Archive for category Culture of Quality

Medicare For All — what does that mean?

Bernie Sanders popularized the idea of US national healthcare during his 2016 campaign. He described the idea as “Medicare For All”. That was a genius idea since most Americans have a family member with that program for seniors. In fact, with its 44 million participants it represents a very large, although incomplete, national healthcare program. It is very popular among seniors since it reduces insurance premiums dramatically.

There are two major versions of Medicare: Standard and Advantage.

Medicare Standard

  1. It sets the allowed price for hospital and medical provider services
  2. It pays 80% of the “allowed” price leaving 20% for the individual or a “medical supplement”.

Medicare Advantage

  1. Limits participants to one insurance company or organization
  2. Has lower premiums
  3. Wraps Medicare and a supplement together

What about Medicare For All

  1. What about premiums or supplements or services? (the specifics need to be chosen, not guessed at.) It’s like a dream house, but without a drawing or a list of deliverables.

The Choices

This is really the nuts and bolts of a national plan no matter what you call it. And, if the current providers sense they will make less money, the self-serving complaints will be very loud. Who will complain if patients don’t get a better deal — not very many people. That’s because not very many people understand healthcare. So, what do you as a consumer want?

☐ Same old insurance, high drug prices and poor quality
☐ Premiums paid via payroll deduction
☐ Premiums paid via annual income tax
☐ Allow supplemental insurance for non-covered items (like plastic surgery or special drugs)
☐   Profits for drug companies limited to 5%

All covered medications available for $10/month
☐ All approved hospital days available for $400/day

☐ Out of pocket annual expenses limited to $5000/year
☐ Approved child medical care is free
☐  0.5% of premiums for research
☐ Regional claim processing (by current insurance carriers, limited to 5% profit)
☐ Limited list of available medications, generics are required where available, brand name drugs are selected by the plan
☐ 30% of provider payments linked to quality and quantity measurements
☐ Medical school tuition paid in exchange for 5 years of service in designated (poorly served) areas
☐ Mental health service included same as other health care (includes PhD psychologists)
☐ Maternity care, including midwife care at home when safe

☐ Primary care provider available for all persons
☐ Physicians and surgeons are salaried (not paid by number of services)
☐ Same day service for urgent problems
☐ Clinics open nights and weekends
☐ Massive increase in numbers of physician assistants and nurse practitioners with tuition paid in exchange for service

☐ Video visits with providers via Internet if desired
☐ Hospitals paid according to diagnosis (DRGs)
☐ Regional specialty hospitals (5% for growth and development)
☐ Local general hospitals
(5% for growth and development)
☐ Providers all use the same secure medical record
☐ Annual adjustment of payment levels based on a budget

☐ Ongoing and up-to-date quality measurements on all services
No need for malpractice suits — immediate compensation for injuries instead
☐ Strong quality system capable of sanctioning administrators and providers (important!! may need lawyers here)

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Medicare Penalizes Hospitals — safety problems

MC Hospital Penalties

Hospitals in the lowest quartile of safety scores from Oct 1, 2014 to Nov 30, 2015 were recently penalized 1% of Medicare billings as detailed on the Medicare.gov web site.  The above graphic highlights the results in terms of the number of hospitals penalized per million medicare enrollees in each state.  Red indicates the most hospitals penalized and green indicates the least with the lighter shades in between.

New York had many hospitals penalized but Alaska only had a few.   However, Alaska does not look very good considering they don’t have very many Medicare enrolees (or other people for that matter).  So a patient’s chance of experiencing safety problems is higher in Alaska.  This reflects poorly on the State-wide hospital quality programs and the importance hospitals in that state place on quality.   If you live in a state with poor performing hospitals then be especially careful to pick hospitals with the best scores.  KHN.org  lists the poor performing hospitals.

The four Medicare safety measures were somewhat limited and heavily focused on surgery:

  1. The AHRQ Patient Safety Indicator (PSI 90 Composite)
  2. Central Line-Associated Bloodstream Infection (CLABSI)
  3. Catheter-Associated Urinary Tract Infection (CAUTI)
  4. Surgical Site Infection (SSI) – colon and hysterectomy

What should be done?

  1. Patients should avoid hospitals with lower scores
  2. Poor performing hospitals should make better use of state quality resources.  Spend more money on boosting quality than on remodeling or building new facilities.
  3. High performing hospitals should redouble safety efforts.  Improved performance by competitors could push complacent hospitals toward lower ratings.
  4. Hospitals should not just focus efforts on the few areas that are rated — overall safe care and quality care are the goals.  The basis for financial penalties could, and very likely will, change.

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Hippocrates — the missing duty

hippocratesHippocrates missed something big — a doctor’s responsibility to improve the care of other doctors.  OK he did get some things right — here are his points from the 5th century BC:

  • use good judgement — nice
  • revere your teachers — nice if you are a teacher
  • order a good diet — still a matter of question
  • don’t hurt or damage people — really or just statistically?
  • don’t poison people — makes sense to me
  • comport oneself in a Godly manner — doctors have no problem here
  • don’t do surgery if you don’t know how — duh
  • doctor visits should be for the advantage of the patient — patient centered care is nothing new
  • keep medical information private — HIPPA before its time

Doctors often take some revised or modernized version of the Hippocratic Oath.  Sadly, the idea that doctors have some responsibility for the care provided by other doctors is missing.  The idea is front-and-center in most work on quality improvement — where the idea is indeed to improve everybody’s care.  Doctors should have 2 responsibilities:  1) care for the patient and 2) improve the quality of care for all.

Most doctors don’t accept item #2, instead the list is:  1) care for the patient and 2) care for personal finances.  In essence, doctors shun quality improvement because “I’m not paid to do that”.

How many doctors participate in quality improvement activities?  Meaning, find a problem, make a plan,  do something, study the result, then act to improve the plan and repeat the cycle.  This is not rocket science.  A physician is not expected to do molecular biology research in the office but there is an expectation they will improve waiting time and reduce prescribing errors — things easily within their grasp.  How many physicians have a quality improvement meeting each morning or at least once a week — I dare say less than 1%.

Systems of care are very important.  But, the lack of physician involvement in quality improvement is a serious deficiency in many health care systems.  In some respects this is a structural issue for health care — it’s not a process, and it’s not an outcome.  It’s like a foundation for a house — no foundation means the house will not last.

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Wrong Aspirin Dose After MI — frequent errors

ASA81Highly educated and experienced cardiologists just can’t get it right:  the correct dose of aspirin after a heart attack is 81 mg (called low-dose), NOT 325 mg (called high-dose).  The current prescribing error rate is 60.9%  as published by the American Heart Association in 2014.

Personal communication with several cardiologists elicits the comment:  the higher dose is needed because of the risk of another heart attack — and “in my experience” it just works better.   It’s hard to believe this clinical error in this age of quality assurance.  The problem is BLEEDING not heart attacks!  The stomach BLEEDS due to aspirin and the higher the dose the higher the risk of BLEEDING.

bloodinsinkJust imagine the risk and strain for a recent heart attack victim who vomits blood, needs a transfusion and must undergo a stomach scope — some patients die.  From a cardiology standpoint: “they died from something unrelated to the heart attack” — great thinking.

Cardiologists completely and totally get it wrong when they simultaneously prescribe high dose aspirin and the anticoagulant warfarin — the ghastly mistake happens 40% of the time.

The chemical reaction of “acetylation” is caused by aspirin within small blood cells called platelets.  Acetylation of platelets is responsible for the favorable heart effects of aspirin.  It has been known for at least 30 years that 81 mg of aspirin completely acetylates every platelet a person has — more aspirin does no more.   According to the 2012 TRITON-TIMI trial:

“We observed no difference between patients taking a high dose versus a low of aspirin as it relates to cardiovascular death, heart attack, stroke or stent thrombosis,” according to Payal Kohli, MD involved in the study and quoted in Science Daily.

Hospital quality improvement programs need the “guts” to just say NO.  325 mg is not correct.  Cardiologists are the sweetheart doctors making millions of dollars for hospitals — it should not matter, JUST SAY NO.

It’s almost impossible for even the most proactive patient to question the great doctor that just saved their life.  So, hospital quality assurance has an even greater responsibility than usual.  The prescribing error needs to be corrected — hospital pharmacists and quality improvement departments need to be strongly involved — this error has gone on far too long.

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I’m Sorry — difficult for doctors

sorrybearSaying “sorry” is the human thing to do.  Doctors and nurses should say it when they feel it.

Saying “sorry” seems to have two meanings:  1) something bad happened and I understand your emotions  2) something bad happened and I had some connection with the event for which I feel partly responsible.  Bad things do happen in health care but “sorry” is a very uncommon utterance for health care providers.

Dr. Abigail Zuger writing in the New York Times 7/14/14 “Saying Sorry, but for What?” compared how she felt about a plumber who broke a valve in her house with medical personnel who broke other things —  neither said “sorry.”  Sorry truly does not fix anything;  but, the absence of “sorry” is infuriating.

The problem is ego.  Ego infuses some health care providers with the notion bad things are an act of God but good things are an act of ME.   Absence of “sorry” is a sure sign of defense (a defense of self).  Perhaps the health care provider was spanked as a child or yelled at by teachers.  Who knows … ego has gone wild.

Quality health care depends on people believing errors are due to system failures.  When providers fail to embrace that philosophy they fail to correct problems.  No failure, no correction.

A fall in the hospital can be deadly.  Recently, a family member fell in a room while no nurse was present and they died.  The nurse did not say “sorry.”  There was no acknowledgement of responsibility.   No acknowledgement the system was at fault, no realization there was a better way, and no reason to prevent future deaths.  The simple statement “sorry, I wish I had been there to stop the fall, we will investigate this to help others” would be the right thing to say, and believe.

Lawyers are not the cause of excessive health care ego.  However, lawyers with the threat of suit are a convenient excuse.  When bad things happen honesty and caring are much more likely to assuage the displeasure of a family than stonewalling.

 

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Provider Certification — proving competance

fltsimDoctors could learn a lot from pilots.  Flight simulators have revolutionized commercial aviation so pilots can train without endangering passengers.  Patient-care simulators do the same for doctors yet doctors fight the idea.  See the article in the Wall Street Journal 7/21/14 by Melinda Beck “Doctors Upset Over Skill Reviews.

There are cognitive skills and procedural skills; both are amenable to testing and training.  The current buzz words are “maintenance of certification” or MOC.  The specialty societies have raised the bar –and the price –for the MOC tests.  Each state empowers a board, or group of people, to oversee medical quality and issue licenses to practice medicine at a much lower educational standard than the MOC.  So, many physicians feel the specialty boards have gone too far.

Examples of specialties include: family medicine, internal medicine, general surgery, ophthalmology, and gynecology just to name a few.  The MOC process requires many hours of education each year and periodic tests.  If  the process is not completed the physician is designated “not meeting MOC requirements”  which is a black mark for any specialist.

The offended doctors object to being forced to learn about subjects like:

  • how to recognize abuse of children and elderly adults
  • teamwork during operating room emergencies (a simulator lab)
  • how to review a chart to identify areas for improvement
  • principles of quality improvement
  • new information about cost effective drugs

Of course, all those topics are a waste of time for busy doctors that stay on the cutting edge of medicine by getting information from drug reps and journal ads.  The high cost of continuing education, $2000 for a refresher course, is ridiculous since that is the usual salary doctor receives for 3 days of work.  Who ever heard of using a simulation laboratory;  it’s not proven.  Practicing on live patients to see what works and what doesn’t  is the way — some live and some die.  Besides, what does a pilot really learn when they crash a simulator rather than a real plane!

 

 

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Medical Care — research, quality improvement and program evaluation

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It sounds like a paradox:  science studying itself.  But, that is exactly what is happening in medicine.  Basic research has led to applications of the research and the applications are studied for effects, benefits and cost.   For example:  invent robotic surgery and apply it to patients, then set it up as a program in an operating room and try to improve the technique and patient selection, and finally evaluate the program to see if it meets stated goals of quality and cost and decide if it should continue and under what conditions.

This huge simplification helps with terms doctors and hospitals often talk about:

  • Discover and apply — called research.
  • Try to improve — called quality improvement (QI).
  • Continue the effort? — called program evaluation (PE).

Patients can be subjects of research.  But, participation in research requires explicit permission since the outcome is not known and it could be bad.

If we knew what it was we were doing, it would not be called research, would it?    (Albert Einstein)

Patients are hopefully impacted by quality improvement since the purpose is to make things better and thus no patient permission is required.  As part of QI a hospital may try to make sure antibiotics are given before surgery because there is research evidence the practice reduces infection.  Quality improvement focuses on a cycle of planning, doing, study and revision.  QI has become a huge area of study with numerous books and journals on the subject.  Virtually every hospital has a quality manager who is charged with improving the care at a hospital.

Patients are only indirectly affected by program evaluation.  Clinics and hospitals constantly evaluate programs for positive or negative effects.  Whether programs continue depend on such studies.  People may read about evaluation of medical programs like care at VA hospitals and may be impacted by decisions of policy makers based on such evaluations.  PE is likewise an important and growing discipline.

The concepts of research, quality improvement and program evaluation do tend to overlap.  One could imagine using QI techniques to improve the quality of research.  And, one could imagine research to find the fastest way to do program evaluation.  However, research is mainly for the purpose the researcher decides.  Whereas QI and PE are mainly for patient care, business or institutional purposes.

Quality healthcare depends on QI and PE.  Patients often don’t see these efforts in action.  But, ineffective QI and PE are hazardous to your health.  Although doctors and hospitals don’t like the idea:   law suits are a warning flag of inadequate QI and PE.

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