Why are Hospitals Dangerous? The Business of Medicine
Why are hospitals so dangerous? Is this a new problem, or worsening of an ongoing problem? How do we fix it? This is my take on the subject.
During my career, I have watched the Medical Profession fall into a trap driven by The Business of Medicine. Yes, that's right, it is all about money. When I started, it was not easy to do the right thing for patients, but we did it. The Medical Profession, the Art of Medicine and the Doctor-Patient Relationship were important considerations at that time. Now, for many reasons, dwarfed by the focus on money and business, the Doctor-Patient Relationship has been sold out to the Business of Medicine. Let's take a brief look at the problem and the fix.
Patient care has never been and will never be perfect, so Quality and Performance Improvement (QIPI) have always a part of what we did to take stock of errors and bad outcomes. At the start of my career, QIPI generally took the form of Peer Review and Morbidity and Mortality (M+M) reviews. The traditional reviews of adverse outcomes were strictly medical, mostly confidential and Peer Review has generally been undiscoverable as well. These processes were not strictly scientific, because they only looked at the cases that surfaced. Generally they focused on deaths and major adverse events which were perplexing or major errors. We all learned from these case conferences and, having been actively involved from the start, I learned how to turn the QIPI process into a scientific way of monitoring quality and outcome of care, and how to make care better and best. So, I have been watching Quality and Outcome in healthcare from the start of my career and I have watched the deterioration over time. This is what I have seen.
Over time it has become progressively more difficult to focus on the patient first and the Doctor-Patient Relationship. At this stage, third parties have so much control over the profession, that it is virtually impossible to stand for patients, because the Profession and the Doctor-Patient Relationship have been hijacked by third parties that hold the money. If a doctor stands up for patients and, in the process slows "the line" down, he or she becomes the identified problem. The "real problem" gets lost in the shuffle. Now, the business people drive Doctors to "perform" and that often puts Profit over People. As the money holders push Patients into "product lines" and Doctors into "line workers", the human factors and rough edges are dismissed, and corners are cut for the sake of "efficiency". That translates into running patients "through the mill" as fast as possible to "save money".
Nothing wrong with saving money, right? But, think about it and look at the facts. In fact, when we "save money", it does NOT go back to patient care, it goes to third parties who care only about profits and bonuses. Consequently, the bottom line is this: corners are cut, quality of care goes down, people are hurt and third parties get more money. That money comes out of the pot that should be used to improve patient care, and goes into the pockets of corporations, share holders, executives, managers and other folks who do not care for or about patients.
This background sets the stage for deterioration of patient care in hospitals. As corners are cut and fundamentals are ignored, the most vulnerable of the vulnerable, our patients, become the victims. Pushing for speed over quality under the guise of efficiency and "cost containment" has interfered with good old fashioned basics of quality patient care. Generic 'benchmarks" have lowered quality by creating a group think mentality that reinforces bad care as acceptable. Why? Since we look at hospitals as they compare to each other, standards are lowered to "we are all bad together" levels, instead of reaching up for better and best care. Hospital QIPI programs are sluggish, disconnected from front line providers, not transparent, dysfunctional at best, and do not come close to the scientific scrutiny required to build the best possible care.
ANESTHESIOLOGISTS and the Anesthesia Patient Safety Foundation (APSF): Encouraging Patient Safety for Decades
Anesthesiologists: Do the survey (link in the email below from R. Stoelting) and support APSF!
Patients: Encourage and support APSF!
Below is my recent email conversation with Robert K. Stoelting, MD, APSF President. It starts from the bottom and works up to the top.
Patients, Providers and Patient Safety Advocates will find it valuable. Anesthesiologists are your PATIENT SAFETY ADVOCATES on the front lines of operating rooms around the world. Don't let the Business of Medicine pressure them to cut corners on patient safety!!!
From: rstoel7145@aol.com Date: August 8, 2012 21:53:31 EDT To: masciam@aol.com Subject: Re: Request from Anesthesia Patient Safety Foundation/Please Consider
Hi Mike:
Thanks for confirming continued support.
I appreciate your comments regarding the checklist initiative but did not realize you were expecting a response. I am pleased with any visibility you can give the survey including sharing the link with colleagues and encouraging participation. For the moment, APSF needs maximum input to create a template that is compatible with multiple practice models.
-----Original Message----- From: Michael F. Mascia MD, MPH <masciam@aol.com> To: rstoel7145 <rstoel7145@aol.com> Sent: Sat, Jul 21, 2012 9:35 pm Subject: Re: Request from Anesthesia Patient Safety Foundation/Please Consider
Thanks, Bob, This is GREAT! I will do my best to work the survey ASAP.
As an advocate for check lists, I have been using them effectively for 30+ years with/to benefit both PATIENTS and RESIDENTS.
Sadly, today's production lines often PUSH Docs to ignore optimal practices, and encourage cutting corners. I started anesthesiology in 1989 (my second career) under Jane Matjasko, and safety was THE priority at that time. Since then, conditions on the front lines have deteriorated drastically and patients are often neglected for the sake of speed. This is unacceptable for many reasons, not the least of which is "cutting corners" is dangerous, a violation of the Hippocratic Oath, and disregards of the "first do no harm" principle. And, toward what end? We both know it is speed, which boils down to MONEY.
My M/O has always been, "Treat the patient as if you are the one going for surgery = you are the patient." & "If it is NOT RIGHT, PUT the BRAKES ON." When I started, these were workable operating principles. Now, there are morons in power who would consider my practices "disruptive behavior" and to be sure, they would (and do) complain about the way I work. Generally, I get away with it, because I ALWAYS put the PATIENT first!
So, the bottom line is this. I am happy to see the APSF take this on, and I will do what I can do ... on the front lines, in the larger community ... and with the APSF. Operating principles that allow the physician/anesthesiologist to STOP the production line with impunity would go a long way toward protecting the patients.
Thanks for doing what you do. APSF support is essential for Patients and FRONT LINE PROVIDERS.
Salute! Amore e buona fortuna! Ciao for now,
Mike Mascia Michael F. Mascia, MD, MPH President Infinity Health Solutions MFM@IHS ip
On Jul 21, 2012, at 18:54, rstoel7145@aol.com wrote:
Anesthesia Patient Safety Foundation Building One, Suite Two 8007 South Meridian Street Indianapolis, IN 46217-2922 Tel: 317,885,6610 Fax: 317.888.1482 E-mail: stoelting@apsf.org Dear Colleague:
On behalf of the Anesthesia Patient Safety Foundation (APSF), I am writing to request your participation in helping the foundation create the content of a template for a “Pre-anesthetic Induction Patient Safety (PIPS) Checklist” that could be utilized by anesthesia professionals and anesthesia groups to create a safety checklist that best fits their practices.
Specifically, based on your experience and knowledge, but now as the patient (the passenger rather than the pilot), what would you want to be part of a safety checklist immediately before induction of your anesthetic?
This is my transitional week; my last week of ICU duty for PGY 39, and the start of my first week of duty for PGY 40. That means we have the short timers now and newbies to start on July 1 ... house staff that is. In other words, the more experienced interns and residents will move up a notch, while the interns move in. This transition is always exciting
A few observations/thoughts/teaching points from rounds ... these reflect my collective experience ... not just this week's events.
1. Monster Healthcare Organizations (as well as other corporations and governments) generate momentum and inertia that is dependent upon size and responsiveness. Like Giant Ships (eg. Titanic) they have a tendency to "stay the course" for many reasons, not the least of which is the failure to have accurate "sensors" in and on the front lines and they lack facility to change direction. In other words, they loose their sensitivity to the people they are serving and the servers (providers), get preoccupied with and distracted by things that are essentially phobias, impose top down "solutions" to non problems, increase burdens on front line providers, interfere with quality front line care and, basically, miss the mark on many opportunities to improve care quality and outcome. Basically, they lack the ability to move smart and fast. Electronic Medical Records are a perfect example of new technology that was imposed top down without proof of effectiveness and safety. This technology consumes between 25% and 50% of front line provider time, and that takes away from patient care time. Scribes can eliminate the time wasted on computers, but the safety and effectiveness of first generation EMRs is yet to be determined. My bet is that drastic changes in form and function will be mandated in the near future.
2. Benchmark Quality "Standards", lower the quality of care, by justifying mainstream levels of performance. In other words, mainstream performance becomes a standard by default. This is dangerous in healthcare, where optimal performance and outcome is always the goal and mainstream performance may well be substandard. Disinguishing comparative benchmarks from true quailty measures is a serious problem that can only be addressed through solid scientific research. This research should take the form of Continuous Quality and Performance Improvement measures that review 100% of care provided and examine the impact (outcome) of changes in practice, new techniques and technology. The goal is to optimize patient care constantly and to raise the bar continuously. That is the only way to provide the best possible patient care at all times.
3. Causes of vascular injury in trauma
4. Need for and Implementation of Continuous Quality and Performance Improvement Process to Measure Outcome: Provider Role
5. Need for Advanced Directives to prevent unnecessary and inappropriate care
6. Comparison of Morphine and Hydromorphone, cost, effectiveness, dose, side effects
7. Arterial and Venous Gas Embolism
8. Brain and Spinal Cord Protection Strategies
9. Nosocomial Pneumonia, Colonization, Transmission and other assorted issues related to Ventilator Associated Pneumonias and Hospital Acquired Pneumonias
10. Targeted Strategies for Patient Care and Organ Preservation in the ICU
As I was about to leave the hospital tonight, during a conversation after evening rounds with my night coverage resident ... one of the more experienced and competent residents on service ... about patient care and teaching, and the fact that this is "a labor of Love", and stating, "It is a good thing I love what I do." We both laughed about the difficulties encountered in teaching and providing services, and I think he got the point that I reiterate on a regular basis. Specifically, "there is not enought money in the world to make this right."
I have to give it up now, and try to get some sleep. On call, but the coverage tonight is solid, and tomorrow will be a Long Day!
PGY 40, Day 1 meets PGY 1, Day 1! LOL ... we will see how that goes.
Love to all!
"Love is the Power, Care is the Mission, Safety and Optimal Care are the Goals and The Hippocratic Oath is our Guide."
Medical Killing is a clear violation of the Hippocratic Oath, it undermines the Doctor-Patient Relationship and it is just plain wrong. Don't let the Business of Medicine and the Politicians enable medical killing!
Below you will find two emails: the first is my respnse to the Care Not Killing administrator, Robert Colquhoun, and the second is the email that prompted my response. It appears that the movement to enable medical killing is growing, and this is a very dangerous policy for many reasons. Read the emails below to get a better understanding, and let me know if you have any comments, or questions.
This is the complete title/author info on the MUST READ book to see how we are allowing the mainstream to slip into the Nazi mode ... AGAIN! It is a compelling and nauseating read.
The Nazi Doctors: Medical Killing and the Psychology of Genocide
Robert Jay Lifton
Thanks for your help.
I will try to tweet/blog on this soon.
Interesting that I just put out a Tweet #quote yesterday about Killing ... as there is never any justification for intentional killing. With rare exceptions ... perhaps someone like Hitler being the exception ... oddly enough. Now ... with greedy and selfish people pushing the mainstream for profit over people ... we see this surge again with all sorts of excuses for the bad behavior.
Doctors should NEVER participate in KILLING for ANY REASON. That said, there are some triage situations, and some allowing people to die in dignity ... which is clearly distinguishable from, and not to be confused with active killing. Abortion to save the mother of an unborn baby perhaps being the most extreme example. But, many can't make the distinction, as their minds are clouded with all sorts of nonsense.
That's why the Hippocratic Oath has stood the test of time ... despite the fact that many have messed with it over time including Hitler's people ... it always come back to the original, wise document +/- that serves as a foundation for our work.
It is time for Doctors to restore the Doctor Patient Relationship and this must go against the grain of the Business of Medicine ... which is clearly on a very bad path ... bad for Patients and Doctors.
Let me know if you need any other contact information.
Ciao for now,
Dr. Mike Michael F. Mascia, MD, MPH President Infinity Health Solutions dr_mike_ihs @ twitter
The next few weeks are shaping up to be extremely busy on the euthanasia front as pro-euthanasia activists are gearing up for a new assault on the media, the courts, the medical profession and Parliament.
The pro-euthanasia lobby has begun its campaign in earnest with three articles in the British Medical Journal which aim at neutralising medical opposition to euthanasia.
Please respond and comment on the articles below on the BMJ website:
Raymond Tallis, chairman of Healthcare Professionals for Assisted Dying, argues that medical institutions should take a position of studied neutrality on assisted suicide: http://bit.ly/M6rUBX Tess McPherson, tells the story of her mother who died from cancer last year: http://bit.ly/LG9VmX The journal’s editorial by Fiona Godlee, ‘supports’ call for assisted suicide: http://bit.ly/OGdjz7 Vote NO on the opinion poll on this page (scroll down on the right).
Iona Heath, President of the RCGP, argues that assisted suicide would marginalize the most vulnerable: http://bit.ly/K4scan Many thanks,
-- Robert Colquhoun, Administrator
Website: http://www.carenotkilling.org.uk/ E-mail: info@carenotkilling.org.uk Address: 6 Marshalsea Road, London, SE1 IHL Phone: 020 7234 9680; Skype: carenotkilling Registered as a Limited Company in England and Wales, Company No. 06360578 Newsletter Get Involved here Donate Follow on facebook or twitter
I am happy to report encouraging news for Patients and Doctors. The American College of Physician Executives (I am a member, and encourage all physicians to join this organization) hosted a very fine webinar on Re-Humanizing Health Care, which I participated in, largely because I was encouraged to do so by Charisse Jimenez. Our email exchange that preceded this webinar will be abbreviated and included on future blogs, because it reflects my fundamental belief that The Profession of Medicine is driven by the Power of Love, and put to work in accordance with The Hippocratic Oath. This webinar was outstanding, encouraging and heartwarming, for several reasons. They include, but are not limited to these facts:
1. The topic is very timely. It reflects a growing recognition among physicians (and patients) that the business of medicine is routinely failing physicians and patients
2. Technology enabled a broad audience from across the country (around the world?) to participate.
3. This "boots on the ground" member was encouraged to participate and
4. was able to participate from my rural location in Maine,
5. "Important" People are listening,
6. I was encouraged and able to share my views on the need to realign Medical Care and "Health Care Institutions" in the USA to the needs of the patients, by focusing on our professional obligations and primary mission as it is outlined in the Hippocratic Oath for Patients and Physicians. Specifically, I was able to make this statement at the end of the webinar.
"The Organizations appear to be confused. In some cases, they have become so preoccupied with money that they have completely lost sight of their Mission, and realignment is essential. Our Mission is based upon Love and Care. The Oath is our practical guide."
Dr. Rubin's response was ... beautiful. Through this, I see hope, that the ACPE will truly facilitate moves in the direction that will at least encourage reconstruction of the Doctor-Patient Relationship and use of The Hippocratic Oath, as the Doctor-Patient Relationship, as it is defined in the Hippocratic Oath is the foundation of any proper fix for America's Health Care "System". My bias is toward development of Non Profit Doctor-Patient Cooperatives, but most models can work, if they are rational and based upon the Hippocratic Oath ... Not money ... Patients ... not Profit.
Here ... for now, is the email that was sent to me after the conference. There are links to the details of the meeting, which may, or may not work for you. If you need further information, please feel free to talk with me. Email works best.
Feel the Love and Enjoy!
Dr. Mike
From: Charisse Jimenez Date: May 25, 2012 9:02:57 EDT To: Michael F. Mascia, MD, MPH (dr.mike@ihealsolutions.com) Subject: ACPE - Post webinar evaluation and links.
Michael Mascia,
I found yesterday’s webinar, Physician Leaders: Their Unique Perspective Re-Humanizing Health Care fascinating and I appreciate you sharing an interest in this topic. A link to the slides and an audio recording appear below. Many of you requested a copy of the references and citations so Dr. Rubin is collecting these and I will send them to you next week. If you were able to listen to the whole session, would you take one minute to complete this post-webinar evaluation? Thank you in advance for your feedback as ACPE continues to work to support your work as a physician leader.Links: · Slide deck: http://net.acpe.org/webinars/rehumanizing.pdf · MP3 recording: http://net.acpe.org/webinars/rehumanizing.mp3 Enjoy your Memorial Day Weekend, Charisse Jimenez Director, Membership 800-562-8088
The Business of Medicine: For profit and non profit corporations (third parties) hijack the Doctor Patient Relationship and take 30 - 60 % of Health Care Money Out of the Patient Care Pot
The Information is slowly making it out to the general public.
A Recent Wall Street Journal Publication
Why America's Doctors Are Struggling to Make Ends Meet - WSJ.com
are consistent with my previously published views.
But it is now time to reiterate for purposes of reinforcement. Below are the letters as they had originally been posted in 2009.
>>
Open Letters to President Obama
“Such a pessimist … you are,” I said to my college friend and fellow physician in a recent email.The email continued as follows.
Here are the facts:
1. We … physicians have chosen to apply and lock to our wrists, the golden handcuffs created by third parties … not the least of which is the federal government.
2. When NON PHYSICIANS and PHYSICIAN EXECUTIVES (not frontline boots on the ground guys and gals) dictate the care we provide and TAKE MONEY away from the frontlines of patient care … on our backs, nurses’ backs and patients’ backs … they take the money, put it in their pockets and into shareholders’ pockets … and when that happens everybody suffers, especially the patients.
3. When physicians bicker, everyone loses … including, but not limited to … Patients, Doctors, Nurses, Hospitals, and the larger community.
4. Physicians have more power than any group in the nation, but many are COWARDS, and they do not know how to work together toward their primary mission … which is … or should be … provision of optimal patient care.
5. I say, change the paradigm and get all the middle men out of the picture … the ones who have hijacked medicine for the sake of greed … the ones who steal about 30% of the healthcare dollars away from the frontlines of patient care. I say … let’s unite with the patients and create a new paradigm that works … for all of us. After all, we are all patients, too. I am thinking of a cooperative model.
6. If we can get 10% of the population to join a cooperative/joint venture with 10% of the docs and nurses, we should be able to reduce healthcare costs for the group by about … at least … 30% and that should easily be self-sustaining.
The hijackers … with our help … and with the help of bribes … have created the categorical “Dysintegrated and Disintegrated Healthcare” that we now know so well. These third parties have stolen millions of dollars away from frontline patient care, and they want to dictate the way physicians provide care. We, physicians and patients, need to take the power and the money back, but that can only be done when we ALWAYS PUT PATIENTS FIRST.
Bottom line is this … Priorities are Patients, Patients and Patients. Cooperation among docs, and among Doctors, Patients and Nurses; then, after cooperation comes definition of minimum performance standards for patient care and PUSHING THE THIRD PARTIES OUT OF THE BUSINESS OF HEALTHCARE. That should free up a minimum of 30% of every healthcare dollar … and, if it is put back into the frontline care of patients, we should realize costs savings in the 50-75% range.
Interested in helping to solve the problem? Click on the link [GJC1]to join me and others in the process of taking back the healthcare business from the hijackers.
Ciao for now,
MFM
President
Infinity Health Solutions
www.ihealsolutions.com
Hearings to address impact of medical helicopter industry’s business structure on air safety, medical care.
The New York Times (2/3, B1, Meier) reports that “the National Transportation Safety Board on Tuesday will begin four days of hearings,” during which “safety advocates are expected to demand a crackdown on the medical helicopter industry, a fast-growing and loosely regulated business with annual revenues estimated at more than $2.5 billion.” Instead of “focusing solely on the causes of accidents, the hearing will also consider the impact of the industry’s business structure on both air safety and medical care.” Some “safety advocates say necessary changes include tighter federal and state regulation.” Meanwhile, “industry officials say that they recognize a need for some safety mandates, including rules governing flights at nighttime,” but say “that companies should be free to choose the technologies best suited to their operations.” The Times notes that during “the last decade, the industry has doubled in size while undergoing a business transformation.” Although “hospitals used to be the primary operators of such helicopters, they now largely outsource that work to commercial operators.”
The above helicopter issue is another example of a great opportunity for Federal, State and Local Governments to spend federal money well … to COOPERATE in efforts to promote Public Health and Safety. Government monitors and operators under the military, coast guard, and Public Health Service should be cooperating with the private sector to GUARANTEE that transportation for critically ill and injured patients meets minimum performance standards, equivalent to, or better than the tightest of military and commercial airline standards. This is a no brainer … and again, when talking about salaries and profits, put a CAP on both SALARIES and BENEFITS! They (the Feds) are talking about caps for bankers, now, and they are talking about billions to be dumped into the healthcare sector. So, to prevent similar and ongoing greed and robbery in the healthcare sector, now, while talking about spending additional billions on healthcare, put the caps on healthcare executives’ salaries and corporate profits … otherwise the money will go down the drain … or should I say into the executive and shareholder pockets. They have already joined the rip off bandwagon, and when the Government starts to unload money into the healthcare sector, you can be certain they will be there shoveling as much as possible into their pockets.
Also, while talking about infrastructure projects for the nation as a part of the economic recovery plan, think about this: development of a secure health information network … to be used exclusively by registered healthcare providers and their patients … for the exchange of privileged information … not storage … exchange ONLY.
And, while thinking of delivering casualties safely, why not think of an integrated system?… And don’t forget the need for a real Disaster Preparedness Network that will be composed of frontline providers … the Doctors and Nurses who now take care of the casualties.
Tune in for more ideas and opinions and ciao for now,
Dr. Mike
The Wall Street Journal (1/22, Martinez) reports, “A bill making its way through Congress to provide more low-income children with health-insurance coverage could spell financial trouble for scores of hospitals owned by physicians.” The proposal would “prohibit ‘the unethical kickbacks that physicians receive from ownership hospitals,’” Rep. Pete Stark, chairman of the House Ways and Means health subcommittee, said. The children’s health insurance bill “was passed by the House last week” and included a provision that “would effectively put a halt to the construction of any new doctor-owned hospitals.” Brett Gosney, president of Physician Hospitals of America, noted that “if the final legislation contains the proposed restrictions, existing doctor-owned hospitals wouldn’t be allowed to add any more beds or to increase capacity.” In addition, the proposal would outlaw “Medicare payments to any new doctor-owned hospitals,” and without those payments, “most hospitals couldn’t survive.”
Editorial Comment: My take on the above is this. LEGISLATORS think it is OK for non-physicians to make money from a hospital, but it is not OK for physicians to make money from a hospital. Why not BAN for-profit hospitals and for-profit insurance companies, or put a cap on salaries and profits? Level the playing field. In my opinion, nobody should be allowed to make excess profits on the backs of the sick. Right now, for-profit hospitals and insurance companies allow executives, and shareholders to walk away with excess “profits” by restricting the care provided to the sick patients for whom they are supposed to provide coverage.
Have you ever had trouble when trying to file or get reimbursement for a healthcare claim? Let us know.
Dr. Mike
President Obama:
Congratulations! … and let the work begin.
Before Bill Clinton was first elected, I wrote to him and gave him a few ideas that might help with funding for patient care related to behaviors that cause health problems. I suggested that adding “healthcare” taxes to tobacco, alcohol, motor cycle licensing, auto licensing, road use, “unhealthy” foods and other high risk products and behaviors might provide a disincentive for some maladaptive behaviors associated with the health problems we see so often and the funds generated could help pay for the healthcare of the casualties. But, that was long ago, and although some of that work was done by Clinton and others, much more of it needs to be done, and, of course, there is the larger healthcare arena. The letters that follow will reflect my opinion(s) on the subject: Reforms needed to improve the quality of healthcare … to which I have dedicated my career since graduation from medical school more than 30 years ago.
Thanks and ciao for now,
Dr. Mike
Michael F. Mascia, MD, MPH
President, Infinity Health Solutions
The letters will focus on the following subjects, and more.
1. Compassion without knowledge is dangerous! Encourage Comprehensive Smart Card Development and use. Get Advanced Directives Done and be careful about who you pick as a healthcare proxy. DO NOT PUT PATIENT DATA IN CENTRAL DATA BANKS. Put the data on the smart cards that the patients hold and in patients’ computers and in provider (doctor and hospital) computers. Government should make the “health net” for secure transfer of the information. Do not leave it to the private sector …
2. Restore the Doctor-Patient Relationship: Government Should Encourage Moves towardDoctor-Patient Cooperatives in which responsibility for healthcare is appropriately shared by, rather than imposed, upon the patients.
3. Eliminate the MIDDLE MEN: More than 30% of the healthcare dollars are wasted in profit to shareholders, executives and other non-providers who know nothing about providing quality care and take money out of the process of providing quality care.
4. The for-profit system is incompatible with quality healthcare: Greed and the beancounters will take the money out of the business of providing quality care.
5. Insurance is for the insurance companies … not patients: Another example of profit over quality because these people working in insurance companies are there to do everything in their power to keep every dime they collect. They know nothing about quality healthcare, and do not intend to pay for your healthcare services, despite the fact that you give them your hard earned cash. Get them out of the picture!
Raise the bar on Quality and Performance improvement
Nov. 15, 2008 at (Updated Nov. 15, 2008 at ) by Dr. Mike
Quality and Performance Improvement can be combined with Cost Containment. In other words, the best care is the most cost effective care and cost containment can be achieved while simultaneously improving quality. Past efforts have separated these goals and cost containment has always been an obtuse way to increase short-term hospital profits … or limit losses. However, these shortsighted “for-profit” goals have always sacrificed quality and service … and to what end? … lower quality of care.
Of course, these moves are always based upon the advice of the same “business oriented” consultants who have gone through the industry like a wave since 1985 … the year that insurers started to squeeze reimbursement to hospitals.
You can see that the results of their disastrous recommendations are ubiquitous in the healthcare arena … they took the care out of the healthcare industry and now is the time to put it back and here are the fundamental principles.
1. All quality improvement (QI) activities should have a simple goal: improved patient outcome.
2. All quality improvement activities should be designed with scientific rigor.
3. Cost containment should never be isolated from quality and performance improvement strategies.
If you want to see an example of one QI-PI-Cost Containment project, see my article in Critical Care Medicine, July 2000:
Pharmacoeconomic impact of rational use guidelines on the provision of analgesia, sedation, and neuromuscular blockade in critical care.
Clinical Investigations
Critical Care Medicine. 28(7):2300-2306, July 2000.
Mascia, Michael F. MD, MPH; Koch, Manfred MD; Medicis, Joseph J. PharmD, BCPS
Abstract:
Objective: To determine the cost-effectiveness and safety of a set of rational use guidelines for analgesia, sedation, and neuromuscular blockade in critically ill ventilated patients when compared with similar factors in standard prescribing.
Nov. 16, 2008 at (Updated Nov. 16, 2008 at ) by Dr. Mike
This is a letter I sent to United Healthcare when they denied coverage for my lab tests last year. They still refuse to pay … even though I had paid them thousands of dollars over the many years of coverage, and I had NEVER previously made a claim for coverage.
Here is my letter to United Healthcare. I will see if I can find their response, and, if I can find it, I will include it in a future blog.
Michael F. Mascia, MD, MPH
Infinity Health Solutions
November 6, 2007
United Healthcare Insurance Company
United Healthcare Appeals
P.O. Box 30432
Salt Lake City, UT84130-0432
Ladies and Gentlemen:
It is my understanding that you have denied the claim for medical services rendered to me on September 20, 2007, as shown on the attached “Explanation of Benefits” sheet. I was told that this is a penalty for not using an HCA facility. These services were right and necessary services provided by BridgtonHospital, as part of my evaluation by Robert P. Doyle, MD . The penalty is unjustified, because, there are no HCA facilities in the State of Maine, and, as best I can tell, the nearest HCA facility is about 2 hours from my home. You could easily have determined the absence of HCA facilities by looking at my zip code and a map, and by doing so, you could have avoided this unnecessary trouble. It might have taken 30 seconds to figure it out. Nevertheless, on the basis of the facts presented, I presume that you will now pay BridgtonHospital for the services they have rendered.
If, for some reason, you are still unwilling to pay for the services rendered, please contact me @ — — —-. I will also need written confirmation as soon as possible, so that I can be sure to get the proper word out on United Healthcare Insurance Company. And, if, in the future, you would like me to travel to Portsmouth, New Hampshire for hospital services, I will be glad to include a bill for my time, and travel expenses.
Nov. 16, 2008 at (Updated Nov. 16, 2008 at ) by Dr. Mike
Back to Basics in Healthcare: Put the care back in and take the bureaucracy back out … put the money back into the care of patients and take it away from the executives, bureaucrats and corporate shareholders.
1. Restore the Doctor-Patient Relationship
2. Eliminate the middlemen in the reimbursement rip off.
3. Eliminate non providers from leadership positions in healthcare (use boots on the ground providers only for all health services administration).
4. Eliminate the for-profit option from healthcare institutions.
5. Eliminate the for-profit option from health insurance carriers.
6. Enable and facilitate Doctor-Patient cooperatives as an alternative to traditional insurance.
7. Establish government sponsored “catastrophic” health insurance.
8. Facilitate health savings plans as coverage for routine healthcare.
9. Government coverage for basic care via health savings plans.
10. Run pilot programs on all new government sponsored and government enabled programs so as to avoid massive and expensive programs that do not work. Small programs can be fine tuned and “perfected” before they are disseminated.
11. Fund healthcare for maladaptive behaviors with proper taxes.
True … It Is Bad and My Comments on NY Times Article
Nov. 18, 2008 at (Updated Nov. 18, 2008 at ) By Dr. Mike
This is a copy of a piece of a NY Times article … outlining at least a part of the problem caused by categorical programs designed by beancounters to get money from third party payers, rather than focusing on providing care to patients. This has caused what I call the “disintegrated healthcare system” which is not a healthcare system at all. It is, rather, a collection of small factories designed to “process people and diseases” in an effort to make money for lay executives and shareholders. Put the money back into the hands of the caregivers and back into the care of the patients. Healthcare reform is another term for moving more money away from the care of the patients. Here ya go …
The NY Times calls overall US healthcare performance “abysmal.” In an editorial, the New York Times (11/18, A26) highlights the problems chronically ill Americans face in comparison with seven other industrial nations as detailed by the Commonwealth Fund report, calling it “the latest telling evidence that the dysfunctional American healthcare system badly needs reform.” The Times argues the study shows high quality healthcare is available “at a handful of pre-eminent medical centers, but is unavailable “to a huge portion of the population.” The US “did comparatively well in some areas, such as providing relatively prompt access to specialists and clear instructions to patients leaving the hospital.” But, “the nation’s overall performance was abysmal.”
By Dr. Mike. Nov. 18, 2008 at (Updated Nov. 18, 2008 at )
I have several things on a “to do list,” but the fundamental principle is very simple. All hospital and healthcare administration needs to be done by the frontline, boots-on-the-ground patient care providers. Yes … that’s correct, I did say ALL and this is why. Non-providers (be they doctors, nurses, or lay administrators) are disconnected from the problems they create in their efforts to MAKE AND SAVE MONEY TO PUT INTO THEIR POCKETS AND THE POCKETS OF SHAREHOLDERS. They do not understand, or they have lost the capacity to understand, the problems they cause in these efforts. In essence, they lose sight of or DON’T CARE ABOUT the needs of the patients, and this problem can be eliminated by requiring a minimum of 20% frontline patient care time from all members of any hospital administration. For example, all nurse administrators would be required to provide bedside care of patients at least one day per week and all physician administrators would be required to provide bedside care of patients at least one day per week, and all non-provider administrators would be asked to leave.
All non-providers should be removed from executive positions in hospitals and other healthcare institutions … take the crooks, money grubbers and other greedy folks out of healthcare systems administration and put a cap on greed as a motivator. Unfortunately, it was the government under Clinton that enabled for-profit corporations to operate with impunity as they took the care out of the healthcare and put the money in their pockets … as the care and outcomes deteriorated … year after year. Let’s put the care and money back where it belongs and take the profit out of the hands of the executives and shareholders.
By Dr. Mike Nov. 22, 2008 at (Updated Nov 22, 2008 at )
Regarding the report Joint Commission statement below … the Joint Commission and their “panel of experts” is just plain wrong. The solution is boots on the ground and back to basics … at the bedside patient care … more experienced nurses and doctors who care … more care at the bedside and LESS technologic interference with bedside care. Technology does not provide patient care, and, in fact, it gets in the way of good patient care. Information is useful and necessary, but most of the essential information needed comes from patient and/or family. This IT phase is another example of noise that creates more and more barriers … barriers that interfere with proper bedside care that is delivered by dedicated doctors and nurses. Hospitals and Governments want to lower the costs of healthcare … get rid of “panels of experts” and get experts who actually provide the care on the frontlines.
More to come on the deterioration of the Doctor-Patient relationship noted over the last 35 years.
Medicine by the Numbers is Painting an Unacceptable Picture
By Dr. Mike Nov. 26, 2008 at (Updated Nov. 26, 2008 at )
Do you remember those “Paint by the Numbers” kits we used when we were kids? Have you ever used one? Have you seen the results? Sure, on the cover they show a masterpiece partly completed to perfection by the numbers.
Then, you or your child eagerly rips the kit open in anticipation and rushes to create your own copy of the masterpiece. You paint away by dutifully dipping your brush into each little container and carefully applying each color in the proper spot … yes, “according to the numbers.” After hours of careful work you have finished … ah … and you hold your finished product up to stare in admiration … only to find that you have created something that, at best, only grossly resembles the masterpiece. The finished product is most likely gross; a very disappointing and poor representation of the real masterpiece upon which the kit is based.
When I stand back and look at the products we deliver in American medicine today, it is only rarely that I see a true masterpiece … the work of a master craftsman. Frankly, I am often grossed out by what I see. Why? Currently, American Medicine is done “by the numbers.”
What do I mean? Modern American medicine is driven by reimbursement and not by patient needs, so many patients fall through the cracks. Hospitals and other care systems have clearly been forming their organizational structures and operational strategies based upon the “return on investment” and other production principles … the same business systems that drive factories, assembly lines and factory workers. Nothing against return on investment, production principles, business systems, factories, assembly lines and factory workers, but the model simply does not work in healthcare.
When I started working as a Critical Care Anesthesiologist at TulaneUniversityHospital in 1999, it soon became apparent that patients were being treated like hamburgers in a fast food chain, and I often said, “They treat patients like hamburgers … as if they were all the same … as if they all needed the same treatment for the same diagnosis.” I would say, “Imagine trying to run an airline … with 100% special need customers. It could not be done. But, each patient is a special need customer. Patients don’t fit into the cattle herding and hamburger production models, and that is one of the reasons why many hospital administrators have no understanding …
