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Mass. Has Too Many Hospitals for Its Own Good

  • By
  • Shannon Brownlee,
  • New America Foundation
June 15, 2012 |
Take a walk down practically any major thoroughfare in the city of Boston, and you’ll be hard pressed to go more than a few blocks without running into a hospital. The cities of Cambridge and Boston have nine hospitals and medical centers between them, and a whopping two dozen hospitals are packed into the greater Boston metropolitan area.
Knowing that state-of-the-art medical help is always close at hand is probably a comforting feeling. But it shouldn’t be.

The End of an Era

May 29, 2012

It’s the end of an era in modern medicine. House is no more.

The Fox show House ended last week. It was entertaining, but as far as health policy is concerned, we’re not sorry to see it go. The main character (Dr. Gregory House, played by Hugh Laurie) exemplifies the kind of “cowboy doctor” too many patients have come to expect. The cowboy doctor rides in on a lab result and offers a brilliant diagnosis, saves the patient’s life, and rides off into the sunset, never to be heard from again. It’s the dominant image of heroic doctors in television. Even Hawkeye Pierce, the caring Army surgeon in M*A*S*H whose demeanor is the polar opposite of House, saw his patients in one-off interactions before sending them home or back to the front.

For most of us, though, that’s an entirely unrealistic portrait of medicine. Our interaction with doctors is usually about trying to stay healthy and avoid problems, or managing long-term, chronic diseases like diabetes, heart disease, obesity, cancer. We need doctors who will listen to us, who can explain things clearly, and who we’re comfortable telling our concerns. Chronic disease management makes for lousy TV, but in recent years it has become the dominant kind of problem doctors and patients face day to day.

That's not our only quibble with Dr. House. In addition to being a cowboy, he's not much of a diagnostician. Through the magic of scripted TV he somehow manages to stumble on the treatment that saves the patient, almost by accident. He practices what I call “spaghetti on the wall”  medicine—as in, “throw the spaghetti on the wall and see if it sticks.”  He diagnoses his patients' rare illnesses by throwing treatments at patients and seeing what happens—often causing significant harm in the process. That's just bad medicine, and it isn’t something that doctors should do lightly. To us, House isn't a hero, he's a hazard, a catastrophe waiting to happen. Blinded by his own pain, he's indifferent to the suffering he causes through his reckless, unscientific, non-evidence based treatment decisions.

But there’s one point in House’s favor: he works with a team—and that team actually talks to each other. Unfortunately, that’s as unrealistic as the rest of the show. There are only a few hospitals and medical practices (Virginia Mason, in Seattle, comes to mind, and the Mayo Clinic in Rochester, Minnesota) where communication among providers is very good. In most places, the ball gets dropped between the hospital and primary care doctor and home, or even between different specialists in the same hospital.

Maybe one day TV will produce a more realistic version of medicine, but beware: it won't be the clean-cut single interactions we saw in House, or any of the other medical dramas out there. It'll be messy, and it'll be ambiguous: something a lot more like The Wire than Marcus Welby, M.D.

And we're back, with Health Wonk Review!

March 1, 2012
Alistair Cookie

Apologies for our extended hiatus--we've been hard at work on an extended report, and it hasn't left a lot of time for blogging lately. But we're back, and hopefully we'll be blogging more often in the coming weeks.

Now, without further ado: this week's Health Wonk Review is up! Check it out.

Many thanks to Joe Padua at Managed Care Matters for hosting!

Join us again on March 14th, for the next exciting edition of Health Wonk Review!

Loss Leaders, Ahoy!

February 13, 2012
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In her latest installment at TIME Ideas, Shannon Brownlee takes on hospitals that use marketing tactics like offering free screening tests to patients to generate revenue and find new recurring patients, and then claim the cost of those tests as charitable activity to become eligible for billions of dollars in tax breaks. As Brownlee points out, those tactics (minus the tax exemption part) are common across retail--and nobody accuses Amazon of being a charity:

"Hewlett Packard and other manufacturers sell computer printers at rock bottom prices. Once you run out of ink, you find out the cartridge costs almost as much as the printer did. The biggest product launch of last Christmas — Amazon’s Kindle Fire tablet — sold for less than the price of its components, even without accounting for Amazon’s advertising costs. Amazon makes it up on the e-books, TV shows, and Amazon Prime subscriptions purchased by Fire users."

You can read the full piece here: http://ideas.time.com/2012/02/13/direct-marketing-and-deep-discounts-come-to-health-care/#ixzz1mHdv3qXb

What Doctors Know — and We Can Learn — About Dying

  • By
  • Shannon Brownlee,
  • New America Foundation
January 16, 2012 |

Last month, an essay posted by retired physician Ken Murray called “How Doctors Die” got a huge amount of attention, some negative but mostly positive. Murray tells the story of an orthopedic surgeon who, after being diagnosed with pancreatic cancer, chose not to undergo treatment. The surgeon died some months later at home, never having set foot inside a hospital again.

Mattress Graves

January 17, 2012
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Shannon Brownlee's back at TIME Ideas with a new op-ed yesterday: this one about the article we mentioned last month, called How Doctors Die. Brownlee adds more context to the first commentary, by retired physician Ken Murray, with gut-wrenching descriptions of precisely why doctors tend to avoid intense, invasive care at the end of life:

"Doctors also know that undergoing heroic measures is a lousy way to die. They’ve seen what it’s like for an elderly patient to end up in the ICU, hooked up to machines, often semiparalyzed, in pain, lying on what philosopher Sidney Hook called “mattress graves” during his own terminal illness. At a recent meeting I attended, one emergency physician tearfully admitted she didn’t think she could stand to hear the sound of ribs breaking as she perform CPR on yet another elderly patient who almost certainly would not survive."

Brownlee also mentions Angelo Volandes, a physician who's working on a series of videos illustrating what it actually means to go through various heroic efforts at extending life. We think such an effort could be incredibly valuable to patients, and will help prevent a lot of unnecessary suffering, and we applaud the project.

An American Hospital: The Most Dangerous Place?

  • By
  • Shannon Brownlee,
  • New America Foundation
January 9, 2012 |

Imagine you are sitting in first class on a plane, waiting for the plane to push off from the gate, when you see two people in uniform, the pilot and co-pilot, dash from the Jetway into the cockpit. A few seconds later, a voice comes over the intercom, saying, “This is Captain Jones, please be sure your seat belts are fastened. We’re ready for takeoff.” What crucial event could not have occurred in this scenario? The pilot and co-pilot did not go through their checklist of safety measures. Fuel tanks full? Check! Flaps up? Check!

One in Seven

January 10, 2012
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If you ran a summer camp that never reported the vast majority of times that you hurt one of your campers, you'd probably be shut down, arrested, or worse. The situation would be similar if a restaurant repeatedly made customers sick, or if a skydiving business habitually gave people the wrong parachutes.

Why, then, do hospitals only report about one in seven of the hundreds of thousands of medical errors, infections, and other adverse events that harm patients every year? And why can they get away with it?

That's a crucial question posed by Shannon Brownlee's most recent piece on TIME Ideas: An American Hospital: The Most Dangerous Place? Brownlee addresses the recent report from the US Department of Health and Human Services, which catalogued problems with the reporting system for medical errors and other patient harm. She argues that the reporting problems are only a piece of a larger quality and safety problem, and that hospitals need to move quickly to adopt checklists and other types of safety mechanisms:

"Some hospitals have made great strides in reducing errors and infections using — you guessed it — checklists. About 10 years ago, Dr. Peter Pronovost, an intensive-care specialist at Johns Hopkins Hospital in Baltimore, and a team of colleagues put together a series of checklists for some of the most common procedures performed in the intensive-care unit. For example, they created a list of steps for how to put in a central line — a tube for delivering medication directly into a vein in the patient’s chest — in a way that reduced the risk of infection. They made a checklist to prevent patients on a ventilator, or breathing machine, from contracting pneumonia. When Pronovost was given a grant to get every ICU in the state of Michigan to use just three of his checklists, the result was 1,500 lives saved and the state of Michigan saved $100 million."

You can read the full story here: http://ideas.time.com/2012/01/09/american-hospitals-the-most-dangerous-place/

Doctors of Lake Wobegon

September 28, 2011
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The most recent issue of the Archives of Internal Medicine includes a provocative survey of primary care physicians—one that indicates a significant, long-overdue change in how both providers and patients see medical care.

The study surveyed over 600 physicians by mail, and found that 42 percent believe their patients are getting too much medical care. That’s seven times as many as the six percent who believe their patients aren’t getting enough. Further pressing the case, about 30 percent of PCPs surveyed said that their own practice was more aggressive than they’d like.

Think about what this means. Four years ago, when the Health Policy Program’s director, Shannon Brownlee, published her book Overtreated, most Americans, and a lot of providers, legislators and policy experts thought the only real problem in U.S. healthcare was too little care – because nearly 1 in every 6 Americans was uninsured. Now we have a study that shows that physicians are well aware that overtreatment is also a problem

Reality Check for Health IT

September 27, 2011
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Implementing new health IT may decrease hospital mortality due to medication errors and uncoordinated care, but is the effect great enough to justify multimillion-dollar investments in new technology?  Maybe not, according to a new study from Health Affairs.

Spencer Jones and colleagues from the RAND Corporation looked at hospital outcomes data for Medicare patients from 2007 to see whether use of CPOE technology (Computerized Physician Order Entry) was associated with lower mortality for heart attack, heart failure, and pneumonia.  They looked at 4,644 general acute care hospitals, categorizing them by the percentage of orders written using CPOE.  There was a small reduction in mortality for heart attack and heart disease, but not pneumonia, associated with CPOE use – really small.

Based on the results, the authors predicted “complete uptake by hospitals of electronic medication ordering at levels comparable to the requirements of stage 1 meaningful use (at least 30 percent of orders written using CPOEs) could result in 1.2 percent fewer deaths of hospitalized Medicare beneficiaries from heart failure and heart attack,” but this result was not statistically significant.

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