Group Project: Interest areas?

A few of us spoke after class today about using this blog as a space to share what we may be interested in working on for the group project, since our smaller cohorts (MPH, MPH/MPP, 11-month-ere) don't routinely see each other outside of Foundations class. Perhaps that's due to schedule differences that will be difficult to work around, but perhaps not!

So here's a starting point. Post interests and ideas to the comments section, so if folks are gravitating towards specific issues, we'll have a centralized place to find that out and clump up!

"Have you recently experienced a medical mistake?"

With the goal of making health care safer, the Obama administration is drafting a novel system for patients to report medical errors.  No system of this scale currently exists.  The primary questions in the draft are, "Have you recently experienced a medical mistake?  Do you have concerns about the safety of your health care?"  Respondents are also asked to indicate potential reasons for the error such as "A health care provider was too busy" or "Health care providers failed to work together."  They even have the option to report specific names of providers (physicians, nurses, etc) and their addresses. 

After reading this article, a few questions came to mind and I'd be interested in hearing other people's thoughts.  

1.  Are consumers the best source of information for medical errors?  

While I absolutely agree that patients' perceptions are a key components of their health care experience and they often have helpful insights to improve their care, I do not think that they are the best judge of what went wrong.  And focusing on vague reasons such as excessive provider workload and cultural competency do not get to the heart of the problems nor do they offer specific solutions.  Further, it is unlikely that patients can provide enough detail of their care to allow adequate evaluation of the holes in a health care system.  However, this information may be useful to identify broad trends in patient care over time.  

2.  How should this information be used?  Will it be made public? 

In other industries where workplace safety is a significant concern, the threat of punitive action impedes error reporting.  The ultimate goal is to minimize preventable adverse health effects from medical errors not just reduce the apparent number of errors.  Also, I think patients who experience medical errors but have them acknowledged and explained by the provider would actually be reluctant to use this reporting system if it could get their provider "in trouble." 

3.  Are there better alternatives? 

I think so.  Focusing on quality measures, requirements for all health care organizations to have a process for medical error reporting and evaluation, and making specific health outcomes (eg. surgery mortality rates) transparent are more effective solutions, in my opinion.  

http://www.nytimes.com/2012/09/23/health/new-system-for-patients-to-report-medical-mistakes.html?_r=1&ref=health

A closer look at public opinion

Hi all,

Here is a different look at American's opinions on ACA, in which Michael Sakes pulled together disparate data from a variety of public survey polls to show that disapproval may not be as widespread as high-level polling sometimes suggests.  I am particularly interested in his point that a lot of the apparent disapproval is correlated to a poor understanding of how the ACA will affect individuals.  The author is confident that as people start to experience it, and thus understand its effect on them, in 2014, approval ratings are likely to rise.

http://healthaffairs.org/blog/2012/09/21/what-do-polls-really-tell-us-about-the-publics-view-of-the-affordable-care-act/

This touches on a question I have been toying with for the past couple weeks - is the high level of disapproval of the ACA due to the policy itself being unpopular, or due to the government doing a poor job of selling this new idea to the public?  Whose job is it to educate the public about new legislation that will affect them?  The government?  The media?  It seems like information dissemination *should* be a much easier problem to solve.

Big Med & the Cheesecake Factory

In case you, like me, missed Atul Gawande's August 13 article in the New Yorker, here's a link to it, titled 'Big Med.' It leads off with lessons for medicine taken from the Cheesecake Factory.

Yup, you read that right. After recovering from my knee-jerk foodie reaction (what??? trade Oakland/Berkeley/SF local fare for the Cheesecake Factory?? no way!!!), I read on and have been thinking about challenges and opportunities for innovation, change and improvement in healthcare ever since, including two thoughts:

1. You can't get good care without some thoughtful coordination across team(s) of care providers. 
• Great description of an experience with uncoordinated care on page 4.
• Astute (and challenging) prescription for improvement from a Cheesecake Factory manager: "...study what the best people are doing, figure out how to standardize it, and then bring it to everyone to execute."
• Why don't we put more resources into this in provider/system workflows? 
2. Standardization has numerous cost and quality of care outcome benefits. But how you implement standardization matters immensely.
• Remote ICU oversight stations as a second set of eyes
• Poorly received if just catching errors; sought out and respected if praising what was done well by the teams the oversee

If you haven't seen it yet, it's worth the read. Would love to hear what folks think about standardization, care coordination, and team-building to improve care.

Oregon Medicaid Program and the Rand Experiment

Many of us are currently in Health Economics and just learned about the famous Rand Health Insurance Experiment of the 1970s which found that people with health insurance coverage used it--they spent approximately 50% more on health care than those without it. The study also found that copayments reduced the use of services. This famous experiment was a classic demonstration of moral hazard at work: the concept that when people are detached from the costs of behavior, they are more willing to take risks.

I came across this article this summer discussing Medicaid in my home state of Oregon. This “experiment” by the Oregon government essentially turned the Rand study into reality: Medicaid coverage was randomly assigned to certain individuals and not to others through a lottery system. One of the original Rand researchers, Joseph Newhouse, is watching this scenario unfold carefully with a group of researchers to determine the effect this lottery has on health care costs and health outcomes. The results essentially show exactly what the Rand study did: those with coverage spend more than those without. Moreover, those with coverage had better health outcomes.

What is striking however, from the story, is the level of impact that coverage really has on those in poverty. This article really gets to the heart of a question posed to us in class: what should we be spending on health care? We focus so much in this country on how much health care costs us, but perhaps this article is highlighting that for many, these costs are worth it. Quality of life improves to such a degree with insurance coverage that maybe health care is worth spending approximately one fifth of our GDP. I just thought I’d share it.

Medicaid Block Grants: Theory vs. Reality

Although the debate about converting Medicaid into a block grant program has been lingering on partisan lines for decades, the Paul Ryan budget proposal is again bringing the debate to the forefront. Under Ryan’s proposal, states would receive a set amount of federal funds to sustain their Medicaid programs, but then bear the financial risks should their programs exceed their grant allotments.  While Ryan believes this will curb federal Medicaid spending and give states increased “flexibility” in running their programs, the reality of this drastic change at the state level is proving to be a contentious issue.

In the worst case scenario, it seems like converting Medicaid into a block grant program could inevitably lead to rationing care. Conservative state leaders believe block grants will allow states to run their own programs without government intervention and tailor their programs to their own populations. However, I seriously doubt states will welcome this freedom at the cost of bearing the risks once their funds are depleted. If states already want to cut Medicaid spending under the current system, what would prevent them from making dangerous cuts to Medicaid beneficiaries without guaranteed federal assistance in the horizon? Another shortcoming of this system is the fact the block grants may not be adjusted for inflation and in the event of another recession, low-income families may be worse off.  For example, lessons learned from the TANF program, another block grant program for needy families, shows that states may be able to funnel block grant funds to free up state funds that may not directly benefit low-income families and children.

All in all, I think the block grant debate if more an issue of political ideology. I understand that states want flexibility to run their programs, but this should not be done at the expense of limiting access and care to those that need it most. I would hope that if Medicaid does become a block grant program in the future, states would develop ways to limit the impact of budget shortfalls on Medicaid budgets. But perhaps this is why entitlement programs have been left to the federal government: to ensure equitable access and guaranteed financial support for those eligible in all states, not just those that can afford to do so.  

Iran vs. Mississippi

Not sure how many of you read this New York Times Magazine article from a few months back but it has stuck with me and I have been reminded of it several times since starting school.  SO, I thought I would share it with you.
One way in which I found this article interesting was the way it addressed the issue of community health workers and ancillary providers, and how in developing countries they are relied upon to bridge the gap between the abundance of patients and the few doctors often available to care for lage populations.  It is a way to address the issues of cost and access, among others.
In the US we also have a great need for this sort of "gap" care which for many people could be in place of the majority of their primary care and if provided in a proactive way, could not only eliminate unnecessary hospitalizations and reduce healthcare costs, but could improve the quality of life for many people.  I think Americans tend to be very closed minded to the idea of someone other than a doctor providing medical care, exhibited by many peoples' reluctance to see nurse practitioners, etc.  Our healthcare system doesn't put enough emphasis on the "medical team" approach, although there have been several attempts to bring this to the forefront with managed care, etc.  I think more people would get the care they need if more resources were put into programs like the one profiled in this article.