Ethics, Chronic Care & Cost Prudence.

Hospitals care for thousands upon thousands of people with chronic medical conditions. The cost associated with providing chronic care is staggering. In fact the cost of providing care for patients with chronic medical conditions is so high that most insurance companies will not offer individual policies to those folks because of the high costs. Alternatively, those folks that would be given individual policies that have chronic conditions would likely not be able to afford the premiums.

Those individuals that have chronic medical conditions such as diabetes spend a life time monitoring their blood sugar, their diet, and their activity level. Several diabetics are compliant with their treatment program. They eat correctly, they exercise, and they take their medications. They also monitor their blood sugar several times a day. Despite doing the best they can to control their disease, these folks will periodically end up in an emergency department because their blood sugar is either too low or too high. They are admitted to the hospital for what I call a quick tune up and then they are back home. Their conditions is well managed.

What about those individuals with chronic medical conditions that do not follow their treatment plan? They don’t take their medications as prescribed. They continue to indulge in behaviors that put them at risk for further hospitalizations. The diabetic that eats whatever they want, and doesn’t monitor their blood sugar. Perhaps they don’t even take their medications. The alcoholic that continues to drink for a life time and ends up having gastrointestinal bleeding that requires blood transfusions and intensive care unit hospital stays. They are discharged from the hospital to only come back a short time later intoxicated and bleeding again. Other patients that spend a life time smoking and develop emphysema and are using oxygen at home twenty-four hours a day and they continue to smoke. These people frequent local emergency departments regularly and require hospitalization. Many times I hear from rescue personnel how they pick up people that are smoking while they are attached to an oxygen tank.

In 2005, 133 million people, almost half of all Americans lived with at least one chronic condition.

Chronic diseases account for 70% of all deaths in the United States.

The medical care costs of people with chronic diseases account for more than 75% of the nation’s $2 trillion medical care costs.

The direct and indirect costs of diabetes is $174 billion a year.

Each year, arthritis results in estimated medical care costs of nearly $81 billion, and estimated total costs (medical care and lost productivity) of $128 billion.

The estimated direct and indirect costs associated with smoking exceed $193 billion annually.

In 2008, the cost of heart disease and stroke in the U.S. is projected to be $448 billion.

The estimated total costs of obesity was nearly $117 billion in 2000.

The numbers are staggering. So here are some questions. Why should we as a society continue to pay for and use precious medical resources on those patients that have chronic medical conditions that refuse to be compliant with their established care plan? While most of us agree that life is a very prized thing, at what point do we draw the line? Can we as a society draw a line and say no?

Source: CDC

Presidential Hopefuls Ignoring Larger View of Healthcare Reform.

Right now taking center stage is the continuing financial saga which has most of us more than just a little worried. However, other domestic issues such as healthcare reform are of equal importance, and should not be ignored.

The presidential hopefuls are battling it out in town hall meetings and other public venues in hopes of garnering the necessary support from John Q Public who will pull levers, and push buttons that will decide the fate of this country for at least the next four years. Voters are watching closely to see how the candidates respond to questions about the “issues”.

With respect to healthcare, both candidates have laid out their broad brush strokes providing a glimpse void of any real detail about how they would reform healthcare. Senator. McCain wants to effectively create a tax credit swap of sorts which would focus on providing people with individual insurance coverage and there would be a movement away from group employer based health plans which many of us have today. Senator Obama’s plan would basically increase health insurance coverage through social programs like Medicaid and the State’s Children’s Health Insurance program. Both plans are focusing on whittling down the 45- 47 million Americans that do not have any health insurance.

Each of the candidate’s plans will put the cost of providing more insurance coverage for people into the trillions of dollars. Furthermore each of the proposed plans is estimated to reduce our current 45 million uninsured by approximately 20 million or so. This still leaves some 20 - 25 million or so folks without any healthcare coverage.

For my money it seems that the two presidential hopefuls are missing the boat with respect to healthcare. Our current healthcare system is fragmented. There are a lot of moving parts. The main focus from both candidates seems to only address the numbers of uninsured. Little discussion if any is centered on mitigating costs associated with healthcare. No one seems to be speaking of introducing some smart regulation into healthcare to cap costs.

Several months ago while most of the world was dealing with out of control healthcare costs the Japanese Health Minister was dealing with a health cost related issue for Japan. Their system is highly regulated right down to the price hospitals can charge for tests such as an MRI – which is $98.00 there. The Health Minister had to raise the prices because healthcare costs were too low and hospitals were not being paid enough. A one night stay in hospital in Japan costs $10.00.

I am not suggesting we introduce regulations as tight as Japan has into healthcare. I am suggesting that if our government leaders are planning on reforming healthcare in a fragmented way, then we are likely not going to be solving much of anything. Our fragmented system needs an inclusive approach in developing solutions.

Source: Yahoo News

Healthcare has Highest CEO Turnover Rate.

The corporate ladder as most of us know is not an easy climb on a good day. Many dream of getting to sit in the CEO chair and directing operations, enjoying the perks, bonuses, and just plain "living the dream" if you will. Well being number one has its drawbacks. Even CEOs have to answer to someone.

This year 1,132 chief execs have left their position. Some have retired, some have left for better jobs, and some have been pressured to leave by displeased boards and shareholders due to economic reasons. It is yet another sign of the poor economic times that we are in. When companies report losses someone is usually left holding the bag. The smoking gun quickly gets pointed at top level executives, especially those that have mismanaged company operations.

Being a CEO is a high visibility position, like working and living in a fish bowl. These days CEOs are expected to deliver even more than before. Compensation packages that CEOs receive have garnered much attention of late and shareholders and boards expect results for shelling out such large salaries. I suspect the bottom left hand drawer of many CEO desks in which a bottle of scotch used to reside has now been replaced with Tums, Protonix, Pepcid, and an airsickness bag.

Challenger, Gray & Christmas Inc., a consulting firm who tracks such statistics in a recent survey that they have on their blog showed that CEO turnover was likely to reach record levels before this year is over. Healthcare had the highest level of CEO turnover with 206 changings of the guard. Financial firms were second on the list with 133 CEOs walking. Once again healthcare is not so recession proof after all.

Patients Use Express Lane to Access Emergency Department Care.

Emergency departments (EDs) are busy places these days and with the winter cold and flu season fast approaching the work load is likely to pick up. Despite that the kids are back in school and colleges are in session, and people are back from their annual trek to what ever vacation spot they went to this summer, EDs are still seeing large volumes of patients. There are still waiting rooms filled with any number of patients with minor injuries, kids with broken bones from sports, and the usual ills that seem to target the elderly all year long without any sort of abatement.

Patient's tolerances for waiting to be seen by an emergency department physician have also not changed, and in all honesty will never change. In fact as time goes on patients with non-emergent medical problems will likely not tolerate waiting times of any sort as our society becomes used to having things done in the now time frame.

Savvy patients that use local emergency departments for their primary care have learned however to bypass the normal triage and registration processes when they seek care. Waiting in line is not an option for these folks. Instead, many times these patients will come to the ED by using the local 911 rescue service that are typically provided at the behest of the local fire department. While many emergency medical services (EMS) cost several hundreds of dollars plus mileage, there seems to be little concern for spending or should I say squandering precious healthcare dollars on an ambulance ride for a laceration (cut) on one's leg or hand. The goal here is to get into the ED by way of EMS and bypass the waiting room for many patients.

Several times I have heard patients who are in the ED waiting areas say: "I should have taken an ambulance here." "I would have gotten in sooner." Despite healthcare's best efforts it would seem that most people do not understand that emergency medicine is not about who came first. It is about acuity. How sick or injured are you? The closer you are to dying, the sooner you get seen. Perhaps a blunt measure, but it makes the point.

Other than the added cost of a $500 taxi ride in the back of an ambulance for minor injuries and illness where patients could have used alternate transportation to get to the hospital, there are several other issues here. Inappropriate use of EMS ties these very finite resources up when they could be available for other more appropriate reasons. In some cases municipal EMS vehicles will not be available due to high demand volumes for minor medical problems and someone who is suffering a cardiac arrest will have to wait until another ambulance becomes available, or one is dispatched from a neighboring town using a program called mutual aid. In both instances there are delayed response times. Seconds and minutes count when a life hangs in the balance.

Secondly when patients use EMS services for minor problems it only compounds the already problematic issue of emergency department crowding. To help solve some of this, ED managers and nursing staff will send patients who are not seriously ill that present to the ED by ambulance out to triage to be processed as if they came in through the ED front door. On several occasions I have seen this and done this myself and many patients become indignant when they find out they are not going to an ED bed right away. Again it is about acuity.

Furthermore, there is an increased risk of injury for EMS workers and the general public when ambulances are responding to a 911 call. When these resources are used inappropriately again, the cost can be very high. While many of these people [EMS workers] have advanced driving skills, bad things still happen when other motorists are not paying attention.

Patients that are entangled with local law enforcement and those patients that are requesting detox from addiction have also learned to say the magic words that put them close to if not at the head of the line in the ED, or get them out of a holding cell for a while. "I am having chest pain." "It is going to my arm." "I am a little short of breath."

Once again the ED is misused by the more savvy and less savory patients causing back ups, longer waiting times, and adding unnecessary cost, and misusing EMS services. In time my hope would be that EDs will be able to turn away patients that misuse services or at least if that scenario carries too much liability for risk managers to sleep at night than some sort of financial penalty could be levied against them.

Got Flu?

It is that time again when the ads for flu shots hit the airways, pharmacies, physician offices, and hospitals. Last year's influenza vaccine seemed to miss the mark and most emergency departments were inundated with patients with the flu.

Each year a new vaccine is prepared based on the most likely strain of influenza. Due to the high mutation rate of the virus the vaccine is typically only good for a year, and as we all know the makers of the vaccine have to have some luck in picking the right recipe.

The first influenza pandemic was recorded in 1580; since that time various methods have been utilized to eradicate its cause. Other notable flu outbreaks included:

• 1889–90 — Asiatic (Russian) Flu, mortality rate said to be 0.75–1 death per 1000 possibly H2N2
• 1900 — possibly H3N8
• 1918–20 – Spanish Flu, 500 million ill, at least 20–40 million died of H1N1
• 1957–58 – Asian Flu, 1 to 1.5 million died of H2N2
• 1968–69 – Hong Kong Flu, 3/4 to 1 million died of H3N2

This year's flu season is fast approaching and most of us should get the vaccine. However not everyone is a candidate for the vaccine and if they are unsure they should check with their own primary care provider before getting the shot.

The other side of the equation which is yet to be written is what kind of impact will this year's flu season have on local hospitals? What will the cost be to businesses in terms of sick time? How much will insurance companies dole out reimbursing medical costs associated with the flu? Emergency department crowding took on a new meaning last fall and winter with large numbers of patients flooding local hospital acute care services with flu symptoms. The cost alone of providing care had to have been staggering.

In any event let us hope that this year's flu cocktail hits the mark. Best of luck to all of us.

Call for 2009 Healthcare Summit.

Perhaps Wall Street's latest troubles that have many in a near state of being apoplectic are better equated with disasters like Katrina. Reporters have been thumbing through their thesaurus' to come up with some different meanings for disaster. That being said, healthcare economists are saying that healthcare will remain essentially untouched, unscathed, and otherwise immune to this latest wave of financial discord that is effecting I dare say millions of us.

Even though healthcare economists may have a more rosy outlook than most, their outlook is related to the access that healthcare organizations will have to capital assets and triple A credit ratings. What healthcare economists are not seeing is the equally important and alarming changes that are sweeping healthcare organizations from coast to coast now.

Healthcare leaders are pondering future organizational moves. Do we go ahead with the cancer center expansion project? Do we break ground on the new emergency department? Are our investments still in good standing? While healthcare leaders are mulling over such issues their employees such as their nursing staff, housekeeping members, lab technicians and others are wondering if they will have a job to take them through the winter.

Every day more and more headlines tell stories of hospitals that are laying staff off and not filling already vacant positions. Hospitals are experiencing higher operating costs, budget shortfalls and increasing debt. Money is tight and reimbursements are low. The year 2008 can not come to a quick enough end for many of us.

Perhaps a new year will bring a clean slate and a chance to right the wrongs of old. There will be a new group in the dugout on Pennsylvania Ave. Perhaps by next summer we will be sipping our beers on the deck and making jokes about 2008. Perhaps this is just the beginning and the worst is yet to come.

I think healthcare leaders more than ever before need to open the lines of communication with their staff. People need to know what is going on so that rumors and inaccuracies do not become realities. People need some level of assurance that "things" are OK. Even if things are not OK healthcare leaders need to communicate organizational worries accurately to their staff. No body likes to be surprised by bad news. The road ahead likely has some pot holes and will be a bit bumpy. Some of us may need to wear our seat belts over the coming months.

I should think it is time for healthcare leaders to establish state healthcare delegates and have their own version of the G-8 summit so they can collaborate together and collectively improve healthcare for all us. Call it HC50 - Healthcare 50.

Healthcare Reform Not #1 Issue.

Healthcare reform will take a back burner position for now. For most of us this should not be surprising in light of the financial crisis and other national issues that are competing for legislator's time. Barry Welsh, Democratic candidate for the 6th District House seat in Indiana said "It’s [healthcare] not the No. 1 issue in the election right now, but it’s certainly the top priority when you get sick.” Statements like that epitomize the advanced cerebral activity that politicians are so well known for.

The question here is at what point will healthcare reform move to the front burner and garner the appropriate attention from law makers that it needs? Clearly one worry is that other agenda items will circumvent reform activities and force healthcare to the back burner again once it gets to the active to do list? In time if law makers and healthcare leaders do not mitigate the current problems affecting healthcare the issues will reach critical mass as our current financial crisis has. Should that happen it will likely take more than $700 billion to bail healthcare out.

Neither one of the presidential hopefuls have developed plans that would alleviate the high costs associated healthcare today which is the single most pressing issue healthcare faces. Obama’s plan would have the government take a stronger role in reducing the number of uninsured Americans which would increase reimbursements for healthcare organizations but this is not likely to curb costs. McCain’s plan would tax workers for the value of their employer-provided health plan and at the same time give tax credits of $2,500 to single people and of $5,000 to families. The idea is for the employees to use the money to buy individual health insurance plans. In my mind this does little or nothing to improve the current state of healthcare too. In fact obtaining individual health insurance policies can be more difficult than employer group plans.

At the end of the day healthcare reform is unlikely to get much attention in 2009. Perhaps 2010 will see some headway on the issue. A lot can happen between now and then.

Source: Business Courier

EMRs Turn Providers into Cashiers.

With the implementation of electronic medical records and charting programs nurses are slowing changing their vocation from professional healthcare providers to professional cashiers. Most if not all electronic charting systems are tied into ICD-9 (International Classification of Diseases) and CPT (Current Procedural Terminology) codes, and other point based systems that are translated into billing charges that will be sent off to patients and insurance companies for remuneration. Simply put, each time a nurse or physician enters data about a patient into an electronic medical record (EMR) they are not only documenting assessment findings, they are ringing up the bill if you will. Like going through the check out counter of your local grocery store every time that bar code scanner beeps another charge is registered. Similarly each time nurses document procedures the bill grows for patients.

Healthcare leaders in organizations that use EMRs are banging the drum hard about more and more documentation, almost to the point of nit picking staff. Staff meetings, intraorganizational e-mail and face to face talks about dotting the "i"s and crossing the "t"s are daily occurrences. How long did you have that IV running? How many times did it take to start that IV. What was the total time for this that and the other thing. Electronic medical records have all kinds of places to check off for procedures that cost patients money. Points and codes are even generated for giving patients warm blankets.

With today's ill fated healthcare economy, managers are pushing bedside nurses hard to spend more and more time making sure documentation is complete. "We can't get reimbursed for that if you don't chart such and such." It's gotten to the point where a shift is being made from patient centered care to computer centered care.

While EMRs clearly have some great attributes such legibility and improving revenue capture for organizations the problem of allocating finite amounts of time to care for patients and then write about what you did often causes conflict. On one hand if the documentation of patient care is poor, then so will be the reimbursement rate, but more time is spent caring for patients. On the other side, if more time is spent ensuring completeness of documentation then less time is spent caring for patients which is also a problem. A fine line exists between balancing patient care and the documentation of that care so that the EMR is complete. As EMRs come into vogue this issue will become more prevalent. Nurses and healthcare leaders must develop strategies to ensure completeness of EMRs and ensure that the appropriate care is delivered to patients based on standards of care and evidence based practices without over taxing provider assets.

An Ounce of Prevention is worth a Pound of Cure.

For years many healthcare leaders and professionals have been promoting a change in our current medical model of "disease care" to one of prevention. The desire is to shift focus. To instill a paradigm shift if you will within the patient community where there are incentives to develop healthy life styles and behaviors. The U.S. spent $2.1 trillion (16.5 percent of GDP) last year on disease care - treating medical problems after they had occurred. Almost every cent of every healthcare dollar - 95 cents - went to treat diseases after they had occurred. Millions of dollars were spent on chronic conditions like heart disease and diabetes.

Clearly our current methodology of providing healthcare is not working. A change is needed. The problem has been changing people's views and minds about healthcare and their own health. Day after day emergency departments are flooded with patients with chronic diseases and injuries that are largely considered the result of poor health choices or the involvement in high risk behaviors. People that spent a life time smoking and now have emphysema. People who have spent a life time drinking excessively and are now looking to healthcare providers to help them with a failing liver. People who drive under the influence and crash their cars and are brought to busy emergency departments for care. People who are morbidly obese and suffer from horrible cardiovascular disease because they spent a life time eating fast food and never exercised. There are countless examples of how Americans do not engage in healthy behaviors.

Americans need an incentive to change. Perhaps one suggestion is to incorporate the application of fines and penalty costs for those that habitually live a life style that is not considered low risk. Specifically I am speaking of shifting some of the current cost that insurance companies pay for medical care away from the insurance company and on to the patient. Those patients that have been deemed to have preventable medical conditions would be responsible for a much larger portion of their medical bill than they are now. Preventative healthcare cost less than our current retrospective approach to care. Some $81 billion could be saved annually with a full implementation of health information technology and health prevention programs. The question is not will we change but can we change?

Developing Innovation to Improve Healthcare.

Breaking out of experience dependent categorization to develop new neural pathways to enhance our innate creativity is what neuroscience experts suggest so that we can develop the ability to see what could be and not just what is. Fast Company has an interesting article that discusses the ability that some of us seem to have and others do not. That is to see the possibilities of something, that innovative idea that makes the rest of us say "what a great idea".

Through new experiences we - all of us - can grow new neural pathways so we can develop those visionary ideas and improve our businesses. Many companies use off site meetings to bring a collective think tank together in a relaxed and sometimes exotic location and as the article states "plop" them into a conference room similar to the one at work which does nothing to stimulate creativity.

Gaining new perspectives and developing new experiences away from the office seems to help generate these neural pathways. I guess that's why so much business is conducted on the golf course. Not only does it get you out of the office for a few hours it lets your mind relax and wonder a bit.

"By deploying your attention differently, the frontal cortex, which contains rules for decision making, can reconfigure neural networks so that you can see things that you didn't see before. You need a novel stimulus -- either a new piece of information or an unfamiliar environment -- to jolt attentional systems awake. The more radical the change, the greater the likelihood of fresh insights."

Most of us can recall coming into a situation as a third party and we analyze a process. A thought comes to us and we wonder why that process isn't done a particular way. The rest of the room that deals with the process day in and day out has never had the outside look in that we have. When we bring up our idea it is like a light bulb goes off over everyone's head. New experiences.

So what does this have to do with healthcare? Everything. Healthcare, as we are all finding out is not immune to recession. In fact healthcare I would say is very vulnerable to market changes. Those that are in executive medicine, the ones in the front office should start looking outside the box for new innovative ideas to help improve operations, patient safety, quality of care, and organizational responsiveness to changing environments. Some of you may say we already do that. I would argue that you don't, or at least don't do in a way that you could get more out of your frontal lobes than you do.

How many hospital CEOs, Directors of Nursing, etc. spend an entire day in the clinical areas of your hospitals just watching what goes on? How many of you go to to other hospitals to see what they do? How many healthcare leaders look outside healthcare for ideas to improve day to day operations?

"Chemist Kary Mullis came up with the basic principle of the polymerase chain reaction, or PCR -- the fundamental technology that makes genetic tests possible -- not hunched over his lab bench, but on a spring evening while he was driving up the northern California coast. Walt Disney was a decent illustrator, but he didn't imagine the possibilities of animation until he saw his advertising illustrations projected onto the screen in a movie theater. In an extreme example, the preeminent glass artist Dale Chihuly didn't discover his sculptural genius until a car accident led to the loss of an eye and literally forced him to see the world differently. Only when the brain is confronted with stimuli that it has not encountered before does it start to reorganize perception. The surest way to provoke the imagination, then, is to seek out environments you have no experience with."

Mark Twain said, "Education consists mainly in what we have unlearned." It is time for healthcare leaders to unlearn and few things so that they can learn a few things.