The healthtweets of 2010

No surprise – health care reform & meaningful use are the top health stories of 2010.

Presented here in Twitter format: 140 characters or less. (Shameless rip-off of friends’ clever Xmas letter – thx 4 the idea, Dana & Rae!)

Contentious health care reform bill falters, then is revived & passed by Congress & signed by the president. A historic moment.

The official name is a mouthful: the Patient Protection and Affordable Care Act.

We’re talking major overhaul: health insurance mandated for everyone, establishment of insurance exchanges & high-risk pools.

Restrictions eliminated for pre-existing conditions & lifetime caps. In most cases, adult kids can stay on parents’ policy until age 26.

Controversy continues over elements of the law. Efforts to repeal gain momentum when Va. courts strike down insurance mandate. Stay tuned in 2011.

Meaningful use? What’s that? You’d have to be an IT wonk to know. But in brief: regs were issued for effective use of the EMR in patient care.

(P.S. – EMR = electronic medical record. Lengthy health care jargon resistant to tweeting.)

Providers who meet meaningful use objectives can receive bonus $$ from federal govt. Big incentive for docs to adopt EMR. 

Salmonella contamination triggers massive recall of eggs, largest in history. Concerns persist about food safety.

Are we drowning in obesity? First Lady Michelle Obama launches “Let’s Move” campaign. Hot topics: menu labeling, high-fructose corn syrup.

Harsh reminder of infectious disease: Whooping cough upsurge in California; 4,000+ cases reported, at least 9 infants die.

WHO declares H1N1 pandemic is officially over. Will diabetes be the next big thing?

Kids’ medicines recalled. Study finds growing incidence of sports-related concussions. Ick-factor story of the year: resurgence of bedbugs.

Earthquake devastates capital of Haiti. Volunteers, supplies pour in to help injured & homeless.

R we overscreened & overtreated? Debate re necessary care gains traction. Key ?s: What’s the harm? What’s the benefit? Where’s the evidence?

If it’s health, there’s an app – Google, iPhones, online medical records. Social media takes hold in connecting consumers with health info.

What else we talked about in 2010: prescription drug abuse, autism, Alzheimer’s, vitamin D, bullying of gay youths, stress, stress, stress.

Here in MN: Twin Cities nurses vote to strike. Walkout is averted but debate continues re nurse-to-patient ratio.

State’s 1st “medical home” is certified, more to follow. Legislature struggles w. fate of GAMC while clients wait & worry.

Demographics poised for growing pop. of elders. R we ready?

Local news: Bethesda opens sr. wellness center, Rice Hosp. to close radiology school, Dr. Rick Wehseler of ACMC is MN Family Doc of Yr.

From this blog, Happy New Year & a healthy 2011. Tweet this!

The efficiency factor: One visit or five?

It’s game show time: Behind Door No. 1 is a 30-minute visit with the doctor during which you’ll be allowed to address multiple issues. Behind the other door is a series of three 10-minute visits addressing one issue apiece.

You chose the 30-minute visit? Bzzzt! Wrong answer.

It’s an unfortunate reality that most doctor visits are short, and patients who want to bring up more than one concern will likely be asked to make another appointment.

The issue came up awhile back in a guest column by Dr. Danielle Ofri which appeared in the New York Times health section, lamenting an encounter with a patient who arrived with a long laundry list of problems. How do you sort through them all without becoming overwhelmed – or, as in this patient’s case, possibly missing something critical? Dr. Ofri says she learned a lesson:

When a patient presents with so many complaints that it’s not possible to cover them all in depth, I openly acknowledge the limits and say, “Today, we are going to review three of your concerns: you pick two and I pick one.” This allows the patient to select the two most concerning issues, and allows me to home in on the one I think might conceal a serious illness.

If there are other issues that haven’t been addressed or resolved, the patient presumably would be told to make another appointment.

On many levels this is a reasonable course of action. After all, doctors have other patients who need to see them too. And patient volume, rather than time spent with individual patients, essentially is what supports the practice’s overhead costs.

Is this really better, though, for overall patient care? Dr. Ofri’s column was picked up this week at Kevin, MD, where the online discussion quickly grew interesting. The comment that most caught my attention came from a medical office practice manager who wrote, “Patients… resist numerous shorter appointments as they feel they are getting less for their co-pay, and want the most bang for their buck.”

Whoa… what?

Money certainly enters into the equation. There’s no getting around the fact that two office visits and two co-pays are more expensive for patients, especially if they’re uninsured or underinsured or have a large deductible. Sometimes this is the main reason patients show up with a long, and frustrating, list of issues that need addressing: They save up all their concerns and bring them to one visit because they can’t afford to come in more often.

But I can think of many other reasons why patients wouldn’t be thrilled with a system that requires them to make multiple appointments to get all their issues addressed. For working-age adults, it means taking more time off work. For adults who are caregivers or who have small children, it means making arrangements each time to reorganize their personal responsibilities. What about older people who no longer drive and must find transportation for each of those additional doctor visits? What about people who are frail or not very mobile, for whom a trip to the doctor can be an exhausting logistical challenge?

There are many times when a face-to-face visit is necessary, regardless of the hassles it might entail. Nor is it reasonable for patients to expect unlimited time with their doctor. But from the patient’s point of view, being asked to restrict their visit to one or two issues and make additional appointments to deal with the rest is a fragmented and inefficient way of doing business – and providers should not be surprised that patients sometimes “resist.”

It would be interesting to speculate on how this practice might be contributing to the escalating cost of health care in the United States and the increasing burden on the health care system. Ten-minute visits can help churn patients through the process more quickly, but if many of those patients have to keep coming back, what has been gained? How does it save money or help the system operate more efficiently?

Much of this goes back to how doctors, particularly in primary care, are paid. They’re rewarded for volume and procedures, not for diagnosing, problem-solving, coordinating and managing. There’ll be little progress until this changes.

In the meantime, how about a little more mutual understanding? Patients aren’t villains for resisting multiple short appointments when a single longer appointment would do, any more than doctors are villains for asking patients to keep it short and come back another day.

Techno seniors

This year for Christmas, my siblings and I gave our dad a Kindle. Apparently we aren’t alone in wanting to introduce technology to older parents to help make their lives easier and more enjoyable.

It was with a great deal of interest that I read this article from the New Old Age blog at the New York Times, outlining some of the issues for older adults in choosing, using and becoming adept with the many forms of digital communication.

It makes an important point: Just because someone is older doesn’t mean they’re unable or unwilling to learn something new. (Dad wanted a Kindle and even helped pick out the one with the features he liked best.) The main thing, according to the article, is to make it worth their while:

Experts say the key to making tech work for Mom and Dad is not to buy the newest cool thing, but to look for a device or software that fulfills a basic need, that does something they particularly want to do. And it’s helpful if the learning curve involves an element or two already familiar to them.

The writer offers several examples: for instance, Skype’s video calling service that allows older parents who no longer travel to connect with their family for the holidays.

As is so often the case, the comments in response to the article are almost as illuminating as the article itself – especially the responses from readers who objected to the ongoing stereotype of older adults as technology-resistant and unable to learn. “Are you telling me my brain will stop working as soon as I reach the age when you youngsters decide to patronize me?” one person asked.

The teensy keypad on my dad’s new Kindle brings up another issue: the manufacturers’ apparent blindness to engineering, design and marketing that’s user-friendly to older consumers. How is someone with arthritis or vision impairment supposed to use those little bitty keys? “The tech industry done a rotten job of selling their products, both hard and soft, to people over 50!” one of the New York Times commenters wrote. “How can we older folk get to know what is available, let alone how to use it, if no effort is made to try to sell to us?”

Perhaps older people simply have a more realistic, or utilitarian, perspective on technology and are less likely to be wowed by something simply because it’s new. This lesson was driven home rather bluntly at the GeriPal geriatrics and palliative care blog, where a study on the benefits of telemonitoring for patients with heart failure was recently analyzed. The study found that telemonitoring made no difference in outcomes for these patients, prompting the blogger to ask, “Is all this enthusiasm for telemonitoring justified?”

Well, yes and no. When technology falls short, sometimes it’s because it isn’t being used in ways that are most effective. On the other hand, adopting new technology for the sake of newness doesn’t automatically guarantee it’ll be helpful.

I suspect that for many older people, having the latest electronic toy just isn’t a priority. What tends to matter most for them is whether a new gadget will improve their quality of life. Deliver something they can use and enjoy, and they’ll adapt with minimal trouble, the same as any other age group. Come to think of it, this is a standard more people should follow, regardless of how old they are.

Photo: Wikimedia Commons

Linkworthy 2.4: The giftwrapped edition

Christmas shopping? Done, done, done. Decorating? Done. Clearing snow out of the driveway? Done (for now, anyway). Baking? Mostly done. Giftwrapping? Need to get on that today. Blogging? Oh, wait. Need to update the blog. So here goes: a condensed version of some of the more linkworthy/thought-provoking items I’ve encountered online recently.

- The health blogosphere has been buzzing in recent days about the story of a middle-aged nurse who underwent an angiography and ended up needing a heart transplant. The case report, which appeared last week in the Archives of Internal Medicine, is unusual for its frankness about the risks vs. the benefits of medical intervention, particularly when the benefits are questionable.

Here’s the case in a nutshell: A 52-year-old woman goes to the emergency room with vague chest pain. After evaluation, it’s determined that she’s unlikely to be having a heart attack, but her doctors decide to order an angiography anyway, just in case. The angiography comes back positive so the patient undergoes cardiac catheterization, accidentally has one of her coronary arteries torn by the procedure, needs bypass surgery, develops heart failure and ultimately requires a heart transplant.

To be sure, this is a rare situation – but I seriously doubt it’s much comfort to the patient or her family to experience a 1-in-a-million cascade of serious complications. The truly ironic part is that the angiography, which led to this medical disaster, was ordered mainly as reassurance and most likely wasn’t even necessary. Lessons from this cautionary tale are discussed in more detail here by Dr. Marya Zilberberg, who is a researcher, physician and blogger at Healthcare, etc., and here, by MinnPost health blogger Susan Perry.

- The cost of health care seems to be on several bloggers’ minds lately. After writing about this issue last week, I came across a couple more blog entries that address the same thing. In “$437 in 60 Seconds,” Bjoern Kils of MedPage Today laments the cost of going to the emergency room for a tetanus shot after a foot injury. Check out the discussion that follows. Although on the surface it’s about the cost of emergency-room care, at a deeper level it’s also about the thought process that needs to happen when patients are thinking about going to the emergency room.

One of the commenters, Dr. Paul Dorio, uses the online discussion as a springboard for his own blog entry: “Emergency? Or Can It Wait – Use Our Resources Wisely.” I’ll reiterate one of the points I tried to make last week: Health care professionals tend to assume the average person should know whether that trip to the emergency room is necessary, and this assumption is often incorrect. But I agree with Dr. Dorio’s message, especially when he says, “Perhaps we could all use better judgment in our decision-making and be more judicious in our use of our precious, shared health care resources.”

Here’s yet another take by Dr. Danielle Ofri, courtesy of the New York Times Well blog, about what can happen when patients insist on expensive testing and doctors feel forced to cave in. She titles it, appropriately, “Patient 1, Society 0.” There’s more food for thought from readers in the comment section.

- In case you missed it, the Minneapolis Star Tribune carried a story this past weekend about an initiative by the St. Paul School District to make all its public schools ”sweet-free zones” by the end of the school year. Good idea? Bad idea? On the one hand, changes in policy and environment can help lead to long-term change in people’s habits. On the other hand, banning sweets in school might ultimately have little effect if the rest of the environment – neighborhoods, the family dinner table and so on – doesn’t change too. Read the article and decide for yourself.

- Since this is supposed to be the season of good will, it’s timely that the Schwartz Center for Compassionate Healthcare has released the results of a national survey on “The State of Compassionate Healthcare in the U.S.” The findings suggest there has been a decline in the ability of providers to deliver compassionate care – but the survey also reinforces how important it is to patients to feel they are cared for.

- Finally, this story by Dr. Sid Schwab totally caught my attention when it first appeared four years ago. Dr. Schwab, a retired general surgeon, no longer actively blogs, but his “Winter’s Tale” about a late-night patient in the emergency room is a classic, both for its ER attitude and the surprise ending. Enjoy!

And there you go – all wrapped up and tied with a bow.

Bah, humbug

I’ll bet Ebenezer Scrooge would find something in common with the publishers of modern-day medical journals: their miserly tightfistedness.

I can’t count how many times I’ve heard about an intriguing new study or report and gone online to read it, only to encounter something like this. Yes, you read that right. In order to gain access to the article – in this case, from the Journal of the American Medical Association about the role physicians might play in health care reform – you either have to be a subscriber or pay $30 for one-time access to the article (and let’s note here that the access is only good for 24 hours).

It’s a practice that’s extremely common among the medical journals: The majority of the content is available only if you subscribe or pay an access fee. If you’re lucky, you can at least read an abstract, or summary, free of charge – but it’s not the same thing as reading the entire article, details and all. More than once, I’ve retrieved an article through PubMed that sounds promising, only to find there isn’t even an abstract.

Some of the medical journals have loosened up in recent years. You can now find articles that are open free of charge to anyone who wants to read them. Some publications, such as the Annals of Internal Medicine, also feature summaries for patients, which recap two or three of the main articles in layperson’s terms.

Overall, though, many medical publications remain extremely stingy about sharing their content with non-subscribers, i.e. the vast majority of the lay public.

On many levels, I get it. We in the news industry are in the business of publishing information too, and we’re well aware this comes with a cost. There continues to be significant debate within the industry about the pros and cons of pay walls for news content. How do you balance the open sharing of information vs. the need to maintain a viable business model? It’s not clear where this line should be drawn, but I’ll point out the largest difference between most news organizations and the medical publishers: Most news organizations make all their online content available free of charge. When there’s a pay wall, it typically takes effect after one week (or longer). Nor does it cost anywhere near $30 to obtain an online copy of an archived news article or a back issue of the newspaper. Here at Forum Communications, we’ve taken the further step of eliminating the pay wall altogether for stories tagged in five main categories: health, food, family, money and travel. The Area Voices blogs and forums are entirely free.

Why should it matter whether the public has access to the articles that appear in medical journals? Because many consumers want to be smart and informed about what researchers and thought leaders are saying. There’s a contingent of lay readers who are using this information in sophisticated ways – often to research their own health and to help shape conversations with their doctors about treatment options and decisions. How, exactly, are they well served by restricting access to information?

Here’s another thing: More than a few of the studies published in the medical journal are publicly funded – that is, through tax dollars. Why is the public expected to help subsidize research and then have to leap over hurdles to read the results?

To be sure, the Internet has made it easier for lay readers to peruse the medical journals. Many libraries – public libraries as well as medical and college libraries – also have institutional subscriptions to the most prominent medical journals. This isn’t the complete solution, however. What about readers who live in rural or remote areas? What about the financial constraints that unfortunately are making it harder for many institutions to continue subscribing to a wide range of research publications?

You could probably argue that even if the public had access to medical journals, many of them wouldn’t be able to understand the contents or, worse yet, might misunderstand or misinterpret what they were reading. But I’m not convinced this is a valid excuse to limit access. For one thing, the medical profession doesn’t hold a monopoly on intellectual smarts. For another, wider readership might spur an effort by researchers and journal authors to write in a way that’s more readily understandable.

This is a debate that has been going for quite a few years, with no end in sight. (You can read more about it here and here.) I don’t have the answer but I think it’s time this issue received some thoughtful and open discussion.

The weekly rundown, Dec. 22

Blog highlights from the past week:

Most-read post: Health care’s four-letter word.

Also-ran: Holiday spirits.

Most-read from the archives: Who are you? Misadventures in misidentification, from July 23, 2009.

Links with the most clicks: the Kandiyohi County Drug-Free Communities Coalition alcohol-free drink recipes; the Costs of Care blog.

Search term of the week: “being bald in Europe.”

Speak now

Patients and their families are always being told to speak up if they have questions or if they’re concerned something isn’t right. The phrase “speak up” is used so often, it has become synonymous with patient advocacy.

There’s another piece to this equation, though: the listener. What’s the good of speaking up if health care professionals don’t welcome the message?

I came across an interesting study in the current issue of the British Medical Journal that explores this very question. The authors conducted individual interviews and focus group sessions to find out what happened when patients spoke up about safety concerns and the communication dynamics surrounding the conversation. What the findings suggest is that this kind of self-advocacy often is easier said than done.

Women with breast cancer who participated in one of the focus groups described the self-doubt that crept in when they reported symptoms or problems that were dismissed:

If you have got something happening, whether it’s you’re in discomfort, pain or you feel sick or whatever, especially if you get nothing back when you tell that person, “I feel sick,” if there’s no acknowledgement of your pain or discomfort, I think personally I feel left [thinking] “Well, maybe I shouldn’t,” “Maybe I should be able to tolerate this pain” or, do you know what I mean? It’s that feedback that you don’t get. So you’re left with it, basically. And then that affects the next time you want to speak up and ask them again, you know?

Patients worried that voicing questions or concerns would have repercussions for their care. One focus group participant told the researchers, “I think if you complain, your number’s marked and you’re a difficult patient.”

Whether patients spoke up also seemed to depend on their seriousness of their concern and their perceptions of the staff’s workload and attitudes. The researchers noted patients were less likely to say something “when they thought other patients had more pressing needs and staff were very busy or didn’t want to be ‘bothered’ by or with patients.” Past experiences made a difference as well. Patients who’d previously been shot down or ignored for asking nurses to wash their hands, for instance, were less confident and more reluctant to speak up, whereas patients who had an encouraging response were more likely to feel empowered.

This last point is interesting because it suggests the strong positive influence of a health care culture that welcomes patient involvement. One of the focus group interviewees, a mother whose child was hospitalized with asthma, described how much more confident she felt when her request for a nebulizer was backed up by a senior doctor.

What happened when patients spoke up and weren’t heeded? Often they had to repeat their concerns to someone else before they got action. Sometimes the encounter escalated into a confrontation, the researchers reported. But in many other cases, the patients backed down, leaving the problem unresolved.

Not surprisingly, the study’s authors conclude, “Overall, participants’ comments strongly suggest that speaking up is easier when healthcare staff give the impression of caring, having time and welcoming and supporting patients as legitimate contributors to their care.”

What’s more, campaigns urging patients to speak up and be involved in their care could backfire if health care professionals don’t respond appropriately, the authors said.

The study was conducted in Britain, so it’s hard to say whether the same results would apply in the U.S. I’ve heard American health care consumers discuss some of these same issues, though, and many of the concerns are similar – reluctance to impose on overworked health care staff, feeling undermined when their questions are dismissed, and feeling encouraged when the response is positive.

In a conversation posted at the U.S. Agency for Healthcare Research and Quality, Geri Amori, vice president for the Education Center at The Risk Management and Patient Safety Institute, recounts the experiences she had while caring for friends who were hospitalized. At one hospital, she was literally told to “go away” when she offered to make an ice pack for the patient. But at another hospital, the nurses and staff talked to her, answered her questions, invited her participation and gave her positive reinforcement. She observes that these differences are rooted in “the individual cultures of those hospitals and how welcoming they were to families.”

Perhaps the “speak up” movement would gain more strength if it also had a “listen up” component.

Photo: Wikimedia Commons

Health care’s four-letter word

A nurse midwife’s encounter with a patient struggling to pay a $1,400 bill and the sabotage of a graduate student’s effort to be a smart consumer have been chosen as the winners in a national essay contest about health care costs.

The writers, Tarcia Edmunds-Jehu and Brad Wright, will each receive $1,000, along with the knowledge that the personal experiences they’ve shared have helped put a human face on the abstract thing known as the cost of health care.

It’s the first time, as far as I know, that an essay contest like this has been held. I hope it won’t be the last. The sponsor, a nonprofit Massachusetts organization called Costs of Care, is working to make health care providers more aware of how their clinical decisions can affect the patient’s ability to pay. If you think patients are in financial control, consider this: According to Costs of Care, health care providers “ultimately determine how 90% of healthcare dollars are spent.”

One of the great things about essay contests is their power to illuminate real-life stories about the collision between patient care and the cost of providing that care. Reading each of these entries made me think hard about this issue. Some observations, in no particular order of importance:

- We talk a lot about the cost of health care – so much so that it has almost become one word, “thecostofhealthcare.” Yet we remain ambivalent about what it actually means. Many, if not most, consumers know health care is expensive and they recognize the need to be cost-conscious, but they don’t always connect these dots when it comes to their own care, nor do they realize how rapidly the costs can mount. Once Mike and Susan, the couple featured in the essay titled “From pain to poverty,” decided to call an ambulance and go to the emergency room, it triggered an inevitable cascade of high-cost services. How many consumers truly understand that if they show up in the ER with chest pain, they’re going to get the full monty, with all the expense this entails?

- There’s often a squeamishness over the fact that money needs to change hands when services are rendered. Many providers don’t discuss it openly with their patients, either because they don’t know how, they think it’s too sensitive, or it just doesn’t occur to them. Patients, for their part, can be reluctant to tell a provider they can’t afford a prescription medication or a CT scan. The conversation also is sometimes complicated by a belief that providers are greedy for wanting to be paid. But the math is simple: It costs money to provide health care and it costs money for consumers to receive it.

- Why are the uninsured billed the full price, while those with insurance can take advantage of the discounts negotiated by the their health plan? In Minnesota most hospitals now charge the uninsured the same rate as the largest commercial plan with which they do business, so they can receive a discount. This isn’t the case in most other states, though. The practice of charging full freight for the uninsured seems akin to Victorian-era debtors’ prison, in both cases penalizing those who are least able to pay.

- Much of the discussion about cost tends to focus on how consumers use (or overuse) health care services, how much they’re charged, and the need for price transparency. Less is said about in-network and out-of-network providers and how hard it can be for consumers to figure this out. Brad Wright, who submitted the winning essay titled “Blood test surprise,” tried to do everything right. He had health insurance and he was persistent in researching costs ahead of time – but he still got tripped up by the intricacies of in-network vs. out-of-network services. He writes, “My mistake was assuming the lab was in-network because the in-network internist I had just seen worked in the same building and referred me to the lab.”

- Although we’d like to think consumers can make rational decisions about health care spending in the same way they make decisions about buying a car or a pair of shoes, they often don’t. Emotion can enter into it, as in Mike and Susan’s case: He complained of indigestion and wanted his wife to drive him to the hospital but Susan, alarmed and fearful, insisted on calling an ambulance. If the couple had evaluated the situation more clearly, they might have realized the risk of a heart attack was probably low. But in the heat of the moment, how were they supposed to know? Which brings me to the next point:

- There’s often an enormous disconnect between the perspective of health care professionals and that of the lay public. It’s easy to criticize Mike for incurring unnecessary costs. Heart attacks are rare among 29-year-old men and a couple of antacid tablets would probably have relieved his symptoms without an expensive trip to the emergency room, or so the argument goes. This assumes, however, that Mike has the same knowledge as many health care professionals and can accurately assess his risk level, interpret his symptoms and take appropriate action. More than likely he can’t; he’s a layperson.

Ditto for some of the online reaction to Tarcia Edmunds-Jehu’s winning essay about the pregnant woman who had to pay for extra, and possibly unnecessary, ultrasounds. Some readers took the position that if the patient agreed to the additional ultrasounds, it was because she chose to do so. It’s a simplistic interpretation that ignores the possibility that the patient didn’t know, or didn’t understand, that the extra ultrasounds might be optional or that the patient may have felt pressured because the ultrasounds were recommended by a provider. And that brings me to another point:

- Patients can be held hostage in subtle ways to the whims and quirks of providers and the system. Mike was willing to go home from the hospital after it was determined he was unlikely to be having a heart attack – but he was told that if he did, it would be against medical advice. Because it was a weekend, he was forced to stay in the hospital until he could have a stress test on Monday. Then because of an equipment breakdown, he had to stay yet another day. He was billed for all of it, even though he had no control over when the test was scheduled.

Or take the case of “Sticker shock,” a finalist entry in the essay contest that describes how a patient ended up with $10,000 worth of out-of-pocket expenses for a surgery because the anesthesiologist turned out to be out of network. Dr. Grayson Wheatley, the author of the essay, writes that patients rarely are given any say over who their anesthesiologist will be. “Despite the anesthesiologist meeting the patient in the holding area before the procedure, no one informed the patient about his upcoming out-of-network charge related to anesthesia services or gave the patient an option to choose another anesthesiologist who was within his insurance’s network,” he wrote.

- If the patient’s out-of-pocket expenses are relatively small – and by “small” I mean a couple thousand dollars or less – the perception can be that this is no great hardship. But as the two winning essays clearly demonstrate, this is a false assumption. For Edmunds-Jehu’s patient, $1,400 worth of medical bills meant she had to choose between paying the bill and buying food for her family. It took Wright six months of economizing to pay the $478 he owed for an out-of-network blood test.

- There’s often a lack of creativity in developing ways to help reduce the cost to the patient. If you show up at an emergency room with chest pain, your choices are typically the full barrage of treatment or nothing. Whatever happened to a reasonable middle ground for patients whose chest pain is unlikely to be a heart attack? Here in Willmar, Rice Memorial Hospital created a pathway for these lower-risk patients, ensuring they’re appropriately evaluated and monitored but not subjecting them to aggressive, expensive and possibly unnecessary care. More hospitals ought to follow this example.

- The public dialogue about health care costs often focuses on consumers, as if they’re somehow to blame for all of it. The health care system itself has contributed significantly to the problem, however, and providers need to recognize the role they’ve played in the escalation of costs.

The conversation launched by Costs of Care isn’t over yet by a long shot. Starting the first week in January, a new story will be posted on the Costs of Care blog each week for the rest of the year. Information, links and updates also will appear on the organization’s page on Facebook. Is it too much to hope that at some point, “cost” will stop being health care’s unspeakable four-letter word?