Checklists and Physicians’ Behaviors

January 12, 2010 / Michael D. Miller MD / Delivery of Healthcare, Economics & Financing, Quality of Care & Safety / 1 Comment

I recently heard Dr. Atul Gawande talk about his new book “The Checklist Manifesto.” While the evidence demonstrating the value of checklists for improving the quality of healthcare is increasingly abundant, in his presentation Atul talked about how in a study assessing a surgical checklist they ran into resistance from about 20% of physicians.

Another story he told involved his surgical group’s considering how they might manage bundled reimbursements, e.g. accepting a single payment for all the care and testing related to thyroid cancer surgery. Their discussions came to a screeching halt when it became clear that this “might” mean less money for each of the surgeons.…

Thanksgiving Conversations About Health – Engage With Grace Blog Rally

November 24, 2009 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Miscellaneous / 3 Comments

For many years I’ve used the Thanksgiving dinner table conversation as a model for discussions about healthcare – but usually I’ve put it in the context of people who work for healthcare companies, (e.g. pharmaceutical or managed care), trying to address, rebuff and rebut the criticisms they might get from family members, (e.g. Aunt Lilly), about the problems with the US healthcare system and the actions or positions of various companies or industries. However, last year – and again this year – several bloggers have been cooperating to promote Thanksgiving weekend discussions about end of life care issues. This effort has been called the Engage with Grace, and last year it was a great success, with over 100 bloggers participating.…

Cost and Coverage c. 1989-91: Part 2 of Historical Perspectives on Health Reform

November 17, 2009 / Michael D. Miller MD / Access to Healthcare, Delivery of Healthcare, Economics & Financing, Health System Reform / 2 Comments

As I mentioned in my last post, in going through old files I found many memos and articles about health reform. Some of them from 1989-91 illustrate the long history of the challenge of controlling costs and providing care for more people – and eerie similarities to the current debate:

For example, below are some pieces of text from articles and commentaries published in the New England Journal of Medicine from January 1989 – October 1990:

“A Consumer-Choice Health Plan for the 1990. America’s health care economy is a paradox of excess and deprivation. We spend more than 11 percent of the gross national product on health care, yet roughly 35 million Americans have no financial protection from medical expenses.

…

Historical Perspective on Health Reform – Part 1, Medical Effectiveness

November 16, 2009 / Michael D. Miller MD / Comparative Effectiveness, Delivery of Healthcare, Public Health / 1 Comment

Since the time-line for health reform legislation has continued to be stretched, I recently spent some time cleaning out old files. In my excavations I came across papers, articles, memos and briefing books which demonstrate that no matter how much things change, some aspects of health reform have stayed the same. For example, below are a couple of snippets from memos about a proposed Medical Effectiveness Initiative from circa 1989:

Establishing a Medical Effectiveness Initiative at the OASH [Office of the Assistant Secretary of Health] level. (FY90 request = $52 million) This initiative would assess which medical treatments are cost-effective, and identify inappropriate and unnecessary medical practices.

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Morphing Medical Homes into Advanced Primary Care Model

October 18, 2009 / Michael D. Miller MD / Delivery of Healthcare, Health System Reform, State-Level Healthcare Reform / 4 Comments

The concept of patient centered medical homes (PCMH) has been evolving since it was first presented by 4 primary care medical societies, (AAFP, AAP, ACP & AOA), in March 2007. Since then, the PCMH concept has been endorsed by many other medical societies and interest in PCMHs has grown. Some of the significant steps forward have included:

The National Committee for Quality Assurance (NCQA) created specific requirements and a certification procedure for PCMHs
Several states are moving forward with PCMH pilot projects
Congress passed a law for Medicare Demonstration projects and the Department of Health and Human Services created draft guidelines for these projects – however, these guidelines haven’t been finalized although the demonstrations were scheduled to start in 2010

Steps Sideways
Along with all the interest and activity related to medical homes, there has been a blurring of the definition about what constitutes a medical home. …

Off-Label Communications: Is More Less?

October 4, 2009 / Michael D. Miller MD / Delivery of Healthcare, FDA, Information & Communications, Quality of Care & Safety / No Comments

Allergan corporation has filed a law suit against the Federal government challenging the FDA’s limits for companies discussing or promoting off-label uses of approved medicines. This is not a new issue, but the news reports indicate that Allergan is going very old school and basing their legal challenge on Constitutional freedom of speech rights.

The issue is not can doctors and patients use approved medicines for conditions, (or in ways), which are not specifically approved by the FDA, but can companies discuss these off-label uses with physicians or provide them with published information about these off-label uses?

Competing Risk-Benefit Perspectives
The competing risk-benefit perspectives that surround this issue are nearly identical to the trade-offs that all stakeholders in biomedical research and development face – including the FDA, companies, patients, clinicians, and legislators:

Creating a landscape that protects individuals and public safety
Being flexible enough to provide clinicians and patients access to the best available treatment possibilities
Providing companies a reasonable market environment that creates incentives for developing new treatments and investigating new uses for already approved medicines, which also has marketing rules that are as clear as possible so companies can conduct business without being excessively concerned about straying into regulatory gray zones

Off-label use is common in clinical practice – particularly for disease areas like cancer – because it often represents the standard of care. …

Bending the Cost Curve: Trees and Forests

September 25, 2009 / Michael D. Miller MD / Delivery of Healthcare, Economics & Financing, Health System Reform / 1 Comment

Bending the curve of cost growth has been a expanding issue within health policy discussions – as opposed to the public plan option, which has increasingly been the focus of political health discussions. Recognizing how important cost growth is to health reform, the September/October issue of Health Affairs is dedicated to this topic, and it contains great articles describing various factors causing spending to grow faster than the GDP or general inflation, and some solutions to this ongoing conundrum. However, these articles are like trees in the forest, i.e., they are very important, but a close examination of each one doesn’t provide a broad understanding of the whole forest – or in this case, what bending the curve of healthcare cost growth might look like.…

Encouraging Communications About Patients’ Goals

September 18, 2009 / Michael D. Miller MD / Clinician-Patient Relationships, Comparative Effectiveness, Delivery of Healthcare, Economics & Financing, Information & Communications, Quality of Care & Safety / No Comments

I attended a great event yesterday where experts discussed how to improve healthcare quality and safety by increasing patients’ involvement in making healthcare decisions.

This seminar, “Patient-Centeredness and Patient Safety: How Are They Interconnected,” was organized by the Kenneth B. Schwartz Center and sponsored by the Massachusetts Medical Society and CRICO/RMF. Don Berwick (President & CEO of the Institute for Healthcare Improvement) was the main speaker followed by a panel consisting of two patient safety leaders from local hospitals and a patient involved with promoting patient engagement in quality improvement.

To start the event, Dr. Berwick discussed how his thinking about healthcare quality had evolved over several decades, and his increasing belief in the importance of patient involvement.…

Beyond Health Insurance Reform: Transforming Health Care Delivery

August 21, 2009 / Michael D. Miller MD / Delivery of Healthcare, Health System Reform / 2 Comments

“Health insurance reform” has become the latest label for national health reform legislation, but this renaming has pushed discussion about how to transform healthcare delivery farther back into a poorly lit corner of the debate.

Transforming the delivery of healthcare can improve quality and efficiency because the current system has two fundamental impairments: 1) lack of integration and coordination among clinicians and organizations like hospitals, and 2) a shortage of primary care clinicians. There have been many proposals for how to address these structural problems, but they have tended to not be bold enough, i.e., they would take many years – and in some cases decades – to produce significant results.…

What is Health Reform, and Why?

August 6, 2009 / Michael D. Miller MD / Access to Healthcare, Delivery of Healthcare, Health System Reform / 1 Comment

As Congress enters the August district work period, (the official name for the August recess), the debate about health reform has shifted from Congressional hearings and mark-ups to local Town Hall meetings, the media, (print, talk radio, talking heads on TV, and the blogo-YouTube-osphere), and the astroturf campaign styled world of organized phone banks, shout downs, and meetup/get-together rallies/service days.

Proponents and opponents on all sides are participating in and supporting all these types of activities. But the questions I keep getting are, “what is the proposal?” “What is in the President’s bill?” “What is health reform?”

Simply answered, 1) There is no single proposal – three House Committees have passed bills, (which need to be melded into one bill for consideration by the full House of Representatives in the fall), and one Senate Committee has passed a bill and another is still trying to cobble together a bipartisan bill; 2) The President has 3-4 principles, but doesn’t have his own “bill”; and 3) That is still being determined – but if you listen to the escalating frenzy, (which is why I frequently wear earbuds that may or may not be connected to an MP3 player), health reform is all about a public insurance plan option.…

Real Health Reform in Massachusetts

July 29, 2009 / Michael D. Miller MD / Delivery of Healthcare, Federal Healthcare Reform, Health System Reform, Quality of Care & Safety, State-Level Healthcare Reform / 5 Comments

The Massachusetts Special Commission on Payment Reform recently issued its recommendations for shifting the state’s health care system from Fee-For-Service (FFS) to Global Payments over a 5 year period. The Special Commission’s report lays out a good case for making this change, describing why it needs to be adopted by all payers, (although each payer would still pay different rates, they would all use the same fundamental global payment structure), and some of the challenges for successfully navigating a 5 year transition period from the current mostly FFS system to one dominated by global payments.

The report summarizes its recommendations into 9 areas:

The development of Accountable Care Organizations (ACOs).

…

Making Health Reform’s Parts Work Together – Keeping It From Jamming

July 22, 2009 / Michael D. Miller MD / Delivery of Healthcare, Health System Reform / 1 Comment

As health reform legislation moves forward, (having been passed by one of the two Senate Committees and two of the three House Committees last week), the tension between policy and politics is increasing. This political process can make it hard to maintain the practical functionality of the legislation, i.e. not sacrificing the substantive policy goals to the political realities.

One of the great challenges in making these trade-offs is to retaining reasonable functional relationships among the many necessary financing and delivery system changes to actually improve the healthcare system.

Keeping the Implementation of Health Reform from Getting Jammed Up
An analogy for this challenge came to mind when I was in DC last week. …

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