Tuesday, December 04, 2007

Pursuing Perfect Care in Ohio

Several weeks ago, I mentioned the retreat we held with the BIDMC and BID~Needham hospital boards to review the role and scope of the governing bodies of our organizations, as a precursor to establishing audacious quality, safety, and patient satisfaction goals for the two hospitals. In just a few weeks, the two boards will meet again, and I will be able to report to you on the overall direction voted by them. In the following months you will be able track our progress towards exacting, quantified goals.

Several days ago, I had a chance to visit with a board member from Cincinnati Children's Hospital about their self-improvement process, entitled Pursuing Perfect Care. This has been an extraordinary program, pervading the entire institution, and achieving great results. A key aspect of the process has been utter transparency about the organization's progress towards its goals. Check this page for a summary of the operational definitions of the items that are measured and reported upon publicly. As I have noted elsewhere, transparency is not a matter of trying to create a competitive advantage for one hospital versus another. It is a way of holding one's own organization accountable to itself and to the public.

In the last several days, executives from several of the state's insurance companies have made suggestions regarding cost control of medical expenses in Massachusetts. As reported by our friends at Health Care for All, they suggested legislation that would include the following items:

1. Public Reporting of Preventable Errors and Prohibiting Billing for Avoidable Mistakes
2. Strengthening the Determination of Need Process
3. A Special Commission to Study State-Funded Stop-Loss Coverage
4. Allow for the Operation of Limited Service Clinics
5. Medical Malpractice Reform
6. Require Electronic Transmission of Health Care Transactions
7. Repeal Mandated Benefits that are no Longer Effective
8. Comparative Effectiveness Studies of Medical Services
9. Extend the Moratorium on Mandated Benefits
10. Permit Mandate-Lite and Mandate-Free Products
11. Hospital Reporting on Measures to Reduce Duplicative Diagnostic Services
12. Hospitals Reporting on Measures to Eliminate ER Diversions and Overcrowding
13. Make Greater Use of Managed Medicaid
14. Eliminate Duplicative Regulatory Requirements
15. Standardized Reporting Requirements
16. Streamline Administrative Processes
17. Standardize Physician Credentialing

Perhaps some of these might be good ideas in their own right, but they do not get at the underlying structural problem in the delivery of care in hospitals. This is not to say that hospital costs are the sole or main determinant of cost increases in health care, but they are admittedly an important part of the trend. We do not need to wait for legislation to make improvements.

The clear message from my colleague in Ohio was this: THE most significant step hospitals can take to improve cost-effectiveness is to reduce harm to patients in their institutions by adopting aggressive quality and safety goals, measuring their success towards them, and reporting on their progress to the public. Not that we should need an economic argument to do a better job for patients, but it is good to know that two go hand in hand. We intend to pursue this agenda with all due energy at BIDMC and BID~Needham.


Anonymous said...

With per capital healthcare spending in Massachusetts at or near the top among the 50 states, I wonder to what extent the cause is too many hospital beds and too many specialists resulting in practice patterns intended to fully utilize these resources. Other providers like Mayo and Inter-Mountain cost the Medicare system far less per beneficiary than hospitals in Boston, NYC, LA, and Miami while outcomes are no different. Utilization of hospital resources, especially at or near the end of life, is far higher in the high cost markets. Why is this and what can be done about it? I can't see either hospitals or doctors volunteering to shrink their own business, but there seems to be a lot of demand for medical services that is supply induced. Maybe you folks have met the enemy and it's you! That all said, I applaud the transparency initiatives.

Anonymous said...

Barry, I've seen those figures, too, and I don't have a good explanation. I don't think we have more beds per capita in the state, but MA does have lots of specialists and subspecialists. We also have a greater proportion of academic medical center beds per capita, which adds research and teaching costs to the mix, as well as new therapies under development. In contrast to other states, those AMCs really serve as the community hospitals for much of Boston. (They also attract international patients, who pay full freight and therefore add to the total health car espending amount in the state -- but presumably in a good way!)

But whatever the reason, I think that academic medical centers have a special obligation to improve quality, safety, and cost-efficiency.

e-Patient Dave said...

First, Paul, thanks for letting us know of other instances where people are aggressively pursuing better quality. The more of these we all see, the less unusual it becomes, and the sillier it seems when someone isn't moving in that direction.

I'm intrigued with Barry's observation about how many beds and specialists we have. (Note: I don't have an opinion (I don't know the data nor the reality behind them), I'm just intrigued.) Is it accurate to say the *cause* is too many beds? Or is it that more are available, so it's POSSIBLE to give someone the care they need?

I'd also wonder how much is due to any differences in hospital practices and how humane the care is. I'll never forget my father's hospitalization 10 years ago in Annapolis, where none of the staff seemed to have a clue about his care plan or anything else. Then one Monday morning they snapped suddenly into alert, focused intentionality. I thought "Hallelujah, a new team must have come on shift." But no, based on insurance rules, the hospital had decided it was time to get his butt out of there - and THAT was something they were truly good at.

My point here is that although his "outcome" may have been statistically fine at that moment, the whole culture sucked. The focus was on money, not care. I'll spare you the specifics, but if we hadn't had people with him every minute, his "outcome" would have been worse.

If what we're up to is managing cost above all, then we go right back to that great scene in As Good As It Gets where Helen Hunt says "[bleep]ing HMO sons of bitches," and the audience in my theater erupted in cheers. The punch line is that a few weeks later NPR interviewed the head of the country's biggest HMO, and he said he'd had the same experience when he saw the movie, and he was totally stunned, because he really thought his industry was going a good and diligent job of what the public wanted - controlling costs. That's a man who had his head stuck so far up his own silo that he couldn't see what was all around him, right outside the silo walls.

Anyway, to return to causality, if motorists were spending lots of money on fixing flats, would we say the problem is that there are too many tire repair shops? It's not a perfect analogy, but it's worth looking at. (Some cultures think women are the cause of rape, because if there weren't all those women, there wouldn't be all those rapes.)

I also feel strongly that any statistics about costs and outcomes in a system should have an accountant's note specifying what proportion of the population goes without coverage in that system, so they don’t even have an outcome. Until we get honest about that, all we're doing is chasing a bubble under the blanket.

Whew. Well, you can see why I'm finally starting my own blog. (None of this is on there yet, but I guess it's time.)

Anonymous said...

In the interest of transparency and public sharing of quality and cost information, I thought you might like to check out this state site: http://www.minnesotahealthinfo.org/
It's one of the best I've come across in my market research, just as BIDMC's transparency website is a model for health systems.
Linda McManama

Anonymous said...

Patient Dave,

Most of the information about regional differences in healthcare costs and practice patterns was developed under the leadership of Dr. John Wennberg of the Dartmouth Atlas Project.

According to the California Healthcare Foundation, the costs that we most commonly think of as healthcare costs covered by health insurance (hospital charges, doctor and clinician fees, prescription drugs and other medical products) account for approximately 65% of U.S. healthcare costs. The remainder consists of dental fees and miscellaneous professional services, 10%; nursing home and home health care fees, 10%; public health initiatives, 3%; investments (like hospital construction), 6% and administrative costs,7%.

Hospital charges account for 31% of total healthcare costs and 48% of the subset of costs normally covered by health insurance. If we include physician fees for services rendered in a hospital setting (either inpatient or outpatient), the total would comfortably exceed 50% of insured costs.

Virtually all of the healthcare costs within the hospital, doctor and drug subset are driven by doctors through their decisions to admit patients to a hospital, order tests, prescribe drugs, consult with patients or perform procedures themselves. It is these practice patterns, over which the patient has little control or influence that vary materially on a regional basis, and it is these charges that are increasing in cost faster than general inflation in the economy.

By contrast, dental fees, nursing home charges and home healthcare costs are generally not driven by doctors but by patients or family members, often with the help of social workers and, tangentially, by doctors when they recommend, say, one nursing home over another. Interestingly, only about 40% of the population has dental insurance (I don't have it myself), and even those who do have it often pay a significant portion of their dental bills which usually are not all that high to begin with. As a result, the price of dental care is rising far more slowly than for medical services driven by doctors' decisions. Nursing home and home healthcare charges are paid largely out of pocket except for the poor who are covered by Medicaid. Medicare pays for nursing home costs under extremely limited circumstances and then only for a brief time period. Since the most significant cost of providing these services is for generally low paid labor, they are not rising as fast as hospital, doctor and drug costs either.

Your flat tire analogy also represents costs that are driven by consumers and paid for out of pocket. Not surprisingly, there is lots of competition in the tire market, and the cost of tires has increased more slowly than general inflation while quality has improved. It's too bad that healthcare costs are not subject to the same dynamic, at least not yet.

e-Patient Dave said...


I can't pass up the opportunity to note that rapid inflation is inherently part of the tire repair shop. Heh. I crack myself up.

But, seriously, your point about cost and quality and variety (competition) of tires is well taken. I hope we'll continue to see similar improvements in healthcare. What it takes, in my experience in business, is continued efforts to get rid of reasons you're not better. And that's why we all benefit from both transparency and competition.

Do you know if Dr. Wennberg's studies included noting who was unable to receive care? This is a really big deal to me - we (as a culture) have a tendency to make the numbers look pretty by conveniently excluding the parts that are hard to solve. That's what I meant about chasing a bubble around under a blanket.

It's not limited to healthcare. I think I'm gonna write something about it.

Anonymous said...

Patient Dave,

I don't know enough to answer your question. However, there is a lot of good information on the Dartmouth Atlas website which can be found at www.dartmouthatlas.org.

Separately, I certainly agree with you on the need for price and quality transparency, and I advocate for it every chance I get.