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Craig Duncan joins us as a Contributor

When Craig Duncan began, he was running a 16 bed nursing home. When he retired, he had built it into Northeast Health with an intense commitment to integrating care, especially for those with chronic illnesses. He's been one of the leaders in expanding the use of information technology to improve care, increase efficiciencies, and, even better, integrate and transform care.

Craig is joining us as a Contributor at signalhealth.com and I look forward to his observations on a wide range of issues. We could tease by calling him an elder statesman, but he's got way too much energy for that. We'll post his bio shortly.

To get the conversation going, Craig's agreed to an online interview. I'll post some questions and he'll respond with his own postings.

Craig, thanks for joining us and welcome. Here are some questions to get started:

1. What are the most significant changes you've seen in health care since you started?
2. What concerns you most about where the health care system is now or where it's heading?
3. What in today's environment or on the immediate horizon do you think offers us the best opportunities for significant improvements in patient care or system efficiencies?

Thanks. We look forward to reading your perspectives on these and many other issues.

A new online physician voice

Many of you met Dr. Paul Sorum here or here as an advocate for single-payer. Paul's not only a physician. He's also a historian with great expertise on the French medical system.

Paul now has his own blog at www.signalhealth.com and his first post is EMTALA Blues.

Welcome Paul!

Decision making in complex systems emergencies

By way of A Chance to Cut is a Chance to Cure, we have Stephen Cass's Apollo 13, We Have a Solution on IEEE's Spectrum.

Rather than hurried improvisation, saving the crew of Apollo 13 took years of preparation.

And I would add simulation and not making hasty decisions. This is a fairly lengthy story, but it's engrossing and has useful lessons in other sphere's, including ours.

Once more on employment based coverage

Buried way too deep in this lengthy post is a reference to the new book by Susan Sered (an anthropologist) and Rushika Fernandopulle, MD, Uninsured in America: Life and Death in the Land of Opportunity (Amazon Link).

Here at Medscape (registration required) you can read or listen to Fernandopulle talk (far more briefly than I) about "Breaking the Link," why it's time to let go of employment based coverage.

When I posted on this earlier, Matthew Holt commented:

I think that this is how things will eventually play out. Sometime after the next recession, the votes in favor of solving the uninsurance/employment based-mess will be there because so many voters will be uninsured and facing their 50s and early 60s in a real crisis.

BUT saying this is how it ought to be just accepts that we are going to have several more years of the continued tragedy of uninsurance. And I can't say that I want to have that, even if it's a necessary evil to get to universal coverage. There are just too many awful human stories connected to it.

He's right. There's going to be lots more needless suffering.  But there already is suffering. This is not a theoretical projection. It's here now. That's what Sered and Fernandopulle have captured. And no matter how much we may disdain Wal-Mart and some other employers who can afford coverage, avoid paying for it, trying to shore up a failing, dysfunctional system is increasingly wasted time, energy ... and suffering.

Go listen to Fernandopulle. And kudos to him and to Sered for humanizing the story that's far too old.

 

Patient blogs

High Point Regional Health System, in High Point, NC has set up patient blogs! Well this is a dangerous but interesting experiment.

Patients reportedly can write about any negative experiences. We'll see about that won't we. Readers can e-mail comments. So far it's not evident what happens with those comments. Patients may post from home.

Reportedly, a hospital staff person reviews each blog to make sure it is relevant before posting it to the hospital's site.

Here's a staff posting with a bit of (self) back-patting. 

Well, think of it this way. Anybody with a computer and a connection can set up a blog in an afternoon. The way things are going, it's just a matter of time before an unhappy patient sets one up or uses one they already have to rip into a hospital. We've already seen it with a disgruntled Blue Cross employee.

So why not tip-toe into the environment in a very controlled manner?

 

IBM moves

IBM has made two large moves this week expanding their presence in the market for hospital information systems.

The first was to buy Healthlink. Here's the New York Times story.

The second is their developing a test bed to evaluate standards for interoperability.

The third is their $400 million deal with the University of Pittsburg Medical Center to (note what they list first. Hmmmm.):

• Develop new technologies and organizational approaches
• Develop a patient record system that can be shared across a network of hospitals while ensuring patient privacy. Doctors and other medical personnel will be able to locate relevant treatment data via a global system while the public can be notified in emergencies
• Include use of wireless handheld computers, radio ID tags, monitoring devices in treatment and patient rooms, as well as tools for coping with large-scale epidemics or even human-initiated biological attacks

I guess they figure it's finally happening.

Counting the uninsured

The LA Times reported today that there is (another) dispute over the number of uninsured in the US. Here's a summary at the Kaiser Family Foundation.

We've been around this barn a couple of times before. I don't want to pre-judge the quality of the new analyses. However, due to both recent and not-at-all recent history, I'm much more wary than usual. I'm no longer as ready as I once was to give an analyst challenging data the benefit of the doubt.

Why not? Well, we had this. And then we had this. And of course, we have this. And then there's this. As they say here, does ending data collection make the problem go away? All too often with this Administration, the answer has been yes. So of course, we're wary.

The very first estimates I ever worked on used a different and much more rigorous source, the predecessor to the MEPS, which you can find current here. People from the health insurance industry, who should have known better, testified at a public hearing that I organized, that there were only tiny numbers of uninsured. How did they know? They counted the number of people they covered (estimating the number of people in each family). There was only one small problem. Their total count was considerably greater than the population of the entire country. They were double counting lots of people.

Then, when we started using the CPS, Medicaid officials informed us that they had the "truth" and there was no problem. Of course, we haven't heard from them about where all those additional Medicaid clients came from when we expanded eligibility. They can't all have come from Wal-Mart.

CPS numbers are single point-in-time. Note that the MEPS measures the changing status of those counted (always covered, sometimes covered, never covered during a specified period), the estimate for uncovered "first half of the year" is about the same as the CPS.

In fact, disputes about the use of the Current Population Survey as a source on this issue started back in the early 1980s. Extensive analytical work was done comparing the various surveys. The CPS was modified and things settled down.

Because it's done each year, the CPS remains today, the best source of trend information. MEPS and the SIPP also give us a different and useful perspectives.

Well, we'll watch this dispute closely, maybe even read the reports and listen to other researchers. But for now? Stick with what we've got.

Medicaid management?

Senator Ray Meier, Chair of the Senate Social Services Committee has introduced a bill aimed at "gaining better management of the Medicaid system in New York State ..." What a concept!

The bill is modeled on a South Carolina law (overly proud New Yorkers will be horrified) and (summarized from the bill memo) it requires the Department of Health to:

• Convene meetings at least quarterly with all state agencies receiving Medicaid funds and appropriate representation of local departments of social services to identify:
  • Methods to contain the growth of Medicaid spending;
  • Methods to improve the quality of and recipient satisfaction with Medicaid state agency services;
  • Opportunities for consolidation and methods to improve the efficiency and effectiveness of existing service delivery;
  • Opportunities for education and prevention;
  • Numbers of persons on waiting lists for services; and,
  • Collective priority of critical needs for the Medicaid population.
• Report annually on
  • Results of multi-agency meetings;
  • Medicaid expenditures made to other state agencies in the preceding fiscal year
• Develop outcome results-based objectives for Medicaid service and administrative contracts with other state agencies
• Develop an annual plan to conduct periodic audits, reviews and inspections of state agencies receiving Medicaid funds

Given the heavy emphasis on Medicaid funds going to other State agencies, Senator Meier has clearly zeroed in on the use of Medicaid as a verb.

Want to read it yourself? Go here and search for S5069.

Oh, and one more thing ...

In thinking about ideal healthcare systems, don't just look at the variation between countries. Look at the variation within as well.

While Elliott Fisher, MD and his colleagues were focused on a different question, their findings are relevant here too. (Summary, first article in the Annals of Internal Medicine, second article.) Within the US and limited to Medicare patients:

Fisher's team found that in regions with nearly identical health-care needs, the overall quantity of services provided varied by as much as 60%—from an average of $9,074 per person per year in low-spending regions to $14,644 in high-spending regions.

Now mind you, these are comparable Medicare beneficiaries within the US. (It's the same argument I've made when analyzing Medicaid and suggested initiatives for comparing service use within states as well as between them.)

If all those folks with identical coverage showed those kinds of differences in per capita spending patterns, then why should we be confident that comparisons between different coverage systems really tell us anything? Useful? Yes. Instructive? Yes. Definitive? No way.

And another thing ...

More on the US vs. other developed countries and single payer vs. something else debates ...

Healthy systems have some mechanism for self-correction. If not, they die. Different self-correcting systems may operate differently, their sensitivity and response times may differ, but they have something in common. They know their goals, they sense their environments, they respond like the furnace turning on or off in relation to its thermostat.

So perhaps, the US through numerous private and public fiscal thermostats, has been partially successful in cooling things off, restraining cost growth while their counterparts in other countries have been heating things up, making larger healthcare investments. Part of it may be demographic as Theora suggests, but it may also be nothing more complex than a social preference to spend more. Are all these countries regressing toward a mean?

We've been arguing about mechanisms while assuming that all healthcare systems have precisely the same social goals. While the healthcare goals may be similar from one society to the next, it is also possible that one values medical interventions (and more expense) more than another, one values technology more while another values personal interaction more, and so on. These are perfectly reasonable differences, but they lead to different systems, different patterns of correction and just maybe different spending levels.

Deeper questions emerge when we begin to think about adaptability - not just turning the furnace on, but changing the structure of the system, insulating the house, or adding solar power. Some systems are more adaptable. I suspect that while they are also more volatile, confusing, and annoying for those emerged in them, they are also, over the long term, more robust. We should keep that in mind both in our daily struggles with the healthcare system and when we think about the system we wish for.