Wednesday, October 25, 2006

Are there any doctors out there?

If so, I can't imagine that you don't have an opinion about my comments on Transplants, below. In that posting, I am suggesting that not all hospitals should be permitted to do all kinds of clinical procedures. Are you going to let a non-MD like me make a clinical judgment like that -- unchallenged? (I got more comments on the cookies!!)


Alexis said...

I suppose I didn't feel it required too much of a challenge for several reasons. While I'm not in MA, it does seem that you have (and I imagine many areas are similar) a large number of providers for a small number of "consumers" in terms of transplants. I would like to think the majority of doctors would agree that the goal is quality rather than a sort of willy-nilly distribution.

I would be more in favor of a more centralized transplant location with the idea that surgeons from across the state could come and learn (perhaps in a fellowship sort of arrangement) to perform transplant surgeries if they so desire. I would be in greater favor of the idea, if I could feel secure that patients' insurance companies would respect that centralization in terms of how they bill (network/out-of-network) and cover care.

While I believe you and I disagree on the issue of universal health care, I would suggest that one advantage of it could be the centralization of proficiency in highly specialized treatments with relatively small "consumer bases."

I whole-heartedly agree with the idea of putting more money towards transporting patients, because I can assure you from experience that it is a problem. I would actually expand this idea to say "let's put money into pre-transplant care" including improved transport to and from things like dialysis centers (and more of them), better dietary/nutritional support, PT/exercise support, and psychological care. There are a number of people here, for example, in ESRD who have almost no familial support system, and rely on a fairly underfunded transportation system to often overbooked dialysis centers, and have relatively little assistance in controlling their diets, managing their long lists of medications, dealing with the paperwork, or even coping with the exhaustion and disability hemodialysis inherently creates. The cost of a brand new transplant center could easily fund an improvement in the care of those waiting for an organ. After all, it's not as if building a new center will suddenly increase the number of organs available.

Richard Dale said...

I am not an MD, but I watch them on TV... ;)
Perhaps our clinical friends are floored by your logic, which seems impeccable to me.

Richard Wittrup said...

Don't be apologetic about having an opinion on a clinical matter. Clinical matters are the business of the organization of which you are the CEO. How can you ever be expected to improve quality and control cost if you are not allowed to have an opinion on clinical matters?

Richard Wittrup

Anonymous said...

I'm an MD, and I agree with you that there are serious issues to be considered here.

When I was a student, I spent some time in Ireland doing my neurology rotation. I was based at the national referral hospital for neurology. All of the complex neurology in the country was there. This was very good for a student in terms of learning, but also very good for patients, and efficient in terms of costs.

It absolutely doesn't make sense that BIDMC and the B&W both try to be all things to all patients. It would be much better for them to split things. Only one place should do neurology, for example. And only one cardiology. Of course, it's not hard to see the problems with this. Both places will want the profitable services (like cardiology), but not the unprofitable ones (like primary care).

By any reasonable analysis, both the BIDMC and B&W should not be doing transplants, unless it just wasn't possible for one to do all of the procedures (I very much doubt this is the case). But who would decide which institution should be the Longwood area transplant hospital?

I think the geography argument has some merit. While patients in northern New England certainly would (and do) travel to Boston for tertiary care, transplant patients need life-long followup. This is best provided by centers with expertise in transplant medicine, and it's a stretch to imagine transplant docs working at a center that isn't actually doing transplants. So maybe a Boston hospital should give up its transplant program to Dartmouth :-)

BI Deaconess Doc

Patient Dave said...

So, I'm wondering (I'm not an MD), is there a reality that some MDs might feel they're risking punishment (the silent, unofficial type) if they blow the whistle on goofy practices by hospital administrators?

Maybe not - I don't know. I just know of people in the business who feel (for one reason or another) that it's best not to attract attention with one's opinions. I sure would like to know if it's risky to do so.

It seems to me that any manager who pulled that crap would be interfering with a joint community effort to deliver the best health care possible within the constraints of today's budgets, and such a manager should be shot. (Figuratively.) Or at least outed.

Patient Dave
(Becoming less patient, the more I think about these things. And that's a good effect of this blog, I think.)

Anonymous said...

Trust me on this one, Dave; Doctors never hesitate to express their opinions to administrators or about administrators!

I think ultimately the insurance companies may be the important players in the issue raised by "BI Deaconess Doc." See my discussion below about bariatric surgery, for example. These highly complicated and expensive procedures are different, though, from specialties like neurology. They require lots of money, time, and practice doing hundreds of procedures. You could have two somewhat small, but excellent neurology practices in adjacent hospitals, each seeing a moderate number of patients per year; but you cannot be an excellent transplant surgeon if you do not do lots of procedures and have an extensive back-up system of other doctors and professionals.

Janders said...

Not an MD (but will be in a few months). My opinions in easy-to-type and less-than-beautiful bulletpoints:

*Everyone is welcome to have opinions on healthcare and even clinical matters. While I certainly may know a bit more about transplants than Joe Off the Street, we are both consumers in this mess of a healthcare system, and we both should talk about our opinions.

*Transplant medicine is an interesting little side show when it comes to issues such as supply and demand, ethics, funding, distribution of resources and the like. Who gets one of the rare livers we have availible? Why them? What if it fails, should we re-transplant them, or do you only get one chance? It is a ripe field for debates.

*When is comes to highly-specialized medicine, especially procedural medicine, quality is variable. Quality increases dramatically when you have a team that does a lot of cases. Two hospitals doing 100 Livers each will have beer outcomes than 10 hospitals doing 20. It is given that we need more than one transplant center in this country secondary to basic logistics, but how many are necessary? Shouldn't there be centralized planning to reduce the number of unnecessary centers?

*Well, why would a random hospital want to start a new transplant center? The best reason is that there are patients nearby who need transplants that can't easily get them elsewhere. I can imagine that there are other reasons though... but how can we control that? We live in a capitalistic country. Which reminds me of a lesson I was taught once by an older attending:

He showed a map of the smallish city we live in, and showed the 3 hospitals that serve it, along with maps of income distribution, insurance distribution, and disease distribution. The poorer, eastern part of town had only partial access to an older, run-down hospital on its border. This hospital was threatening to close for financial reasons. This area of town also had the lowest expect age of death, and highest rates of numerous diseases such as diabetes.
Now, he asked, if you were trying to make this city healthy, where would you put a new hospital, and what would it have? Well, you'd plop it right in the middle of the east part of town, within easy access of the citizens who have the least access to transport. And maybe you'd equip it with extra primary-care doctors, since so few of these citizens have doctors of their own.
Now, he said, if you were a for-profit company running hospitals, what incentive would you have to make that hospital, which would serve medicaid and non-paying clients on a regular basis. Why would you want PCPs on your staff? In fact, why would you even want to keep that old hospital running on the edge of the "bad part" of town, since it was just a cash sink. Wouldn't you want to open something with a cardiology wing and interstate access up in the nice subarbs on the other side of town?

Which was exactly what was happening.

Of course, the people in charge of the hospitals aren't at fault; they are beholden to their shareholders. They are not cruel-hearted. It is a system error. A built in limitation when you deal with life-and-death using the mechanisms of a partial free-market economy.

Not saying a single payer system would fix any of this, but boy, don't you think some central planning would do some good?

Anonymous said...

Just to clarify: The hospitals in New England, for the most part, are non-profit organizations. There are no shareholders, so decisions are not being made to provide money to investors. Any operating margin that we earn is plowed back into the hospital to provide better patient care in the future.

I am suggesting that the insurance companies could have a stronger say in these decisions to rationalize care -- based on quality concerns. They say they want to achieve higher quality, but they have been timid about stepping into the arena we have been discussing. As you note, sometimes hospitals have to get a strong outside signal not to invest in certain areas.

In other countries, the government bureaucratics who run the national system (or single payer) make these decisions. As I have asked below, can you point to one where it is runnng really well?

Bwana said...

I have thought quite a bit about your original post on transplants because something about it keeps nagging at me.

First, I am pleased to see that you are addressing a wide range of topics showing just how eclectic the issues facing a CEO in a complex organization can be and are.

I would not subscribe to the idea that insurance companies should determine who does or does not do a procedure -- perhaps their role should be limited to verifying that a provider (institutional or individual) meets minimum certification standards to apply for benefits -- but I am not suggesting that insurance companies be the certifying authority. Too much experience with too many insurance companies leave me convinced that they have neither the skill set not the interest (from a public welfare as distinguished from a self-serving profit motive point of view) to do that job.

Taken to its logical extreme, your argument devolves to saying that all hospitals should be judged by what they do best and not permitted to do anything other than that.

Yet, the mission of a hospital should be to do everything it does well ... or at least to a threshold standard.

The problems here are a mix of social, economic, institutional, and logistical dimensions. I am sure there are other considerations too.

Let us say, for example, that BIDMC decides not to offer transplant services. Might this lead to a loss of patients who go to say, MGH, for other procedures as well? Would a hospital that was not a "full-servie" facility be perceived in a lesser light?

Is the profit margin for doing complex procedures so high as to warrant doing them even if the numbers are small? I don't know the answer to this.

The corollary is that, as is the basis, for at least a good portion of your opinion, if an institution does not have the volume of surgery to build experience and expertise, there is a risk that standards will falter.

This dilemma is not easily resolvable, but perhaps, having a team of doctors do the procedure either at an independent location -- or even at a shared location within one facility is the answer. But from an institutional standpoint, would Partners be comfortable telling patients that their transplant services are provided at an OR in BID? Or vice versa?

Our extant system is to allow market forces to filter all this stuff -- after all if one hospital does only a few procedures and gets poor results, ultimately, it will lose business. However, patients may lose in the process -- referrers will be tempted or pressured to make internal referrals and the "discovery" time could lead to unfortunate negative results for some.

There was, at one time, a Certificate of Need required for equipment, etc. I don't know if that still exists and whether it applies to decisions to provide a certain procedure or not.

A variant on the theme above is for BID to form a regional alliance much as it tried to form Care Group and see if that can be a unifying force around such issues.

Anyway, this is too long already ... and I am not a physician so perhaps I should not have responded, but I think the issue is considerably more complicated than being a mere Administrative or Clinical decision.

Keep up the great work.


Anonymous said...

I'm not a doctor, however, I hope to be one soon!

I am currently taking a health care policy course and we briefly discussed transplant centers. I think it comes down to the fact that having too numerous transplant centers will cause people to not be as experienced with them. Similar to how too many level 1 trauma centers would be bad, transplant centers I feel have the same problem. There would be significant costs of keeping a transplant center and patients will not be getting the treatment they deserve. On the contrary, however, not enough centers would cause major accessibility problems and cause the ones that are open to be too busy.

I think that if the system waited just to see what happened that it would even itself out eventually however that could mean patients not getting top quality care. Perhaps a report, in the fashion of the Flexner Report, is needed? Someone to come in, look at all the places and come up with some suggestions? Would anyone listen to these or does there need to be some type of regulation?


Anonymous said...

I might be wrong about this, but I think programs want as many high tier speciality programs they can acquire because it boosts their reputation.

If community programs have brain surgery and valve repair, what does the tertiary care center offer? It has to be unusual--deep brain stimulation for movement disorder, non-myeloablative BM transplants, KP transplants for type I DM, etc. Even if these things are redundant, don't you have to offer them to retain high quality staff and attract new research?

I suppose the elephant in the room is how many tertiary academic centers are necessary? And if someone computes that we need only half as many, who decides which program ramps down? Temple or TJ? Duke or UNC? This is one of the few instances where I see a central government health care plan have some benefits.

I guess the things you already know about transplants don't need to be said--a certain level should be done each year or else competency is called into question (UC Davis anyone?). The support staff including transplant coordinators, pathologists with transplant training, etc would only be economically feasible with a certain critical mass of patients. And lastly, where do you get your patients from? Who wants to refer their long term patients to the new program?