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Chandler Bramlett at age 74, as quoted in Health Care in Mobile: An Oral History of the 1940s
The Alabama Academy of Family Physicians flew me to Washington DC last week to represent the interests of family docs to our congressional delegation. I have been up to the Hill several times representing the interests of my rural colleagues, but this was the first time I was exclusively representing physicians. When you are representing all of rural Alabama’s health care needs, people tend to give you a lot of respect. When you are representing the economic interests of a group of people who, although relatively underpaid, still make in the top 3% of Americans and the top 1% of Alabamians, respect is not nearly as forthcoming.
I had the privilege of having John Waits as the other half of the small Alabama delegation. John is a family physician in Centreville, Alabama, who has established an FQHC and is in the process of using the Teaching Health Center mechanism to bring family medicine training to his small town with the first class starting this year.
The five-year, $230 million Teaching Health Center Graduate Medical Education (THCGME) program is designed to boost the number of primary care residents trained in teaching health centers (THCs), which are community-based ambulatory care centers that operate a primary care residency program.
Unlike Medicare GME funding, which goes mostly to hospitals, THCGME funding goes directly to community-based sites. The funding is tied to specific health care workforce goals, and THCs must report annually on the types of primary care training programs offered, the number of resident positions, and the number of residency graduates who care for vulnerable populations in underserved areas.
That’s the good news. The bad news:
One area of concern, however, is the funding uncertainty for the future of the program…. The THCGME program is funded only through 2015, which creates a challenge for the THCs…. Unless Congress provides additional funding for 2016 and beyond, THCs may have residents in the middle of their training without THCGME payments to support them.
It was this message we chose to bring to our delegation, asking them to help us make a difference.
We were doing OK with our message except for two little roadblocks. The first, especially problematic for our deeply Red delegation, is how the program got its start. It was included in the Affordable Care Act. Given that we were there on a Wednesday and the vote scheduled for Thursday was REPEAL OBAMACARE (which won 229-195 on a partisan vote), no one in our delegation could see a way to supporting a part of a law which was described this way by one physician congressman: “Obamacare is terminally sick and we need to call the time of death.”
The second obstacle was, well, the physician congressmen. While Alabama has no physician members, our delegation tended to defer health issue specifics to a group referred to as the “Doc Caucus.” Formally known as the Republican Doctors Caucus, it was formed by Republican House physician members and includes all 15 GOP physician members as well as a psychologist, two dentists, and three nurses. Their issues (from their website) include: Repeal ObamaCare and end federal government’s involvement in healthcare; Encourage (but not mandate) state based high risk pools; Encourage (but not mandate) adoption of Electronic Health Records; Tort reform; Medicare and Medicaid reform (through competition and the repeal of the IPAB); Allow health insurance to be purchased across state lines (not through the exchanges in ObamaCare); Transparency of quality data (different than what was in ObamaCare or outlined by Dr Berwick while he was at CMS); Fix the sustainable growth rate.
Rather than move backwards, I would encourage them to listen to one of their former colleagues, Bill Frist, and consider using the Affordable Care Act to effect change by fixing the payment system:
“We are convinced that reforming our nation’s health care system to prioritize quality and value over volume will not only improve health outcomes and the patient experience, but also constrain costs and produce systemwide savings.”
“Care is organized around what the patient needs, not around what is expedient for an individual provider,” says the report. “Information, such as lab tests, referrals, notes and updated medication lists, is shared seamlessly among health care professionals without the need for patients to intervene.”
Maybe the American public should get to be the gods for a change.
Don Berwick left CMS last week. When he was appointed, he was vilified because he used the word “rationing” in polite company. So vilified, in fact, that he was never able to gain the needed 60 votes in the Senate or confirmation and was appointed via the recess route. As a consequence, his appointment expired after a calendar year and it was for this reason that he stepped down.
Dr Berwick was never known for his shy, retiring demeanor and now that he is no longer in government service he is once again “telling it like it is.” He was awarded the Picker award at the Institute or Healthcare Improvement annual meeting and in his address he seemingly called out his opponents:
The true rationers are those who impede improvement, who stand in the way of change, and who thereby force choices that we can avoid through better care. It boggles my mind that the same people who cry ‘foul’ about rationing an instant later argue to reduce health care benefits for the needy, to defund crucial programs of care and prevention, and to shift thousands of dollars of annual costs to people — elders, the poor, the disabled –who are least able to bear them,” he said, according to a copy of his remarks.
Dr Berwick points out that the country is at a crossroads. If we attempt to reduce our country’s health care responsibilities through indiscriminate cutting, his concern (as is mine) is that the cutting will begin at the “voiceless and the poor” but won’t stop there. Soon, as a consequence of lower benefits, less access, increased payment burden for necessary services, and delays in care delivery, our country’s health care quality will further decay and the cost will remain high. Dr Berwick identifies six domains that our health care system has failed us:
- Overtreatment – the waste that comes from subjecting people to care that cannot possibly help them – care rooted in outmoded habits, supply-driven behaviors, and ignoring science.
- Failures of Coordination- the waste that comes when people – especially people with chronic illness – fall through the slats. They get lost, forgotten, confused. The result: complications, decays in functional status, hospital readmissions, and dependency.
- Failures of Reliability – the waste that comes with poor execution of what we know to do. The result: safety hazards and worse outcomes.
- Administrative Complexity – the waste that comes when we create our own rules that force people to do things that make no sense – that converts valuable nursing time into meaningless charting rituals or limited physician time into nonsensical and complex billing procedures.
- Pricing Failures – the waste that comes as prices migrate far from the actual costs of production plus fair profits.
- Fraud and Abuse – the waste that comes as thieves steal what is not theirs, and also from the blunt procedures of inspection and regulation that infect everyone because of the misbehaviors of a very few.
How do we avoid this undesirable fate? Dr Berwick refers to the Affordable Care Act as a “majestic law” and feels that if we work effectively we can save $1,000,000,000 in health care costs. He outlines 5 prinicples all of us in healthcare should follow:
- Put the patient first. Every single deed – every single change – should protect, preserve, and enhance the well-being of the people who need us. That way – and only that way – we will know waste when we see it.
- Among patients, put the poor and disadvantaged first – those in the beginning, the end, and the shadows of life. Let us meet the moral test.
- Start at scale. There is no more time left for timidity. Pilots will not suffice.
- Return the money. This is the hardest principle of them all. Success will not be in our hands unless and until the parties burdened by health care costs feel that burden to be lighter. It is crucial that the employers and wage-earners and unions and states and taxpayers – those who actually pay the health care bill – see that bill fall.
- Act locally. The moment has arrived for every state, community, organization, and profession to act. We need mobilization – nothing less.
It is not going to be easy work. As Dr Berwick points out, the “pace of change is majestic.” We now have the framework for health care improvement. Leadership will now not come from the top but will come from those of us in the trenches. Let’s get to work!
There is an interesting article in the New York Times (found here) about sleep deprivation and physicians-in-training. A new set of work rules for doctors in training (residents) took effect on July 1st of this year. There was one rather odd requirements where the 1st year resident can work up to 16 hours but must then get 10 hours off, causing those of us involved with training to do a little head scratching about how to make that work. Did that mean residents come in 2 hours later every day? Talk about a screwed up circadian rhythm.
The article in the Times pointed out that despite severe reductions in work hours over the past 10 years, care related errors have not decreased and have in fact increased. The implication was that perhaps the hours, themselves, were not to blame. The comments accompanying the article were predictable. Many were from older doctors (likely my age) relating how they were able to resurrect folks from the dead but only after working for 35 hours straight. Some were from physicians who are currently in training (and thus only know the work-limited training model) talking either talking about how they would never learn resurrection without being allowed to work 30 hours straight or conversely how they disbelieved the older doctors stories. I trained in a time and setting where the hours were unlimited. I do not recall any specific abilities granted me by virtue of working long hours. I do recall being bone-tired after a day in the office, a night of working to fix some very sick people, followed by a day in the office. I certainly never felt I was doing my best at hour number 36.
The real story is not about one young woman (Libby Zion) who died in New York and her dad’s efforts to affix blame and correct a common sense problem (working for 36 hours straight can never be good). It is about system change:
But all of these hospital reforms ignore what may be the biggest problem in physician training today: the yawning chasm between what most doctors learn during the 80 hours a week they spend training in hospitals and what they actually do after leaving their residencies. Defenders of the old-school way argue that the demands of medical practice justify the brutal hours. But after their residencies, most doctors practice in outpatient settings and work regular daytime hours as members of large groups. They treat chronic problems that need weeks or months of periodic outpatient follow-up, not high-intensity hospital-based care lasting only a few days.
The old method of physician training is dead. We used to think we could put physicians in training and really sick poor people in the same building, and poor people would get at least some care and learners would get training. It was this model that Medicare put money into in the 1960s. This evolved into a different model. In the current model some (if not all in some teaching hospitals) of the inexpensive trainee labor is re-purposed to provide help for physicians providing complex care for paying patients. As we ratchet back the inexpensive labor, changes are going to have to happen.
As I have discussed here and here and as Dr Sanghavi discusses much more eloquently, the current training system does not prepare learners for practice and now is shown to contribute to fragmented, error prone care. It is time to re-think the entire process. In the words of the man who sets policy:
“For people who came out of the old training system, it may be hard to imagine one that works better,” says Donald Berwick, the director of the Centers for Medicare and Medicaid Services and former president of the Institute for Healthcare Improvement. “The point is, it’s all about design and coming up with optimizing models.”
Poor people need care other than in the hospital provided by over-tired trainees. Trainees need to learn about care delivery in settings that prepare them for a future of error free practice. Hospitals need to wean themselves from cheap labor provided in the name of training.
Also, I kind of think the resurrection stories were exaggerated.
Ok, so a follower sent me an article from the New York Times that I feel compelled to share. CMS (the folks that run Medicare) have gotten some data regarding CT scans of the chest done in 2008. The radiology experts feel that there is little to no reason to do a CT scan of the chest at the same institution twice in one day and to bill for both studies. They are now using the power of shame to improve patient care. The list has been made available to the general public (and the NYT has put it in a neat interactive graphics package found here) to allow you to look up your hospital and see how they are doing. Remember, there may be a perfectly good explanation but, on the other hand, better to seek out quality at every opportunity.
We are slowly working on redesigning the way we deliver care in our Family Medicine Center. We have focused on care of folks with chronic illness for a while but recently (with the passage of the ACA and the coming of ACOs) we are working on hitting the sweet spot. A couple of weeks ago Dr Berwick made it easier. He published an article in the New England Journal of Medicine that identified areas of care delivery that primary care physicians will be required to focus their quality energy on in the future if they expect payment and recognition in a post-ACA world. For those, like me, who believe the future is now below are the areas where documentation of level of care (followed by improvement) in the primary care setting will be expected:
Ability of the practice to provide an enjoyable patient and caregiver experience
• Getting timely care, appointments, and information
• How well your doctors communicate
• Helpful, courteous, respectful office staff
• Patients’ ratings of doctor
• Health promotion and education
• Shared decision making
• Health status or functional status
Ability of the practice to facilitate care coordination —transitions
• Risk-standardized, all-condition readmission
• 30-Day post-discharge physician visit
• Medication reconciliation
• Care transitions measure
• Management of ambulatory-sensitive conditions: diabetes; chronic obstructive pulmonary disease (COPD); congestive heart failure (CHF); dehydration; bacterial pneumonia; urinary tract infections (UTIs)
delivery of services related to preventive health and early disease detection
• Influenza immunization
• Pneumococcal vaccination
• Mammography screening
• Colorectal cancer screening
• Cholesterol management for patients with cardiovascular conditions
• Adult weight screening and follow-up
• Blood-pressure measurement
• Tobacco-use assessment and intervention
• Depression screening
Care for members of at-risk populations —diabetes
• Composite and individual measures (glycated hemoglobin, LDL cholesterol <100 mg/dl, blood pressure
<140/90 mm Hg, tobacco nonuse, aspirin use)
• Poor glycemic control (glycated hemoglobin >9%)
• Blood pressure control in diabetes
• Screening rates for microalbuminuria
• Dilated eye exam; foot exam
Care for members of at-risk populations — heart failure
• Left ventricular function assessment
• Left ventricular function testing
• Weight measurement
• Patient education
• Heart failure prescription rates for left ventricular systolic dysfunction (LVSD)
• Angiotensin-converting–enzyme inhibitor or angiotensin-receptor blocker (ACE/ARB) rates for LVSD
• Warfarin therapy for patients with atrial fibrillation
Care for members of at-risk populations — coronary artery disease
• Coronary artery disease (CAD) composite and individual measures (oral antiplatelet therapy for patients with CAD; drug therapy for lowering LDL cholesterol; beta-blocker for patients with CAD with prior myocardial infarction; LDL cholesterol <100 mg/dl; ACE/ARB therapy for patients with CAD and diabetes, LVSD, or all of the above)
Care for members of at-risk populations —hypertension
• Blood-pressure control rates (<140/90 mm Hg)
• Hypertension plan of care
Care for members of at-risk populations— COPD
• Spirometry evaluation
• Smoking-cessation counseling
• Bronchodilator therapy based on FEV1
Care for members of at-risk populations — frail elderly
• Screening for fall risk
• Osteoporosis management in women who had a prior fracture
• Monthly INR for beneficiaries on warfarin
CMS has identified 3 National Aims
The National Quality Strategy will pursue three broad aims. These aims will be used to guide and assess local, State, and national efforts to improve the quality of health care.
- Better Care: Improve the overall quality, by making health care more patient-centered, reliable, accessible, and safe.
- Healthy People/Healthy Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social and, environmental determinants of health in addition to delivering higher-quality care.
- Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government.
- Making care safer by reducing harm caused in the delivery of care.
- Ensuring that each person and family are engaged as partners in their care.
- Promoting effective communication and coordination of care.
- Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.
- Working with communities to promote wide use of best practices to enable healthy living.
- Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.
and has identified 10 areas of policy change going forward to accomplish these priorities
Those of you that read this blog on a regular basis are no doubt aware that I feel very strongly about the need for the American health care delivery system to perform better. This is based on many years of working with a group of patients who would be in much better health had they had sufficient access to high quality health care. In addition, I have been training physicians for many years, helping them to develop the skills to deliver high-end family medicine interventions to a group of patients in need only to have them take jobs in lucrative areas of health care that lead to high patient satisfaction but do not improve health outcomes. Lastly, I work in a medical school setting where we deliver very expensive care very inefficiently. As a potential consumer of health care, I have to wonder why others can’t see what I am certain of: change is needed and fast.
In the 1990s, it was apparent that the health care system in America was causing a problem. As I have written previously, the high cost of health insurance led to lower real wages (all increases went to health insurance premiums), 15% of Americans were denied all but emergency access to health care, and care providers who were so inclined were able to game the system and make lots of money. Good managed care was able to co-opt the system and this resulted in better access, reduced costs, and better quality to a certain extent. We believed that the value of excellent managed care was self-evident so were surprised when the entrenched establishment was able to take several glaring examples of bad managed care and tar the entire care delivery process with them.
Those interested in care reform then took the intellectual high road. Crossing the Quality Chasm, published in 2001 by the Institute of Medicine, had as its opening paragraph:
The American health care delivery system is in need of fundamental change. Many patients, doctors, nurses, and health care leaders are concerned that the care delivered is not, essentially, the care we should receive (Donelan et al., 1999; Reed and St. Peter, 1997; Shindul-Rothschild et al., 1996; Taylor, 2001). The frustration levels of both patients and clinicians have probably never been higher. Yet the problems remain. Health care today harms too frequently and routinely fails to deliver its potential benefits.
Aside from a few headlines regarding deaths caused by medical errors, those in health care continued to deliver expensive procedures regardless of potential benefit to the patient. Kaiser Family Foundation began documenting disparities in 1994 and became one of the best sources of data documenting health disparities, but the disparities continued unabated through the 2000s.
President Obama took public interest in changing our broken health care system, combined with support for change from major corporations as a mandate. He took the evidence from the IOM report, the data from Kaiser, the support from industry and used it to convince Congress of the need for change. The passage of the Affordable Care Act is the consequence of these forces coming together. While not perfect, the bill offers a significant increase in access to health care with the potential to improve care and reduce costs. Unfortunately the hard work has not yet been completed. Building a framework for change into a law is one task. Convincing people that the framework is necessary and sufficient is another. The vast majority of people are fed up with the “system” but happy with their doctor(s). They are unhappy with the cost of other people’s care but unconcerned with the cost of their care. Why would they want to move out of their “comfort zone?”
In his important work Leading Change: Why Transformational Efforts Fail, John Kotter identifies the 10 reasons that large-scale change fails to occur at the corporate level. Error #1 is not establishing a great enough sense of urgency. In the 1990s, the HMO system was dismantled in many areas very quickly because of patient demand. A sense of urgency prevailed. Those who want to see “Obamacare” fail are doing their best to establish a sense of urgency for “repeal and replace.” Their case is not being made with data and policy suggestions but through hyperbole and outright deception.
Mike Huckabee, currently “not running” for the Republican nomination for the presidency, has come out against the “comparative effectiveness research” aspect of the ACA. Although
even Republicans [likely] recognized that we shouldn’t be spending so much money on drugs, devices, and procedures that don’t actually make people better than existing treatments.
But Republicans and their allies in the conservative movement no longer say such things. Instead, they say that government will use CER to deny people beneficial treatments–that it is, as Huckabee puts it, “the poisonous tree of which death panels will grow.”
What could be more urgent than stopping that?
Or what about the claim that if the federal government can mandate health coverage they can force broccoli ingestion as well. That should put fear into many Americans regarding the overreaching federal government as well as mandatory broccoli burgers. STOP THE BROCCOLI!
Those of who want to see most (if not all) Americans with access to high quality health as well as leave something in the national treasury for our children need to yell from the rooftops that the ststus quo is unacceptable and the ACA, while not perfect, is the best start on improvement we’ve had in 20 years. My friend Paul Grundy is doing his part. Don Berwick will likely lose a job as a result as well. Let’s all be real clear: #37 is UNACCEPTABLE.
At the Rural Policy Institute I heard many people’s views on the Affordable Care Act (or PPACA as it is known by folks that don’t use “ObamaCare” in polite company). As a prelude to our Hill visits we heard from representatives of HRSA, the VA, the National Health Information Technology office, and the USDA. We heard about the problems with PPACA from Senators Pat Roberts (R-Kansas), Senator Mike Johanns (R-Nebraska), Senator Mike Enzi (R-Wyoming). We also heard about the huge opportunities of the Affordable Care Act from Senator Daniel Inouye (D-Hawaii) and Senator Bernie Sanders (I-Vermont). I had to leave before Senator Ben Nelson (D-Nebraska) spoke so I don’t know if he spoke of the Affordable Care Act or PPACA.
The highlight for me was getting to hear Don Berwick. Dr Berwick spoke of his new vision for CMS
CMS can and should be a major force and a trustworthy partner for the continual improvement of health and health care in this country. We all agree that we want the highest quality health care system possible, a system that coordinates and integrates care, eliminates waste, and encourages prevention of illness. With over 100 million beneficiaries depending on us each day, CMS has an important role to play in improving our nation’s health care delivery system. We are striving to meet this challenge, while attending diligently to the crucial, day-to-day work of our operations and preserving and enhancing the integrity of our payments, our programs, and the Trust Funds.
He again stated his vision to bring the Triple Aim to CMS. He said this would be accomplished through boundarilessness, speed and agility, unconditional teamwork, value innovation, and customer focus. He then went into specific work that CMS was focusing its energy on. This work can be categorized as involving excellence in operations, improved care for patients, integrated care for populations, and improved health for populations and communities.
Like Senator Sanders I think the Affordable Care Act offers incredible opportunities for care transformation, even more so after hearing Dr Berwick.
Addendum: Dr Berwick’s talk can be found here at 1:13:00
I am here in Washington DC at the Rural Policy Institute put on by the National Rural Health Association. My administrative assistant laughed when I told her that at one time I dreamed of working in DC. She felt that although I would get the policy part, she has not known me to be politic. I will admit that I don’t feel compelled to keep my feelings to myself about other folks’ efforts, especially when I feel like the others are STUPID, but I don’t see how that would keep me out of politics. Instead, I get to go and meet with out delegation, thank them for passing the Affordable Care Act, and answer questions about the state of health care in rural Alabama in the most politic manner I can muster.
I did meet a very interesting person from Mississippi on the flight from Atlanta to DC. She is an administrator at North Sunflower Medical Center in Ruleville, Mississippi. On the map, Ruleville looks like the crossroads made famous in O Brother Where Art Thou where the group picked up Tommy Johnson. She told me they are moving towards electronic health records, have just opened a wellness center for all regardless of ability to pay, are looking to deliver dental services to 11 counties, and currently provide eye care for many Rulevillians allowing them to stay close to home. The North Sunflower patient satisfaction is at 92%.
Many people say that if you come to a meeting such as this and bring home one thing to do to make things better, it was a good meeting. As the Affordable Care Act is now the law and the Alabama delegation is ground zero for the anti-earmark tsunami, I won’t be taking home any pork. I will get to hear Don Berwick discuss upcoming opportunities to deliver transformative change should the law remain intact. It is now up to the states to implement transformational changes within the infrastructure established within the Affordable Care Act. I hope I can bring back concrete ideas for Alabama to look at as we seek models to use for transforming care. From what I can see, North Sunflower might be a place to look to for such ideas.
In a post from August I mentioned overhearing the statement “We don’t know what form health care reform will take” and feeling that I had some idea. I pointed out that rule making is very important now that the law is passed and I was encouraged by the calliber of the appointments at CMS. From an article in the New York Times
The final version of the health care legislation, signed into law by President Obama in March, authorized Medicare coverage of yearly physical examinations, or wellness visits. The new rule says Medicare will cover “voluntary advance care planning,” to discuss end-of-life treatment, as part of the annual visit.
Under the rule, doctors can provide information to patients on how to prepare an “advance directive,” stating how aggressively they wish to be treated if they are so sick that they cannot make health care decisions for themselves.
While the new law does not mention advance care planning, the Obama administration has been able to achieve its policy goal through the regulation-writing process, a strategy that could become more prevalent in the next two years as the president deals with a strengthened Republican opposition in Congress.
In this case, the administration said research had shown the value of end-of-life planning.
“Advance care planning improves end-of-life care and patient and family satisfaction and reduces stress, anxiety and depression in surviving relatives,” the administration said in the preamble to the Medicare regulation, quoting research published this year in the British Medical Journal.
Perhaps one day when I have an hour long discussion with a patient regarding end-of-life care I’ll actually get paid for it.