No Advancements in Patient Safety

As a strong advocate of improving patient safety and quality in hospitals, it was very disappointing to read this article. This reported study found that patient harm was common and that over time, the number of incidents didn't decrease. Researchers found that 18% of patents in the study were harmed by medical care and that about 63% of the incidents were preventable. This was especially disappointing since the hospitals participating in the study were more involved in patient safety improvement programs. It makes one wonder what the rate is in hospitals that aren't champions of patient safety.

Study Finds No Progress in Patient Safety

Diabetes Expansion Info Graphic

It's startling to watch the rates go up and up so much, over just a 5 year period:

Map of CDC Estimated Rates of Diabetes in the US, 2004-8

Quality Metrics: Outcomes Versus Process

An area that has caught my interest lately is the concept of quality metrics. In the third year of medical school, we get a two-week block on health policy, including one discussion section on quality metrics. In this section, we discussed some of the public reporting data from the New York CABG studies. In short, yes outcome reporting increases quality improvement activities at the hospital-level and in some cases decreases overall mortality rates. However, what was even more interesting were the unintended consequences reported in this data. In many instances, the sicker cardiac patients were selectively referred out of state and were less likely to receive not only CABG surgery, but also percutaneous coronary intervention (a more common and less invasive treatment) than patients in Michigan where there was not public reporting.

Although physician and future physicians including myself may like to think we are above incentives, it is human nature to respond to financial and peer pressure. Does it make sense to give physicians the incentive to risk adjust their patient populations and penalize those providers that treat the highest risk patients? We tried this incentive with health insurers and saw skimping of benefits, limits on preexisting conditions and underwriting. Health insurance is composed of insurance risk based on the patient’s demographics, adherence and genetics and performance risk based on the provider’s care. Outcome measures place the responsibility for both insurance and performance risk squarely on the shoulders of the provider.

There are two solutions I see to this problem. One would be to develop a comprehensive method for risk adjustment, which is not only difficult to develop for a certain population, but relatively impossible to extrapolate to a broad, diverse patient population. Personally, I believe process metrics make more sense—we should compare providers on whether they follow evidence-based best practice standards thus holding them accountable for their performance risk and not for the patient’s inherent risk factors. For instance, instead of measuring diabetic hemoglobin A1C at 6 or 12 months, we would check to see if the provider ordered this lab test to be done at least twice per year, according to the American Diabetes Association guidelines.

Some say that following evidence-based guidelines produces “cookie-cutter” medicine, where all patients receive average, standardized care. However, if we have proven the best algorithm for a specific condition why wouldn’t we provide this medicine where applicable and individualize therapy when necessary? I don’t think we should be threatened by the standardization of guidelines and best practices. There is no algorithm that can replace the doctor patient relationship, the professional instinct to know when the guidelines don’t apply and the educational and advisory role of the physician as the patient’s partner in medical care.

Fung, C., et al (2008). Systematic Review: The Evidence That Publishing Patient Care Performance Data Improves Quality of Care. Annals of Internal Medicine, 148 (2) 111-123.

Interim rule on medical-loss ratios wins praise

With health insurance plans now mandated to spend 80-85% of premiums on direct patient care and quality improvement or else offer patients a rebate, perhaps those for-profit insurance companies may go the route of not for profit to get the tax exemption as profits will now be decreasing....but hopefully health outcomes will be increasing.

http://www.modernhealthcare.com/article/20101122/NEWS/311229957/#

Senate Approves Bill To Block Scheduled Cut to Medicare Physician Pay Read more: http://www.californiahealthline.org/articles/2010/11/19/senate-appro

http://www.californiahealthline.org/articles/2010/11/19/senate-approves-bill-to-block-scheduled-cut-to-medicare-physician-pay.aspx

Will the House follow? Will we see history repeat?

A bright spot for civil rights

A quickie - we talk a lot about payment policy and delivery system reform, and the intense need to change the way things work at a systematic level. Which makes a lot of sense, given the number of problems the current configuration creates. At the same time, it's good to remember that sometimes, changes in regulations that have no additional cost - procedural, how we do things changes - can make a big difference:

The Centers for Medicare & Medicaid Services (CMS) today issued new rules for Medicare- and Medicaid-participating hospitals that protect patients’ right to choose their own visitors during a hospital stay, including a visitor who is a same-sex domestic partner.

That's something I'm glad to hear.

Follow-up to yesterday's class on doctors and pharmaceutical companies

The SF Chronicle must have known about our class yesterday, because they just came out with this article on doctors receiving money from pharmaceutical companies: http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2010/11/18/MNJU1GDLRF.DTL&tsp=1

Although it mostly focuses on doctors who have been the subject of disciplinary actions, the article also mentions the increased restrictions on doctor-industry relationships (especially as concerns academics) that we touched on in class.

Easy and Incredibly Hard Solutions - Obesity & Nutrition

As promised, here is the crazy article I was talking about a few weeks ago which suggests that overarching causes/treatments for obesity may be much more complex and insidious than simply "eat less, exercise more." Among my favorite depressing yet little researched topic - reduction of variation in ambient air temperature. Unfortunately, this was the only article I could find on the topic, so take the findings with a grain of non-replicated salt.

Second, I wanted to share this infographic on how fortifying foods with vitamins/minerals can improve literally millions of lives in the developing world & the US. It brought home to me how cost- and results-effective population-level public health interventions can be, even though they rarely have the sex appeal of higher tech, "lifesaving" technologies. Unfortunately, sometimes we point to successes like these as solutions for the developing world and fail to see how effective they can and should be here at home.

Fresh air: What Dialysis Taught Us About Universal Health Care

Now that you're all done with your midterm and need something to do, this is a really great story on NPR's Fresh Air about coverage of ESRD (End-stage renal disease, or kidney failure) under Medicare and how the costs to cover this small fraction of Medicare beneficiaries eats up an enormous amount of Medicare spending. ESRD has been called "Socialized medicine for one organ" by some mentioned in the story. This brings up lots of questions about the monetary value of a life, the privatization & commercialization of care, and the burden of chronic disease.

Click and listen to both sections "What Dialysis Taught Us..." and "Medicare Chief MD Speaks...", it is well worth it.

http://www.npr.org/templates/rundowns/rundown.php?prgId=13&prgDate=11-09-2010

Do you now feel shocked & dismal about the future of Medicare, if you did not already? :(

FDA gets feisty / personal choice?

My family had a friend visiting from Ecuador last year when the law passed allowing the FDA to regulate tobacco products. She was outraged. She was a smoker. And she could not believe that the US was going as far as intruding in people's private lives and personal habits. (Ecuador has very little social health movements, so I think this was pretty bizarre to her.) She understood that smoking was bad for her health, but she enjoyed it. And that was enough to keep her smoking.

She is not the only one who feels this way. Isn't personal freedom an American value most of us cannot imagine living without? Why is choosing to smoke any different? (Playing devils advocate here...) Check out the article below, it's about the FDA's new plan to "re-energize the nation’s antismoking efforts". It's a little graphic, but hopefully helpful. It will be interesting to see what kind of backlash this new regulation gets.

http://www.nytimes.com/2010/11/11/health/policy/11tobacco.html?src=ISMR_HP_LO_MST_FB

Public Health Wax Poetics

As most of you may know, the American Public Health Association Annual Meeting ended today in Denver, Colorado. This year's theme was "Social Justice: A Public Health Imperative" and kicked off with inspiring speeches by Drs. Cornel West (Princeton University) and Bill Jenkins (University of North Carolina). If you need to take a break from working on the take-home midterm (ha!) and to remind yourself why we're so disillusioned yet driven to confront health inequities inside and outside of the delivery system, then take a listen:

http://www.youtube.com/aphadc

Higher Premiums and Co-Pays for Employer Sponsored Health Insurance in 2011

A recent Washington Post article discussed the expected rise of health care costs for employers to increase to 9 to 12% for 2011. Employers plan to combat this by utilizing cost-saving methods to bring the increase down to 6%. Methods employers are considering include health management or wellness programs, increasing employee share of premiums, providing plans with less benefits, and selecting plans with higher co-payments and/or coinsurance.

LINK

The article provides a good example of how the rising health care expenditures, coupled with the economy and some health reform provisions, is having a significant impact on employer sponsored health insurance. If cost-shifting from employer to employee continues to increase, at some point, the United States' basis of coverage from employment might need to be revisited. Employers might not want to be responsible for providing coverage if it means they are going to be bankrupt. This makes me wonder about what subsidy amount for small businesses to provide coverage will be sufficient to incentivize them to continue doing so? What penalty amount on big businesses will be enough to motivate them to provide coverage?

Health Reform and the House

http://www.nytimes.com/2010/11/07/health/policy/07health.html?hp

Interesting article in the New York Times this weekend about how the Republican leadership in the House plans to target Health Reform. They talk about limiting funding to the IRS, blocking insurance regulations, etc. As House Republican whip Eric Cantor says: “If all of Obamacare cannot be immediately repealed, then it is my intention to begin repealing it piece by piece, blocking funding for its implementation and blocking the issuance of the regulations necessary to implement it.”