Monday, November 30, 2009

The Poisoned Well

The Engage with Grace movement (see post below) was so impressive because it sought to bring about real and meaningful conversations about important - but difficult -- health care topics.  If we are to succeed as a nation in improving our health outcomes and lowering cost (or at least lowering the rate of cost growth), we need to get much more comfortable having these difficult conversations.  Yet, we continue to allow certain voices to poison the well, as occurred earlier this year with bogus claims of "death panels", which was followed by the immediate stripping of reasaonble provisions from reform legislation in order to avoid the topic like the plague. 

It looks like this may be happening again on another topic: whether women under 50 should get routine annual mammograms.

Wednesday, November 25, 2009

Engage with grace

One of the things all hospital lawyers have to deal with is sorting through issues surrounding family disputes over end-of-life decisions. This is never the happiest part of our job. We see the pain and sadness that often results when individuals and families chose to avoid advanced discussion about end-of-life issues.

Last Thanksgiving weekend, many bloggers participated in the first documented blog rally to promote Engage With Grace - a movement aimed at having all of us understand and communicate our end-of-life wishes.

It was a great success, with over 100 bloggers in the healthcare space and beyond participating and spreading the word. Plus, it was timed to coincide with a weekend when most of us are with the very people with whom we should be having these tough conversations - our closest friends and family.

The original mission - to get more and more people talking about their end of life wishes - hasn't changed. And in light of the the craziness, scare tactics and misinformation in Congress this year over "death panels", it is all the more important to bring sensible, clear information to this important topic.

At the heart of Engage With Grace are five questions designed to get the conversation started. We've included them at the top of this post. They're not easy questions, but they are important. Having a template like this - just five questions in plain, simple language - can deflate some of the complexity, formality and even misnomers that have sometimes surrounded the end-of-life discussion.

So with that, think about them, document them, share them.  If you want to learn more, check out David Harlow's excellent post on his blog from last year.  Wishing you and yours a holiday that's fulfilling in all the right ways.

Tuesday, November 24, 2009

The cost of doing nothing

There has been enormous focus - as there should be - on the cost of national health reform. But in order to have a meaningful debate, we must also consider the cost of no reform. Here are just a few basic facts about the status quo. Per capita spending on health care in the United States is this highest of any country in the World. But not just a little higher. It is double the spending in other industrialized countries with high standards of living. This includes Germany, Canada, France, Australia and the United Kingdom. But that's not all. Our costs are growing at a faster rate than these other countries and our health spending is a higher percentage of GDP than these other countries. In short, by any conceivable measure, we are a huge outlier compared to the rest of the planet. But surely we must be delivering better quality of care for all of this extra spending, right? Wrong. Under most standard measures of quality (except perhaps for "rescue" care), other countries are delivering far better results than we are. If we were a business, we would be on the verge of bankruptcy. And the only way a business avoids bankruptcy is to substantially reform its business. (If you are interested in two views on the economic benefit lost from not pasing health reform, see this Op Ed in the Globe from earlier this month by Linda Bilmes and Rosemary Day.

Monday, November 23, 2009

Hospital boards have work to do

Earlier this month, a survey by Harvard researchers found that the practices of hospital boards of directors can have a positive impact on the quality of care in their institutions. That's the good news. The bad news is that the survey also found that only half of all hospital boards surveyed ranked quality as one of their top priorities. And only 20% believed that the board can have a strong influence over quality.

This study should be a wake up call to all hospital boards. How a board engages and what it chooses to focus on does make a big difference. That is why the Institute for Health Care Improvement launched a "Boards on Board" initiative to get boards to focus not just on finances, but on improving the quality of care in their institutions. There is still plenty of opportunity for improvement and boards have an important role to play in helping us get there. The study appears in the journal Health Affairs and you can find it on their website. It was conducted and written by Ashish K. Jha and Arnold M. Epstein.

Sunday, November 22, 2009

The Big Cost Shift

Health care reform moved one step closer to reality last evening when the Senate attained the necessary 60 votes to begin debate. Passage is still anything but certain, but it is looking more promising than just a few short weeks ago when many wrote it off as all but dead. One remaining concern is that many in our country do not see the uninsured as "their" problem and lack sympathy because they believe the uninsured will always get care they need in an emergency room if they have a true crisis. The Obama administration and Congressional leaders have failed to clearly and directly rebut these misperceptions. For health reform to gain broader support, we need to do a much better job of getting people with insurance to understand that the plight of those without insurance is their problem too. Here is how we can do it.

Those who lack insurance do in fact show up in emergency rooms and they are taken care of. But this becomes what is known in the hospital world as uncompensated care. Hospitals are required to provide the care, but in order to survive, they must find a way -- like all businesses in similar circumstances - to cover the costs of that care. So they shift the cost of that care to private payers (the same way they do for underpayments from Medicaid and Medicare, our government programs that pay all hospitals at rates that are below their costs). They do so by negotiating higher rates from private payers. Those private payers then pass on these higher rates to employers in the form of higher premiums. And those employers then pass on those higher premiums to their employees. The result is that all employees are in fact already paying the cost of uncompensated care. It is indeed a societal problem. What's worse, when those who lack insurance seek care in the emergency room, they are doing so in the most expensive setting - so the costs are extremely high. If they had insurance, they would get preventive care (at much lower cost) and would be able to avoid those expensive ER visits and hospitalizations. That is a key reason we need health care reform.

Until the public clearly understands the big cost shift that goes on in our health care system, we will continue to struggle to gain broad support for national health reform.

Saturday, November 21, 2009


Welcome to my new blog. Ruminatio is the Latin word for rumination, which means "a musing or continued thinking on a subject." Health care is in great need of continued thinking. In this blog, I will try to stimulate thinking around ideas for improvement and innovation in health care. And my focus will be mainly on topics that are not well developed in the media or well understood by the general public. This is what I have tried to do in my writings -- for recent examples, see articles in the side bar. I hope you enjoy it and, most of all, provide your ruminations as well.