A recent Tele-Talk posed the question: “Has there been a noticeable change in services at Memorial Hospital in the past few 
years?” I believe the community responses to that question may be seen as a microcosm of what is going on in health care throughout the nation and why it needs to be fixed. The issues people raised are valid and are national health care challenges that must be addressed both locally and nationally.
General Comment:
1. The Hospital focuses on minor problems
Health care has become incredibly complex. There was a time when physicians could know everything about their specialty. In fact, prior to World War II, most physicians were general practitioners who completed four years of medical school and one year of internship and did whatever they felt they could handle. Many of you remember the legendary Dr. Duprey who did everything from obstetrics to general surgery to orthopedics to pediatrics. By the 1960s, specialization had taken hold and physicians focused on a narrower area of expertise to take advantage of new technology and new procedures. Today, we are in a world of sub-specialization (e.g. Maine Health) and sub-sub-specialization (Massachusetts General Hospital). At Mass General, neurosurgeons sub-specialize so much that each surgeon does the same type of neurosurgical procedure procedure over and over again to ensure accuracy and safety.
Clinical research has demonstrated that for higher risk diagnoses and procedures (e.g. critical care and less often performed surgeries) patients have better outcomes in settings where there is a high enough number of cases handled. The actual number varies by diagnosis and procedure (e.g. if you perform open heart bypass surgery you should do at least 50 cases/year) and there is growing research in this area. The bottom line is that physicians and other health care practitioners increasingly refer higher risk problems to medical centers where there is 24/7 sub-specialization and coverage and keep cases in community settings that are frequently encountered and can be well handled in a consistent way.
National trend to address this issue:
Smaller hospitals and health care organizations increasingly partner with larger organizations and systems to provide a more seamless and integrated model of care, thus enabling communities to take advantage of convenient access for routine treatment and sub-specialty access through onsite referrals and clinical protocols.
2. There are occasional errors
Until 1999 when the Institute of Medicine released its landmark report “To Err is Human,” disclosing that between 44,000-98,000 people die in U.S. hospitals annually as a result of medical errors, our entire nation was in a state of denial about medical errors. Physicians and nurses were expected to conform to a “perfectibility model” that assumed that if they worked hard and did the best they could, they would never make a mistake. This was simply not true and paradoxically caused more harm through the “deny and defend” model of medical malpractice lawsuits. Today, organizations like Memorial Hospital perform root cause analyses to honestly look at medical errors in a confidential way and work to modify and improve their systems of care so that errors do not recur. Ironically, there are fewer errors today than in my early years of clinical practice in the 1970s because we look for them to better manage and mitigate them.
National trend to address this issue:
Rigorous medical error reporting systems are being established with centralized reporting structures (Patient Safety Organizations or PSOs) so that errors can be collected, analyzed and prevented. Hospitals perform root cause analysis (RCA) to look back on errors or increasingly failure modes and effects analysis (FMEA) to anticipate potential errors and address them before they occur. An outstanding book describing a truly safe hospital of the future is “Why Hospitals Should Fly-The Ultimate Flight Plan to Patient Safety and Quality Care” by John Nance, Second River Healthcare Press, 2008.
3. Health care is too expensive
The major culprits of health care expense are new technology, medical malpractice fears and cost shifting. New technology is tremendously beneficial because it enables physicians and health care practitioners to learn more about a diagnosis in a less invasive way. I remember the pre-CT scan days of exploratory laparotomy when surgeons would open a patient’s abdomen to find out what was wrong. Except in rare life threatening situations, this is almost never done today. However, technology is over-utilized because of public expectations and fear of a medical malpractice suit. For instance, when a child injures his/her ankle, a parent may bring the child to the physician for an x-ray; not necessarily for a clinical evaluation. After all, isn’t that how a potential fracture is diagnosed? Sometimes the child may not need an x-ray, but rather a period of observation. However, with the expense and aggravation of waiting in an emergency department or waiting area, a parent wants to be sure and so wants the x-ray anyway. This drives up the cost of health care for everyone (and exposes the child to a minor radiation risk). The physician is likely to go along with this, because in the unlikely event that a fracture is missed (even if it is of no long term consequence), the parent may blame the physician and hospital for the delay in diagnosis and treatment. Finally, because there are so many uninsured people in the country (approximately 52 million at last count), every person who is billed for a service is paying for the service more than once to compensate for the number of people who can’t (charity care) or won’t (bad debt) pay their bill. In 2011, the national average for unpaid medical care was 7 percent (3.5 percent charity care and 2.5 pecent bad debt) and this causes everyone else’s bill to go up.
National trend to address this issue:
Greater national support for evidence-based clinical and functional protocols (standardized best practices based upon clinical research) to guide physicians, nurses and patients in more cost effective care.
The creation of a medical jurisprudence system to balance individual and systemic accountability and provide insurance coverage for patients who are victims of inadvertent harm.
Greater public support for universal health care coverage for basic preventative and stabilization services with the creation of state-run insurance exchanges to support lower cost private insurance to supplement basic coverage.
4. Some key physicians are leaving the hospital
Not so long ago, physicians tried to be all things to all people all of the time. They worked full days in the office, provided on call services for emergencies and unassigned patients at night, went to the operating room to perform scheduled and emergency procedures, and dedicated leadership and committee time to the hospital and medical staff. Today with declining reimbursement, increasing costs, increasing public expectations around quality, service, and access and the desire to attempt to balance a professional and personal life, physicians are making non-traditional choices to limit their practices in new ways. Many out-patient physicians are giving up their hospital membership and privileges to dedicate their time to their ambulatory practices. Some surgeons are restricting their practice to fewer procedures (e.g. knee or ankle). Some physicians are considering a smaller or part time practice. Other physicians are pursuing other professional interests (as I did when I moved from emergency medicine to healthcare consulting). In short, physicians are responding to significant environmental changes by modifying their lives and the way they work.
National trend to address this issue:
Healthcare organizations are becoming far more flexible and adaptive in working with physicians and mid-level practitioners to create new ways to work together to ensure a more sustainable relationship during rapidly changing times.
5. Some hospital leaders/physicians are paid too much and some employees are paid too little
Most people don’t realize how strictly healthcare organizations are regulated and monitored by the federal and state governments. Management, physician, and employee compensation in a not for profit entity or 501 (c)(3) is scrutinized carefully by the internal revenue service (IRS) and the state attorney general’s office to ensure that private benefit or inurement is not provided to any individual. Everyone in such an organization must be compensated at fair market value (FMV) rates based upon local, regional, and national compensation data. Within these rates is a range that permits the board (for the CEO) and the CEO/Human Resources Department (for others) to incentivize individuals based upon articulated performance expectations to encourage everyone to work towards important performance goals and objectives. The reason that some individuals are paid higher than others has to do with the relative number of individuals in the market with the skills to be able to perform a job. For instance, according to the 2011 Memorial Hospital 990 form (based upon 2010 performance), the hospital has approximately $67 million in total revenues. How many individuals in New Hampshire have the skill set to manage a healthcare organization of this size and complexity? How many physicians can safely operate on a fractured hip/knee? How many nurses can care for sick or traumatized patients or deliver a baby? The relative number of individuals who are trained and skilled to perform these jobs determines the relative value or compensation for the position. In addition, in many healthcare organizations, employee salary is approximately 60%-65% of the total compensation as the remainder is covered by benefits (35%-40% of total compensation) that often include: medical insurance, paid vacation and time off, workman’s compensation insurance, and employer payroll contributions to social security and Medicare.
National trend to address this issue:
There is increasing transparency so that communities understand the benchmarking process for compensation models with fewer perquisites (or perks as they are fondly called) and more accountability and aligned incentives for everyone.
6. Service isn’t what we’d like it to be
Decline in service parallels a decline in reimbursement with an increase in overhead costs. Physicians used to spend a great deal of time with patients talking to them, meeting with family members, and even making house calls. Today that is a luxury that fewer can afford. In fact, many physicians and healthcare organizations hire mid-level practitioners who can spend the additional time patients crave, enabling physicians to manage a larger and increasingly complex population of patients. Because we have to do more with less, there is a new industry teaching professionals how to provide better service with fewer resources and working ‘smarter’ and not ‘harder’. As it turns out, service is critically important because it leads to higher compliance rates with recommended treatments, higher trust and sense of well-being, better outcomes, less liability costs, improved loyalty, and better reputation. The cliché today is that quality gets you in the door but service helps you to succeed.
National trend to address this issue:
Organizations are re-designing their processes to enable a higher level of service with fewer resources. In addition, the configuration of the work force (e.g. fewer physicians, more mid-level practitioners and nursing/administrative support personnel) is changing to enable professionals to spend more time doing what they are trained to do and to provide patients with the time they want and need.
7. Death panels will restrict your choices as you get older
Death and dying is a real problem for us. In almost every other industrialized nation, death is considered part of the normal life cycle with greater support for hospice and palliative care and a humane approach to the end of life. In our country, we spend 30% of our lifetime healthcare costs in the final six months of our lives. Many people die in intensive care units on ventilators or receive heroic measures that neither add significantly to the quality nor length of life. Paradoxically, 35 nations have a longer life expectancy than we do as a result of expending more resources on prevention and public health measures (decrease smoking and over eating etc.) and fewer resources on critical care which benefit relatively few (<0.1%). Rather than an inflammatory dialogue (e.g. ‘death panels’) we need to have a rational and humane discussion around how we can help individuals to have a respectful and fulfilling end of life surrounded by family with appropriate measures to control pain and suffering.
National trend to address this issue:
There is a slowly emerging trend towards palliative and hospice care with increasing numbers of people who are choosing to die in the comfort of their home with hospice care and home health services.
Conclusions:
The issues and frustrations addressed by readers in the Tele-Talk article reflect national trends that must be addressed to secure the kind of healthcare system that we all want. Political rhetoric is not helpful. The community can work with hospital leadership to ensure that Memorial Hospital, like every other healthcare organization is on the right path so that care can be provided that is more affordable, humane, and accurate. We are in a global economy and every business (healthcare or not) must find a way to offer superior services at lower costs in order to survive. Without the support of the community, an organization has no chance and it is up to people whether to work with the organization to secure the care and services it needs or to go without. A not for profit organization is a community benefit that cannot be taken for granted and must be guided and supported if it is to succeed.
Jonathan H. Burroughs, MD, MBA, FACHE, FACPE is President and CEO of The Burroughs Healthcare Consulting Network, Inc. and works with some of the nation’s top healthcare consulting organizations to provide ‘best practice’ solutions and training to healthcare organizations throughout the country in the areas of governance, physician–hospital alignment strategies, credentialing, privileging, peer review and performance improvement/patient safety, medical staff development planning, strategic planning, and physician performance and behavior management.
Sumber: conwaydailysun.com
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