The Doctor Weighs In

Maggi Cary, MD MBA MPH

During my residency training “Private pay” entered on patients’ check in sheets often meant “no pay.”  Anyone with financial assets to protect would have medical insurance.  “No pay” was code for negative wallet biopsy.  Two words took less time to write than “Doesn’t have medical insurance, assets or salary to cover bills so this one is free.”

If these folks landed in a private hospital, they were often shipped to the county hospital.  This was before EMTALA (Emergency Medical Treatment and Active Labor Act, also known as the patient anti-dumping law) made this illegal.  The transferring physician would say to the resident on call, “This is a good teaching case,” another synonym for negative wallet biopsy.

In my last essay I mentioned Medicare would no longer pay for some hospital-acquired infections and medical errors.  The headline on Robert Pear’s front page story in Sunday’s New York Times reads “Medicare Says It Won’t Cover Hospital Errors.”

Medicare funding has joined the “no pay” ranks for some avoidable errors.  As Medicare mandates, so will other payers line up behind Medicare. 

Lots of consulting opportunities here.  Hospitals and consultants may focus their efforts on following the spirit of the Medicare guidelines, perhaps even aspiring to the goals I mentioned in my last essay—that we should have a system that is transparent, quality-driven and does not distort economic incentives.

Or maybe not.

Skip to the last paragraph in the Robert Pear article and read the quote from Ken Kizer, who had the vision to turn the Veterans Health Administration from backwater healthcare system to the best in the country.

“I applaud the intent of the new Medicare rules, but I worry that hospitals will figure out ways to get around them. The new policy should be part of a larger initiative to require the reporting of health care events that everyone agrees should never happen. Any such effort must include a mechanism to make sure hospitals comply.”

Well said.

Yes, there are numerous consulting opportunities here.  When I had my own medical practice I took the billing courses that taught us how to unbundle services, separating medical treatment components into separately billable procedures.  This was legal then, at least in the letter of the law.  We could get paid more for exactly the same services.

Except that merely getting paid more for the same work does not create value to anyone but the folks who are getting paid.  It does not include transparency or quality and certainly does not align economic incentives.

I wonder whether in the short term hospitals and consultants will follow the spirit of the Medicare guidelines or focus on gaming the system.

Dr. Maggi Cary is Director of the Washington, DC office of the Institute for Medical Leadership. Click here to read her other posts. You can reach Dr. Cary at mcary@medleadership.com.

by Pat Salber, MD

In the early days of the clinical practice guidelines movement, doctors used to complain that it was “cookbook medicine.” As a pretty good cook, who still uses cookbooks, I say, great – when you follow the directions of experts, instead of “winging it,” you increase the odds of getting a good outcome.

So it should be not a surprise that a new study, in the July 23 issue of Archives of Internal Medicine, found that outcomes of hospitalized heart-failure patients are improved when hospital personnel follow clinical guidelines.

OPTIMIZE-HF (“Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure”) is a heart failure guidelines/quality improvement program adopted by the American Heart Association (and sponsored by drug maker GlaxoSmithKline). The program provides hospitals with tools to help improve the reliability of care, including standardized admission orders, discharge checklists, pocket cards, medical chart stickers, best-practice algorithms and critical pathways. It is currently being used by 259 hospitals across the US.

The study, led by Gregg Fonarow, MD from UCLA’s Department of Medicine, looked at data entered into an online OPTIMIZE-HF performance improvement registry. Admission, hospital, discharge care, and outcomes (death and hospital readmission rates) data on 48,612 heart failure patients were entered into the registry between March 2003 and December 2004. A subgroup of 5,791 patients were followed for an additional 60-90 days after they were discharged from the hospital.

The researchers found statistically significant improvements in three of four of the Joint Commission on Accreditation of Healthcare Organization's performance measures used to gauge the quality of heart failure care in hospitals. They included:

· Better patient discharge instructions. The rate of giving complete medical instructions to patients increased from 46.8 percent at the beginning of the study to 66.5 percent by the study's end.

· Smoking cessation counseling. Hospitals provided smoking cessation counseling to 75.6 percent of the patients at the end of the study, compared with 48.2 percent in the beginning.

· Left ventricular function assessment. Evaluating the heart's left ventricle systolic function rose from 89.3 percent to 92.1 percent.

A fourth measure, the rate of angiotensin-converting enzyme inhibitors (ACEIs) prescribed to eligible patients at discharge was 75.8% at baseline. This rate did not improve during the 2-year study.

There was a statistically significant reduction in the mean length of stay for these patients, going from 7.5 days at baseline to 6.2 days at the end of the study. In addition, were trends for reduction of in-hospital mortality, postdischarge death, and combined postdischarge death and rehospitalization, but they did not reach statistical significance.

So patients did better and hospital days were reduced (and so were costs presumably). What’s not to like? According to the lead author, Dr. Fonarow, as quoted in the Washington Post:

"If similar improvements had occurred at hospitals nationwide, this would translate to 40,000 less deaths and 1.4 million costly hospital days eliminated per year. Despite compelling scientific evidence and national guidelines for use of key life-prolonging agents and lifestyle changes, gaps exist in heart failure treatment. We hope more hospitals will adopt this validated model for enhancing heart-failure patient care."

Amen.

Brian Klepper 

Been to see Sicko yet? If you haven't, I'd urge you to go right out and catch it. The audience in my conservative Southern community was riveted and clapped at the end, and everyone I've traded notes with has told me their audience applauded too. While it has its flaws, its central argument – that America's health care system is clinically and financially failing a large and growing percentage of our people – is compelling and undeniable. By the way, the movie is NOT about how the system is failing the uninsured, but how it is failing those of us in the mainstream, with insurance.

Sicko's has several powerful themes. One is that American health care is like it is because our leaders favor their contributors rather than voters. It's true. It's unlikely we can fix health care until we fix America.

Health care is a $2.2 trillion industry. More than half of all health care is paid for through government, and government sets the rules that shape how care is supplied, delivered and financed. A vast network of health care associations and corporations - the drug and device companies, the health plans, the hospitals, the doctors - lobby Congress and the legislatures to make decisions that benefit their enterprises.

Think I'm exaggerating? Go to www.opensecrets.org, the site of the not-for-profit, non-partisan Center for Responsive Politics.  They track the political contributions made by individuals and organizations. You can look at the contributions by donor, party, industry, politician, issue, zip code. It's pretty revealing.

In 2006, lobbyists of all kinds - they think of themselves as "advocates" - contributed $2.5 billion to 100 Senators and 435 Representatives. That's an average of $4.67 million each to 535 Congressional lawmakers. Of course, this number refers only to direct contributions, and doesn't consider the internal staffing and logistical dollars that most companies spend working to influence policy.

My understanding of the numbers is that health care represents about $350 million, or 14 percent of total lobbying dollars. Actually, health plans aren't properly categorized in the tally, so I may be underreporting a bit, but its close. But since health care is nearly 16 percent of the larger economy, this number seems about right.

Notice in the table below who gave most. Drug, device and supply companies contributed fully half of all health care lobbying dollars. By contrast, when you dig down deeper on the site (to figures that aren't listed in the table), you learn that:

• the American Association of Retired Persons gave $23 million,
  
• the American Medical Association  handed over  $20 million (part of the larger pool of $58 million sent in by the health professionals lobby),
  
• the Pharmaceutical Research and Manufacturers Association gave $18 million
• the American Hospital Association gave $17 million, and
  
• Pfizer forked over $12 million.

 Clarifies who has Congress' attention, doesn't it.

Acting according to its incentives, Congress has given us a health care sector increasingly focused on profits (and independent of quality, safety or appropriateness), care where at least half the costs are wasted, specialist physicians who sometimes make ten times more than primary care physicians, certain conditions (like heart and cancer) that are worth many times more than others (like newborn deliveries), exorbitantly higher reimbursements for unproven new technologies, payment to doctors and hospitals for their mistakes, and many other irrational realities. All this has resulted in uncontrollable costs that are pricing a growing percentage of individual, commercial and governmental purchasers out of the market for health care and coverage.

When you consider how powerful groups press their interests with Congress, its doubtful that Sicko will have a real impact on health care. One option is for the leaders of non-health care business to mobilize and demand change, once they realize that the destabilizing influence of the health care industry's current practices could increasingly poison their own economic environments. Another would be for, somehow, miraculously, the American people to demand that Congress put an end to lobbying contributions and their corrosive effect on our democracy.

But failing those possibilities, its hard to understand how the buzz we're hearing now from Sicko can translate to reforms by a Congress that knows who really butters its bread. 

I have a file full of warranties on things I have purchased. They give me peace of mind. Sometimes, they even save me money. Now, a hospital system – The Geisinger Health System in central Pennsylvania -- is providing warranties for heart surgery. You don’t have to pay extra to get your defects related to surgery repaired if they occur within 90 days of the operation. Brilliant idea!

Only in health care, with its many perverse financial incentives, do you have a situation where a provider has the opportunity to make more money by providing shoddy care than providing good care. What do I mean by that? Let me give you an example. If you are admitted to the hospital and get an infection related to inadequate infection control. Treatment of that hospital-acquired infection prolongs your hospitalization and you use more expensive services, such as intravenous antibiotics. In a fee-for-service world, that means more revenue for the hospital. Not only does this generate extra costs, it also fails to provide an incentive to do things right the first time (and every time).

Starting in 2006, Geisinger Health System began exploring how to make elective heart bypass surgery flawless. And, to put there money where their mouth is, so to speak, they combined their quality improvement efforts with a 90 day warranty.

Doctors at Geisinger reviewed all of the steps in these elective surgeries and identified 40 as essential to achieve good outcomes. Then they created procedures to ensure these 40 steps are always followed, not matter who the surgeon or where the operation is performed. Hmmm….sounds like the checklists pilots use to make sure everything is in order before the plane takes off.

Here is the checklist:

1. Preadmission documentation:

a. Document the American College of Cardiology/American Heart Association indication for surgery

b. Screening for and consultation regarding IMI (inferior myocardial infarction)/RV

(right ventricular) involvement

c. Record treatment options and patient preferences

d. Determine and document the need for anticoagulation with warfarin – Anterior MI (myocardial infarction) or WMA (wall motion abnormality)

e. Record whether the patient is a current user of anticoagulation medications (clopidogrel or warfarin)?

f. Screen the patient for risk of stroke

g. Obtain a carotid doppler ultrasound exam (test for stroke) if the test is indicated

h. Obtain a vascular surgery consultation if indicated

i. Obtain and/or record the ejection fraction

j. Screening for need to use intra-aortic balloon pump (IABP)

k. Screening using epiaortic echo as indicated

l. Document that the patient did not take anticoagulation medications (clopidogrel/warfarin) in the 5 days before the operation

2. Operative documentation:

a. Did the patient receive the correct dosing of beta-blocker (pre-op)

b. Was there correct use of intra-aortic balloon pump (pre-op -->post-op)

c. Did the patient receive appropriate and timely pre-op antibiotics within 60 minutes of incision; if Vancomycin within 120 minutes)

d. Record any blood cardioplegia (on-pump patients)

e. Document epiaortic echo of the ascending aorta and the peer consult

f. Obtain and record intra-operative hyperglycemia screening

g. Apply correct insulin management (as indicated; per protocol)

h. Use of LIMA (left internal mammary artery) for LAD (left anterior descending)

grafting

3. Post-Operative patient documentation:

a. Anteroapical MI within prior 7 days: post-op echo

b. Monitoring for atrial fibrillation for >48 hours

c. Anticoagulation therapy (as indicated)

d. Were antibiotics administered post-op for 24-48 hours

e. Was aspirin given six hours post-op or 24 hours post-op

f. Was a beta-blocker given within 24 hours post-op

g. Was a statin administered post-op

h. Document any surgical debridement and revascularization of any sternal wound infection

i. Obtain a plastic surgery consult regarding ongoing management of sternal wound

j. Tobacco screening and counseling

4. Discharge documentation:

a. Referral to cardiac rehabilitation

b. Discharge medications (e.g., beta-blocker)

c. Discharge medication: aspirin

d. Discharge medication: statin

5. Post-Discharge documentation:

a. Is the patient correctly taking beta-blocker?

b. Is the patient correctly taking aspirin?

c. Is the patient correctly taking statin?

d. Is the patient correctly administering anticoagulant?

e. Did patient resume smoking?

f. Is the patient enrolled in cardiac rehabilitation?

Gisinger calls this new program “ProvenCare.” That is because the 40 items on their check list are supported by medical evidence. Imagine that…design protocols based on evidence and follow them to get better results.

According to a story about Geisinger in the NY Times, the system was only documenting the performance of all 40 steps 59% of the time before implementing ProvenCare. Now an operation is cancelled if any of the pre-operative measures have not been done. Recently, Geisinger’s surgical teams have had scored 100% in following the recommended steps before, during and after surgery. And it has paid off in terms of reducing complications:

• 35% of patients had any type of complication after compared with 39% before ProvenCare
• Only 16% of patients required supplemental blood products compared with 23% before
• 19% of patients were not able to be discharged directly to their homes before the program; only 9% after
• There were fewer readmissions within 30 days, fewer pulmonary complications, fewer re-operations for bleeding, fewer readmissions to the ICU, and a lower in-hospital death rate (in fact, it was 0 after implementing the program.

So how does the warranty work? Geisinger charges a fixed fee for the surgery and half of the historical costs of related care provided in the ensuing 90 days. If the patient has to be readmitted, Geisinger absorbs the costs. If they do a great job and there are no problems, they have a larger profit. Now that is aligning financial incentives with good patient outcomes.

Geisinger is developing similar approaches for other types of medical care, such as hip replacements. It will be interesting to see how far and how fast they are able to go with this new model. I hope this is not a one-shot wonder. The concept of standing behind your work by offering a warranty could prove to be a powerful driver of health care quality improvement and patient safety.

Great work, Geisinger

Pat Salber, MD

Remember how shocked we were when we first heard about Dr. Moon and Dr. Realyvasquez. These are the heart doctors who performed unnecessary cardiac procedures, including coronary artery bypass surgeries, at a Tenet Hospital in Redding, California.

These guys may have been at the far end of the spectrum when it comes to driving inappropriate cardiac care, however, a study in the March 7, 2007 issue of JAMA adds to the growing body of evidence that suggests that cardiac procedure rates are strongly influenced by competitive market dynamics and not just patient need.

A group of well-respected health services researchers, led by Brahmajee Nallamothu at the University of Michigan Medical School took a careful look at the impact of introduction of specialty heart hospitals in geographic areas that represent distinct markets for tertiary (advanced) cardiac care. As opposed to general hospitals, specialty heart hospitals provide services for, and generate revenue from, a narrow spectrum of diseases.

Some health policy gurus have argued that such specialization could lead to greater efficiency and better quality of care. However, others worry that adding excess capacity could drive demand, particularly if the owners of the hospitals are doctors in that same specialty. It doesn’t take a brain surgeon to understand that filling beds, operating rooms, and catheterization labs with high revenue patients is better for the bottom line than leaving them unused.

Of course, it is possible that new specialty hospitals would just compete with existing facilities in general hospitals, taking volume from them, but keeping the overall rates of services the same. But that doesn’t appear to be what happens when one of these cardiac specialty hospitals opens in a community. Instead, the JAMA study documents that there is an incremental increase in the number of coronary revascularization procedures performed after a specialty heart hospital opens. Capacity increases and more people get these procedures.

Now this study doesn’t prove that all of this capacity was supply-driven. In fact, some of the increase may be due to meeting unfilled need. The researchers tried to understand if this was indeed what was happening by comparing what occurred when a general hospital increased its capacity compared to what happened when capacity is increased via the opening a new specialty heart hospital. What they found was a greater increase in certain cardiac procedures in communities with a new heart hospital compared to those communities with a new cardiac program at a general hospital.

Of note is the finding that there is no increase in the number of PCI (percutaneous coronary interventions) in the subset of heart patients who might benefit most from that procedure (those coming into the hospital because of a heart attack), but there was a dramatic increase in the number of PCIs being done for individuals not having heart attacks, a situation in which there may be more discretion in deciding whether to do the procedure or not.

For all of you who think, more is better when it comes to health care, I suggest you read about Drs. Moon and Realyvasquez. They had some of the highest rates of coronary procedures in the country, but some of their patients would have been better off with nothing at all.

Pat Salber

When I doing my internal medicine residency, I knew it was best not to be admitted to a teaching hospital in June and July.  That's when freshly minted MDs start their internship and learn how to "practice" medicine. 

Now, a new study published in the journal, Stroke:  Journal of the American Heart Association, finds that it is better not to have a stroke on the weekend.  It turns out people admitted to the hospital with a stoke on a Saturday or Sunday have a higher mortality rate than those who get admitted on a weekday. 

The American Heart Association issued the following statement about the study:

"After adjusting for age, gender and other medical complications, researchers found that patients admitted on the weekend had a 14 percent higher risk of dying within seven days of admission compared to patients admitted during the week."  

According to a CNN report on the study, the "weekend effect" has been identified before in other conditions such as cancer and pulmonary embolism (blood clot in the lungs).  The weekend effect was greater for people admitted to rural hospitals compared with urban hospitals.

The study was done in Canada, but there is no reason to believe that things are any better here in the US.  Why is it that I can get the same quality help 7 days a week in many other areas of my life, say tech support for my computer problems or on-line banking issues, but I can't count on getting the same quality of hospital-related health care if I happen to get sick on a weekend?  Shouldn't we have systems in place to ensure that we can get quality care no matter what day of the week we get sick?

There is an important caveat to this report.  It is that you should not, not, not delay seeking care for stroke symptoms just because it is the weekend.  When it comes to stroke, time to treatment makes all the difference in terms of preserving brain function.  So, if you think you are having a stroke or other serious medical problem, head to the ER.  Meanwhile, us "wonkie" types need to work on making health care safe and effective 24 hours a day, 7 days a week.

Pat Salber