Friday, March 30, 2012

Community Rating for Health Insurance: the Way to Get to Better Health, Better Care, and Ultimately Lower Cost for Our Citizens

When I was studying for my master’s degree in medical care organization in the mid 1980s, one of the first things I was educated on was the different ways a group’s insurance rate could be calculated.

The notion of insurance is that everyone pays upfront for the protection, even though only some will need it during a given policy year. There are very few people that could afford to rebuild their house if it burned down. For this reason, we have homeowner’s insurance. The companies that sell the insurance have actuaries who calculate the probability of a house burning down and they set the rate for the entire community. No one would sell a policy to someone after the fire had already begun to burn. Happily, most people won’t lose their home to fire and they don’t resent buying insurance.

With health care it is different. Everyone will eventually get sick and consume health care. Some people believe that they could save enough money before they get sick to be able to pay out of their own funds when they eventually do need health care. Of course with the average cost of one hospital stay being in the vicinity of $10,000, very few Americans could actually pay from their own funds….and that would only be for the bill from the hospital for one stay.

So, most people want health insurance so that they are protected from financial ruin when they get sick. In America, all citizens over age 65 get Medicare. It is our elders, of course, who are at the highest risk of needing health care. In our public discourse about health care, I don’t hear many people saying that we should get rid of Medicare. We don’t have a choice to opt-out of Medicare. From our first paycheck as a young person, Medicare taxes are taken out. Most of us realize that this is worthwhile protection for us when we get older. This sure seems like “a mandate” from the government to me, “an individual”. People over 65 pay some out of pocket, but the majority of their health care bills are paid by the program. The costs are spread over the entire community of working Americans. This is a form of “community rating” and it has worked quite well since 1964.

But what about people under age 65, who find themselves with a disease? Before the Affordable Care Act (derogatorily called “Obamacare” by people who don’t like the act), if you had a “pre-existing condition”, in other words, you had a chronic disease before you applied for insurance, the insurance company could refuse to cover you or to use “experience rating”.  In experience rating, you could be charged a very high premium because you were already sick. Is this fair? What if you had just lost your job and while you were looking for a new one, you learned that you had breast cancer? What if you were a small business owner with 25 employees and your premiums were experience rated and two of your employees developed cancer?  Most Americans believe that this is not fair.

The Affordable Care Act eliminates this unfairness. It says that insurance companies can’t discriminate in setting higher rates because someone already has a disease. But, in order for this to work, the insurance company needs the healthy people to pay the same rate as the sick people, just like fire insurance companies need the payments of the people whose homes won’t burn down in a given year to pay to rebuild the ones that will. There must be an individual mandate for all Americans to have health insurance just like there is a mandate for us all to pay so that Medicare will cover us when we reach 65. I was a citizen of Massachusetts when Governor Romney introduced their law and I was proud of him for doing that. In Massachusetts now, almost everyone has health insurance and they don’t have to worry about not being able to get care or go bankrupt when they are sick. Hopefully, the Supreme Court will understand this logic, so average Americans in the other 49 states won’t have to worry.  

What do you think about ensuring that all Americans have health insurance?

Doctor’s Day

Today, National Doctors' Day is recognized across the United States. March 30th is a day to celebrate the contribution of physicians. The first Doctor's Day observance was March 30th, 1933 in Winder, Georgia.  Eudora Brown Almond, wife of Dr. Charles B. Almond, decided to set aside a day to honor physicians.  On March 30, 1958, a resolution recognizing Doctors' Day was adopted by the United States House of Representatives and in 1990, legislation was introduced in the House and Senate to establish a national Doctor's Day. Following overwhelming approval by the United States Senate and the House of Representatives, on October 30, 1990, President George Bush signed the bill designating March 30th as "National Doctor's Day."

We have a wonderful medical staff who do marvelous things. Every year we get laudatory comments about how much they mean to individual patients.  We can never lose sight of the wonderful contributions of our hard-working physicians and their dedication to those they serve. I am glad that at least one day a year we reach out and thank physicians for all of the things they do 365 days a year.

Tuesday, March 20, 2012

A Beautiful Campus Makes for Better Care

The doctors, nurses and other clinical staff at the hospital are very visible in healing our patients.  But there are many others on our Team who are “behind the scenes” in helping people get better and in providing the best possible care experience.

Last week I spent a few hours working alongside three of those employees – grounds supervisor George Dillon and his groundskeepers Bob Marshall and Eduardo Rivera (a third member of George’s staff, Dave Mier, was off).  These guys do an amazing job of maintaining our campus that covers 114 acres.

If you come to a beautiful environment it gives you a real sense of peace, and this is very important for the emotional and physical healing process. We are very grateful for the hard work and dedication of our grounds crew.  They aren’t medical experts, but people get a good feeling coming on campus just from seeing how clean and orderly it looks. When I first came to the GBMC campus when interviewing for this job, I dropped my jaw at how beautiful the campus was.  We certainly didn’t have any hospital campus like it in Massachusetts.

With the suit and tie replaced by blue jeans, work boots and a GBMC Grounds Crew shirt and cap, it was off to see how I could help the guys continue readying the campus for spring.  Working outside the main lobby entrance, we planted new pansies in planters, replaced liriope plants and planted rose bushes by the Rose Park sign.

Just 20 minutes into refreshing the plants though, George had to correct my technique and explain that it was easiest to plant from the middle moving out.  That left me wondering for a second if perhaps I ought to head back to the Executive Office and work on the budget and other pressing issues, but I instead chose to refocus and keep planting.

You can tell that George – who has worked at GBMC for more than 20 years and formerly was a contracted landscape foreman when the Physician’s Pavilion East building was built in the early 1980s - really enjoys his work and landscaping is his favorite part of the job.  “Making things “pop” and look better is what it’s all about,” George said.

Besides landscaping – which will take the crew all spring and most of the summer to finish – the grounds crew is also responsible for daily trash removal across the campus including at all garages, working with contractors on snow and ice removal (although thankfully they didn’t have much of that to do this winter!), road repairs, leaf removal, power washing, sweeping, general maintenance and a host of other tasks.

It’s a lot of work for a four-man crew and we are glad they do such a good job.

Has the beauty of GBMC’s grounds been able to offer you comfort and solace in a time of need?

A Bit of History at GBMC

Have you seen the flag flying near Rose Park and the main entrance / Lobby B? I’ve been asked by many people about the flag, so I thought I’d share its significance.  The flag has just 15 stars and 15 stripes and is a replica of the American flag that our National Anthem was written about. The 15 star flag flew over Fort McHenry during the War of 1812 and inspired the writing of the The Star Spangled Banner. The original is in the Smithsonian Institution in Washington, DC and is huge (30 feet by 42 feet).  The 13 stars represent the 13 original colonies, and in 1795, two stars were added, representing Kentucky and Vermont, bringing the total number of stars to 15.  The flag was purchased by Bob Marshall of GBMC’s grounds crew and proudly flies above GBMC today as Baltimore gets ready to celebrate the War of 1812 Bicentennial at Fort McHenry later this year.

Friday, March 16, 2012

How might a Patient Centered Medical Home help you?

Many of us have experienced a situation like this before: you call a friend or loved one late on a Friday afternoon and find out that she is in the Emergency Room. Presuming that something terrible has happened, you ask what’s wrong. “Oh, I don’t think it’s anything serious,” your friend reassures you. “I have a chronic disease and I wasn’t feeling well and I called my doctor’s office and they told me that they couldn’t see me and suggested that I go to the ED.”

There’s no emergency at all – your friend or loved one has simply been sent down medical care’s pathway of least resistance. This is what’s wrong with our country’s current approach to healthcare: the system is not designed to get the patient what she needs in the most caring and efficient way.

The type of care your friend or loved one needs should have been provided by her usual source of care, by a team led by her primary care physician … a team that she is familiar with and that has her medical record so she doesn’t have to tell her story from scratch and hope that she hasn’t forgotten anything …. a team that is expecting that she will call and is expecting to care for her. A primary care system that is part of an organized, coordinated larger system of care so that she wouldn’t need to visit the Emergency Department for something that isn’t an emergency. 

GBMC is making significant strides to redesign the system and solve this wasteful and frustrating problem. As I previously announced in late February, the Hunt Valley primary care practice has become GBMC’s first official Patient-Centered Medical Home. The team was recognized at the highest level possible – Level 3 Physician Practice Connections-Patient-Centered Medical Home (PPC-PCMH) – by the National Committee for Quality Assurance (NCQA). This is a marvelous recognition of the hard work the team has invested towards our vision of being the place that treats everyone the way we would want our own loved ones treated (see “Our New Vision, Our New Plan to Get There"). If it was your own loved one, you would like him or her to be part of an organized, coordinated system of care, not caught in the middle between care providers trying to glue the system together on the fly.

Dr Chessare (L) and Dr. Lamos (top right) pose with staff members from the Hunt Valley practice.
The Patient Centered Medical Home is an approach to coordinating better health, and better care at lower cost. By earning the Level 3 PPC-PCMH recognition, the staff members of GBMC at Hunt Valley have proven that their practice is now designed to do the two most important things needed in a medical home:

1)     Focus on prevention, wellness and the management of chronic disease rather than treating individual episodes of illness
2)     Help patients manage their own care with the team’s active and on-going guidance through improved two-way communication and accessibility (the patient portal, myGBMC, is a visible example of the improved access we offer…see Using Technology to get to Better Health, Better Care and Lower Cost”)

Again, congratulations to all of the dedicated employees who, under the leadership of Mark Lamos, MD, Robin Motter-Mast, DO, and Robyn Schaffer, practice manager, have made this goal possible.

In addition to GBMC at Hunt Valley, our other Greater Baltimore Medical Associates (GBMA) physicians have also embraced the concept of a Patient Centered Medical Home. They, too, are steadily making progress to earn the same recognition by implementing the specific elements set forth by NCQA. Ultimately, we will take what we’ve learned at Hunt Valley and GBMA and incorporate changes at all of our affiliated private practice primary care sites who are members of the Greater Baltimore Health Alliance (GBHA).

Do you have questions about GBMC’s transition toward better care and coordination through the Patient Centered Medical Home? Feel free to comment on what it means for you in the box provided below.

Getting in Action Toward Patient Safety
We continue to redesign our healthcare system to higher levels of reliability and patient safety. Yesterday, we launched a new video course that all employees will be required to take in the  coming months. The video is called “Getting in Action For Patient Safety” and it’s intended for viewing in a group setting so that teams can have open discussion about applying critical safety measures in their specific work environments. From the four modules – Safe Behaviors, Reliable Systems, Just Culture and Learning – come principles and behaviors that are expected from all employees (not just those who provide direct patient care), like “follow the rules,” “pay attention to detail” and “communicate clearly and effectively.” Stay tuned for more information from your managers.

Thursday, March 8, 2012

Why Many Doctors Die Differently

How do doctors prefer to die?  Are they in a better place in their last days than non-physician patients are?

Ken Murray, retired clinical assistant professor of family medicine at the University of Southern California, recently wrote about this issue in the Wall Street Journal in a piece called: “Why Doctors Die Differently”.

Dr. Murray wrote about a 68-year-old physician who, when diagnosed with pancreatic cancer, immediately closed his practice, focused on spending quality time with family and passed away at his home several months later.  The physician opted for no chemotherapy, radiation or surgical treatment and Medicare did not spend much on him.

Dr. Murray also cited the case of his 60-year-old cousin diagnosed with lung cancer that had spread to the man’s brain.  Aggressive treatment including up to five hospital visits a week for chemotherapy might have given the man another four months to live.  Knowing he wanted a life of quality and not quantity, he opted against advanced interventions and to take some medication by mouth for brain swelling.  He moved in with Dr. Murray and the family enjoyed the next eight months, during which their cost for care was about $20 – for the pills.

This is a good conversation that has to happen between doctors and their patients. Sometimes doctors are unwilling to limit a patient’s access to something even if they know it’s not going to benefit the patient because they are reluctant to withhold care and leave the patient without hope. But doctors who are in the same situation - facing the end of life – don’t have this burden. They know the evidence already, so as Dr. Murray writes, they often don’t take questionably beneficial care and seek a death that is as comfortable and respectful as they can get.

As a physician, I’m not sure that this is “routine”, but that’s what I’d want for myself.  Our health system’s vision phrase - “To every patient, every time, we will provide the care that we would want for our own loved ones” (See: Our New Vision, Our New Plan to Get There suggests a choice.

As physicians, we really need to present the best evidence to the patient and make sure that the patient has understood…..and then let the patient choose. When care is not likely to help, we need to make this clear to the patient. We need to have this dialogue with members of our community. Physicians have to be unburdened of the belief that unless they are doing something that somehow they have let their patient down.

We are trained to be healers – and the proclivity to action is part of being a healer but the tenet primum non nocere (“first do no harm”) must also be kept in mind. When our actions have a very low probability of benefiting the patient we need to avoid misleading the patient. Although the societal cost of providing care that is unlikely to help is immense, it is not the job of a physician at the bedside of an individual patient to limit that care. It is her job to assure that the patient knows the probability of cure and the risks associated with the treatment. I believe that as we get better at having conversations with patients about what they want at the end of life that the cost issue will take care of itself.

Shared-decision making is an essential part of today’s care planning.  Some medical schools now even have formal classes in shared-decision making.   Certainly patients are wondering, “What is this likely to mean to me and my case?  Am I going to live longer, am I going to be pain free quicker, am I going to have a better quality of life over my last few days?”, and those conversations with doctors need to happen.

While these conversations are necessary they are not easy. Some doctors are naturally better at it than others. Those who are more empathetic and better able to connect with the patient begin the conversation more readily.

With the aging population and with healthcare costs skyrocketing, this is the right time for the American people to become engaged. We should never withhold care that will save life but it may get to the point that since we are providing care for patients who will not benefit that we may not be able to serve some who will.

What are your thoughts on the issue of shared decision-making with end of life care?  

Kudos to Emergency Department Staff

I have to give kudos to our Emergency Department staff yet again! GBMC’s Rapid Response Team recently brought a patient to the ED who was in another area of the medical center and experienced severe cardiac issues. The patient was brought in with a “STEMI”, a clear heart attack. Within 16 minutes the patient was stabilized and transferred to the cardiac catheterization lab at a nearby cardiac intervention center to open up the blocked arteries. I’m told this is the fastest we’ve ever gotten a patient to the cath lab.  Rapid transport to a healthcare facility capable of performing percutaneous angioplasty, is critical to the survivability of such a heart attack. Experts say the sooner that a patient is treated to relieve the blockage causing the STEMI, the better the heart muscle will recover. Great job to the team who made sure this patient had the very best care possible and treated him the way they would want their own loved one to be cared for.

Friday, March 2, 2012

A Validation of Our Hard Work

For hospitals, accreditation from the Joint Commission is the “gold seal” of approval. It means an organization’s patient safety and quality of care standards and practices meet a certain threshold and demonstrate a commitment to provide the highest quality of healthcare services.

Their mission statement reads, "To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value".

In order to maintain state licensing and be able to collect federal reimbursement, hospitals must maintain their Joint Commission accreditation. Hospitals such as Greater Baltimore Medical Center are surveyed on a triennial basis – once every three years.

Last week, it was our turn, and a team of four surveyors (physician, nurse, life safety / facilities professional and administrator) arrived at our doorstep for the hospital’s “checkup.” Staff from across the organization spent many hours with the surveyors for four days, visiting both areas seen everyday by our customers such as the inpatient units and the operating rooms as well as the “behind the scene areas” such as the laboratory and our physical plant.

I’m happy to report that it’s time to give each other a pat on the back … We did very well on our triennial Joint Commission re-accreditation survey.

Many people have mentioned to me that this survey seemed less stressful than previous surveys. I’m not sure that anybody believes that it was stress-free, but we have tried to make people believe that we should be ready for the Joint Commission surveyors to come in at any time. In reality, all they are doing is checking to see if our systems are reliable such that everyone, every time, will get the right care.

So I’m glad that many people have gotten into the mindset of continual readiness.

Where we have created standardized work and reliable systems, we did very well on the survey. One of the areas where I was very pleased with the survey results was in the maintenance of the physical plant. I’ve been around long enough to remember the days when the physical plant surveyor would find many problems and here they only found a couple of areas to correct. Michael Forthman and all the facilities management and staff should be applauded.

The reviewers specifically noted how clean the facility was and the overall lack of clutter - thanks Chris Broadway and everyone who works in Transportation. However there was one corridor that we considered non-clinical and had several beds stored in, but the surveyors disagreed and we were cited for that. So the message for staff is still a call to get things like extra beds to the transportation hub and not have these items scattered all over the facility.

Another area in which we need to improve is in clinical documentation of timing and dating orders in those areas where we are not yet using the electronic system, such as the PACU. We have to get better at that and keep marching along to make everything electronic. The non-timing of an order is potentially dangerous and we need to eliminate that problem.

On the clinical side, so much of our work has paid off. Everyplace where we have created reliable systems of care, we did very well. The medical staff review was outstanding. The files were well-maintained and the leadership, under the direction of Dr. Harold Tucker and Dr. John Wogan, have really done a marvelous job of creating ways for us to assess whether or not clinicians are maintaining their levels of competency.

Nursing as a group also did an outstanding job. I was quite impressed with our nursing team’s willingness to present cases to the surveyors and to show what excellent clinicians they are. I sat through a number of presentations and was very proud.

Our Emergency Management efforts, led by Dan Tesch and Michelle Tauson, also were praised, with surveyors very complimentary about our preparations to deal with critical incidents.

(L-R) Carolyn Candiello, GBMC's Vice President for Quality and Patient Safety, and Blood Bank Medical Technologist Ann Eldridge (in white lab coat) meet with one of the Joint Commission surveyors.
One of the areas where high reliability was evident was in the blood bank. I went on a “tracer” with the nurse surveyor and Carolyn Candiello, GBMC’s Vice President for Quality and Patient Safety, and saw the rigor and standardized work around making sure that the right patient gets the right blood. It’s a combined designed effort of physicians, nurses and blood bank personnel to do that. It was something the surveyor was very laudatory of and we should all be very proud.

No one expects that a Joint Commission survey will end without any findings of items that need correction (although the last Gilchrist Hospice Care survey had no findings!) but we received fewer than average findings, and where the reviewers found something, it was generally something we are already working on fixing. Where we find a defect in one of our systems it’s an opportunity to fix it before it creates a catastrophe – see “Every Defect A Treasure”

So, we should all look forward to our next Joint Commission survey about three years from now, not with trepidation, but with excitement when we can once again demonstrate how GBMC is an even more highly reliable healthcare organization.

Tragedy On Campus

Sadly the GBMC family experienced a tragic event on campus Thursday afternoon, with the apparent suicide of a patient. On behalf of the entire GBMC HealthCare organization, I want to express my condolences to the individual's family. Several members of our staff were also personally affected by this situation, and we have provided those individuals with crisis intervention and emotional support. Employees seeking additional support may also contact the Employee Assistance Plan (My Life Resources) at -1-800-437-0911 or access code 9SJ87. This incident reminds us all of the fragility of life.