.comment-link {margin-left:.6em;}

Fixin' Healthcare

Tuesday, December 19, 2006

The Lifestyle Chronicles - Trying To Do Good And Achieving Less

The Center for Medicare and Medicaid Services (CMS) is trying to do good by establishing quality standards and protocols for medical care. Although their effort is not getting the expected results, the issue may be a turning point that could transform health care. Transforming health care is likely to be more productive than reforming medical care.

The predominant form of medical care in America is the diagnosis, treatment and follow-up care of individual patients with illness and disease. The increasing capability of the medical care system has been matched by an increasing incidence of chronic diseases, which are not cured by treatment. It is a situation characterized by greater inputs yielding diminishing returns. The CMS project has inadvertently demonstrated that point.

A recent report from Harvard University and the University of California San Francisco identifies health disparities between population groups within the United States. The report serves to illustrate the current health situation and how much needs to be done to improve health status.

The US population was divided into eight groups based upon race, location of the county of residence, population density, race-specific county-level per capita income and cumulative homicide rate. Assessments were made concerning life expectancy, the risk of mortality from specific diseases, health insurance and health care utilization for the eight groups.

The gap between the highest and the lowest life expectancies for the race-county combinations in the US is over 35 years. The mortalitiy disparities are most concentrated in young and middle aged males and females, and are the result of a number of injuries and chronic diseases with well-established risk factors. Between 1982 and 2001, the ordering of the life expectancy among the eight groups and the absolute difference between the advantaged and disadvantaged groups remained largely unchanged.

This means that millions of Americans identified by their sociodemographic characteristics and place of residence have life expectancies that are similar to some low-income developing countries. And, the situation is not getting any better.

Self-reported health plan coverage was lowest for western Native Americans and low-income southern rural blacks. However, crude self-reported health-care utilization was slightly higher for the more disadvantaged populations. The available data suggest that the variation in health plan coverage across the eight groups is small relative to the very large gradient in health outcomes.

The observed disparities in life expectancy cannot be explained by race, income, or basic health-care access and utilization alone. The authors conclude that health disparities will have to be at least partly addressed through public health strategies that reduce risk factors for chronic diseases and injuries.

That, good people, is health and health care in the real world. It may be the explanation as to why qualitiy measures of medical care to distinguish between hospitals does not reveal a significance difference in deaths between high and low rated hospitals. Something more powerful than medical care is at work. Changing the course of the Titanic would have avoided the iceberg; rearranging the chairs on the deck would not.

Technorati Tags: , ,

Wednesday, December 13, 2006

The Lifestyle Chronicles - Process And Outcomes

The quality measurement and health assessment group at the Center for Medicare Medicaid Services (CMS) has selected 22 quality measures to evaluate and rank hospitals. A study of hospitalizations during 2004 involving heart attacks, heart failure and pneumonia presents an intriguing view of this methodology. Moreover, these results suggest that health care functions differently from the extrapolated projections of clinical trials.

The difference in deaths associated with heart attacks over the one-year period was 0.5 percent less in the highest ranked compared to the lowest ranked hospitals. The difference in deaths due to heart failure between the best and the worst hospitals was 0.1 percent. The death rate from pneumonia was 0.5 percent higher at low-rated hospitals.

These are not the expected results and the descrepancy is sufficinetly important to merit further investigation. Undoubtedly, one or more procedural factors will be proposed to explain the findings but the possibility has to be considered that the current perception of health care quality is flawed.

Medical care has moved far into the realm of aggressive therapy based upon drugs, medical devices and surgical procedures. Data from clinical trials supports these forms of therapy. It is a logical assumption that clinical trials can be extrapolated to apply in the real world.

But, what if it doesn't work that way? There are many more things in the real world than can be accounted for in clinical trials. What if a significant difference in clinical trials becomes an insignificant difference in the real world? The variability in biological systems and human organisms is a difficult adjustment. And, there is the behavior factor on the part of patients, as well as health care providers.

Whatever the case, I do hope the Mandarins will take a good look at the basis for these study findings. They should consider the situation comparable to a phase IV trial where Mother Nature is the principal investigator. The task is to determine what she is doing. It may lead to an entirely different perception of health care.

Technorati Tags: , ,

Tuesday, December 12, 2006

Academic Health Science Centers - The Same, Only More

Conflicts of interest are as old as sin itself. Most of the time and in most ways, people are aware of these conflicts and they are overlooked unless obvious harm results. "No blood, no foul". As the stakes grow higher, there is growing concern about situations involving large amounts of money and/or blatant disregard for rules and regulations. The most concern, however, is directed to whether conflicts of interest both small and large corrupt the system in which they lodge.

It is difficult to eliminate all conflicts of interest. Some are not discovered in a timely fashion or become known long after the fact. Others are considered acceptable due to the expertise of those involved. Whether or not disclosure of conflicts represents adequate response depends upon who is passing judgement.

Some conflicts of interest are so large they defy response. "Steal thousands of dollars and end up in jail; steal millions and become a king". The reasons for this are not always clear. Most often the explanations are that it is a necessary tradeoff to do business and to change things would destabilize the system.

Academic health science centers and teaching hospitals are heavily invested in the current health care system. Patient care is a necessary aspect of teaching and, initially, the income was incremental and supplemental. However, the academic health science centers learn over and over the painful lesson of the leverage exerted by supplemental income. Depending upon the environment, one dollar of supplemental income can command as much energy and attention as ten dollars of previously allocated budget.

The cash flow from clinical care has become a tsunami for academic medicine. It permeates every nook and corner of the academic health science center. The specialists generate the most income, so the specialists rise to the top of the totem pole. A sizeable amount of this money ends up in the pocket of those who generate it and it is allocated to other forms of support for their own departments. This is an environment that mimics broader society comprised of different socioeconomic strata with stars and ordinary citizens.

It is this environment that educates the health care practitioners of the future. Would health care be different, if this environment was different? What circumstances would be required to change this environment? How do Mandarins view the future when they are heavily invested in the present? Could it be the same, only more of it?

Technorati Tags: ,

Sunday, December 10, 2006

The Lifestyle Chronicles - Risk-Based + Problem-Based = Health Care

Does anyone remember when they began to recognize the widespread use of the word "risk"? To be sure, the concept of risk has been around a long time even when people did not recognize it as such. But, there is an apparant "newness" for popular perception of risk that represents wider public understanding of the concept. Identifing and managing risk has moved quickly into all aspects of society and daily life.

The recognition of risk and how it affects society is a work in progress. It is difficult to imagine that it will ever be completed. The financial industry is an example where risk is codified and implemented on a broad scale. Presumably, this is to reduce risk but failure persists and new risk based products continue to be developed.

Identifing risk and managing risk are dependent upon reliable information and the practical use of information. The two are linked but not necessarily coordinated. Prevention and safety are working concepts to implement and utilize risk. These are complex issues with many facets, such as cost benefit ratios and personal values.

As modern society becomes more complex, the concept of risk becomes more important. That being said, civilization has a long way to go to derive full value from the concept of risk. Without systematic and universal risk management, the health care system fails to achieve optimum health status for individuals and the population.

Health care in America is a problem-based system. Problem-based health care is responding after the fact. This is a retrospective view of health with increasing incidence of chronic health problems. The task is to determine how risk-based health care can change problem-based health care to achieve improved health status for the nation.

It is a matter of choice but it is several orders of evolution beyond the choices presented by the health care system of today. The dynamic mixing of risk-based health care with problem-based health care is already underway and it will create a new and different health care system.

Technorati Tags: , ,

Sunday, December 03, 2006

The Lifestyle Chronicles - The Need To Know

My last post expressed a view that some academic health science centers would adjust to changing conditions and design methods to contribute to health care reform. Certainly, these centers have the capability to assist and even lead some aspects of reform. The question is whether they are in a position to do this. Are they part of the solution or part of the problem?

To be sure, health care reform is a complex undertaking that is unlikely to be addressed in a single comprehensive plan. The role of the academic health science centers at this stage is to evaluate the health care system and efforts to change it, design and establish demonstration projects to highlight and clarify high priority issues, and define the important questions and goals for reform.

For example, physicists can design a model that predicts what the universe would look like if several basic conditions such as gravity were changed. What would the health care system and health status look like if every person had health insurance? What other aspects of the nation and the economy would be altered or need to be altered? What is likely to be the impact of Medicare Part D upon health status? What other programs might have contributed more to improved health status? Does the evidence indicate a reasonable probability to eliminate 25% (or even 50%) of acute medical care? Does providing more medical care represent reform? If people are to be made to chose about medical care, could they not chose about behavior to improve health and could these be effectively linked?

I'm sure these specific thoughts are superficial, flawed and/or biased, but the idea of identifying the important questions and providing answers that clarify goals is a viable approach. And, somewhere there has to be a mechanism to collect and formulate what is known into workable policy and bring the public on board. Otherwise, we are left with piecemeal solutions that are molded and promulgated by whichever special interest has the upper hand at the moment.

By the way, West Virginia has launched a medicaid project that bears watching. Lessons learned from other past projects, such as TennCare, need to be retained and added to the equation.

Technorati Tags: , ,

Saturday, December 02, 2006

The Lifestyle Chronicles - Tending The Garden

The academic health science centers and teaching hospitals have played a curious and influential role in the development of the health care system. Policy makers and those interested in reform of health care would do well to study this situation as an object lesson.

The subdividing of academic units in the health sciences has been underway for at least 50 years. Specialties and sub-specialties have developed in association with the increase of scientific knowledge and development of technology.

The awarding of government research funds to speciality units solidified their separate academic identity and fueled their growth. However, the largest source of funds have come from patient care. In that regard, academic health science centers and teaching hospitals are major players in the health care delivery system. But, they are very special players with significant advantages and tremendous influence.

Academic health science centers and teaching hospitals exert leverage in the patient care arena with the manpower provided by residency and fellowship training programs. With the funding of Medicare and Medicaid, the large patient population cared for in the clinics became a source of revenue in addition to referrals sent to specialty units.

There is no organization more decentralized than academic medicine. The period of rapid revenue growth was uneven throughout the organization and the revenue has leveled or is decreasing in most areas. The academic units have expanded to the limit or beyond the resources allocated and everything is viewed as absolutely necessary for a mission that was outgrown long ago.

The secret is to avoid throwing the baby out with the bath water. There will be pain but some centers will carve out new missions early and lead health care reform.

Technorati Tags: , ,