Health Care Reform 2.0 – Time to Reboot Friday, Jan 29 2010 

Health Reform Ronald Wyatt MD MHA 19:14

So it is sleeting in Alabama (my home) but sunny and very cold here in Cambridge Mass. What? This is not the way it is scripted. Before leaving  and after arriving here in New England, I was repeatedly warned about the winter chill. Little did I know that the Big Chill would be the recent Senate election to fill the Senate seat left empty after the death of Ted Kennedy.

What happened? Seems no one is real sure or wants to admit it, so I will take a stab at it from my perspective. The Democratic candidate had never faced a tough campaign, the Democrats and Republicans assumed it was a forgone conclusion that Martha Coakley would win hands down, even the now Senator Brown did not expect to win until a few weeks before the election (trust me on this one),the Democrats largely ignored middle class independents and minorities and there was/is an anti-Obama sentiment.

The independents and middle classes are truly fearful of their future, have anger that Wall Street came before their needs and concerns, and that they would somehow have to help pay the health care tab for the rest of the country.

The new operating system has now stalled. Health Care 2.0 was to be the new operating system. Now, what we can expect is probably a Beta test version.

We can expect fewer bold initiatives like universal coverage and the public option. They no longer exist. What may remain may include accountable care organizations, patient-centered care, medical home models, comparative effectiveness research and improvements in health IT, focus on sustaining Medicaid, requirements to decrease hospital associated harm and error reduction, ways to incentivise primary care and general surgery in underserved areas  and hopefully no penalty for preexisting conditions. The commercial insurers will likely continue to adjust and innovate which is a good thing. There is already some evidence of this. United Health and Wellpoint are involved in really tough negotiations with hospitals and all insurers are putting more efforts and resources into quality improvement, patient safety and clinical outcomes. Their sincerity has to be met with skepticism.

Bob Blendon, renowned for opinion research, Professor of Health Policy at the Harvard School of Public Health told my Health Policy class that Health Care reform will not become a reality because of Obama but it will be the public and politicians who will determine the course. The public has spoken here in Massachusetts. Politicians are now on the clock.

As a country, we have to reboot, clean the hard drives, defrag the system and restart. Let’s hope we don’t have to hit the roll-back tab.

Or maybe it will it all comes down to money and getting re-elected. Which operating system to you prefer?

–Ron

 

Pardon My Disruption….Please. Sunday, Jan 24 2010 

Health Care Improvement Ronald Wyatt MD MHA 01:15

I got a nice haircut today. It was a shivering 22 degrees when I set out from here in Cambridge, across the frozen Charles River to the Mission Hill area. As I sat waiting my turn, it occurred to me that since childhood I can honestly say that I have not witnessed an incident of disruptive barber behavior.

On the other hand, I have witnessed, been a recipient of and have been guilty of disruptive physician behavior. In a recent study, “90% of the 2,500 survey participants ( physicians, nurses and senior level administrators) witnessed disruptive behaviors in physicians and more than one-third were aware of a nurse who left the hospital specifically because of physician disruptive behaviors.”

Before going on, let me give you a definition of disruptive behavior.

“Disruptive behavior is any behavior that adversely affects the ability of the team to achieve  its intended outcome. Let’s paraphrase Jim Reason. It is important to include the patient and family as team members.”

This is the definition given me by Gerald Hickson MD , Director of the Center for Patient and Professional Advocacy at the Vanderbilt University Medical Center in Nashville Tennessee.

January 2009, the Joint Commission, one of the organizations deemed by The Centers for Medicare with the authority to accredit health care organization,issued a definition and guidelines for organizations to use. Hospital who are Joint Commission accredited are now  required to implement a Code of Conduct that will address disruptive behavior. Why now? This is a problem that has been around for many decades.

Several studies have found that disruptive behavior can and has resulted in serious threats to patient safety due to it’s impact on human performance by leading to stress, frustration, poor hand-offs, adverse events, fear, errors and death. Despite these outcomes, many hospitals have lagged behind in addressing this issue for many reasons including  reluctance of leadership to communicate the problem to physicians who admit lots of patients or perform many procedures because of the potential to lose revenue if the physicians takes his/her practice to another hospital.

Disruptive behavior has been ignored by too many for too long. The time has come for hospitals to take action. Grena Porto, a nationally recognized expert in patient safety, writes that  the keys to success include:

  1. Enhance awareness and knowledge of the quality, safety,morale, and cost benefits of professional behavior.
  2. Connect to the mission and values and the calling of health care professionals.
  3. Address disruptive behavior not in a punitive way, but in a supportive way that helps everyone do the right thing.
  4. Be prepared for a multi-year commitment; culture change takes time.
  5. Never let up: this cannot be “the flavor of the month”

We can do this, for the sake of the safety of our patients, family members, and staff.

–Ron

 

“Haiti Lord Haiti…From Misery to Poverty” Saturday, Jan 16 2010 

Health Care Improvement Ronald Wyatt MD MHA 18:18

I got up this morning and put on my coat, boots and took my shopping bags to the #77  MBTA Bus stop…about a 2 minute walk. After a 5 minute wait and a 5 minute bus ride is was stepping off the bus at 950 Massachusetts Ave.  I walked into the Stop n Shop and 30 minutes later I was walking back into the house where I live in Arlington.  For many of you, you will get into your vehicle and drive to the local supermarket and have the same experience.  Or, you may say ” I am glad I don’t have to walk over the ice and snow in Boston, wait on a cold corner for a bus and then carry grocery bags back to my house”. We have also all experienced the angst of waiting to check out and the cashier has difficulty or the person in front of you cannot remember their debit card number or maybe cannot find it and you think to yourself “why does this always happen to me”. Go ahead and admit it..yes you have felt that way. Maybe you have even walked away and left a cart of goods out of frustration with the wait time to check out. Maybe you have raged because someone cut in front of you and took that parking space that had your name on it. Well, imagine if you were in Haiti right now, go ahead close your eyes and just imagine if you cannot find your loved ones, if your childs body was broken, if you did not know where or how to get help or water. Imagine!!

Before this devastating earthquake, PBS did a special on the recovery of Haiti and I was struck by this remark made by the Prime Minister , “we are trying to get from misery to poverty”. Imagine!!

Your prayers and your dollars are needed. Don’t just sit there in front of CNN and shake your head saying how awful and terrible this is. Partners in Health headed by Howard Hiatt, Ophelia Dahl and others have 0ver 500 people in Haiti( all accounted for post earth quake). They had clinics and Operating rooms going the day after the quake. The link is below so that you can get real time updates such as the one I pasted in below:

01/16/2010

What’s been on the minds of Partners In Health/Zanmi Lasante staff over the past 24 hours? Below are just a few thoughts plucked from the torrent of emails that circulated through our servers:

  • From ER in Hinche: “Patients trickling in throughout the night. Doing all the surgeries we can around the clock.”
  • From St. Marc Hospital: “We are receiving a lot of people. Most of them are surgery cases. We have operating rooms, anesthesiologist, nurses, equipment but no surgeons.”
  • From a PIH doctor helping out at Diquini Hospital: “There are about hundred people lying on the floor and suffering. The pharmacy there ran out… Now I worry about infections of wounds and septicemia.”
  • From Belledere: CHAI truck from Santo Domingo in the Dominican Republic arrives with surgical supplies and “First Things First” kits.
  • From Florida: Planes with surgical teams (30 people) arriving in Port-au-Prince later today!
  • In Cange: Getting desperate for diesel. Fuel costs are soaring to $25/gallon in-country.

http://www.standwithhaiti.org/haiti

IHI is and has been a supporter of the work that PIH has been doing in Haiti.

Please join us in this effort. You can donate easily by going to IHI’s Stand with Haiti Fund raising page at: http://act.pih.org/page/outreach/view/haitiearthquake/IHI

I know these are tough economic times for many of us. I put the Oreos and Ben and Jerry’s ice cream back this morning. Do the same, you will not miss it but you can help ease the misery.

Blessings, –Ron

 

Saving Primary Care – Is It Too Late ? Saturday, Jan 9 2010 

Health Reform Ronald Wyatt MD MHA 20:18

Hi, Hard to believe that a decade has passed since the Y2K scare. Also hard to believe that Huntsville Alabama is colder than Cambridge Massachusetts today.

The last decade has seen a continuation of the death march of Primary Care medicine in the US. We primary care providers struggle to provide accessible quality care while trying to maintain the viability of our practices and sustain our relationships with our valued patients.

When I was in Huntsville for the Holidays the refrain continued to be “how are we as primary care providers going to survive”. The anxiety is palpable. Many  of my colleagues struggle with overhead, malpractice, lower reimbursements, fear of litigation, less time to spend with patients and family, how to afford EMR and more.

The US will have a Health Reform Bill by mid Febuary 2010. The Bill, in my opinion, has the beginnings of the resurrection of Primary care including  more focus on establishing a patient-centered medical home.

The components of the Patient Centered Medical Home are:

1. The medical home represents a relationship between an

individual and the health care system, that provides a point of

first contact, is continuous over time, and provides or secures

comprehensive services.

2. The medical home relies on teamwork to get the right things

done at the right time.

3. Comprehensive service means that people of every age and

background are welcomed into the medical home and that the

services rendered or secured for patients are sufficient to resolve

their problems to the extent possible.

4. The key function of the medical home is integration of care for a

particular individual. Integration means the pulling together of

what often are apparently disparate parts into a coherent whole

that has meaning for the patient and the health care system.

5. Quality and safety are hallmarks of the medical home, relying on

recurring measurements that depend on electronic health

records and information technologies sufficient for

interoperability across care settings, decision support at the

point of care, and assessment of results that matter to people.

6. Access is reliable in the medical home, achieved through face to

face visits, but also through other channels including

asynchronous communications by email, telephone, and via the

internet.

7. A crucial characteristic of the medical home is derivative from

the above capacities, ‐‐value. When the medical home functions

correctly, care and results improve and expenditures are more

controllable.

” The U.S. health care reform legislation anticipates a strong foundation

of primary care — but that foundation is crumbling.”

Fewer US Medical school grads are going into primary care and graduate medical education ( GME) favors specialty and sub-specialty training over primary care and why? Simple accounting, hospitals get paid more for specialty and sub-specialty services.

This trend has to be reversed and Health Care Reform will be the path to resurrection of the value of primary care by implementing, funding and continued support of the medical home model.

According to the Robert Phillips MD MSPH of the Robert Graham Center, the mandate to graduate medical education will include:

  1. Provide incentive and remove statutory barriers to the establishment and expansion of training venues in non-hospital primary care settings, including rural and under served settings.
  2. Mandate accountability for GME funding in order to reshape the incentives for teaching hospitals and academic medical centers to improve the health of the nation.
  3. Make GME sites laboratories for innovation for primary care delivery and responsible for producing the next generation of physicians who will work in them.

“How can a country as generous as the United States fail repeatedly to accomplish in health coverage what every other industrialized nation has achieved?” Morgan JJ, Lee TH. Do We really want Broad Access to Health Care?

Further reading:

1. http://www.graham-center.org/online/etc/medialib/graham/documents/publications/mongraphs-books/2007/rgcmo-medical-home.Par.0001.File.tmp/rgcmo-medical-home.pdf

2.Patient-Centered Medical Homes in Ontario
Walter W. Rosser, M.D., Jack M. Colwill, M.D., Jan Kasperski, R.N., M.H.Sc., and Lynn Wilson, M.D. 10.1056/nejmp0911519 nejm.org

 

WE ARE # 1 Friday, Jan 8 2010 

General Ronald Wyatt MD MHA 05:26

HEY LONGHORNS…….HEY LONGHORNS !!!!!

WE JUST BEAT THE HELL OUT OF YOU

RAMMA JAMMA YELLA HAMMA
GIVE EM HELL ALABAMA
ROLL TIDE ROLL!!!!