The lessons from one of the best hospitals in the world...

During the past month at MGH, arguably one of the best hospitals in the US, if not the world, I looked for subtle, innovative ideas that outsiders might not notice from simply taking a brief tour around the hospital. Health care is a complicated beast, and it really was the little things that made a big difference, not the obvious surgical robots or shiny buildings that meet the eyes of visitors.

1. The Get-to-know-me chart
In the room of every patient who cannot communicate for various reasons (stroke, delirium, intubation, whatever prevents a person from communicating), there was a Get-to-know-me chart, which consists of:
- Name AND "Likes to be called"
- Important people in my life
- Favorites
- At home I use (patients check all that apply): glasses, contacts, hearing aids, dentures
- I understand information best when...
- Achievements
- Things that stress me
- Things that cheer me up
- Others
Some of these charts are filled by the patient before surgery expecting that they might not be able to communicate post-op. Others are filled by their family members. We can imagine how important these answers are when a patient is unable to communicate well with their providers, when they may only be conscious enough to respond to the names they are called everyday, when their world tumbles in times of sickness and the important people in their lives or things that usually cheer them up can make a huge difference, when they are thrown into a new environment and things you usually rely on to function (like hearing aids, glasses) are taken away.

2. The ED observation unit
It is the limbo between the ED and the floor. Many times ED patients await beds or lab results to determine whether they need to be admitted, at which time they no longer need the specific sets of skills and services from the ED staff. The ED observation unit houses these patients so that the ED can triage new patients that need urgent care.

3. Radiology consult
Any physician in the hospital can walk into radiology reading rooms (all of which are located in the same area: neuroradiology, CT, MRI) to review imaging of their patients with a radiologists in person, in order to ask field-specific questions that are usually not answered by the broad comments in the final read. Every time we walk in, the radiologists say with a smile, "How can we help you?," as if they were greeting customers. It is definitely a far cry from Elmhurst hospital, where you can't get a hold of radiologists at whom you need to yell and argue to have them approve the study that you want. Asking them for a personal imaging review would be asking for insults coming your way.

4. Location, location, location
At MGH, all microbiology labs (virology, parasitology, etc) are grouped together, next to the Infectious Disease offices and team rooms, and that is no accident. Whenever a test result is positive, the teams walk down the hall to review lab findings in person, ask questions and get rapid updates as soon as a culture turns positive. A neurosurgery ward is across the hall from the neuro SICU - crashing neurosurgical patients can be rapidly whisked across the hall to be stabilized in the ICU. The CCU is next to the cardiac step down unit - cardiac patients can move rapidly between the two units depending on their cardiac status.

5. The Bigelow service
In most hospitals, interns on a team split patients - one intern does not know anything (or care) about another intern's patients. On the Bigelow service, all the interns share all the patients on the floor. This requires the interns to communicate among themselves regarding all development and treatment choices for each patient. It fosters a foreign concept of teaching physicians to work together and communicate with one another regarding a shared patient, which above the intern level actually happens everyday and everywhere. It also makes sense that an intern knows all the patients on the floor, since all of them are only cared for by one intern on call each night.

6. Communication
On the consult service, I learned to uphold utmost politeness in communicating with other doctors. At the end of every consult we write - thank you for this interesting consult, we will follow along with you. We also make it a point to always communicate recommendations verbally to the primary team, ON TOP OF recommendations written in the chart. At Sinai, I inched gingerly up to the consulting team and before I could ask a question, their first comment was whether I had read the chart, as if we were meant to talk to one another through pieces of paper deprived of personal cues that enhance our grasp of a message.

7. The staff
Most of the hospital staff (nurses, in particular) were there for the grind to earn money - many took no interest in the medicine or in their patients. They clock out right at the end of their shift. Many refuse to do anything other than the required lab draws and vital checks - they refuse to assist others looking for information on the status of their patients, which arguably nurses know best. Others do not care to learn what the patient has and what treatments are coming their way. None of this is true at MGH - nurses ask to be present when doctors explain treatment plans to patients. They suggest care alternatives that improve patient outcomes or reduce costs.

MGH may have flaws that plague other hospitals across the nation (commercial-driven hospital policy, budget cuts in times of depression), but it has merits that sure make for a special place for the lucky patients that can afford it.

Ex-Director of PR of Cigna testified to the Senate about the dirty deeds inside insurances companies and why we *need* a public option.

Wendell Potter, an ex-director of PR of Cigna, has been coming forward to expose the dirty practices used by insurance companies to please Wall Street investors. In this testimony to the Senate, Potter explained how insurance companies think and how that thought process ends up in creating angry, misled Americans now yelling at town hall meetings, not to mention the utterly inadequate health care system that we have now.

At the end of his testimony, Potter delineates why the public option is a must:

Thank you, Mr. Chairman, for beginning this conversation on transparency and for making this such a priority. S. 1050, your legislation to require insurance companies to be more honest and transparent in how they communicate with consumers, is essential. So, too, is S.91278, the Consumers Choice Health Plan, which would create a strong public health insurance option as a benchmark in transparency and quality. Americans need and overwhelmingly support the option of obtaining coverage from a public plan. The industry and its backers are using fear tactics, as they did in 1994, to tar a transparent, publicly-accountable health care option as a ―government-run system.‖ But what we have today, Mr. Chairman, is a Wall Street-run system that has proven itself an untrustworthy partner to its customers, to the doctors and hospitals who deliver care, and to the state and federal governments that attempt to regulate it.

Our choices at this crossroad in the reform are not between the government and freedom in the free market - it is between the government and Wall Street/for-profit insurance companies. Doing nothing leaves us in the hands of hungry Wall Street wolves looking to profit from our sufferings.

It is not an option.

Great videos - highly high-larious!

This first video is a great and simple animation explaining why we *need* a public competitor in the health care reform.

This other video is just high-larious, but somehow I'm afraid some people (like Sarah Palin) will watch it, actually believe it, propagate it, and someone else will end up really buying it. Prove me wrong, America.

Get your facts straight!

Get your facts about health care reform here, compiled by mediamatters.

Based on a prior post, I'd like to draw you attention to Myth 10:

MYTH 10: Co-ops are an adequate substitute for a public option
CLAIM: The co-op "compromise" eliminates the need for the public option.
REALITY: Progressive experts argue public plan is necessary for successful reform. Numerous media figures and outlets have characterized Sen. Kent Conrad's (D-ND) cooperative health insurance proposal as a "compromise," "hybrid," or bipartisan "alternative" to a public insurance option without noting the view by progressive experts that a public option is necessary for health care reform to be successful and that any departure from that will result in the failure of reform efforts. These experts dispute suggestions that Conrad's co-op proposal is a plausible midway point between competing methods of addressing health care reform, because, they say, it precludes a fundamental component of effective reform: bargaining power against the health care industry. For example, former Clinton Labor Secretary Robert Reich described the co-op proposal as a "bamboozle" and said that "[n]onprofit health-care cooperatives won't have any real bargaining leverage to get lower prices because they'll be too small and too numerous. Pharma and Insurance know they can roll them. That's why the Conrad compromise is getting a good reception from across the aisle." And University of California-Berkeley professor Jacob Hacker argued that Conrad "has offered no reason to think that the cooperatives he envisions could do any of the crucial things that a competing public plan must do." Additionally, ABC's Charles Gibson reported that "several health care experts" have said, in Gibson's words, "[I]f you take out the public option in terms of insurance, there's going to be no restraints on the cost of insurance." [ABC's World News with Charles Gibson, 8/17/09]

Without a significant public option that would cover a sizable protion of the population with adequate bargaining power to lower prices, this reform would not accomplish much. Even if there is temptation to pass a watered down bill and declare victory, a failed reform would not bode well for Obama or dems at future elections.

A side point: it would be reasonable to expect that the new and cheaper public plan will absorb the previously unhealthy/uninsured and the lower-income groups that may be a proxy for bad health - a setup for the death spiral. However, the same may be assumed for Medicaid, but somehow it still costs much less and provides more care to its members than most private insurances. And what is the alternative to no competition and downward pressure on prices from the public option? Private insurance companies fueling profits on people's sufferings and fulfilling its goal of providing as little care as possible regardless of need, all the while passing costs on to consumers. I think the clear winner is some form of significant public competitor that will drive down costs and focuses on health and not profit, for once.

It's not over until the ?fat senator sings...

An article by Maggie Mahar delivering a glimpse of hope to progressives everywhere - I can only hope she is right, and to help her be right, maybe all of us liberals have a role to play in all of this.

In brief, there are many proposals out there on how health care should be reformed, but here is the bottom line - without the public option, no significant changes will be made.

Why? You ask.

It is simple - any combination of subsidies, payment cap, cost shifting, mandate, or any other fancy tricks we could come up with, does not matter without a reasonably-priced, outcomes-based alternative that could be the public option, because with only private insurers to choose from, insurance will remain overpriced as these companies' only goal is to please shareholders, and not to protect consumer's health. Any combination of the tricks mentioned above, again, only alters ways money is channeled - in the end, all that money still goes to the richest 10% of this country, and all that money still comes from you and me. The only difference is the forms in which we pay through our noses - taxes, premiums, deductibles - that difference does not make us healthier in the long run.

So if anyone tries to convince you that our healthcare can change without the public option, listen to them with a grain of salt. But more importantly, it is not over until the last senator sings at the conference, and until then, the least we can do is to pipe about how we will not rest until a reasonable public option is part of the bill.

Hilarious - socialism sarcasm FTW

We got rid of the public option, let's get rid of all of these too!

Liberals: Sarcasm FTW

Republicans: *does not compute*

Obama - what a disappointment (that is still better than McCain)

There is talk coming down the pipeline of democrats weakening once again, with the public option likely to be dropped and the health reform plan so watered down, it is basically the status quo. What kind of reform will this be if it creates no change?

How is this most recent proposal any different than status quo? The only difference is the potential mandate, which is even worse than no change at all. Now lower income family will have to forgo food and be forced to pay for expensive health insurance, forced into the open arms of private insurance companies who now claim the newly open market of the uninsured. Public option will be dropped in exchange for an allowance of not-for-profit co-ops, which we ALREADY HAVE. Big not-for-profit providers? Sounds like Kaiser Permanente - I'm not sure if there are subtle differences I'm not aware of. Anyone who does - please enlighten me.

I won't go into the terms fascism, communism that are thrown around the debate - please read this post as I hate to glorify these terms as if they were valid. Let's just say - I see people in USPS, they don't seem to be complaining, and still FedEx did not get push out of the market. Everyone loves the fire department, our beloved heroes from 9/11. Some seniors would rather die before the public option is passed, yet they love their Medicare - I don't understand how these things do not compute in their heads. Many countries around the world has the single-payer system, and they are much happier and healthier than we are - really, what could be SO bad about it compared to the mess we are in now?

Not to mention reimbursement for end of life discussions will be dropped. How do we let idiots (for lack of a better term) like Sarah Palin push this out of the bill? It boggles my mind - I hope any health care professionals agree that end of life discussions are extremely important and are really one of the most difficult things you'll have to do as a physician. Anyone who has participated in the discussion or has actively dying relatives - I hope you agree that the discussions were helpful. This is really a huge setback for palliative care, which in many circumstances heal patients and their family more than any medications we can offer.

Obama is no Kucinich - Obama has no uncompromising integrity that Kucinich possesses, which explains why one is the president and the other is only a senator. The strength of Obama's message for change before the election has vanished. The public option is really one of the main pieces of his health care proposal, now claimed to be only a "sliver" of the whole reform. What a 180.

Read the comments and not the analysis

A really crude analysis on the cost-effectiveness of health care - findings were not surprising. I think the comments by the readers were more interesting.

Many of the comments mentioned that this analysis may not be relevant due to the fact that Americans start off less healthy or have more unhealthy habits compared to other countries.

This is probably correct, but it does not make the analysis irrelevant. PYLL (Potential Year of Life Lost) is a crude proxy for health outcomes, which include people developing bad health habits and starting off more obese/unhealthy in life compared to other nations. Our starting points in health and unhealthy habits should improve if we spend wisely.

Other posts argued that in this analysis, we make an unsubstantiated assumption that spending more on health care will lead to better health - this assumption is, indeed, untrue. (One comment says: If I'm an obese smoking couch potato I can assure you that no amount of spending will make me healthier than a vegetarian marathon runner). But I think that is exactly the point of this argument - because the US is ridden with managing chronic conditions like diabetes and heart disease, we are spending more on people at the end of their disease spectrum without much return, hence more PYLL/dollar and hence why we suck so much compared to others - because we are not spending money on prevention and stop people from getting sick to begin with.

I think this article is on to something, but not in terms of right wing thinking oranges and left wing thinking apples. I think it is on point in that right now we are arguing about how the money will be channeled to the final benefactors: through insurance companies as premiums, through the government as taxes, etc. We are ignoring the fact that in the end the money comes from you and me - the government does not make money without its taxpayers, insurance companies do not make money without their customers. If the cost does not change, changing the channeling is not going to save us any money. We indeed should look at the cost-effectiveness of our health care dollars, in order to ascertain where to save (reflex EKG) and where to spend more (prevention and public health).

Disappointing statement from the president of the American College of Physicians

A statement sent to the American College of Physicians members from its president, Joseph Stubbs. It has some good points, but all in all still physician-centered and not advocating for the best interests of patients (even though it pretends to do so), as demonstrated by his support for physician-negotiated reimbursement rates and not discounted Medicare's rates, which are most likely more efficient and cheaper for patients.

Also find it funny that he advocates for "increased Medicare and Medicaid payments to primary care internists and other primary care physicians, funded in a way that does not cut payments to other internal medicine specialists." I wonder where he thinks that money should come from.

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Dear Colleague,

Today, I write to you in my role as President of the American College of the Physicians, but first, let me tell you a little bit about my "day job." When I am not traveling around the country to represent your views as ACP President, I spend my time taking care of patients in a general internal medicine practice in rural Albany, Georgia, as I have done for the past 30 years. Like you, I take enormous professional pride and satisfaction in keeping my patients healthy, helping to heal them, and providing comfort and relief when they are nearing the end of life.

I also share the frustrations with a health care system that often is stacked against patients and their doctors. Too many of my patients can't find affordable health insurance because they have a "pre-existing condition" -- as the insurance companies like to call it. Some of them have lost their jobs -- and their insurance -- during these economic hard-times. Rising premiums and out-of-pocket expenses have brought some to the brink of bankruptcy. At the same time, patients and doctors alike are drowning in a sea of red tape, rules and regulations we cannot understand.

We physicians struggle to provide our patients with the best care possible, even as payment systems reward rushed, episodic care over spending time with patients on prevention and care coordination. Regrettably, few young physicians are choosing internal medicine or other primary care fields, and as a result, we are facing a shortage of tens of thousands of primary care physicians. All of these are barriers to our ability to provide our patients with the care they need.

All of these are barriers that health reform legislation can help overcome. This is why ACP believes that health reform cannot wait. Not just any kind of health reform, but health reform that does at least the following:

1. Provide all Americans with access to an affordable health insurance plan that does not exclude or discriminate against those with pre-existing conditions. We believe that people who can't afford coverage should be provided with help, in the form of tax credits, to buy coverage. We believe the public should have a wide choice of health plans. We believe that health plans should compete based on innovations to improve patient care, not on cherry-picking out the young and healthy. We advocate that all insurers cover preventive services and other essential benefits. We believe that if a public plan option is included, physician and patient participation in the plan must be completely voluntary, the public plan should compete on a level playing field with private insurers (no unlimited access to federal funds) and it should pay competitively -- and not base its payments on Medicare's discounted rates.

2. Create incentives to increase the numbers of general internists and other primary care physicians. We support providing medical students with loan forgiveness and scholarships if they go into general Internal Medicine or another primary field. We advocate for increased Medicare and Medicaid payments to primary care internists and other primary care physicians, funded in a way that does not cut payments to other internal medicine specialists. We support funding and pilot-testing, on a national basis, of paying internists for the work involved in care coordination through a qualified Patient-Centered Medical Home.

3. Put an end to the annual cycle of Medicare payment cuts due to the flawed Sustainable Growth Rate (SGR) formula. Year after year, Congress has used the SGR to threaten physicians with cuts, and then it ends up passing a short-term fix that makes the cuts in future years even worse. This must stop.

4. Reform the medical liability system and reduce the administrative burdens imposed by health insurers. We advocate for caps on non-economic damages and testing of new models -- like health courts, which would have cases heard by an expert panel rather than by a lay jury. We call for standardization of insurance credentialing, quality reporting, and patient eligibility verification, and other reforms to simplify and reduce administrative costs.

As ACP evaluates pending bills, we lend support when they are consistent with the above priorities, and call for changes when they are not. For instance, although we support provisions in the current bills that would make health insurance coverage more affordable by providing subsidies to help people buy coverage from qualified plans, we expressed strong concern about a new public plan that would pay doctors based on below-market Medicare rates. The House has since agreed with us and decided to change its bill so that a public plan would have to negotiate its payment rates with doctors and hospitals, up to prevailing private sector rates.

Congress has decided that it will not take a vote on legislation until after the August recess, which began on August 7. Congress will return after Labor Day. The recess gives us an opportunity to continue to influence the bills so they meet our priorities, as described above. To get the changes we want, ACP needs to continue to participate in the process -- being insistent in supporting the policies we like and seeking changes when they do not. We can't move the ball toward our policy goal posts if we walk off the playing field.

Now, I know that some of you are concerned about ACP lending its support to particular bills. ACP represents a diverse membership of 129,000 internal medicine physicians and medical student members, and no two internists will agree on every issue. Some of you are deeply conservative and distrustful of any reforms that involve a larger role for government, and you especially object to a public insurance option. Some of you are deeply liberal and favor a single payer system and oppose any plan that would cover people through private insurance and eliminate a public plan option. Many of you, like me, are somewhere in-between.

Still, we are all internists who share a passion for patient care and the desire to make sure that health reform meets our patients' needs. As internists, we must be unified in our quest for health care reform that delivers on the priorities I've described above – priorities that came from ACP's members and that are supported by most of us. While unity is important, so is respectful recognition and discussion of our differences as we, together, sort through the often conflicting and large amount of information on health care reform. I, along with everyone at ACP, will do my best to make sure that we provide you with up-to-date and accurate facts so you can assess the various health care proposals and engage in a productive dialog. You can learn more about how to become involved in ACP's advocacy activities through our Legislative Action Center.

We should also consider the consequences if health reform fails, and we leave it to a future Congress to pick up the pieces of a broken health care system -- years or even decades from now. The result will be more uninsured patients, more families going bankrupt because of high health care bills, more cherry-picking, Medicare insolvency, and continuation of a payment system that undervalues the care provided by internists, leading many young physicians to choose other fields. This is not a future I want for my patients or our noble profession.

Within our grasp is achievement of health reform legislation that makes coverage affordable by building upon and improving our current employer-based system, providing incentives for young doctors to go into primary care internal medicine, reforming and improving Medicare physician payments, and reducing the costs associated with our broken medical liability system. Let's not let it slip away.

Yours truly,

Joseph W. Stubbs, MD, FACP
President

Why Can't Americans Get Health Care Right?

A good article by a professor at the Harvard Business School, outlining points similar to my earlier post on why health care really cannot be left to the market forces.

The misguided debate that is health care reform

The health care problem that we have now is complicated - many aspects of it needs to be fixed. The current debate focuses so much on the payer that it misses other points, such as supply and demand that drive costs. Ultimately, only individuals pay for the costs of health care, through premiums if they pick private insurances, taxes if the public plan goes through, etc. The money comes from you and me, and right now most of what we are debating is on how it will be channeled to the payees. In the end, this debate is moot if we don't fix inflating costs driven by many factors, including the fee-for-service system, which is a major agency problem where agents (physicians) are also suppliers, and they almost always decide whether products are consumed (I can't imagine patients negotiating with doctors whether they need an MRI or a surgery).

Even a debate that focuses on reducing costs or on health care in general is still limited. Health care is in no way equal to health. Considering that the majority of health costs today stem from managing chronic diseases, health care is really a bandage on health already lost. By the time patients first present with a stroke, there is little medicine can do, when if only a fraction of the same resources is spent on public health initiatives affecting various root causes of health, we can prevent people from getting sick to begin with and improve health much more effectively. Similar points are put forth in this testimony

The testimony also make a salient point about individual vs social responsibility in terms of health - it really speaks for people who most likely do not have resources to blog or explain to people that matter why they continue to consume unhealthy food and do not exercise.

Stop Playing Homework and Do Your Video Games - A Video Game Quintet

Check out this awesome video! Really, stop playing homework and do your video games!