Friday, August 27, 2010

Just What Does This Mean for Health Care?

In reading the positions of the current Administration regarding the recent health care bill I was struck by one written by the WH Chief of Staff's brother and a few others. It appeared in the Annals of Internal Medicine and is worth a read not for the content but for what I would consider some of the worst Pollyanna writing I have ever experienced.

Let me address the table as an example. Here is the Table and my comments:

How the Affordable Care Act and the American Recovery and Reinvestment Act Are Likely to Affect the Practice of Medicine:

1. Focusing care around exceptional patient experience and shared clinical outcome goals.

Just what does exceptional patient care mean? It is never defined and cannot be achieved. It takes the use of the word quality to a new extreme. If you cannot measure it then it does not exist and in turn you can never achieve it.

2. Expanding the use of electronic health records with capacity for drug reconciliation, guidelines, alerts, and other decision supports.

Expanding means what? A capacity means nothing unless it effects a change, an improvement. At least Blumenthal tried to quantify it. This makes no sense at all. What do they mean by drug reconciliation, how about effectiveness, safety, and the like.

3. Redesigning care to include a team of nonphysician providers, such as nurse practitioners, physician assistants, care coordinators, and dietitians.

This will mean the added costs to the system which will drive the rate of increases to multiples of any inflation, if we even see that any time soon. What of individual responsibility. What of the obese patient who continues to snack, to smoke. What are their responsibilities? Adding non physicians will add frankly a drag on the system, it adds all too often people with an entitlement mentality and an attitude. Give me a good head nurse anytime, even better that a dozen residents, but please hold back on the hordes.

4. Establishing, with physician colleagues, patient care teams to take part in bundled payments and incentive programs, such as accountable care organizations and patient-centered medical homes.

Here we go with the bundled payments. Solving this problem is a nightmare. Frankly we should not be sending obese diabetics top endocrinologists to begin with. The same is true for most cardiologists. However when we have a PIN prostate problem no internist will be able to deal with it, it is fundamentally surgical. Besides these are all just words, the authors seem to mumble on with the catch phrases which have become the mantra of the current Administration's health care disaster.

5. Proactively managing preventive care—reaching out to patients to assure they get recommended tests and follow-up interventions.

Try and get a patient who has been morbidly obese for 25 years to get the weight off. Any practicing physician has battled with this problem for years. The same is true for the smokers. You tell them, you warn them, they see the consequences but the costs just keep adding up. At what point is it their problem and not the systems? What of the woman who just does not want the mammogram, we know she should but she is terrified. That is a classic practicing physician problem.

6. Collaborating with hospitals to dramatically reduce readmissions and hospital-acquired infections.

Frankly this is the hospital problem almost always. It is a slip up in procedure, failure to wash hands, and the like. The recent H1N1 non-epidemic was an example. For the first time last winter there were hand sanitizers at every corner in every building I went to, The Brigham, Children's, MIT, just everywhere. I bet that was a factor. So get the staff on the institution to do the same.

7. Engaging in shared decision-making discussions regarding treatment goals and approaches.

This works well in an academic institution and in most large scale hospitals but it just does not function is the stand alone practices no matter how large. There just is not enough time. Does the urologist coordinate with the internist and then deal with the cardiologist and so forth, no way, they are all at sixes and sevens. The processes are defined and followed and the results transferred if the system works. Otherwise we all too frequently rely on the patient as the communicator.

8. Redesigning medical office processes to capture savings from administrative simplification.

This is a good one! In 1971 when I got out of school a typical internist might have a nurse/office manager. Two people, that's all. Fast forward and with all the rules and regulations they now need a staff of five or six per physician at some time. Why, the Government rules and regs! How does an internist make any money after the low balling on reimbursements and the need for massive overhead. The problem is not a redesign of process it is a redesign of mandated overhead. One would assume that the authors never went to a normal physician's office.

9. Developing approaches to engage and monitor patients outside of the office (e.g., electronically, home visits, other team members).

More money, more overhead. Yes we can deal with many problems with not visiting. Here I am thinking of video patient contact. I have been trying that since the mid 80s, it has pros and cons. As for monitoring patients there is the Holter monitor and the like. We can monitor blood glucose, we can do all sorts of things but we would have to look at the overall cost effectiveness a term the authors seem to leave in the dust.

10. Incorporating patient-centered outcomes research to tailor care appropriate for specific patient populations.

It is always useful to do research and research focused on patient centered outcomes is motherhood and apple pie. But how does that conflict with the CCE/CER efforts. Here we have the problem of averages versus outliers. When a patient comes down with cancer they always ask, sooner or later, "What are my chances Doc?" The true answer is "You will live or die. You have no chance just the result." However that just would not work but it is the truth. Each patient, person, is different. There is always the melanoma patient who has a regression, never thought that would happen, but that is one in a very large number, but it exists. So how do we really define outcomes for persons who are patients. Carefully and with dignity.

The problem I have with this Table is the way they generalize and seem to fail to understand the real world. That is the problem of the entire health care package delivered by the current Administration.