Quality

It's hard to be ideological when you're in the operating room with a patient's life in your hands.

We assume that's at least part of the roots of the pragmatism that makes Dr. Atul Gawande such a refreshing voice in health reform. Gawande kicked off day two of the Health Action 2009 conference, reiterating the case for health reform that avoids the "lure of the ideal" to build off what we have and what is possible.

Much of Gawande's public presentation followed along the lines of his recent New Yorker piece that our colleague Joanne Kenen wrote about earlier this week. We'll focus on the highlights from a brief round table with Gawande and other health bloggers that followed his presentation.

Gawande reiterated the three basic attributes of a reformed health care system:

We told you about yesterday morning's session of the Health Action 2009 conference, when we heard from members of Congress likely to play key roles in health reform. Now we want to catch you up on the afternoon session, when we heard from some congressional staffers who will actually write the legislation.

The panel featured Yvette Fontenot, who works for Chairman Max Baucus (D-MT) at Senate Finance, Karen Nelson, health policy director for House Energy and Commerce Chairman Henry Waxman (D-CA), and John McDonough, senior advisor to the Senate HELP Chairman Ted Kennedy (D-MA). 

Health Care for America Now's Jason Rosenbaum has excellent summary of the discussion over on HCAN's blog. Here are some of our takeaways from the panel:

In today's New England Journal of Medicine, MIT economist Jonathan Gruber asserts that the choice between saving our economy and making high-quality, affordable health insurance available to all Americans is a false one. He continues, "a smart health care reform bill, which has at its center universal health insurance coverage...can improve both individual health and the economy's health, both today and in the long run". We agree wholeheartedly with Gruber's thesis; and, want to highlight how Congress and the White House have recognized the important interplay of health coverage and healing our economy in the pending stimulus bill.

In his article, Gruber outlines five ways that enacting comprehensive health reform will help our economy.

First, health reform will provide resources to cash-strapped states for their public insurance programs. Gruber cites incentive payments in the SCHIP re-authorization bill for enrolling eligible children in health coverage.

Understanding the need to move quickly, the House has already passed the re-authorization of SCHIP and the Senate is likely to follow when it votes today on the bill.

But Sen. Chuck Grassley (R-IA) will still show up at 8 am to give a special breakfast presentation at the Health Action 2009 conference—hosted by Families USA. We were up bright and early as the ranking member on the Senate Finance Committee began the day's events with a spirited town-hall style discussion.
Next up, the opening plenary session featured House Majority Leader Steny Hoyer (D-MD) and Senator Debbie Stabenow with Princeton Professor Uwe Reinhardt giving an entertaining closing presentation. Chairman of House Committee on Energy and Commerce Henry Waxman (D-CA) just gave the luncheon keynote to standing applause from packed house in the Continental Ballroom of the Mayflower Hotel.
Here are some highlights from the morning's action.

A few weeks ago, New America hosted an event with Health CEOs for Health Reform—a diverse coalition of health care leaders that New America has helped organize. Some of those execs later participated at a similar gathering hosted by the Committee for Economic Development, New America, Better Health Care Together, and the McKinsey Global Institute. One of the execs, Dr. Gary S. Kaplan, Chairman and CEO of the Virginia Mason Medical Center in Seattle, posted on the Health Care Blog about what he, his organization and like-minded colleagues involved in Health CEOs for Health Reform are going to do to bring about change.

"Our goals are lofty and the challenges immense. What struck me in recent months, with the current state of the economy, is the tremendous sense of urgency we all feel and the confidence we have that now is the time to truly transform health care," he writes. Read his essay "CEOs Urgent, Shared Commitment to Change" here.

Robert Wachter, MD, a respected patient safety expert, has a long but fascinating dissection of the recent US Airways landing in the Hudson River, where everyone survived, versus the worst crash ever, when KLM and Pan Am jets crashed on the runway in Tenerife in 1977 . Safety, we conclude after reading his account of how training, culture and technology have changed in the intervening years, is not an accident. He writes:

Two new reports provide further insight into Health IT's potential as both economic stimulus and a building block for broader health reform.

In a letter to Rep. Henry Waxman (D-CA), chair of the House Committee on Energy and Commerce, the CBO estimates that the Health IT provisions of House's economic stimulus package would reduce healthcare spending by 0.3 percent from 2011 to 2019. CBO predicts the savings would come from: "diminishing the number of inappropriate tests and procedures, reducing paperwork and administrative overhead, and decreasing the number of adverse events resulting from medical errors."

A new report from the Commonwealth Fund published in the Archives of Internal Medicine provides even more specific evidence of potential savings by comparing the use of health IT in a diverse group of urban hospitals in Texas. The report's authors conclude that:  "Hospitals with automated notes and records, test results, order entry, and clinical decision support experience fewer complications, lower mortality rates, and lower costs." For a breakdown of the savings, check out this helpful Commonwealth Fund chart below:

You wouldn't ask a plumber to build your house. Nor would you expect a dermatologist to manage your heart disease.

The difference is that in the first case, people hire a general contractor to make sure that the job is done by right people at the right price at the right time. In the second case—well that's exactly the problem according to a recent issue brief by Cato's Arnold Kling and Michael Cannon.

Kling and Cannon begin their discussion noting that "credible estimates suggest that one-third of health care spending is wasted." They problem, as they and many others see it, is in the way health care is delivered. As treatments have become more complex, health care has become less coordinated. Patients with multiple chronic diseases see multiple specialists, with no "project manager" in charge of coordinating a patient's care and overall health. The lack of accountability and communication leads to higher costs and worse outcomes. The problem, the authors argue, is perpetuated by fee-for-service payment and exacerbated by state regulations (the Cato authors are libertarian after all...),

The solution lies in creating more integrated systems of care modeled on principles of corporate organization to lower transaction costs; promote cooperation and standardization; and can realign incentives for quality.

Holy Cross Hospital, just outside Washington, has created a special emergency room section for older patients, complete with staff trained in geriatrics and communication, wooden handrails for safe walking, comfy chairs for family members, and extra thick ER mattresses designed to protect the fragile skin of the elderly against fast-developing bedsores.

Hospital CEO Kevin Sexton got the idea after, what else, a stressed out phone call from his elderly mom in a New Jersey emergency room. "It was the combination of her being there quite some time and it being very crowded and chaotic. It came to me we really do treat seniors poorly in that setting," he told the Washington Post. Developed with the assistance of outside experts on aging, there is apparently only one similar program in the country.

Elderly patients with traumatic injuries or acute crises (i.e. car crashes or heart attacks) will go into the regular ER, but most elderly patients seek emergency treatment because of pain, falls, or problems related to chronic conditions. They will be steered to the special seniors section.

The article focused on stress reduction and comforts, but the care model also has implications for better outcomes, even beyond those extra precautions about falls and bed sores (which can be very dangerous).

Last week I discussed the work of Joseph S. Bujak and Tom Atchison on how to successfully engage with physicians. That same day, the Minneapolis-St. Paul Star Tribune published this story describing the trials and tribulations of Minnesota's state-wide journey toward fewer errors. In fact, the numbers are rising.

Minnesota hospitals say that the rising errors are likely a result of better reporting. During a recent 12-month period, 18 people died and about 100 were seriously injured as a result of medical mistakes, accidents, or negligence; a majority of both deaths and injuries were due to falls. Additionally, 77 surgical errors were reported, including 21 operations on the wrong body part and 2 on the wrong body (err, patient).

What's going on?