Hospital transformation in Maryland, the house call’s triumphant return, and a low bar for top docs: RightCare Weekly
August 14, 2014
The RightCare Weekly is a newsletter that helps you stay on top of important news in the ongoing quest to move the U.S. health care system toward delivering the right care to all patients. We’ll bring you the most important stories, news articles, and opinion pieces of the week, along with our interpretation of why they’re important for patients, doctors, and communities.
A small, poor corner of Maryland has emerged as a harbinger of what the future of American medicine might look like. Business Insider’s Brett LoGiurato writes that several hospitals around Cumberland, MD have worked together to reduce hospitalizations by over 20 percent. Improvements are driven, in part, by the “Center for Clinical Resources,” which connects seriously ill patients to dietitians, nurses, and other clinicians, who have time to work with patients on disease management solutions that fit their lifestyles. The program is financially sustainable because the hospitals receive a budget from the state based on their local patient population, rather than relying on revenue from keeping beds full. The payment and delivery model is similar to other successful primary care-based practices with intensive management of very sick patient populations. The fact that it’s been implemented so effectively in a variety of settings, from inner-city Camden, NJ, and Cambridge, MA, to rural Maryland, is a testament to the power of human relationships in improving care.
For the last couple weeks, Robert Pearl, MD, of the Permanente Medical Group, has been taking the American medical system to task for financial conflicts that exist throughout medical research, prescribing, and referral decisions. The series of articles for Forbes suggests that the system encourages even well-meaning physicians to overtreat. Indeed, financial incentives in medicine go deeper than the series suggests. It’s not just physicians and drug companies with a stake in how patients are treated – sometimes hospitals are the culprits, funneling patients into their lucrative treatment centers with little regard for what patients actually want or need.
Though the sickest elderly patients with multiple chronic diseases comprise only around five percent of the overall Medicare population, they account for roughly half of Medicare spending. Ina Jaffe writes for NPR that providing these patients with a home-based health care delivery team – comprised of doctors, nurses, and social workers – may help reduce that spending. In a recent study of the Home-Based Primary Care program, making a team available for home visits and helping patients “avoid crises” substantially reduced ER visits, hospitalizations, and nursing home stays, all of which, in addition to keeping patients in the comfort of their home, saved Medicare more than $8,000 per patient.
We know that underusing low-tech solutions can sometimes be as harmful as overusing high-tech treatments. Aaron Carroll, MD, brings us another example of this in the New York Times this week with the story of the Guinea worm, once prevalent in Africa and Asia. These parasites infect humans after they consume water that contains the worms’ larvae. Once inside the body, Guinea worms push their way through the skin to exit. The only remedy is to speed up this painful process by manually pulling the worms out. While there is no treatment or vaccine, the Guinea worm has gone from infecting 3.5 million people in 1986 to only 17 cases so far this year. Why? Communities have been taught to filter their water and keep those infected away from water sources. Carroll suggests that the American health care system could learn from the success of low-tech solutions – and indeed we have, as evidenced by programs like those referenced in the Business Insider and NPR stories above.
It’s estimated that 12 million U.S. adults are misdiagnosed each year. But while the health care system has begun to focus in recent years on patient safety, many hospitals still do a poor job of tracking diagnostic errors. Hardeep Singh, MD, of Baylor College of Medicine writes in the Wall Street Journal that many misdiagnoses are the result of insufficient communication, either between clinicians, or between doctors and patients. Giving doctors enough time to understand patients’ needs is critical to absorbing all relevant information, and thereby reducing misdiagnoses. Listening may be the most underused treatment of all.
Shannon Brownlee, senior vice president of Lown Institute, was interviewed by Larry Kaskel, MD on The Healthy Skeptic internet radio program and discussed overtreatment, improving the health care system, and the Right Care Alliance. Their conversation highlighted the importance of reforming payment systems, giving doctors more time to have relationships with patients, and the challenges of creating major change in large systems.
In her New York Times commentary, “Top Doctors, Dead or Alive,” Abigail Zuger, MD, encourages consumers to be skeptical of published doctor ratings. The rankings are often based on subjective evaluations, either from other doctors or from patients themselves. Does intelligence, compassion, common sense, or academic pedigree enter into any of these ratings? It’s not clear. It seems to be “the single biggest mystery in all of health care: that we do not have a clue what makes a top doctor, let alone how to find one.”