Hospitals

Rhode Island is pushing ahead with a new way of paying hospitals, to try to move away from rewarding volume and toward rewarding value.

The agreement, outlined in a story by Felice Freyer in the Providence Journal (a regional paper, incidentally, that does a lot of good health policy reporting) is between a hospital group and a private insurer -- but it was brokered or at least cheer-led by the state’s Health Insurance Commissioner Christopher Koller under his power to review insurance rates. (Tangent alert -- Koller gave an interesting presentation at the Alliance for Health Reform last spring on how the health reform legislation will affect private insurance.)

Jordan Rau of Kaiser Health News has penned a must-read on rapidly rising hospital prices in California that lays out in compelling detail some of the factors that drive sharp differences particularly within local communities. If you are concerned about provider costs continuing to rise in the wake of reform (as you must be if you care about health policy) you should go over and read the whole thing.  

One of the things that jumped out for me was further documentation of the connection between market share and payment rates. We hear a lot about this issue as it relates to differences across regions but this dynamic plays out within local communities as well:

Interesting story in this weekend’s Baltimore Sun about a new residency program at Johns Hopkins that focuses on “urban health,” primary care, and public policy. Young doctors like Deanna Wilson won’t just wear white coats and treat patients in hospitals. They will spend time in community clinics, HIV/AIDs centers, and prisons. They will sit in on police department domestic violence conferences. They will learn about social services that can help improve both the health and the lives of their patients. They will try to address not just diseases, but some of the larger social circumstances that contribute to poor health and poor health outcomes.

Sun writer Jonathan Pitts describes Wilson’s half-hour appointment with a 17 year old with ADHD. She asks him about what he eats for breakfast, how much TV he watches, what kind of chores he does at home, what that tattoo on his arm means, what his friendships are like. He leaves -- feeling listened to -- not only with a traditional prescription for a medication but with a letter to his school so he can get all the educational support services to which he is entitled.

We’ve written before about the issue of hospital readmissions, but we just wanted to point to an excellent post this week by Anne-Marie J. Audet, M.D., MSc., the VP of Health System Quality and Efficiency at over at the Commonwealth Fund. Audet points out the deficiencies surrounding rehospitalization rate reporting -- though we have solid rehospitalization studies looking at Medicare patients only, these studies are limited in scope and cannot give us an accurate picture of the health system as a whole. She calls for a standardized national measure for reporting rehospitalizations and improved data systems to make sure reporting is timely. Audet writes:

Several national reports published…feature rehospitalization rates, and some have tracked rates over time. Yet, two problems persist: each group has adopted a different definition of rehospitalization, which makes comparisons and benchmarking across states, regions, and hospitals impossible, and most reports are based on data that are more than two years old.

Several recent articles (links below) on nonprofit and/or public safety net hospitals reminded me that I had in my “in” box an unread essay from the Hastings Center on the future of charity care under health reform by Jessica Wilen Berg. So I read it.

Despite the historic expansion in coverage, roughly 23 million people (including undocumented immigrants) will remain uninsured in 2019. We’ll still need hospitals and clinics to care for them. Berg notes that a lot of nonprofit hospitals aren’t doing all that much charity care, and she cited a 2007 IRS report that found that half of them spent three percent or less of revenue on charity.

For many rural areas of the country, telemedicine has long been more of an elusive dream than an everyday reality. And the challenge of getting up-to-date specialty care and continuing medical education into underserved areas has taken a back seat, on many occasions, to the challenge of creating interoperable electronic health records and streamlining the transmission of clinical data between hospitals and physicians.

But this week's official launch of the California TeleHealth Network is a big step forward for telemedicine. Four years in the making, this effort will link eight hundred medical facilities in the state through telehealth and broadband technologies and will be run by the University of California.

The piece I did for Slate last week on palliative care and the emergency room sparked quite a bit of blogging and emailing and chatter (gratifying). One theme that stood out for me is the people wondering why a palliative care physician (or nurse) had to deal with these tough decisions about treatment and goals of care in the emergency room. Why they asked, can't the primary care physician do this? And I realized there is a really strange cognitive dissonance, or a nostalgic time warp, between the health care that we think we are getting and what we and our family members actually get.

I have a piece in Slate on palliative care in the ER, a topic I'd wanted very much to write about ever since I first heard about Dr. Tammie Quest's innovative work a couple of years ago. Dr. Quest and I talked a few times, we finally met a few months ago, and I went down to Atlanta to watch her in Emory's emergency department this spring. I'll write more on this topic soon, but in the meantime I'm sharing an email one of my oldest friends sent this morning after reading that piece. I've kept it anonymous and edited slightly for clarity:

Palliative care in the ER is so important and, as you show, so hard to bring about, given the culture of that environment. Reading your article I was reminded of the time my Mom ended up in the ER after a seizure, about eight months before she died.

The struggle over health reform arises in part from our collective difficulty envisioning exactly what we want want. Conflicting visions of our imagined future health system -- universal!, private!, public! -- fuel the political conflict. Few outside the health care cognoscenti, however, say they want hospitals to look more like car factories. Maybe they should.

Over the last decade, Seattle Children’s Hospital is one of a small but growing group of health systems gradually applying the principles of kaizen -- the manufacturing philosophy of “continual performance improvement” or CPI made famous by Toyota. (Details in this recent New York Times article).

The horrible hoopla last summer about the fictitious “death panels” obscured a significant challenge for patients and doctors --- how to communicate about, understand, and respect patients' wishes at the end of life (which might change as their health status changes). This is a not only an economic issue (about a tenth of health costs are in the last year of life, more than a fourth for Medicare patients), it is also a profoundly important quality issue.

A study this week in Archives of Internal Medicine (abstract here, full text here, subscription required) by Anne M. Walling, MD and colleagues found room for improvement, even for terminally-ill ICU patients.The study focused on the care given to nearly 500 adults who died in a one year period (April 2005-2006) at RonaldReaganUCLAMedicalCenter, a teaching hospital known for aggressive care of critically ill patients. All had been hospitalized at least three days; many had notations in their chart establishing that the physician expected them to die The study looked both at delivery of certain types of care (pain management, treating shortness of breath) as well as communication about goals of care, family expectations and end -of life wishes of patients and their families.