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'It was a bungee cord accident and I'm having trouble bouncing back.'

‘It was a bungee cord accident and I’m having trouble bouncing back.’

Recently at morning report:

Resident: The patient is a 66 year old woman who had pneumonia and has pretty bad dementia and congestive heart failure and was just discharged from our service 7 days ago. Her family brought her back in.  They had her meds all messed up.

When I was a medical student at Charity Hospital in New Orleans it was also known as The Big Free. The hospital name was derived from the order of religious sisters initially brought in to nurse those in the hospital back to health, the Daughters of Charity. The nickname was derived from the fact that there were no charges generated for the care delivered (Free) and the fact that Huey Long built a series of smaller hospitals throughout the state (Little Charities) that provide less comprehensive care.

Resident: Somehow they gave her the antibiotics but forgot to give the diuretic.

We were not introduced to the concept that care costs money in the entire of medical school. People were admitted, people were discharged, procedures were learned, people were readmitted and no bills were generated. I left medical school knowing little about cost. Fortunately for my patients, because no bills were generated, only the state of Louisiana was responsible for the costs my mistakes generated.

In almost all training programs up until very recently, when a patient came back, whether it was the care team’s mistake or the fault of the patient, it was “bounced back” to the previous team. This at worst meant you had one extra patient on your service and, if the patient had insurance, turns out the hospital made extra money. In some cases lots of money.

A 2009 study published in the New England Journal of Medicine analyzed almost 12 million Medicare beneficiaries and found that approximately one-fifth were readmitted within 30 days of discharge and an even more alarming 34 percent were admitted in 90 days. Wait, it gets worse. If we look a year out from discharge they reported 67.1 percent who had been discharged for a medical condition had been readmitted or had died. This revolving door is expensive and cost Medicare $17.4 billion dollars in 2004.

Beginning 2 years ago, Medicare began docking the pay of those hospitals that have a lot of “bounce backs.” Hospital administrators  were not happy about this. “There are things we don’t control, and we certainly don’t control patient behavior either,” said Nancy Pratt, chief quality and patient safety officer for Irvine, Calif.-based St. Joseph Health System. “You could do everything right and still end up having a patient readmitted.”

Me: People just don’t forget. That’ll count against us.

Resident: Well it was on the medication reconciliation. The visiting nurse went by the house and went over the meds. I don’t know what else we can do short of putting it in her mouth ourselves.

In the post ACA world, there are no more mulligans. More and more, the care delivery system is taking responsibility for the totality of the care. Hospitals are trying a lot of things in addition to reconciling meds, such as discharge coaching and post-discharge phone contact.

Systems engaged in reducing readmissions are now realizing that the cost of care is not random but is aggregated into a very small number of patients. In this recent article from the New England Journal, investigators in Massachusetts (where there is close to 100% coverage) found that, depending on insurance, the costliest 1% of people accounted for between 14% and 22% of total costs. To reduce readmission in this cohort, care delivery systems would have to provide services such as nurse care managers to work with high-risk Medicare patients, integrating mental health services into broader care-coordination and disease-management models for Medicaid patients, and improved access to low cost specialty pharmaceuticals for young folks with severe illnesses.

Improved care delivery just went from a liability (we make our money off repeat customers) to an asset. As the NEJM authors wrote, As reform activities shift payment away from fee-for-service models, the incentives to improve care for high-cost patients will continue to grow.” Now we have the opportunity to not only teach the importance of keeping folks out of the hospital, but get paid for it as well.

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For those of you that have not been to medical school, the clinical years can be a little stressful. Waking up at 4 am to see patients (and waking them up at 5 am with a cheerful “How are you doing this morning?” only to get a “What time is it???”), spending quality time in an operating room, and learning how to “see patients” through very different eyes all contribute to us becoming “doctors.” My 3rd year was spent predominately at Charity Hospital in New Orleans, where the patient base was mostly poor and African-American, in contrast to the Tulane medical students.

Part of this year was spent with one of the fathers of modern cardiology, Dr George Burch.  Dr Burch, who was in his 80s, would appear twice a week and help the team work through problem patients. He would then take the student part of the team up to his lab, where his lab techs (themselves in their 60s) would serve us tea and cookies as he instructed us on the nuances of medicine. We students couldn’t help but notice the three-dimensional vector EKGs inhabiting the room. These were like minimalist sculptures of hearts, and there were many hundreds lining the walls. Finally one of us got up the courage to ask about them.

“Oh, those,” Dr Burch replied. “I’ve been collecting those for years. When the patient died that I’ve done a vector EKG on  I collect the hearts as well. I have 1500 of them. Some day I am going to dissect the hearts and correlate the anatomy with the physiology.”

He died about 5 years later and I suspect never got around to completing this task. I am afraid that the frozen human hearts did not survive Katrina.

I read the Immortal Life of Henrietta Lacks this weekend. The extremely abridged version of the story is that Ms. Lacks, a poor woman who lived in Baltimore at the time, was going to Johns Hopkins for a complaint related to her “womb.” In the course of the diagnostic and therapeutic interventions, some of her tumor was collected and was the first human cell line to be able to grow independently. The HeLa cell was used to develop and test the polio vaccine,  develop techniques used for IVF and creating other cell lines, used to create the building blocks for the human genome project, and is used to test drugs that affect cell growth to this day. Although Hopkins got no money for developing this directly, their reputation was certainly enhanced greatly (5 Nobel prizes can be directly linked to HeLa). Many companies have made a lot of money using this commercially available descendent of Ms Lacks. The Lacks family, on the other hand, struggled for years with lack of access to basic education and health care as well as being treated as research subjects rather than fellow human beings.

Most medical training in New Orleans in my time was (and likely still is)  accomplished while caring for the poor of New Orleans. My choice of Tulane, in part, was because of a reputation for academic excellence and innovation by such folks as George Burch (founder of American Heart Association), Louis Ignarro (Nobel for work on nitric oxide), Michael deBakey (inventor of heart-lung machine key component), and Andrew Shalley (Nobel for discovery of pituitary hormones). I suspect ALL of these folks would have had much less success without their own Henrietta Lacks at Charity Hospital. I suspect Dr. Burch, for example, did not get solid permission for the donation of the hearts, though I could be wrong.

Modern medicine and modern society have moved beyond (I hope) the concept of poor people existing in the health care world so doctors can practice for their well-heeled private clientele. Much of the Henrietta Lacks story is one of objectification of tissue, families, and the entire African-American culture. The ethics of access to modern medical discoveries are difficult. It is when the very people upon whose backs the discoveries are made seem to be denied access systematically that we need to step in. Although not perfect, the Affordable Care Act is a start, and its promise of access beginning in 2014 is a down payment on correcting these disparities.

I was in New Orleans today for the Saints game against Da Bears. The Superdome is walking distance from the old Charity Hospital and Tulane School of Medicine. We were dropped off by old Charity and walked over to the ‘Dome. I found myself looking at the once familiar cityscape but could only think of the events post-Katrina. Charity Hospital was originally established to serve the city in 1736 and is named for the Daughters of Charity who provided care. It was Huey Long who located Big Charity (as it was known when I was in Medical School) on Tulane Avenue and placed the new public medical school (LSU) on the other side opposite Tulane in the 1930s. The two schools both used Big Charity for clinical instruction, but at the time I was in school (the 1980s) the truce was uneasy at best. Tulane, with a private school swagger, had opened a private hospital across the street named Tulane Medical Center (TMC). The poor on the Charity “service” did not get the wonders of the care delivered at TMC from the Tulane faculty. The LSU faculty, feeling outflanked and resentful, soon moved their private practice to another local hospital. As I understand it, the trauma care at Big Charity was still world class, but much of the other specialized services, as well as a lot of bread and butter medical care, had moved from Charity well before the storm.

The storm managed to do what the state of Louisiana could not: close Big Charity. As a symbol of the commitment to the citizens of the State of Louisiana to the health of  its poor, Charity was second to none. However, even before Katrina, it was known as an expensive and not very efficient symbol and as a  rich source of patronage for well-connected Louisianians. Post-Katrina Tulane reopened TMC, moved some clinical care to the suburbs, and moved some of their clinical training (as I have discussed before) into the community. LSU moved into other facilities as well but now seems to have talked the state of Louisiana into a new hospital.

This hospital will cost $1,100,000,000 and will be funded using a combination of general funds, Katrina recovery money, as well as some yet-to-be determined sources. The financial viability seems to be based on the fact that they will attract patients from the  New Orleans region  who are currently using competing health care venues but their physicians have an LSU affiliation (repatriation), they will create new demand (destination programs), and they hope to appeal to the newly “Obama-insured.” There is also a belief that some of the insured citizens are more likely to view a new hospital as less “Charity” than the previous Charity and so will choose to make this their preferred care facility.

My interest was piqued because the construction was blocking the way for us to walk from the Superdome to Canal Street, as it is a huge site. I wish LSU and the state of Louisiana luck, although it seems that they are planning more to capitalize on illness than on health.  To quote:

New Orleans Business Alliance President and CEO Rodrick Miller said, “The UMC Teaching Hospital will be a center for innovation and learning that will dramatically increase the quality of care options for patients in New Orleans, and serve as a key economic engine to spur job growth and new investment in the community. Getting this hospital on-line will solidify Louisiana’s long-term commitments to expand high quality healthcare options for New Orleanians and support a robust bio-medical industry.”

I am glad I’m not a taxpaying citizen of Louisiana. If anyone wants to know why, I refer them to The Amazing Health Care Arms Race.

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