Saturday, March 31, 2012

Naive, Childlike, and Wholly Unrealistic

Let's take a trip together to a hypothetical United States of the future where the health care industry's* prime interest lies in prevention versus treatment of illness.

In this election year, with my irrational hope of meaningful health care reform under the Affordable Care Act, I've been thinking a lot about what health care would look like if health promotion (a skill not usually emphasized by the leaders of our medical-industrial complex) were as highly valued as illness treatment.

I realize my fictional health promotion system will never come to pass. I know that heroic fire-quenching action with its swift, tangible gratification is usually chosen by human beings over the weak satisfaction of making something not happen. But, then again, fantasies help us set goals. So here's my dreamy, wacky, silly, naive, childlike, unrealistic list of what would happen in a reformed U.S. health promotion system, in no particular order, all drawn from what I have myself observed in my 30 years in health care:

  • No one would wait until after their coronary artery bypass graft operation or their heart attack to get a referral to cardiac rehabilitation. Ditto for pulmonary and post-cancer rehabilitation.  And how about we start a rehabilitation program for everyone, not just those with certain diseases?  These programs work for people who benefit from social interaction paired with healthy lifestyle education and exercise. These programs also relieve the fears of people with certain diseases about exercise (in other words, people with heart and lung disease learn that exercise is safe for them.) 
  • People undergoing chemotherapy would not be surprised to find that hair loss is the least of the side effects they will experience. Disabling fatigue is the most common and troublesome cancer symptom, but people do not know this before they start chemo. Other side effects are infertility, depression and instant menopause for even young women. Everyone, in my fantasy health care system, would understand the benefits and risks of their own treatment regimen before one molecule of chemo enters their body. This would mean skilled educators explaining, demonstrating and showing patients what to expect as many times as it takes, for as long as it takes, using many different methods. 
  • Ditto for surgery. Relying on surgeons to do the explanation of risks and side effects is the fox guarding the henhouse. 
  • Just as my mail-in pharmacy phones me to remind me when it's refill time, people would be reminded by phone and email when their children need vaccinations, when they need that regular screening physical or colonoscopy, when to visit the dentist, when to get an eye exam, and so forth. We are overcome by information and demands on our time - the health care system must help people put priority on health maintenance, or it is easily forgotten.
  • Vitamin deficiencies are entirely preventable. A once-daily multivitamin for every citizen should be covered by the health care system. Calcium for women, too.  Both of these are cheap. 
  • Not-for-profit public exercise clubs with group classes would be available to every citizen for a small fee per visit. For personal trainers we would pay out-of-pocket. 
  • Every person could call a single toll-free number to get health coaching by a nurse or person with a degree in health education (i.e., the people who are educated to do this well). The program would not be linked to their employer in any way. Because I suspect assurances of confidentiality from employers who dole out discounts for taking part in insurance company-run health improvement programs do not convince everyone. The baccalaureate-prepared registered nurses and healht educators who answer the lines would perform a focused health interview and use evidence-based strategies to help people live healthier lifestyles. No guilt; no shame; no overwhelming demands to fix everything at once. No idiotic "You should lose weight" to someone who has struggled their entire life with obesity. (I kid you not -  I hear this all the time from physicians; they do not know how to do health coaching, world.)  
So that's my short list. Add your own health care plan improvements in the comments. And thanks. 

* Industry may not be the most apt noun because most of our health care costs are paid in public systems, primarily Medicare and Medicaid. I prefer industry vs. system because there really is no system; we have more of a mish-mash of systems.

News Flash: "Trickle-Down" Does Not Save Lives

This week the New England Journal of Medicine published an evaluation of Premier HQID, a Medicare pay-for-performance program that provides monetary incentives to hospitals to improve quality of care. Hospitals that perform well on certain measures get 1-2% bonuses and hospitals that underperform are penalized by the same amount. 
In the study, a huge number of hospitals, 252 in the Premier program and 3363 not, submitted data to Medicare on 33 quality indicators for common conditions such as heart failure, pneumonia and joint replacement.  Data from over 6 million patients  went into the analysis. 
The headline-making conclusion went like this:
"Tying financial incentives to performance, often referred to as pay for performance, has gained broad acceptance as an approach to improving the quality of health care....We found no evidence that the largest hospital-based pay-for-performance program led to a decrease in 30-day mortality. Expectations of improved outcomes for programs modeled after Premier HQID should therefore remain modest."
To me, and I imagine others who were not consulted when this program was planned, this finding comes as little surprise.  Let me explain why:
  •  Financial incentives in the program did not necessarily go to the people who prevent hospital deaths. They went to hospital administrators who had the freedom to use the dollars as they wished.  So our tax dollars - make no mistake -  might have paid for nurse education or better staffing, and they might have bought a fancy new office suite for the CEO, the benefits of which would presumably trickle down to the little people.
  • Almost all of the Medicare quality indicators concern processes of care, not patient outcomes.  Processes (like which drugs are given and when) are only thinly linked to patient outcomes because of the complexity of human beings (whether patient or health care provider) and big organizations like hospitals.  If the right antibiotic is given at the right interval before surgery, is there certainty that the patient will not have an infection post-operatively? Of course not. It helps, but the maddening and wonderful complexity of humans and organizations means the process can only boost the odds in the patient's favor, not ensure the desired outcome. In short, there are no guarantees.
All the hospitals in the study report their data on Medicare's Hospital Compare website; this characteristic was equalized because public reporting is widely understood as a way to improve hospital quality. However, this understanding is based upon assumption, not fact, and some emerging data suggest otherwise.
This new study's findings about pay-for-performance are not unique.  I did find some evidence of success of the Premier program on (surprise!) Premier's website, where one also finds the list of Premier and other health care executives as well as the cadre of physicians who comprise the Premier board of directors.  Again excluding the largest group of health care providersin the country.
Lest this post appear as a rant from a burned-out nurse, I will add that nearly 1 in 5 older adults discharged from a hospital is re-admitted within 30 days. About half of these patients saw a physician in the interim, so it appears doctor visits did not prevent readmission.  Moreover, errors in health care are deadly - to nearly 200,000 people a year. And studies from across the globe show that nursing care saves lives. We understand the scope o the problem, and we know at least part of the solution. When will we stop making up voodoo quality strategies and start implementing what works?