Dec. 15. 2010
I’m attending the National Forum of the Institute of Healthcare Improvement. This is the largest and probably most influential international meeting of people working to improve healthcare. It is inspiring, as always. I am struck by several themes.
One of the faculty said Sunday, “We are excellent at everything, but not excellent everywhere.” It’s simple, but profound. What she is pointing out is that there are examples at this meeting, and in the improvement literature, of fantastic results in all aspects of health care. There are places that have achieved dramatic reductions in mortality, infections, and med errors, and improved the care of chronic disease and pain. However, there are no examples yet of places that have achieved excellence at everything across all disciplines (although some are getting close), and we certainly have not achieved excellence everywhere on the globe.
So that’s two issues: reliability and spread. We deal with them both here at Cooley Dickinson. We have improved CHF readmission, but not pneumonia readmission. We have reduced harm, but not in-hospital end-of-life management (too many folks come to the hospital to die).
Reliability is sustaining the gain: in manufacturing they call it ‘process control.’ In health care, we tend to improve when we are paying attention, but slip back when we move on to pay attention to the next thing. There is a whole science to reliability. Our colleagues in nuclear power, airline safety, and the military have figured this one out much better than we have.
Spread is the science of good ideas spreading — sounds easy — but it is the whole field of how human beings learn and change behavior. It, too, can be learned.
What is so striking to me is that the solutions in health care are out there. The challenge is to adopt them, adopt them all reliably, and spread the learning. That means ‘continuous improvement’ and continuous change.
Migrating the new CMO blog to the Web: What's Up?
After receiving feedback from several physicians that they have difficulty accessing the CMO blog on the Intranet, I have decided to migrate over to the Internet. Quite a few members of our medical staff do not access the Cooley Dickinson intranet frequently from off-site so have little need to remember or use usernames and passwords. The internet is easier to access and hopefully will have a broader audience for discussion of important topics. Today I want to reflect upon healthcare reform and its impact on doctors.
We all read a lot of generalizations about the impact of health care reform on physician practices and hospital operations. It is apparent to me from reviewing the Health Care Reform Act (patient protection and affordable care act), that real systemic substantial change is no longer a matter of conversation, but is very real. As insurance companies begin calling physicians, the PHO, and the hospital, requesting huge price concessions, we know the future will be very different from the past. Our patients are already experiencing dramatic changes in their employer-based insurance with large deductibles and co-pays which have led to a dramatic drop in outpatient care throughout the country and here in Massachusetts.
So what's in the Health Care Reform Act (H. R. 3590) as it relates to physicians? At a high level, I see the following:
The bill is 1000 pages long and currently the rules and regulations are being written and are estimated to cover 200,000 pages. Here are the big changes:
These are dramatic changes and coming fast. In addition – bundled payment pilots will start in 2013, conditions determined by the secretary of HHS, covering conditions from 3 days before hospitalization through 30 days after discharge.
So there are several imperatives for doctors here.
When payment is tied to episodes of care, we are jointly accountable for the outcomes and costs across the continuum of care. This is, of course, how it should be for the benefit of patients. Getting there will require all of us to think and act very differently.
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