

COVERAGE: Living on a Prayer

Len Nichols — Thu, 03 Jul 2008 14:35:00 -0400

If a pastor gets sick, given a choice between "a wing and a prayer" or "a wing and a prayer and health insurance," he or she would probably choose the second option—if it's available.

A recent survey by the National Association of Evangelicals found that the churches and related evangelical organizations are having the same challenges as other Americans, and jerry-rigging some of the same partial solutions. But significant numbers of pastors—the format of the NAE's survey wasn't designed to produce a precise estimate—go uninsured. Others get their coverage through their spouse's job, or by holding down a second job outside their church that gives them access to coverage. Those over 65 can get Medicare. Some are poor enough to qualify for Medicaid. Young pastors who are relatively healthy sometimes opt to get a private policy instead of buying into a church or denomination-sponsored plan, meaning the bills go up for the older and sicker.

"Only a few of our churches are adequately addressing this problem," one denominational leader was quoted as saying in an NAE report. "We tried two or three items to provide health insurance, but we have not been able to make it work," lamented another.

"This is a large and growing problem for American pastors and churches,' said Leith Anderson, NAE president, "So many churches are small and too many pastors are uninsured. There is no room in limited budgets for premiums or no way to get adequate insurance at any price. As clergy age with the rest of America's population, we may see a growing list of pastors entering retirement with bankrupting medical bills."

The NAE has been instrumental in cultivating support within the Christian community for addressing global warming and issues of environmental sustainability more generally. We have hope they might someday come to play a similar role in broadening support for a more sustainable health care system that works for all. I was in West Virginia last week for a series of meetings coordinated by the West Virginia Council of Churches. Evangelical churches are not part of the Council there, but representatives from their community did come and participate in two of the meetings in Charleston. Let's just say we all learned a lot, and hope and expect to continue dialogue about what Scripture has taught us ought to be and what health policy analysis has taught us can be.

COST: Weighing in on the Value of CT Scans

Guy Clifton M.D. — Wed, 02 Jul 2008 20:39:00 -0400

Sunday's New York Times's article, the first in a series on evidence-based medicine, got me thinking about how we set standards for the practice of medicine, and what it will take to get doctors to follow voluntary ones.

The extensive front-page article examed the prevalence and value of computed tomography (CT) angiography. In brief, CT scanners can generate a complete image of the heart (see NBC's Matt Lauer's here and Oprah Winfrey’s here).The technology is impressive. So is the price. A CT scanner costs about $1 million. Doctors and hospitals that make the investment have a large incentive to recoup their costs by ordering CT scans, ($500-$1,500 a test). In some specific circumstances, CT angiography provides more information than other heart studies. The Times noted certain situations in an emergency room where it could be highly useful. But in most circumstances it is more like a screening tool to search for hardening of the arteries. But the CT scan doesn't say whether someone needs the blockages opened. That has to be determined by coronary angiography, placing a catheter through a vessel in the groin and then threading it up to the heart. That's an invasive procedure that provides necessary details on the exact location and extent of blockages.

The question raised in this article is, "What is the value of CT angiography of the heart as screening tool for heart disease?" How many people have no symptoms of heart disease but have some risk of developing it? Almost any adult. With the possibilities for using the imaging technology virtually unlimited, how do we set limits? Don't assume Medicare will. As the Times noted, Medicare did say last year that it wanted more evidence before paying for these scans, but backed off after extensive lobbying of the agency and Congress by cardiology groups.

Some of the cardiologists in the Times article describe detecting lesions that they otherwise might not have discovered; others, more critical of the spreading technology, countered that they hae other tools to monitor and diagnose their patients. The American College of Cardiology has established some general guidelines for the use of CT angiography of the heart based upon the limited information that is available. The use of CT angiography to detect heart disease in patients with low risk for heart disease is considered "inappropriate". Its use to detect heart disease in patients without symptoms who are at high risk (such as those with high cholesterol and a family history) is of "uncertain" value.

One risk of this procedure is that the level of radiation delivered has a cumulative effect on a patient's risk of cancer. Another is that it can give either false positive or false negative results leading to either unnecessary additional procedures or a potentially dangerous sense of false security. Therefore, the American College of Cardiology considers its use "appropriate" under only very specific circumstances.

These and other guidelines like them are issued by organizations, but an individual doctor's adherence to them is neither measured nor reported. Such guidelines, therefore, have almost no impact on medical practice and pretty clearly have not influenced the debate over the use of this technology.

Not surprisingly, the article generated a rash of responses almost all of them decidedly critical of the current environment in which CT scans are used. The Health Care Blog picked up on an especially interesting section of the article, in which a Dr. Harvey Hetch responded to criticism of his decision to order a CT angiography saying: "it's incumbent on the community to dispense with the need for evidence-based medicine. Thousands of people are dying unnecessarily."

The irony of Dr. Hecht's words is that the opposite is more likely true. I would say that the lack of measured and reported standards of medical practice kills people. The adherence to evidence-based standards of practice could saves lives and a lot of money.

As it is now, a patient that goes to a doctor has only about a 55 percent chance of receiving treatments that are the standard of care.

We in medicine must know what care our patients need -- and then we must provide it. We shuld not provide unneeded care. Thinking about coronary CT scans, and medical innovation in general, raises the following issues:

What is the relative weight of risk to benefit of new technology in specific patient groups?
Since no agency or company is required to determine the value of new technology, only its safety, who should do it?
Doctors can use new technology as they wish, even if they profit from ownership of the equipment. Should use of new technology be restricted to circumstances in which its benefit is proven?
If there were reliable standards for the use of technology such as CT angiography, who will measure the pattern of a doctor's practice to determine if he or she is practicing mostly within standards or far outside of them?

As a neurosurgeon, I do not want to impede the development of new technology. I have seen what technological breakthroughs have done for patients. But appropriate assessment and use are not impediments. They serve to protect the public.

REFORM: Fixing Medicare Could Help Us All

Joanne Kenen — Wed, 02 Jul 2008 20:32:00 -0400

We all know Medicare has problems. What you may not know is that we really do know a fair amount about how to fix it—and part of the solution has to do with changing the kind of medicine we use to take care of our over-65 population. Inside E Street, an AARP television production, (click here to watch—and you don't have to be 50 to learn something from it) invited several experts including New America's health policy program director Len Nichols to brainstorm.

Among the suggestions: use technology not only to keep better medical records that help doctors coordinate care across several specialists, but also to take better care of people at home. We have the means—and we'll develop more in coming years—to monitor people at home, and know when and how to intervene before a crisis develops in a patient with conditions like diabetes or congestive heart failure.

Len reminds us that Medicare can be a catalyst because the program has so much influence over the whole health sector. So fixing Medicare is good for all of us—not just because of the economic implications but because by getting care right for the elderly we can probably improve health for us all.

REFORM: Kennedy Spurs Bipartisan Conversations about Health Legislation

Joanne Kenen — Wed, 02 Jul 2008 17:10:00 -0400

We perk up when we hear phrases like "bipartisan support for a major healthcare initiative," especially when the bipartisan push is coming from Senator Edward Kennedy. Today's Boston Globe reports that while Kennedy recuperates from his brain tumor surgery, his office has begun a series of bipartisan meetings with an array of health care specialists to prepare for a major push to cover all Americans when the new president takes office next year. The paper reported:

Those involved in the discussions said Kennedy believes it is extremely important to move as quickly as possible on overhauling the healthcare system after the next president takes office in January in order to capitalize on the momentum behind a new administration.

Kennedy is chairman of the Senate Health, Education, Labor and Pensions Committee; Obama is a member, and his Senate staff has attended the roundtable discussions, the Globe reported. But Republican staff is also involved, as Kennedy tries to identify areas of agreement, possible starting points. Kennedy has made health care a signature issue in his 45 years in the Senate, and even before his aggressive brain cancer was diagnosed he made no secret that he wants to seize the moment and act next year.

"You have got to think this will be the Ted Kennedy Health Reform Act, because he's a beloved figure and he's championed the issue for so long," said John Rother, policy director for the AARP, which has been involved in the discussions. "There are a lot of unknowns right now, but what we do know obviously is he is very close to Obama, and he also has quite a network of health policy experts that he can draw from."

The newspaper reported that Kennedy's aides have also been working with a network of Massachusetts advisers, talking about ways the state's health program could possibly be adapted to a national model.

The many lessons of the 1993–94 health care reform debacle include that it was too partisan, and that the Clinton White House did not involve Congress enough in developing its plan. Kennedy is not alone in trying to do things differently this time. The Senate Finance Committee, chaired by Montana Democrat Max Baucus, in June held a day-long bipartisan summit on health reform. Oregon Democrat Ron Wyden and Utah Republican Bob Bennett have a health reform proposal that has attracted bipartisan interest. Various nonprofit groups are running bipartisan programs to help congressional staff better understand the challenges of health care reform. We know from our conversations with people around Washington that there really is a desire to do things differently this time, so we're thrilled to see Kennedy make this a priority for his country, even as he confronts his own health ordeal.