Archive for category Hospital care
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.
- It sets the allowed price for hospital and medical provider services
- It pays 80% of the “allowed” price leaving 20% for the individual or a “medical supplement”.
- Limits participants to one insurance company or organization
- Has lower premiums
- Wraps Medicare and a supplement together
What about Medicare For All
- 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.
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)
What an opportunity! A design for American Health Care that is badly needed, a blank slate, an open door, a blank check. So what blogger could resist the obvious invitation. First is the logo — I hope you like it. No more Medicare, Medicaid, Indian Health Service, Veterans Administration, Blue Cross or United Health.
Who gets AHC? Well, every US citizen.
How much does it cost? The annual out of pocket cost is limited to just $1000.
Is there any paper work? NO. No paperwork, no bills, no EOB, and no insurance claims.
What do you need for healthcare? Just your AHC card.
What is the price list?
- Office visits: $25
- ER visits $50
- Thirty day prescription $10
- Surgery $100
- Hospitalization $200
- Medical equipment $75
- Medical devices $75
- Ambulance $100
What is the national healthcare budget? It’s set by congress. Initially budget neutral at three trillion dollars (or whatever budget neutral at this time).
Where does the money come from? Taxes. Instead of insurance premiums it’s included in your taxes.
Do insurance companies go out of business? No. They process claims from healthcare providers, pharmacies, hospitals etc. The person getting healthcare does not need to be involved with all the paperwork.
What government agency runs the program? Medicare, under the AHC name. Providers bill the claims processor and AHC pays the processor.
Is great American health research affected? No. This is a health care system. Research is not health care and is outside the system.
Can people obtain health services, like for cosmetic surgery? Sure. Any services you want to purchase yourself outside AHC is fine. But, you still pay the same taxes. AHC does not pay for private care.
Are the States excluded? No. The States are responsible for managing AHC in their States. The Federal Government sets the standards for the country. The States make it happen.
Why would national costs be lower? Because America as a country negotiates prices and because cost would be capped by the congressional budget for care. The cost would be the same the first year. Waste is a major problem — with better management of a system waste can be addressed. Since about one half of US healthcare cost is consumed by waste there is lots of room for improvement.
What about poor people? The deductible would be lower than $1000 — but because the deductible is low to begin with not many would need this help.
Now would be a good time for the applause. Your humble blogger thanks you.
The U.S. healthcare system is going to change or at least be updated in the coming years. So, when congress tinkers with the system what might be good changes and what might be bad changes? That is the $3 trillion dollar question! It would be fair to say most people and most congressmen do not understand U.S. healthcare — the prevailing notion is overwhelming complexity and way too much cost. However, this blog is going to make the case the key to understanding and the key to making changes is to keep your eyes on the results.
What results? It’s not complicated, it has to do with measurements. Consumer Reports and J.D.Power know we want to buy value. And, value in this case is the reasonable cost for wellness, longevity and successful treatment of disease. That’s it, three things. Whatever changes or tinkering are contemplated we just need to know those three things will be getting better and simultaneously costing less. Politicians have a really bad habit of saying the changes they propose will do the job. Nobody can predict what will work — there are always unintended consequences — so, any proposal must include a dedication to measuring the outcomes we want — if the change does not work it needs to be discarded as soon as possible. And, discarding what does not work can’t wait for the next election and should not wait until tomorrow. Simply, we want results, and we want the data as proof. On a hopeful note, if something works, keep doing it.
The above diagram describes U.S. healthcare. It is more simple than the systems in other countries. The system is linear — people, illness and unlimited money on the left side pass to the results on the right side. This is a flow diagram of the system. The complexity can be hidden by thinking in terms of the five boxes. Later, some of the complexity will be discussed. First, consider the boxes:
- Money to pay for the system. The money people earn is paid to the health care system. Money is money — it does not matter if the money comes by way of taxes, insurance or cash. Funds that do not come from insurance come from the other sources. This is the cost of U.S. healthcare which is about $3 trillion. Don’t pay the money, you don’t get healthcare.
- The healthcare providers. Traditionally we only think of doctors, hospitals and drugs. We often overlook the other things in the box. Things we don’t like, things healthcare providers would like to see in another box. These other things are hugely expensive and fully under the control of the healthcare providers. Unnecessary treatment is perhaps one of the worst — treatment or tests that are not needed. For example, an EKG done as part of a yearly exam on a healthy person. Profit is in this category. Clearly, no profit, no healthcare system. But, profit beyond what is needed is just waste for the system — it is money that leaves the system and does not come back. Inefficiency comes in many forms. Failing to prevent diseases early, only to spend more money later is supremely inefficient. Corruption is a problem in every human endeavor. Errors turn huge amounts of money into waste. The money spent on medical liability suits is just the tip of the iceberg. Money spent to prevent errors is minuscule compared to the money spent on drug marketing.
- Who gets healthcare? Everybody. The aggregate need for healthcare is fairly stable for the system. But, for an individual the need is hugely variable — an auto accident is not predictable. And, when disease strikes most of us can not afford the cost without insurance. Statistics show 50% of Americans do not have access to $4oo for an emergency. The very people who don’t have emergency funds are the very people who do not want to purchase health insurance. Sadly, those people end up in bankruptcy while the system grudgingly provides the care. Now that more people have insurance those without may find less compassion from the providers. Many feel there are freeloaders in the system — people who do not contribute. Does a birth defect, mental illness or low IQ make people freeloaders — that’s an ethical question which is beyond the scope of this discussion.
- Waste. In monetary terms this about $1.5 trillion dollars per year with a huge death toll in the US. A hospital acquired infection is very expensive and kills many of those affected. The high profile infections from spinal injections are just the tip of the iceberg, again. Re-hospitalization for an unresolved health problem is another example. Paying $800 for a $10 epinephrine injector is another example.
- The results. We want those good results. Not just for cancer patients, not just for heart attack victims, not just for you, but for me too. We don’t want promises, we want results. In this age of smart phones and millions of apps there is no excuse for failing to have the data to prove the system is working in our hands every day. We want the results today, not after several years of scrubbing the data in some moldy university. We all must keep our eyes on the results and hold our elected officials accountable.
Complexity. Medicine is a science and by its nature is very complex. Open heart surgery is a good example — there are few people who understand the issues involved. But, the system, from the patient’s view does not need to be complex. In one country the cost of hospitalization is $400/day — the people there know exactly how much the illness will cost. In another country, the prices of office visits are posted in the waiting room — it does not matter what insurance company you might have. In another country all the providers use the same medical record system — not a big deal to move or see a consultant. We seem to tolerate the complexity of our system and think it should be as difficult to understand as heart surgery.
The US pays about twice what other countries do for similar or better care. There is enough money in our system now. Our problem seems to be in the area of wasted money and effort. It seems unlikely that just reducing payments to providers will reduce errors and wasted money — this supply-side economics does not get to the real problem. More than likely, lower payment to providers will only result in lower income for them and perhaps more errors and unnecessary services. But, if it works, do it.
Back to the initial warning. Keep you eyes on the results of the system and the cost. Whether any economic hypothesis proves correct is irrelevant. What matters is the system must move in the right direction, always.
There is a lot to recommend the quality improvement method called “Plan – Do – Study -Act” or PDSA. The idea is to plan a change to a system of care, do the plan, make measurements to study the results then act to change the system to get better results. This is an ongoing process. Congress seems to be mired in a system of management which is one hundred years out of date — if anything, that’s what needs to change first.
Emergency general surgery (EGS) is common in the United States. 11% of surgical admissions require emergency surgery. The statistics on EGS seem to create more questions than they answer:
- The 11% of surgerys classified as EGS are associated with 50% of all surgical deaths.
- Poor people who have EGS have a greater risk of death than average
- Rich people who have EGS have a lower risk of death than average
- Seven surgeries (removing part of the colon, removing part of the small-bowel, removing the gallbladder, operations related to peptic ulcer disease, removing abdominal adhesions, appendectomy and other operations to open the abdomen) accounted for 80% of the deaths and hospital costs related to EGS.
- The cost of ECS in the U.S. is about 7 billion dollars per year.
- EGS patients admitted by a surgeon have lower hospital costs than those admitted by a hospitalist.
- Specific quality guidelines for ECS do not exist.
One might be tempted to say the diagnosis is so complicated nothing could improve the situation for patients. However, this would be like the situation for pilots and passengers 30 years ago when major airliner accidents happened at least once a year. The quality movement swept over the airline industry which is now is rated as one of the safest of complex human endeavors. Those same measures need to be applied to EGS.
When an airplane has an emergency the crew pulls together and acts as a team. They follow a procedure practiced many times. They have simulators and tests. If an engine fails, if there is a fire, if a landing gear fails there’s a procedure to follow. Each pilot does not invent a procedure just because they are the pilot that day. Likewise, every surgeon should not invent a procedure just because they are the surgeon that day.
It would be easy to blame surgeons or the patients themselves for such dismal outcomes. But, as people in the quality improvement department say:
IT’S NOT THE PEOPLE, IT’S THE PROCESS.
The first step is to acknowledge EGS is a process. When a patient arrives in the emergency room with abdominal pain, low blood pressure, free air in the abdomen and a high white blood count there should be no barriers to evaluation an treatment.
- The goal is to have the patient in the operating room within 90 minutes from crossing the ER threshold (T).
- Blood tests and CT scan of the abdomen are done by T+ 20 minutes.
- Surgeon is in the ER to evaluate the patient by T + 30 minutes
- A decision for operation is made by T + 45 minutes.
- Pre-op antibiotics, fluids, and pressors are started as needed.
- Anesthesiologist begins care of the patient in the ER by T + 60 minutes.
- Central line is inserted, operating room is notified, ICU is notified, critical care team is notified by T+75 minutes.
- Patient is transported to the operating room. The opening incision is made by T + 90 minutes.
Such a process is obviously difficult. First, the ambulance crew can not transport a patient with an abdominal emergency to a facility unable to deal with the problem, like a small rural hospital or an urban community ER. This will require training of the ambulance crews and communication with a high level ER.
General surgeons and back-up general surgeons must be available within 30 minutes. It’s a difficult life to be immediately available — the hospital is responsible to either pay surgeons to be on-call or to hire surgeons to stay in the facility. Hospitalists are not an appropriate substitute to deal with an acute abdomen or even severe abdominal pain of uncertain cause. A helicopter ride to a higher level facility is the best solution for patients with severe abdominal pain entering a facility not capable of following the above protocol. The crazy practice of having a night-time hospitalist admit a critical surgical patient for a surgeon to see “in the morning” must come to an end.
Since the mortality rate of EGS patients is quite high the intensive care unit is the place they should go after surgery even if they seem stable in the operating room. Complications are very common so early recognition and treatment is essential. Returning to the operating room later may be needed and should not delayed. Critical care consultation should be strongly considered. Multidisciplinary rounding with critical care specialists, nurses, pharmacists, dietitians, and social workers is strongly advised. Rushing to get the patient out of the hospital to a secondary level of care is a mistake since re-admission is fairly common. The patient needs to be as stable as possible before discharge. Hospitalization for 1 – 2 weeks is not uncommon.
The difference in outcome of EGS between rich and poor is not uncommon for many things in medicine and surgery. Several factors are at play but probably the biggest is fear of big medical bills — if you can’t pay one would wait till the last moment. Second, medical literacy — always a bigger problem for lower socioeconomic groups — if you think Tums or Rolaids will fix anything you might wait too long to go for help. Finally, a negative bias toward Medicaid or “cash” patients — sometimes the finances determine whether a hospital will keep or transfer patients. At midnight many cases seem to be too “hard” and must be sent to a referral hospital which wastes valuable time.
Since prospective research is difficult and time consuming (taking years or decades) a local and national registry should be utilized. The diagnosis, the surgical approach and the outcome must be tracked to find the best combinations for the best outcome. As best practices are identified surgeons and hospitals must quickly change protocols and surgical techniques. U.S. healthcare can not stand the usual 15 years needed to implement new practices.
- Washington Post
- JAMA Surgery
- J Trauma Acute Care Surg.
- The Joint Commission
- J Trauma Acute Care Surgery
- J Trauma Acute Care Surgery
- J Am Coll Surgery
If any nurse out there has a standard order-set for EGS please share it.
According to a study at Johns Hopkins (2/1/15) improving hospital amenities improve patient satisfaction with the facility but otherwise do not improve satisfaction with care. This is important for two reasons:
- Patients really can tell the difference — a crystal chandelier hanging in the hospital room does not make nursing care better!
- Patient satisfaction measurement is a powerful tool to assess medical care — if the patient’s expectations are met, it is likely good care is delivered.
The tremendous building boom for hospitals is strange given this bit of science — are CEOs trying to improve quality by remodeling? Now it seems clear CEOs should focus money and energy on improving hospital quality until the level of quality is very high then if there is money to spare consider improving the physical amenities.
Increasing the distance a nurse must walk to see patients results in decreasing nursing visits. This seems simple enough, but the current trend in hospital remodeling is to eliminate rooms with multiple patients. The trend reduces RN visits, increases the need for nursing assistants, increases hospital cost and may increase falls for elderly patients.
The hospital that looks like a nice hotel seems to be the desire of hospital CEOs. This may be fine for obstetrics but may be wrong for geriatrics. A multi-bed ward with 4 patients allows one nurse to check on 4 patients quickly. 4 times the number of nursing visits makes it much easier to prevent falls. When nurses still wore those pointy white hats they had this figured out.
Progress marches on. American health care quality is as low as many 3rd world countries but at least we have nice surroundings in which to suffer the complications.
Hospitals are responsible to rescue patients from inappropriate treatment — especially when the need to intervene is obvious. The hospital has a board of directors responsible for the care delivered in a hospital. They hire the CEO who hires a quality manager. When bad quality management hurts or kills patients it is the hospital’s fault.
An article by Dr. Behnood Bikdeli and colleagues (JCHF. 2015;3(2):127-133) describes a huge study at 346 hospitals about treatment of patients with congestive heart failure (CHF). Here is the essence:
- CHF is life-threatening condition where the body collects too much fluid, usually due to a weak heart. The fluid gets into the lungs and causes shortness of breath.
- The treatment for CHF is to remove fluid from the body and give medications to improve heart and kidney function.
- The absolutely wrong thing to do is to give extra fluid by the veins.
- The study found about 12% of patients with CHF were treated with 1 to 2 liters of fluid in the veins during the first 2 days of hospitalization. AND, most alarming, compared to similar patients not treated this way, they were more likely to end up in intensive care or die.
- The most telling statistic is how often various hospitals let this dangerous use of intravenous fluid happen: 0% to 71%. This means some hospitals did not let it happen (0%). Some hospitals let it happen a lot (71%) — just hope your grandmother did not go to that hospital!
It is not rocket science to say fluid overload is not treated with extra fluid. This is easy to detect when the admitting diagnosis is CHF and the doctor orders say “NS IV at TKO” (translation: give salt water in the veins at a rate to make sure the veins stay open). NO NO NO the patient does not need extra fluid. This should not happen and there are lots of ways to prevent it or even rescue patients when Dr Welby writes such an order (or tries to use leaches).
- Mandate doctors use standard orders for treatment of CHF — there is plenty of latitude to customize such orders. But, IV fluid is not one of the choices without stating why.
- Educate staff that IV fluid is not required to admit a patient (an old fashioned insurance rule).
- Educate staff that IV fluid is not a cure-all. Fluid would help a dehydrated patient but not others.
- Nurses do a double check before admitting a patient from the ER with the question: does this patient have CHF and an order for IV fluids — if so, call the physician to clarify the situation or to change the order — no clarity=no admit.
- All CHF patients should be weighed daily — if the weight is going up it means more fluid is being retained — the patient needs to be rescued. Fix the problem or find someone who can, NOW.
Attention patient and family. This is easy to spot. The admitting doctor says the diagnosis is congestive heart failure but you see IV fluids being pumped into yourself or your family member. SPEAK UP! “Why is fluid treatment needed?” do not accept the answer of “everybody gets an IV”.
Attention hospital board members: do you know what your hospital is doing to prevent this obvious problem? Quality is your responsibility, you must do something besides listen to financial statements. Is your hospital the one with 0% or 71% record of treating CHF with IV fluids?