Quality Improvement Needed

News reports just came out that a doctor had been shot at Johns Hopkins and that the shooter said he was upset about the treatment his mother had received there.
Having spent 15 years as a professor there, Johns Hopkins sees a spectrum of patients from all socioeconomic strata. Wealthy patients often try to improve the quality of care by donating money to various initiatives (for example, the famous case of the 2 year old burn victim who died of dehydration in the children's hospital, whose mother funded a quality and safety program there). It will be interesting to hear the shooter's story. While violence is never justified, the hospital may be able to learn something important about quality of care for the socioeconomically disadvantaged. AS Hopkins is a center for diversity research and the impact of race, ethnicity and socioeconomic status on the quality of care, many people on the Hopkins faculty should be well-equipped to help the administration find out some of the core triggers that in the presence of a violent man with a gun may endanger staff safety. It would be sad if the only thing that was done were more measures to protect staff from patients.

Effects of health care reform on small medical practices

It is clear from the content of the healthcare reform that the Obama administration wishes doctors to join large organizations which they believe can deliver more efficient care and which will be better able to translate the financial incentives and payment strategies envisioned by the legislation into actual delivery strategies to make things more efficient. Unfortunately such "efficiency" does not necessarily translate into better care. What you can expect to disappear as medical care transitions into large organizations: 1) small intimate practices 2) continuity with one doctor, 3) involvement of the doctor in routine care, 4) your ability to pick the best person to do each part of an episode of care, even if the doctors belong to different organizations. This has to do with the payment mechanism which will be adopted of bundling payments for an episode of care. This means only one organization will be able to deliver the care for the entire episode. For example, if you have a heart attack and require bypass surgery, the organization which admits you for the heart attack will be paid a lump sum for the entire episode of care, and you will not be able to choose a better surgeon in a different center.

While am in favor of health care reform including increasing coverage and preventing insurance companies from cherry-picking the lowest risk patients, I am very much against the type of payment bundling that is being promoted by the Center for Medicare and Medicaid Services and the health care reform legislation. Nothing in this type of bundling promotes high quality care. Just like the prospective payment system for hospital care, this type of payment promotes efficiency and reduced service during an episode of care. Quality measures are imperfect and tend to be very slow to incorporate and reflect new innovations and technology.

Pharmaceutical company and medical device company interests will continue to promote the use of unnecessary expensive technology. On the other hand, we are now likely to see powerful healthcare industry interests promote the underuse of needed care across the spectrum of medical care for each episode of care just as they have promoted decreased use of services during a hospitalization. But now there will be nowhere for the patient/consumer to go and no time or place at which the person CAN obtain the needed service. As with the passage of prospective payment for hospital care in the 1980s, there will be little or no incentive to provide high quality of care. The quality indicators used to date for performance bonuses for physicians (which in the future will go to the large organizations which employ these physicians) are generally inadequate and and reflect little of what makes care truly high quality.

We are now down to 25% of doctors in small practices. Healthcare reform as it is currently constituted will reduce that even further. I find this very sad. As someone who has devoted my entire career to improving medical care, often working in hospitals against the perverse financial incentives of the prospective payment system, and as someone who now works as a consultant helping people find good medical care, I am keenly aware of how these new payment strategies of bundling for episodes of care will reduce consumers' ability to choose good doctors.

Don Berwick to Head CMS

Don Berwick, whom I'm honored to have worked with in the past, has been appointed by President Obama to head CMS (Center for Medicare and Medicaid Services). Don is a mesmerizing speaker and a wonderful physician and human being who has encouraged an entire generation of physicians to bring industrial quality improvement methods to health care. Don founded and has headed the Institute for Healthcare Improvement since leaving Harvard in the 1990s. He has a broad constituency in medicine across many disciplines. I believe he's an excellent physician who is committed to high quality health care in the U.S. in a non-partisan way, despite my having read that Republicans criticize him for having written positive things about England's national health insurance system. Don has praised England's recent emphasis on quality and performance improvement, and it would be pretty hard to argue with that change, whether one favors a single-payer system or not (I do only if it is structured to preserve competition among and choice of providers based on quality of care).

I am hopeful that Don's insight will help Medicare implement the healthcare reform legislation in a way that will promote and preserve quality of care in Medicare as well as the private insurance system. I am encouraged by Don's background in clinical medicine (he is a pediatrician by training although I don't know when he last practiced), and quality of care. Don is an excellent choice and I hope his philosophy can filter down to CMS' day to day operations. As we know, sometimes leaders of federal agencies don't influence their own bureaucracies too much, because managers of individual departments can subvert the intent of the agencies' directors. Don, however, is an inspiring leader who has been an effective leader in several organizations in the past, and I wish him all the best at CMS.

Sedatives

As a visiting doctor, watching the decline of people sent to nursing homes is painful. So often their behavior becomes an issue, resulting in the prescription of sedatives, which starts a spiral of decline. While such behavior problems are often attributed by nursing home staff to dementia, I have also seen behavioral problems among people who were not demented in the hospital prior to coming into a care facility, even when much sicker in the hospital.

While agitated behavior is often attributed to dementia, worsened by an unfamiliar environment, there are other causes in rehabilitation facilities and nursing homes. Often patients are relatively neglected compared to their prior home environment as well as the prior hospital environment. They cannot go to the bathroom alone, and need help with many things they want to do. Sometimes they do not have a means to call for help. However, when they do, staff cannot be everywhere at the same time, so even in the best of care facilities, people may feel neglected. No one likes neglect, so agitation or screaming can result. The feeling of completely social powerlessness leads to intense frustration which has little other outlet. Family members often notice that when they are present and responding to the person, the screaming or agitation stops. Intermittent positive reinforcement occurs, which results in the behavior becoming habitual.

Unfortunately, sedating people to manage their behavior has further terrible effects. Through being insufficiently helped to get up and exercise, and not being helped to the bathroom in a timely way, they lose continence, develop bedsores, and become weak through muscle atrophy. Excessive sedation also means they lose interest in their rehabilitation activities and are less aware of when they need to go to the bathroom etc, thus deteriorating even further. Delirium and confusion can be other consequences of too many drugs acting on the brain, especially in the frail elderly. This leads to more agitation and screaming, which leads to more drugs. Watching this can turn depressing quickly.

Staff requests for medications are understandable because screaming and agitated behavior can create a horrible environment for both staff and other residents.

The real solution lies in increased staffing and responsiveness by nursing home staff. Unfortunately, our society has not figured out how to care well for our elders. All of us should hope for the sake of our own lives to come, that the future will see a greater investment in making our elders comfortable instead of weakening them with under-staffing and over-sedation.

Home care is not feasible because most people are simply unable to care for a family member 24 hours in their homes, and cannot afford full time home care. This leaves working family members, those who find nursing very difficult, such as those too frail to lift a person, little choice but to put their loved one in a nursing home in such a situation. Family members find this decision extremely painful, and it signals an important turning point of decline.

Our society has a great need for better solutions for elder care. Your comments are welcome.