Saturday, March 26, 2011

Bringing Down the Costs of Medical Care

It is currently popular for government officials to single out the insurance companies for the rising cost of healthcare. Not that the insurers are without fault but the real reasons for cost increases are rarely addressed and therefore not appreciated. We are a country with an aging population (“old parts wear out”) and of many adverse behaviors (e.g., overweight, sedentary lifestyle, stress and 20% still smoke.) Combined, these are driving a rapid increase in chronic diseases such as diabetes type 2, cardiovascular disease including heart attacks, heart failure and strokes, high blood pressure, and cancer.

These are illnesses that, once developed, are usually with the individual for life, have a major impact on quality of life and are inherently expensive to treat. The Milken Institute did a comprehensive study of chronic diseases. Among their findings: 109 million Americans have a chronic illness now [that’s about one third of us!] and many have more than one for a total of 162 million. The costs of care today are about $275 million and the total economic costs are well over a trillion dollars per year in lost productivity, etc. They estimate that we are on a track for a 42% increase in these chronic diseases by 2023 (as a result of aging and behaviors,) not that long from now. And if we do nothing to change the way we care for these patients, the costs of medical care will be $790 billion and the total economic costs will be over 4 trillion dollars.

There are two things to do to reverse this trend. These are illnesses that by and large are caused by our behaviors or are the result of aging. We can’t stop aging. So, the first step is to have an active program in behavior modification. Easier said than done, of course but here are some principles. We need to individually accept responsibility for our own health. But we need to understand what we are doing and how it impacts us over the long term. Government can help here with educational programs, rules about school lunches, requiring restaurants to post calorie and fat contents, labeling food packages with a more realistic total calorie assumption (today packages imply that the average person needs a 2000 calorie diet) and other steps. Incentives, primarily monetary ones, can have a big impact. Incentives need to be large enough to be useful yet focused enough to drive toward the desired end. Our employer can help with wellness programs to assist us to stop smoking, loose weight, improve our nutrition or deal with stress more effectively. The incentive here can be asking the employee who is successful to pay a lower portion of their health insurance premium. Insurers can create incentives directly for following a healthier lifestyle by lowering premiums for those who don’t smoke or are at a reasonable weight.

The second major step is to ensure that those who do have a chronic illness get very good care coordination. Unfortunately, this is just not the case for most patients today. They end up with multiple doctors, each doing their own thing, excess specialist consultations, too many medications, unnecessary tests and procedures and sometimes even unneeded hospitalizations. This drives up the cost of care dramatically. When one has a primary care physician that takes the time to fully coordinate all the elements of care, the use of specialists declines as do tests, procedures and hospitalizations and drug therapy is well managed.

Unfortunately, most primary care physicians have too many patients under their care to allow adequate time for prevention sessions or the time needed for care coordination. They need to care for fewer patients meaning they will need to receive a higher fee for each visit and this must include a reasonable payment for preventive activities and coordination efforts. Added to this they need to be paid to take the time to respond to emails and to use other technologies that can keep the patient out of the office unless really necessary. Some docs are doing just this by limiting their practice to about 500 patients (rather than the usual 1200-1400) and charging a flat fee for all care for a year. Others are refusing to accept insurance, both commercial and Medicare, and instead are billing the patient just as a lawyer or accountant or other professional would. The billing includes time spend in prevention and coordination. These may well be the future of primary care reimbursement and a means to assist the patient to first prevent chronic illnesses from occurring and second to assist in good coordination of the care when one does develop.

But all of this raises critical questions. What should and what will government do to help us modify our behaviors? Will insurers be allowed and will they accept the responsibility of a two tiered premium pricing system? Will employers accept the added chore of developing wellness programs? Will physicians, even if they are offered adequate payments, actually spend the time needed for good prevention and good care coordination? And, most importantly, will we as citizens accept our responsibility to lead a reasonably healthy lifestyle?

Friday, March 18, 2011

Getting Nurse Staffing Right Is Critical – Patient Mortality Depends On It.

When I was the CEO of a large academic hospital we were constantly concerned to properly balance nurse staffing. More staff than needed meant wasted money and too little staffing risked lesser quality care and nurse disharmony and even resignations. But adjusting the staffing levels of multiple units, each with differing patient types and needs was a major effort and easily thwarted by rapidly varying census numbers, patient admissions and transfers to other units, nurse shortages, and many other factors. In retrospect it is remarkable that it worked as well as it did. But the risk management group was ever concerned that if the staff levels were too thin it was possible that adverse events could occur.

Now there is a new study reported in this week’s New England Journal of Medicine that links deficiencies in nurse staffing with increases in patient mortality. The investigators evaluated an unnamed academic hospital with a strong record of high quality and lower than expected patient mortality. They looked shift by shift and noted whether that shift was at targeted levels based on patient acuity, over or under. They also looked at the level of patient turnover during each shift. Quoting from the article, “In an institution with a history of success in meeting staffing levels and with a level of patient mortality that was substantially below that predicted by its case mix, we found that the risk of death increased with increasing exposure to shifts in which RN hours were 8 hours or more below target staffing levels or there was high turnover. We estimate that the risk of death increased by 2% for each below target shift and 4% for each high turnover shift to which the patient was exposed.” [Italics mine]

The take away message to me is that hospital executives and boards need to be sure that they are managing nurse shift decisions carefully. In any hospital, personnel constitute about 60% or more of expenses and nurses represent about one half of that so the dollars are not inconsequential and need to be managed appropriately. Clearly, “appropriately” also means assuring that each unit has the necessary complement of registered nurses on each shift. From the article, “Our findings suggest that nurse staffing models that facilitate shift to shift decisions on the basis of an alignment of staffing with patients needs and the census are an important component of the delivery of care.” It also means that hospitals need to look at their approach to transferring patients from unit to unit. Often times this is necessary such as movement of an unstable patient to an ICU. But this study makes the point that excess transfers can be detrimental to patient welfare and may require more than the usual staff numbers. “Our results suggest that both target and actual staffing should be adjusted to account for the effect of turnover on patient outcomes.”
How a hospital aligns its nurse staffing is an important element of quality in addition to cost management. Getting staffing right is critical. When it is correct, mortality will be lower. Further, although not measured, if mortality came down in this study, it is fairly safe to assume that other quality measures were improved as well.

Monday, March 14, 2011

Surviving Cancer As A Teenager – It’s Not Just The Treatments

When Clarissa was 13 she entered Johns Hopkins Hospital to be treated for relapsed acute leukemia knowing full well that she had only a 40% chance of survival. Today she is 16 and in excellent health. But it took 2 ½ years of incredibly rigorous treatments to get there. Equally importantly it meant riding an emotional roller coaster for her and her parents.

Clarissa had been treated for leukemia when she was 2 and had been fine for a decade when the relapse occurred. She found there was not much available to read about coping with the emotional issues that come with a cancer diagnosis during the teenage years nor was there a support group of teens who had faced the same challenges. Consider that a teen wants to be more and more independent but that is just impossible when you now need your parents even more than ever and must depend on doctors and nurses for life itself. Teens are focused on their appearance but what if you have no hair and an intravenous catheter sticking out from your skin – pretty hard to hide. Friends want to be friends but don’t know whether to visit or not and when they do they find you wearing a mask to protect against infection and must shun the instinct to hug. These and other issues surfaced over her two and one half years of treatment, years in which she spent much of the time in the hospital and lost well over a year of school, again much of that to avoid contact with infection while her immune system was at its lowest. With the help of at home tutoring, she kept up with her assignments and now is back in school with her classmates, getting good grades and enjoying the life of a high school student while thinking about college and the future.

Clarissa persevered and now wants to help other teens who develop cancer to cope with what lies ahead. She has started a blog, gives frequent talks and plans to write a book on coping later this year.

A friend of mine, a twenty five year survivor of adult leukemia, told me after reading her first blog entry: “Wow! I am sitting at my desk with tears in my eyes - she is so beautiful - inside and out. So brave - so inspiring. I am coming up on 25 years and have no courage compared to this young woman.”

If you know a teen ager with cancer, I encourage you to direct them to Clarissa’s blog at

Praise for Dr Schimpff

The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.

-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).