Change fatigue in health care

The patient was at the hospital for a straightforward same-day surgery but the admission process fell far short of efficient. She was directed hither and yon – first to the registration desk, then to the lab, then to another location for a pre-surgery assessment, then a fourth stop to collect a medical history.

When an accompanying friend asked one of the nurses why all these steps couldn’t be consolidated at the bedside, the response, delivered with a shrug, was “That’s the process – we’ve tried a lot of other things but they never work for long.”

What’s being described here is more than an obvious failure to be patient-centered. Tammy Merisotis, of GE Healthcare, sees it as a prime example of the apathy brought on by change fatigue.

“Change fatigue occurs when staff are expected to make multiple or continued changes in workflow process and patient protocols, without seeing the benefits of those changes in their everyday work,” she writes. “As they are bombarded with constant change, it is easy for people to become disengaged and resistant to change.”

Change fatigue is nothing new. But there seems to be much more of it these days, especially in health care, which is under intense pressure to change, change and change some more.

Although accurate estimates are hard to come by, it’s thought that as many as half of organizations overall are attempting to implement three or more major changes all at the same time.

In and of itself, change isn’t necessarily bad. A good chunk of the transformation taking place in health care is arguably for the better – more emphasis on evidence-based practices, more emphasis on safety, greater attention to how patients experience the health care system, and more awareness of the role of organizational culture in fostering and sustaining high-quality care, to name a few.

But the dark underbelly of all this transformation is that the people carrying out the work can grow tired of the continual demand to adapt and change, particularly when they may not see any immediate benefit. Burnout has always been an occupational hazard in the high-stress environment of health care; change fatigue is upping the ante even more.

Consider what nurses in an online forum had to say about the growing practice of “bedside report,” or including the patient and family in the exchange of information between nurses as they go on and off shift.

“I only hope it will be a short lived fad, but we were told by our new manager this will not be an option,” grumbled one nurse who was struggling with the logistics of how the bedside report process is supposed to happen.

Elsewhere, nurses shared their experiences with working in a unit that closed because of hospital restructuring.

“We were given practically no notice and they did not help us with a transfer, it was up to us to find a new opportunity,” one person wrote. “I’ve been in a new unit for about 4 months and it’s a constant struggle being the new one on the unit, learning a whole new way of doing things and just learning a new specialty.”

The sense of continually coping with change seems to extend throughout the health care world. Although the patient-centered medical home is viewed by many as the direction in which primary care needs to go, early adopters are learning that it requires deep, structural and sustained change in order to be successful.

Take, for example, an assessment of the first national demonstration project involving medical practices that were transitioning to the patient-centered medical home model. Even in physician groups that were highly motivated, change fatigue was a serious concern, wrote the authors of the analysis, which appeared in the Annals of Family Medicine:

The work is daunting and exhausting and occurring in practices that already felt as if they were running as fast as they could. This type of transformative change, if done too fast, can damage practices and often result in staff burnout, turnover and financial distress.

Surprisingly, there’s been little substantive research on how organizations cope with major changes. But in a study published a few years ago in the Personnel Psychology journal, researchers who tracked employees at a large government office going through major organizational restructuring found that the changes had a huge impact, not only on people’s emotional well-being but on their job performance as well.

Workers who perceived the changes as negative were at higher risk of calling in sick more frequently and performing more poorly on the job, the researchers found. These folks also were more likely to quit.

Another risk is that organizations may simply run out of steam, with new initiatives that go nowhere or fall short of what they intended to accomplish.

One lesson the researchers learned from their study: Although change is usually inevitable, change fatigue isn’t. Organizations that managed change most successfully were those that kept workers in the communication loop and emphasized what was positive about the changes, the researchers said.

“Communicate, communicate, communicate,” is the advice of Angelo Kinicki, one of the authors of the Personnel Psychology study. “In life, stuff happens. What matters is not so much what that stuff is, objectively speaking, but what matters is how we interpret it.”

Reactions pour in to health care ruling

Reactions have been pouring in all day to the Supreme Court’s ruling this morning on the health care reform law.

If there was any doubt that Americans feel a strong personal stake in health care, it’s all been washed away in the commentary, tweeting and water-cooler discussions taking place over the last few hours. Stay tuned throughout the day for updates to this blog.

A sampling of how some of the major media outlets have been reporting the story:

- The big headline at the New York Times: “Health law stands.” Here’s the story, plus a collection of live updates, analysis and reaction.

- From the Washington Post, the main story, a graphic that breaks down how each of the individual Supreme Court justices voted, and an interactive feature to help readers figure out what the ruling means for them.

- If you’d like to read the entire text of the Supreme Court’s decision, it’s here.

- President Barack Obama is known for his use of the social media. Here’s what he tweeted this morning:

- Embarrassing? In early versions of the story, two media outlets got it wrong. What happened? The Associated Press breaks it down for you and concludes that in the rush to report the decision. some of the facts were confused. Alas, some politicos got it wrong too.

So who was first with the news? Early reports said it was the Associated Press, but Bloomberg News issued a statement claiming the honors with a story that moved at 10:07:31 a.m. EDT (and got the facts correct). The Associated Press moved its story at 10:07:55 a.m., a whole 24 seconds later. Does anyone really care? Rem Rieder, editor and senior vice president of American Journalism Review, thinks not.

- Stuart Taylor, legal analyst for Kaiser Health News, offers up this assessment of the Supreme Court’s ruling: “It was the most amazing Supreme Court theater I’ve ever seen.” Watch his video interview or read the transcript here.

Kaiser Health News also has compiled a Q and A on “After the Ruling: A Consumer’s Guide.”

- What does the public think of the Supreme Court ruling? MSNBC Health interviewed two of the millions of Americans who have pre-existing conditions and have been unable to obtain insurance coverage. Jerry Fielder of California and her husband, Charles, were turned down by 16 different insurance providers because Charles had a history of heart problems. The Fielders paid $73,000 out of pocket so Charles could receive surgery; then Jerry was diagnosed with lymphoma that went untreated for 10 months until she was able to qualify for coverage through the health care reform law.

Fielder told MSNBC that she “was on pins and needles” waiting for the Supreme Court to announce its decision. “Then I was like, Oh, my God, they upheld it? I can’t believe it.”

- The conversation on Twitter ranged from ecstatic to sarcastic:

(Do people really want to move to Canada? HappyPlace.com has some news for you…)

- Well-known politicians have been busy tweeting:

- Reaction from the medical community: The American Academy of Family Physicians supported the ruling with a statement saying that “as a result of this decision, more Americans will have access to meaningful insurance coverage and to the primary care physicians who are key to high-quality, affordable health services.”

Ditto the American Medical Association, whose statement also noted that the decision upholds funding for research on the effectiveness of drugs and treatments and protects coverage of preventive and wellness care.

Check out the Health Affairs blog for a more in-depth look at how the ruling is likely to affect providers.

Readers, what do you think about the Supreme Court’s decision? Please weigh in here or join the discussion on the West Central Tribune’s Facebook page.

A vision of future health care

I have seen a vision of the future of health care and it looks like… well, I don’t know exactly what, because it hasn’t happened yet. But it’s intriguing for sure.

Local health providers were offered an opportunity last week to redesign the health care delivery system in ways that help lower costs, enhance quality and result in better outcomes for patients.

Concepts such as “accountable care community,” “episodes of care” and “patient-centered medical home” were a big part of the discussion. But I’m going to skip, for now, an exploration of what these mean and focus on a different issue.

The individuals at last week’s meeting – physicians, medical directors, clinic administrators, hospital executives, hospital board members – were given a glimpse of the view at 30,000 feet. What I want to know, and what I suspect many others want to know, is what the view looks like in a real, boots-on-the-ground kind of way. In other words, how it will affect the patient experience – because all too often, as policymakers start tinkering with the system, this is an element that’s overlooked or misunderstood.

There’s a lot to recommend the new care delivery models that are being talked about and implemented at various sites around the U.S. These models are moving away from the current fragmented, respond-to-the-patient’s-most-immediate-problem approach and moving toward more coordination, prevention and effective chronic disease management.

It would be hard to argue with these goals, yet in the real world something can be lost between theory and practice.

Take the patient-centered medical home. Part of this concept involves team care – physicians, nurse practitioners and other clinicians applying their unique skills on behalf of overall patient care. Sounds like a good idea, yes? But early results from medical practices that have implemented the medical home model found that at many of the pilot sites, patient satisfaction actually went down.

This doesn’t necessarily mean the model itself is fatally flawed or that patient satisfaction won’t improve once the transition phase is past. It suggests, however, that patients themselves aren’t sure they like the experience of belonging to a medical home. Some of it may be confusion or a lack of information on what the concept means. Some of it may be frustration with seeing clinicians other than the doctor at their appointments.

These early patient satisfaction findings could be shrugged off as unimportant or as evidence that patients are resistant to change or incapable of understanding the medical home model.

But they could also be looked at another way. If patients don’t understand why their clinic is turning into a “medical home,” what has been done to educate and prepare them for this change – and whose responsibility is this? If patients are uneasy at seeing multiple clinicians, perhaps it’s because they’re concerned – and rightly so – over the loss of continuity and the potential for lapses in communication, not to mention the disruption of one of the relationships that, for many patients, matters the most – the relationship with the doctor.

I’m not in a position to suggest to local health care providers what they ought to do. No doubt there’ll be many serious strategic discussions in the weeks and months ahead as they hash out their options.

On behalf of patients, though, I’m making a plea: At some point, preferably before final decisions are made, there should be community input – and not just from local movers and shakers but from a cross-section of patients with an honest, real-life perspective on what they want and what they value.

Among the important questions asked at the meeting last week was this: How do you motivate patients to do the right thing? Inevitably, patients are part of this and their buy-in will be critical.

However it shakes out, there’s an opportunity here to do something. Is it going to be done for patients or is it going to be done to them? Better yet, how about doing it with them? Now that would be transformational.

Image: “The Crystal Ball,” John William Waterhouse, 1902

Trend-spotting in health care

We’re still a few weeks away from 2012, but apparently it’s not too soon to take a look at some of the trends shaping what happens in health care next year.

Pricewaterhouse Cooper LLC issued a report last week on the top 12 trends to watch in 2012. Their summary of the findings:

In 2012, health industry organizations will connect in new ways with each other and their consumers as they wade through economic, regulatory, and political uncertainty. Some are stepping forward in cooperation; others are rewriting the rules of competition.

Among the key issues, we’ll see value move from theory to reality, investments ramp up in informatics, the effects of drug shortages, insurers gear up to compete in a new insurance exchange marketplace, pharma companies slim down and healthcare increasing its social media presence.

That’s the view from 90,000 feet. But what does it all mean for the ordinary person? Here’s how some of these trends might show up at the level of the patient/consumer experience:

- Expect to see information technology, i.e. computers, become much more widespread, from the hospital room to the exam room.

- Out-of-pocket costs for health care will continue to rise, forcing many people to think harder about whether to seek care at the doctor’s office or the emergency room. In a survey by Pricewaterhouse Cooper, nearly half of the respondents said they had decided to skip a doctor visit or prescription drug in the past year because of the cost, and one in 10 had done so at least five times.

- Value will be important. Health organizations are under growing pressure to deliver quality, affordable care that keeps their patients satisfied; those that fall short could wind up being financially penalized. Patients can expect to see more surveys asking them for their opinion.The real test, of course, will be whether patient preferences lead to meaningful changes in how care is provided.

- Look for care delivery systems to become more integrated. There are many incentives to do so: efficiency, savings and better coordination of care. According to Pricewaterhouse Cooper, health insurers invested $2 billion last year to acquire or align with physician groups, clinics and hospitals. For patients, there could be more confusion in the short run as the players reposition themselves on the chessboard. In the long run, though, it’s believed that care will be better when it’s less fragmented. Whether this actually will become the case remains debatable; the concept of “accountable care organizations,” contained within the 2010 health care reform bill, has plenty of critics.

- A retail spin is coming to the health insurance market. States are expected to start certifying health plans in October 2012 for participation in health insurance exchanges, allowing consumers to shop for their own health care coverage. This could be a real benefit for people who aren’t otherwise able to obtain affordable health insurance. But the option could be underutilized if consumers don’t have enough information or education to compare plans and make good decisions.

- Is your hospital or clinic on Facebook? If not, they risk getting left behind. The social media are emerging as an important way of reaching out to patients and the community. One-third of the respondents in the Pricewaterhouse Cooper survey – and half of the respondents under age 35 – said they had used social media channels to connect with health care organizations or with other people with shared health interests.

Euro RSCG, a global marketing and communications agency (and the same company that forecast the concepts we now know as corporate social responsibility and helicopter parenting), last week issued its own trend outlook.

The top five trends identified: a rising use of medical tourism, telemedicine and personalized medicine; an increasing worldwide incidence of diabetes; and a rise in cyberchondria, or the tendency of people to Google their symptoms and misdiagnose themselves. According to Euro RSCG, all five of these trends signal a cultural shift in the attitudes, beliefs and values that shape how we think and talk about health care.

Photo: Wikimedia Commons

Better access to the lab report

Raise your hand if you’ve ever waited a really long time to receive the results of lab tests and then were told only that the results were “normal.”

Under a proposal within the federal health care reform law, all patients could soon have direct electronic access to their lab results - without first having to go through their doctor. The proposed new rules were announced last week by the U.S. Department of Health and Human Services.

Essentially, they’d replace a confusing patchwork of privacy regulations that vary from state to state, and strengthen the patient’s right to see their laboratory test results, numbers and all.

When it comes to health care, “information is power,” HHS Secretary Kathleen Sebelius said last week, speaking at a national information technology summit where the rules proposal was unveiled. “When patients have their lab results, they are more likely to ask the right questions, make better decisions and receive better care.”

Talk about a major shift in how information is shared with patients. A handful of states* currently allow direct access to lab results, but it’s safe to say most consumers usually have to leap hurdles to get their test results, especially if they want actual numbers instead of a vague, all-purpose “fine” or “normal.”

Donna Cryer, who blogs at DCPatient, wrote this week about her surprise at receiving a phone call from the doctor’s office within three days of undergoing some tests. “I say surprising because normally I have to beg, plead, call or at least charm a nurse to get my results at all,” she writes.

The caller announced that the results were “fine.” Now in 27 years with a chronic disease “fine” is not a word I usually heard in conjunction with my blood work, so I asked if I could see them. (note: every patient should do this) “OK” was the quick answer. I could fax or email them to you. Yee Haw!! Now we were getting somewhere.

Patients are continually being told that if they want to receive better care, they need to be more engaged. But it’s hard to see how patients can develop an effective partnership with their doctor when they don’t have access to information as basic as lab test results, or when the only way to obtain it is through the filtered version they receive from the doctor’s office.

Of course, having the information isn’t the same as knowing what it means or what to do with it. Many doctors are ambivalent about sharing the full lab report, often out of a belief the patient doesn’t need to know all the numbers or won’t be capable of understanding them.

Dr. Marya Zilberberg, writing for The Health Care Blog, says that all in all, she’s “looking forward to the liberation of my lab data. What I worry about is all the calls I will be getting from friends and family to help them understand them.”

Some physicians have already raised objections to the proposed new HHS rule. One of them is Dr. J. Fred Ralston, former president of the American College of Physicians, who told InformationWeek magazine, “Lab results often contain a lot of information. A patient downloading many raw lab results over the Internet may be overwhelmed by lots of tiny insignificant tiny abnormalities that could each demand an individual explanation – and cause significant worry until those concerns are dealt with.”

But is this a valid reason to withhold the data?

Although there might be some initial confusion, many patients want to learn more about what their lab results mean and they’re eager to become educated. Overall, the trend is clearly in favor of more rather than less access, with polls and studies suggesting that online viewing of lab results, online scheduling and the ability to email their doctor are increasingly important to consumers, especially those who are younger.

If lab reports are difficult for the average layperson to understand, perhaps this is because they’ve historically been designed with clinicians in mind. One spin-off of improving patient access to lab results might be the development of formats that are more user-friendly to patients.

Allowing patients direct access to their test results also could help put an end to the unsafe practice of “if you don’t hear from us, you can assume all your results were fine.” It’s thought that as many as 20 percent of lab results fall through the cracks because of faulty systems for following up. Sometimes, as in this case or this one, the consequences can be fatal. Opening up the lab report to patients is no guarantee that oversights won’t still take place, but it’s one more backstop that might help reduce lapses in communication.

Who owns the lab results, anyway? The responsibility for ordering and interpreting lab tests still rests with the clinician. But no one has more ownership than the patient and it’s becoming increasingly difficult to justify all the barriers between patients and their lab results.

What do readers think? What experiences or difficulties have you had in trying to obtain lab results? Would you take advantage of direct access to your test results if it were available? Please share your comments in the discussion section.

*Delaware, Maryland, Nevada, New Hampshire, New Jersey, Oregon, West Virginia, Puerto Rico, District of Columbia.

Photo: Wikimedia Commons

Telling the patient’s story

I don’t know very much about Ginny, other than her name. But after seeing her video on You Tube, I certainly know her story: how a seemingly straightforward ankle fracture escalated into a nightmare of complications and ultimately the loss of part of her leg.

Ginny’s story and video were shared by Maureen Bisognano, chief executive of the Institute for Healthcare Improvement, during a visit to Willmar last month to speak to a statewide nurse educators’ conference:

It was impossible for the audience not to react as Ginny described the consequences of a hospital-acquired infection that spread to the bone in her leg. People literally gasped at each new medical disaster that piled onto the patient: 28 surgeries over the course of five years, an amputation that failed to remove enough damaged tissue and bone and required a second surgery during which Ginny went into respiratory arrest.

She’s not angry, or at least doesn’t sound angry. She’s honest, though, when she says on camera that this experience “has altered my life forever.”

Why did she decide to make a video about it? Because, Maureen Bisognano explained, “she felt like nobody understood Ginny’s story.”

Think about that for a couple of seconds. Here’s a patient who has clearly had intensive contact with the health care system – but of all the well-meaning clinicians with whom she dealt, apparently none of them really knew or thought to ask about the entire experience from start to finish, what it was like for the patient or the permanent damage a preventable hospital-acquired infection wrought on her life.

In the drive to make health care safer, better and more efficient, where’s the voice of the patient?

I bring this up because the industry is increasingly moving toward payment based on “value.” One such effort is under way with the Medicare program, which is finalizing the details to tie part of its hospital reimbursement formula to patient-satisfaction scores. If routine surveys show patients are dissatisfied with the care they receive, hospitals might not be eligible for reimbursement bonuses.

There’s clearly a place for standardized surveys. They provide useful, consistent information for hospitals, and they help organizations benchmark themselves against their peers.

But I’m not sure any HCAHPS survey or Press Ganey questionnaire could have captured Ginny’s story or the thousands of other stories that expose what the patient experience is really like. For that, you need to leave the world of statistics and consciously seek out and listen to what patients themselves have to say – and not just about the good experiences but also about the bad. Especially the bad, because this is where some of the greatest opportunities for learning often lie.

Here, for instance, is Dr. Ramona Bates, a plastic surgeon from Arkansas and blogger at Suture for a Living, who recently blogged about her husband’s colonoscopy and her frustration with poor communication by a nurse:

When I was called back by the nurse, she mispronounced my name calling me Rhonda (which I forgave easily). She did not introduce herself to me.

As we entered the recovery area, she did not take me to my husband and assure me he was okay. She took me to the desk and abruptly said, “You need to sign this.”

No explanation of what “this” was, so I replied, “What is it I am signing? I don’t sign anything until I have read it.”

She then said, “It’s the discharge instructions. He’s already been given them.”

Note she had not reviewed them with me. I would be the caregiver. Note also that I had no way of knowing if she had reviewed them with my husband (who is not an engaged ePatient Dave) prior to sedation or in his current state of post-sedation fogginess.

She said, “Sign it when you’ve read them then” and quickly moved on to some other task. I felt like a box that was simply being checked off.

Patient handoffs are well known to be a vulnerable point on the continuum of care. Yet without drilling down to the level of patient and family stories, it can be very hard to uncover specific issues that need to be addressed and improved.

Here’s another story, this one from Anthony Cirillo at the Hospital Impact blog, who writes about his mother’s hospitalization. Cirillo has been in the hospital industry for 25 years but he writes that “you truly don’t know what is going on until it happens to you.”

The “defining moment” during his mother’s hospital stay and surgery: when someone from the finance department approached the patient while she lay in her hospital bed, waiting for a high-risk surgery, to discuss how she was going to pay her Medicare deductible.

Cirillo writes:

… Most of us who work in healthcare don’t know “jack” about how it is really delivered. Keep your metrics, those consultants who want to come in and show you how to score better to attract patients, and all the rest of the positioning.

Hospital marketing comes down to word of mouth, and that word of mouth is generated from the experience that people have at the facility. And if any one component breaks down it will affect perception, reuse, and of course impact the ultimate question – will you recommend us to others?

Hospitals and clinics can’t and shouldn’t design their services on the basis of anecdotes. But organizations that are tone-deaf to individual patient stories are missing an important chance to learn about gaps and vulnerabilities in the system – gaps that are frequently masked by standardized metrics such as patient satisfaction surveys and that are allowed to persist because no one is capturing this information.

I’ve blogged here previously about an adverse event I experienced several years ago. Not one single clinician has ever asked to hear the story of what happened. If they had, they might have learned something about the sequence of events and how this situation could have been prevented or at least mitigated. They might have learned something about the patient’s perspective when things go wrong and how to make a negative experience a little less negative.

When organizations rely too much on standardized surveys and data collection to measure their performance, the risk is that they’re not getting the full picture. They’re not seeing health care as the patient experiences it in all its good, bad and sometimes ugly reality. Moreover, they’re failing to make use of one of the richest sources of information available – stories from patients themselves.

Most patients, I suspect, are more than willing to talk about their experiences – not because they want to bash or be critical, but because they see an opportunity to help systems change and become better. What they have to say can be illuminating and motivating - if health care organizations would only recognize the value and take the time to listen.

Paid to get healthy

In theory, everyone can be bought if the price is right. So would you stop smoking, lose weight or do something to lower your cholesterol if you knew there were an incentive involved?

Under the federal health care reform law, a $100 million grant opportunity is being offered to states, allowing them to experiment with a rewards system for Medicaid recipients who make health-related lifestyle changes. States have until May 2 to submit an application if they’re interested.

Kaiser Health News explains how the project is supposed to work:

Medicaid enrollees who demonstrate a commitment to improving their health will be eligible to receive financial rewards, such as coupons or gift certificates. For those who are overweight or trying to quit smoking, that commitment might take the form of weight management classes or tobacco cessation counseling. States are encouraged to provide rewards “on a tiered basis” for attempts at participation, “actual behavior change,” and “achievement of health goals.”

The idea is to try to reduce chronic disease among this low-income population, a move that presumably will help save money.

Sounds like a good idea, yes? But the big question is whether this approach actually works.

The concept isn’t exactly new. A handful of states are already using some form of incentive for Medicaid enrollees. Idaho, for instance, offers $200 worth of vouchers that someone on Medicaid can use to visit a doctor to discuss weight loss or smoking cessation. And in the private-sector business world, a number of corporations have tried a rewards system to encourage healthy behavior among their employees.

Unfortunately, there’s only limited evidence so far that this approach results in any sustained or long-term payoff. According to the Kaiser Health News article, participants in Idaho’s Preventive Health Assistance initiative seem to like the incentives but there’s been little indication they’ve led to changes in health-related behavior or lower Medicaid costs. In Florida, where a five-county program allows Medicaid enrollees to earn up to $125 in credits annually for getting flu shots and the like, most of these credits have been spent on immunizations and routine doctor visits that people would probably have sought anyway.

A rather interesting study that examined the impact of financial incentives on smoking cessation rates found that study participants who received money were much more likely to quit. The study, which appeared in February 2009 in the New England Journal of Medicine, tracked 878 employees of a multinational company who were randomized to simply receive information about smoking cessation or information plus money – $100 to complete a smoking cessation program, $250 if they weren’t smoking six months after enrolling in the study, and $400 if they remained abstinent six months after completing the cessation program.

Although this sounds promising, a couple of points are worth keeping in mind. First, this study was carried out in the corporate world and might not necessarily translate to the low-income Medicaid population. Second, smokers weren’t tracked long term, so there’s no way of knowing how many might have fallen off the wagon after the study ended.

Indeed, long-term sustainability appears to be one of the most challenging issues with health-related incentives. At the moment, there isn’t enough research to address this one way or the other. From the Kaiser Health News article:

Few behavioral studies have attempted to determine whether people who receive the incentives are able to maintain their short-term success long term – the ultimate goal of incentive-based prevention programs. Fewer attempts have been made to address how the design of an incentive program should be adjusted according to the demographics of the target population, such as [e]nsuring that low-income participants have transportation to get to appointments and classes.

The larger problem I see with incentives is that they tend to operate in isolation from other health-related factors such as the work and home environment, family dynamics and psychosocial stressors. Employers can offer their employees a $100 bonus to quit smoking, but if company policy continues to allow people to smoke outside the back door or on the loading dock, the environment isn’t exactly conducive to quitting. Low-income households can be given vouchers for fresh fruit and vegetables, but if there isn’t a neighborhood store with fresh produce or people don’t know how to properly store and prepare fresh produce, the vouchers are mostly a short-term, limited fix. Sustained behavior change generally needs to happen at a deep level, deeper than what a $100 bill or a handful of coupons can accomplish.

It’s entirely possible that some states will design an incentive program that leads to meaningful improvement in the health of the Medicaid population. But if I had $100 million in federal grant money to dole out, I’d rather see it spent on projects that improve social and community environments in ways that are sustainable and long-lasting.

Photo: Wikimedia Commons

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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!

Repealing health care reform?

American voters were expressing many things when they cast their ballots on Tuesday, and one of them undoubtedly was anger, frustration and misgivings about the health care reform law.

The election returns were barely tallied when the issue was placed squarely on the table: Should the Patient Protection and Affordable Care Act be repealed?

Ever since the health care reform bill was signed into law this past March, virtually every poll or survey has shown that Americans are deeply divided in their support. This doesn’t necessarily mean, however, that they want to see the entire package thrown out, as an analysis by the nonpartisan Kaiser Family Foundation found last month.

The overall message from the analysis: While many Americans are unhappy with the law, they also support retaining some of the major provisions – and there’s at least some openness to first giving the law a chance to work.

The Kaiser Foundation analysts examined eight major opinion polls conducted in September and early October. They found that support for repealing the Affordable Care Act ranged from a low of 26 percent to a high of 51 percent.

It’s hard to know what to make of these results, and the analysts concluded that how the questions are worded in each survey, and the order in which they’re asked, might be influencing how the participants respond:

It’s possible that the surveys that ask Americans right off the bat are to some extent picking up a generic opposition to the bill that doesn’t have another channel to flow through. On the other hand, it could be possible that by not asking those with favorable views of the law whether they want it repealed, other surveys are missing some liberals who might be satisfied with the bill but prefer to repeal it in favor of something that goes even farther.

The analysts also noted that “the two wordings which obtain the lowest percentages in favor of overturning the law both include language about ‘giving the law a chance’ rather than offering a more black or white, ‘keep or repeal.’”

The public’s opinion on specific major provisions of the law reveals more nuances. A Bloomberg national poll conducted about one month before the election found that 78 percent of the respondents wanted to maintain high-risk pools that provide access to health insurance for individuals with major health problems. Three-fourths supported the provision that bars insurance companies from refusing coverage to those with pre-existing conditions. On the other hand, half wanted to repeal the “everyone must have health insurance” mandate, and 62 percent wanted to repeal the extra tax on Cadillac health plans.

A couple of take-home points from the Kaiser Foundation’s analysis: Poll-watchers should be careful to differentiate between those who are actively demanding repeal and those for whom “repeal” is another way of saying they don’t like the law. Also, public opinion could continue to shift as more provisions of the law go into effect and people have a chance to bring some personal experience to the discussion.

What do readers think? Should the Affordable Care Act be repealed in its entirety? Are there some provisions you’d like to keep? Why or why not? Leave your responses in the comment section below.

Doc around the clock

If you’ve ever spent a weekend in the hospital, you couldn’t fail to notice how quiet it was. No surgeries, other than those that are urgent. Fewer tests being scheduled. Fewer staff in the building. The underlying mood that we’ve-all-throttled-back-because-it’s-the-weekend-and-we’ll-get-back-to-normal-on-Monday.

But what if hospitals were ramped up around the clock, instead of concentrating most of their activity during traditional hours? This concept is the focus of an intriguing opinion piece that appeared this past week in the New York Times. The author, Peter Orszag, may be familiar to readers as the previous director of the White House Office of Management and Budget.

It’s been well established that weekends aren’t an optimal time for patients to receive care, Orszag writes:

It’s never good to be hospitalized, but you really don’t want to be hospitalized on a weekend. There are fewer doctors around, and people admitted on Saturdays and Sundays fare relatively poorly.

One study in 2007 found, for example, that for every 1,000 patients suffering heart attacks who were admitted to the hospital on a weekend, there were 9 to 10 more deaths than in a comparable group of patients admitted on a weekday. The weekend patients were less likely to quickly receive the invasive procedures they needed – like coronary artery bypass grafts or cardiac catheterization.

If patient safety is one of the weekend hazards, cost and efficiency are the others. Orszag calls it the “the economics of a $750 billion-a-year industry letting its capacity sit idle a quarter or more of the time.”

“If hospitals were in constant use, costs would fall as expensive assets like operating rooms and imaging equipment were used more fully,” he writes. “And if the workflow at existing hospitals was spread more evenly over the entire week, patients could more often enjoy the privacy of a single-bed room.”

This isn’t just idle speculation. Orszag describes what’s happening at one institution, New York University Langone Medical Center, to provide more care on weekends. At Langone, magnetic resonance imaging and elective cardiac surgery are now available on weekends. The facility’s radiologists read medical imaging studies seven days a week. The cancer center provides some treatments during the weekend. Women planning to undergo an elective Caesarean delivery can now schedule it on a Saturday.

Information being tracked at NYU Langone has uncovered some hitherto-unnoticed issues with how the hospital deploys its resources, Orszag writes.

The dashboard data revealed, for instance, that on any given day a disproportionately small number of eligible patients were discharged before noon, so that many people were kept in the hospital longer than necessary. Further analysis revealed a key reason: several routine procedures that some patients need before leaving, like the insertion of central catheters, were not performed in the morning. The medical center has since begun to offer the procedures earlier, and the percentage of discharges before noon has increased significantly.

Reaction around the blogosphere to Orszag’s column has been, uh, interesting. Many people have seized on Orszag’s opening comments, which in essence said doctors should suck it up and work more weekends, as the equivalent of endorsing involuntary servitude. The response, at least from more than a few health care professionals, could probably be summed up by a blog commenter who said, “My first thought was, yeah, good luck with that.”

I can feel a twinge of sympathy. I’ve worked evenings, weekends and holidays my entire adult life. In the news industry it just comes with the territory and I’ve learned to live with it. This doesn’t mean I always like it, though, and I suspect most people would rather not work evenings and weekends if they can possibly help it. I don’t think this was Orszag’s main point, however.

It’s true there’s idle capacity in health care, particularly among hospitals, and that the normal 8-to-5 schedule doesn’t always match patient need. How many of us have wished we could make a doctor’s appointment in the evening so we wouldn’t have to take time off work? There’s a certain irony in telling consumers to call their doctor for non-urgent problems rather than seek expensive emergency-room care – yet giving them no other option if something crops up when the doctor’s office is closed for the day or for the weekend. There’s a certain irony in advising people to try to avoid being hospitalized on a weekend, yet ignoring the fact that illnesses and injuries don’t happen solely during daytime hours Monday through Friday.

Whether this is enough to justify a shakeup of the industry model is a whole ‘nother question, though. Do hospitals and clinics have the wherewithal to expand their hours into the weekend? How feasible is it, in terms of both workforce and financial resources? Would patients use a weekend service? Would it actually improve patient care and outcomes?

On the other hand, it should be troubling to all of us that patients who are hospitalized on a weekend might not receive the same level of care as on a weekday. And the many little overlooked inefficiencies in the system – such as having no one available to insert central catheters until after lunchtime – are frustrating and frankly make little sense, either for patient care or for the financial bottom line.

Maybe some discussion on these issues has been long overdue. Access to care on evenings and weekends isn’t a new problem that only recently sprang up. There has been a long-standing gap in how care is provided outside traditional hours, and solutions such as urgent care clinics and nurse hotlines, even when they do fill some of the need, are not the total answer. Critics might not like what Peter Orszag is saying but he’s nailed an issue that seems to merit further consideration.