Reforming the U.S. health care system


Understanding the issues health care reform should address

Health policy issues (Association of Health Care Journalists, or AHCJ)
Health Reform reading list (Joanne Kenen, AHCJ, resources for journalists) ****
Diagnosing Health of the Healthcare System (animated video, Peterson-Kaiser Health System Tracker, measuring the performance of the U.S. health system). See more Peterson-Kaiser charts, tracking health care trends.
A Chance to Talk About Drug Prices is Slipping Away (Richard Young MD, American Health Scare, 7-9-16) The new hepatitis C drug Harvoni costs $1000 per pill for a total of $84000 for treatment. Initially, state Medicaid plans did not cover the drug except in very narrow circumstances, but under reports of the threat of a lawsuit many Medicaid plans are expanding coverage. "According to a study by the AARP, the average retail price of 115 specialty drugs for diseases ranging from cancer to multiple sclerosis to rheumatoid arthritis cost more per year than the median household income." "Other countries have the maturity and courage to have conversations about the best use of collective resources that always include restrictions on expensive treatments to only those patients who will likely experience significant benefit."
Medical Whistleblower Advocacy Network
Curing Medicare: One doctor's view of how our health care system is failing the elderly and how to fix it by Andy Lazris. Don't have the book yet? Read the blog: An Inside Look at Health Care for the Elderly and Medicare
What we know about how health insurance affects health (Carolyn Y. Johnson, Washington Post, 9-8-15) "The real question now may not be how big the effect of insurance is on health, but how to structure insurance so that it gives people the best chance of staying healthy. There is also growing interest in comparing insurance coverage to other ways that money could be spent to improve health, for example by reducing poverty, which is associated with poor health outcomes, spending on food stamps, or structuring insurance plans differently. 'We know we improve health care coverage, but .... what are some of the other strategies to improve health?' Long said."
The most important thing you’re not discussing with your doctor (Melissa Armstrong, The Conversation, 2-15-17) "The Institute of Medicine (IOM) released the landmark publication Crossing the Quality Chasm 15 years ago. The report proposed six aims for improvement in the U.S. health system, identifying that health care should be patient-centered, safe, effective, timely, efficient and equitable." That means shared decision-making, honoring the patient's goals and values,
Why U.S. medical costs are so high and where the system needs fixing . Links to important series and articles on this problem.
What being overwhelmed by rules and regulations looks like (Fred N. Pelzman, KevinMD, 8-31-14)
Concierge Care (Deborah Pierce, Pulse, 12-20-13) "...very often the efficient, patient-centered care [my cat] Humphrey received is not available to human patients who face similar illnesses. Most people's medical insurance will not reimburse medical providers for two visits on a single day; nor can you obtain ultrasounds or CT scans on the same day as a consultation. Delay is often the norm, not the exception....And I wonder: what if we could set up the human healthcare system so that the communication, competence and kindness that made Humphrey's care so special--that made it so humane--were not only valued but also reimbursed?"
Confessions of a 75-Year-Old Drug Addict (Arlene Silverman, Pulse, 1-22-10) "There's sort of a war going on in the field of pain management, he continues. One camp worries about opiate addiction; the other is more concerned about the effects of long-term pain. It seems that, given my pain's severity, my doctors opted for opiates.

A Generation X physician embraces the millennial doctor perspective (Sherwin Gallardo, MD, Physician, posted on Kevin MD, 2-21-16) "And in the students and residents I teach, I see in their faces, with each repetitive click of the mouse and keyboard EMR shortcut, their passion for medicine slowly fade. Many of them match in our residency program with their wellness accounts already in negative balance, or precariously close to empty — the product of an obsolete, hierarchical medical education system that still often relies on overwork and humiliation as a sort of rite of passage with no formal teaching on how to deal with emotions, time management, financial or business competence, or self-care.
What little they have left to give often evaporates in the face of endless utilization measurements, and required documentation for meeting regulatory mandates and Medicare coding. In the name of efficiency, my residents’ progress notes on the inpatient medicine service all begin to look frighteningly similar and generic. Often at the expense of learning why and how an ACE-inhibitor helps their heart failure patient, they are consumed in exercises of futile box-checking and the metrics game of whether or not they documented that the ACE-inhibitor was ordered upon discharge."
We are not taking care of nurses. Who will heal the healers? (Michael Kirsch, Kevin MD, 10-3-16) Nurses are routinely required to care for more patients than they should because there is a nursing shortage on a particular day. Why do hospital administrators allow this to happen? Don’t administrators fear the risk of medical errors from overworked nurses? Nurses have confided for years how demoralized they are that no one speaks for them.

What do we do when antibiotics don’t work any more? Public health journalist Maryn McKenna's excellent TED talk, recounting the often terrifying stories behind emerging drug-resistant diseases that medical science is barely keeping at bay. "We've squandered the advantages of penicillin and the antibiotics that followed. New, drug-resistant bacteria mean we're entering a post-antibiotic world -- and it won't be pretty. There are, however, things we can do ... if we start right now."
Where Does Rationing Fit Into Healthcare Reform? (Trisha Torrey, About Health, 11-24-14) Rationing is not new, nor will it be any better or worse under healthcare reform. Private insurers too often deny care based on cost -- a form of rationing. Care is also rationed denial of coverage and care for people with pre-existing conditions. See What Is Healthcare Rationing?
In a State of Denial (Norman Bauman, New Scientist, 10-7-95). Thousands of Americans will die of AIDS because politicians refuse to believe scientists who say needle exchanges make good sense
Politicians need to get over their squeamishness about needle exchange programs (Christopher Ingraham, Wash Post, 3-24-15) There's widespread evidence going back decades that needle exchange programs are effective at preventing the spread of HIV and other blood-borne diseases, that they encourage drug users to seek treatment for their addictions, and that they do not promote or encourage drug use overall.
Older people risk losing access to health information if services move online and to the phone (UK) (press release, International Longevity Centre, UK, 2-12-15)
Controversies in Hospital Infection Prevention (Stopinfections.org)
Finding the full story behind hospital mergers, consolidations (Joanne Kenen, Health Journalism blog, 3-10-15) "Across the country, health systems are getting larger, gobbling up community hospitals or smaller chains. Some of this has to do with payment incentives in Obamacare, but just as much has to do with changes to Medicare, Medicaid and providers’ desire for leverage as they negotiate payments with insurance companies." See New York’s leading health systems differ on growth strategy (Dan Goldberg, Capital Magazine, 3-10-15). Goldberg explains how the old model (fee for service, which meant chronically ill patients were good for business), differs from the new model (paying a set amount per patient or per service, encouraged by ACA, state Medicaid reforms, shifting demographics, and Medicare's ACO models and payment penalties), which provides an incentive to treat more patients but also provide less in-patient service. These five NY systems represent two camps: one "believes in aggressive upsizing"; the other, wary of affiliation with other hospitals, "made strategic investments and focused on ambulatory care and their traditional role as teaching hospitals. They have steered well clear of the insurance business." Excellent explanations.
How to destroy a great ER: A step by step guide (Thomas Paine, MD, Kevin MD, 4-19-16) Take a small independent, locally administered hospital in the suburbs, make it part of a large regional health care system (in a merger), and follow his steps for creating an ER department in which emergency clinicians no longer feel valued, respected, and supported.
The time a 28-year-old MBA told a physician where to round first (Sundeel Dhand, Kevin MD, 5-11-16) "The last couple of decades have seen a dramatic shift of power and clout away from individual physicians and towards administrators and the business side of health care....we’ve seen the relentless push towards consolidation and mass employment of physicians, a rise in mandates and bureaucratic requirements, and a general explosion in the number of administrative folks while the number of physicians appears to be shrinking!" and the subtle changes: calling them providers instead of doctors. How did the medical profession surrender so much to the business of medicine? Is there any way that physicians can wrestle back a bit of control over their own profession?
Unnatural Causes....is inequality making us sick? (an important PBS series).
---In Sickness and in WealthWhat connections exist between healthy bodies, healthy bank accounts, and skin color? Four individuals from different walks of life demonstrate how one’s position in society – shaped by social policies and public priorities – affects health. Read transcript here
---When the Bough Breaks (“When the Bough Breaks” examines the mystery of the Black-white infant mortality gap, while “Becoming American” sheds light on the shifting health status of newly arrived Latino immigrants. Read the transcript here.
---Bad Sugar explores the causes and effects of diabetes within two Native American communities. “Place Matters” connects the dots between health, wealth and zip code. Read the transcript here.
---Collateral Damage traces the health challenges of Marshall Islanders from the South Pacific to Springdale, Arkansas, while “Not Just a Paycheck” explores the toll taken by layoffs and job insecurity in western Michigan. Read the transcript here.
Bill Moyer Journal (12-18-09) Amidst fading hopes for real reform on issues ranging from high finance to health care, economist Robert Kuttner and journalist Matt Taibbi join Bill Moyers to discuss Wall Street's power over the federal government. You can read transcript here.
Reform by the Numbers (Robert Wood Johnson Foundation, RWJF)), a source for timely and unique data about the impact of health reform. For example: Eight Million and Counting (RWJF, May 2014). A deeper look at premiums, cost sharing and benefit design in the new health insurance marketplaces. And Health Insurance Exchange Compare (RWJF, May 1, 2014) Benefit design and cost sharing information for health plans in all 50 states.
Stop the privatization of health data (John T. Wilbanks and Eric J. Topol, Nature, 7-20-16) Tech giants moving into health may widen inequalities and harm research, unless people can access and share their data, warn the authors.
HELP Is on the Way (Paul Krugman on why universal health coverage is affordable)
Reach of Subsidies Is Critical Issue for Health Plan (Robert Pear, NY Times, 7-26-09—on another important issue: where the money comes from to cover the costs of the formerly uninsured)
The Republican Case for Waste in Health Care (Phillip Longman, The Health Care Blog, explains why the Republican funders don't want cost-effectiveness research, 3-8-13). "Conservatives love to apply “cost-benefit analysis” to government programs—except in health care. In fact, working with drug companies and warning of 'death panels,' they slipped language into Obamacare banning cost-effectiveness research." Longman explains how that happened and why it can't stand. "[O]verthrowing the ban on cost-effectiveness research now must move high on the agenda, and it requires clearly and forthrightly explaining what it really is and why it’s essential to everyone getting the best care possible."
Health Insurance Consumer Information (news you can use), with blogs that follow the health care debate and discuss news of health insurance coverage around the country, and a Consumer Guide for Getting and Keeping Health Insurance for each state and the District of Columbia. The American Cancer Society and the Robert Wood Johnson Foundation and other organizations provide support for this research by The Georgetown University Health Policy Institute. Worth checking out.
Health Insurance Woes: My $22,000 Bill for Having a Baby (And I had coverage for maternity care!) by Sarah Wildman, DoubleX, 8-3-09). "Our insurer, CareFirst BlueCross BlueShield, sold us exactly the type of flawed policy—riddled with holes and exceptions—that the health care reform bills in Congress should try to do away with. The “maternity” coverage we purchased didn’t cover my labor, delivery, or hospital stay. It was a sham."..."The individual insurance market is like that old joke about the food being terrible and the portions too small; it’s expensive, shoddy, and deeply unsatisfying. Those of us who buy into it are not protected by the federal and state laws that govern employer-based health care. In fact, there’s no one looking out for us at all."
The Politics of Healthcare (Claire Topal, an interview with Tadataka "Tachi" Yamada, of Takeda Pharmaceuticals, formerly of Gates Foundation, for National Bureau of Asian Research, 9-23-13). " The Affordable Care Act in the United States is meant to provide extended basic healthcare to millions of people, but it still uses a system of fee for service. So as you increase the number of people accessing healthcare, you are actually increasing the costs of healthcare, collectively as a nation, unless each episode of healthcare is somehow reduced in cost. " Read this for insight into how in the U.S. we are locked into an inefficient system of care. As co-pay increases and we pay more directly for our medical care, there will be a demand for change. "[S]ome countries are thinking in a very different way about how to deliver care to the masses . . .the most cost-effective solutions often come out of poorer countries that are not locked into an orthodoxy of past-practices."
Health Care In Transition: Fee For Service Vs. Pay For Performance (listen to Kojo Nnandi show, WAMU-FM, or read transcript, 6-4-13) Many health innovators and reformers believe the current "fee for service" system, which rewards doctors and hospitals based on volume, is outdated and unsustainable. Instead, they are experimenting with new "pay for performance" models with a focus on preventive care, coordination between doctors and ways to lower readmission rates. Kojo explores how hospital systems and providers are adapting to the changing health care environment. Guests Bob Kocher and Toby Cosgrove.
Are Price Controls the Answer? (Martin Gaynor, Compassionate Economics, 2-24-13). A few observations about the effects of rate-setting.
Healthcare and the profit motive—do they work well together? Columbia Journalism Review on Eduardo Porter's article Health Care and Profits, a Poor Mix (NY Times, Business, 1-8-13)
The Cost Conundrum: What a Texas town can teach us about health care (Atul Gawande, New Yorker, 6-1-09). Overuse of medical care (over-testing, over-medicating, often performing unnecessary procedures)--both to avoid lawsuits and to increase the bottom line--are increasing costs without improving outcomes.
As medical providers consolidate, questions about effects on costs, quality of care (Phil Galewitz, Washington Post 4-18-14) “Consolidation has not been an effective way of reducing costs or providing more effective care,” [Zelda Geyer-Sylvia] said. “People here have all the best intentions, but once you eliminate competition it’s gone.”
Letting Go Abraham Verghese's review of Katy Butler's book, Knocking on Heaven's Door: The Path to a Better Way of Death . "Although most of us claim no desire to die with a tube down our throat and on a ventilator, the fact is, as Katy Butler reminds us in Knocking on Heaven's Door: The Path to a Better Way of Death, a fifth of American deaths now take place in intensive care, where 10 days of futile flailing can cost as much as $323,000, as it did for one California man." ... "Much of what ails health care, as Butler discovers, revolves around reimbursement issues. Doctors are paid to do things to people, not for people." "My hope is that this book might goad the public into pressuring their elected representatives to further transform health care from its present crisis-driven, reimbursement-driven model to one that truly cares for the patient and the family."
Resource Links on Health Reform (Association of Health Care Journalists)
Post Supreme-Court Health-Care Decision Symposium (SCOTUS BLOG, varying opinions on what happened and what it may mean --between them, you get some sense of what the issues are and were and what Justice John Roberts' swing vote was about )
Health Care and the Court: Who Won? (Clive Crook, The Atlantic, 7-4-12)., You must read this.
Excluded Voices. Trudy Lieberman's penetrating series of interviews on health care reform, in Columbia Journalism Review. Start with her interview with Wendell Potter, who "didn’t want to be part of another health insurance industry effort to shape reform that would benefit the industry at the expense of the public." You can also listen to Bill Moyers interview Potter or read the transcript and Potter's testimony before Congress.
C-Span's programs on health care a good place to find various town hall discussions, hearings, wonderful links. C-Span, you're wonderful!
DrSteveB's blogroll (helpful Daily Kos blogger--and check his blogroll for other resources)
Expert Interviews from CEO's of America's Healthiest Companies, wellness experts, and business leaders (Wellness Council of America, or WELCOA) Several free reports available after one-time registration.
Consumer-directed health plans: Do they deliver? (PDF of report brief, M. Kate Bundorf, The Synthesis Project. Robert Woods Johnson Foundation)
Cost-sharing: Effects on spending and outcomes (PDF of report brief, Katherine Swartz, The Synthesis Project, Robert Woods Johnson Foundation)
Health Affairs (excellent issues on health care reform, in this important policy journal about health care)
Health Reform Source *Kaiser Family Foundation (many excellent resources, including The States (a state-by-state view of health care reform implementation and news--click on a state for state-specific information)
Medical Progress, Social Progress, and Legal Regression (Andrew Solomon, New Yorker, 4-13-13). If we want people to stop terminating pregnancies, we might start by providing better services for people with disabilities; our neglect of decent care is a national disgrace. Solomon has written a wonderful book about how people with disabilities benefit from peer groups with those disabilities (except for individuals with schizophrenia): Far From the Tree: Parents, Children and the Search for Identity . He writes about families coping with deafness, dwarfism, Down syndrome, autism, schizophrenia, or multiple severe disabilities; with children who are prodigies, who are conceived in rape, who become criminals, who are transgender.
What ‘Dallas Buyers Club’ got wrong about the AIDS crisis (Dylan Matthews, Washington Post, 12-10/​13). The movie isn't the "story of a man who got the treatment he needed despite a government that tried to stop him. It's about a man who tried whatever he could in hopes of extending his life as long as possible, and in the process often rejected helpful treatments and embraced harmful ones."
Dallas Buyers Club-inspired “right to try” laws: Good movies don’t make good policy (Orac, Science Blogs, 3-6-14) Analysis of Right to Try laws.
Income, Poverty, and Health Insurance Coverage in the United States: 2012 (by Carmen DeNavas-Walt, Bernadette D. Proctor, Jessica C. Smith, released September 2013 by U.S. Census Bureau, P60-245). 88-page PDF. Real median household income and the poverty rate were not statistically different from the previous year, but the percentage of people without health insurance coverage decreased. Some additional links to census data:
---Income data
---Poverty data
---Health insurance data
---Current Population Survey (CPS) table creator (gives you the ability to create customized tables from the Current Population Survey's Annual Social and Economic Supplement)
Employers Must Offer Family Care, Affordable or Not (Robert Pear, Health, NY Times, 12-31-12)
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Doctors' incentives to prescribe expensive drugs


The Cost of Cancer Drugs (Leslie Stahl, 60 Minutes, CBS, 10-5-14--you can listen or read transcript.) Dr. Leonard Saltz: "We're in a situation where a cancer diagnosis is one of the leading causes of personal bankruptcy." "... we as a society have been unwilling to discuss this topic and, as a result, the only people that are setting the line are the people that are selling the drugs." Dr. Peter Bach: "Medicare has to pay exactly what the drug company charges. Whatever that number is." "The challenge, Dr. Saltz at Sloan Kettering says, is knowing where to draw the line between how long a drug extends life and how much it costs." "High cancer drug prices are harming patients because either you come up with the money, or you die." Gleevec as a life-saving drug that makes patients a slave to it and its high cost. Dr. Leonard Saltz: " I don't know where that line is, but we as a society have been unwilling to discuss this topic and, as a result, the only people that are setting the line are the people that are selling the drugs."
TransUnion, Equifax and Experian Agree to Overhaul Credit Reporting Practices (Tara Siegel Bernard, NY Times, 3-9-15) "The three companies will also establish a six-month waiting period before reporting medical debts on consumers’ credit reports, providing more time for consumers to resolve issues that might amount only to a delayed insurance payment or another dispute. The credit agencies will also remove medical debts from an individual’s report after the debt is paid by insurance." "“Too many people are surprised to learn of medical billing problems only after having a bill sent to collection and being forced to deal with damaged credit,” said Mark Rukavina, a longtime consumer advocate and principal of Community Health Advisors, a consultancy that works with nonprofit hospitals on billing and collection issues. “Having the agencies finally agree to remove medical debts that were reported and subsequently paid by insurers is long overdue.”
Want to see how problematic Medicare pricing is? Look to ophthalmology (Max Ehrenfreund, Washington Post, 4-9-14) "...doctors also receive commissions of 6 percent to cover their own expenses. The commission a doctor collects on each dose of Avastin would be only about $3, as opposed to $120 on each dose of Lucentis. Congress and the courts have refused to allow Medicare to save money by scrutinizing doctors' decisions."
Doctors Often Receive Payments From Drug Companies (Neal Conan, Talk of the Nation, NPR, 9-13-11) A Pro Publica investigation shows that many doctors are being paid by the same drug companies whose medicines they prescribe. By 2013, all doctors must report any payments from pharmaceutical companies to the federal government, and those records will be available to the public.
Pay to Prescribe? Two Dozen Doctors Named in Novartis Kickback Case (Theodoric Meyer, ProPublica, 5-3-13)
Dollars for Docs How Industry Dollars Reach Your Doctors (Eric Sagara, Charles Ornstein, Tracy Weber, Ryann Grochowski Jones and Jeremy B. Merrill, for ProPublica, Updated 3-3-14). See if Your Health Professional Has Received Drug Company Money.
As Full Disclosure Nears, Doctors’ Pay for Drug Talks Plummets (Charles Ornstein, Eric Sagara and Ryann Grochowski Jones, ProPublica, 3-3-14) As transparency increases and blockbuster drugs lose patent protection, drug companies have dramatically scaled back payments to doctors for promotional talks. This fall, all drug and medical device companies will be required to report payments to doctors.
Medicare Drugs Turn Doctors into Millionaires (Walter Russell Mead & Staff, The American Interest, 4-10-14)
Prescribing Under the Influence (E. Haavi Morreim, Markkula Center of Applied Ethics, Santa Clara University)
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Can markets cure health care?


Why markets can’t cure healthcare (Paul Krugman, The Conscience of a Liberal, NY Times, 7-25-09)

Uncertainty and the Welfare Economics of Medical Care (Kenneth J. Arrow, The American Economic Review, Dec. 1963) Health care can’t be marketed like bread or TVs. As Avik Roy points out in the following article, which I lean on here, Arrow identified five principle distortions in the market for health care services and products: 1. Unpredictability of need. (And yet often urgently needed.) 2.Barriers to entry. (There are medical-school driven restraints on the number of medical professionals, and not everyone can practice.) 3. The importance of trust. (Trust is a key component of the doctor-patient relationship, and patient's can test-drive a surgeon etc.) 4. Asymmetrical information. (Patients know less than doctors about what's needed and are thus subject to exploitation.) 5. Idiosyncrasies of payment. (Patients usually pay for services after they're received and rarely directly.)

A physician tells a health insurance CEO what she really thinks (Cathleen London, Kevin MD, 8-24-16) A doctor serving in an underserved area of rural Maine, who believes in a single-payer health care system, is troubled by a health insurance company saying she would get a fee schedule only after she signs a "provider" agreement. She explained that at this point in her career anything under 150 percent of Medicare rates would be unacceptable. They could not meet that. She is starting a direct primary care (DPC) model to avoid headaches of dealing with insurance companies more concerned about company and stockholder profits than about helping patients.

Liberals Are Wrong: Free Market Health Care Is Possible (Avik S. A. Roy, The Atlantic, 3-18-12) Roy explains that Kenneth Arrow endorsed the view that "the laissez-faire solution for medicine is intolerable," that the delivery of health care deviates in fundamental ways from a classical free market, and therefore, that government must intervene to correct these deviations. Roy explains the five market distortions for health care Arrow cited, but says, "No, you can't shop for health care when you're unconscious, or when you're in acute or emergent situations. Does this justify nationalizing the health care system? No." "So, it seems to me, those who strongly believe in the shopping argument for socialized medicine should adopt a hybrid approach. Let's have a free market for the 70-plus percent of health care where market forces can most directly apply, and let's have universal catastrophic insurance for those situations where market forces work less well. This way, we might get the best of both worlds: an efficient, affordable, high-quality market for chronic and routine health care, and a universal system for those who get hit by a bus, or have a stroke, or get cancer. Such a system would leave no one behind. But it would also allow our health-care system to benefit, as much as possible, from the forces of choice, competition, and innovation."
Consumers’ Interest In Provider Ratings Grows, And Improved Report Cards And Other Steps Could Accelerate Their Use (Steven D. Findlay, Health Affairs, April 2016). "In addition to new technology, recent laws and changes in society and the delivery of care are laying the foundation for greater use by consumers of provider performance report cards. Such use could be accelerated if the shortcomings of current report card efforts were addressed. Recommendations include making online report cards easier to use and more understandable, engaging, substantive, and relevant to consumers’ health and medical concerns and choices. "
See
Ratings for hospitals, doctors, surgeons, home health agencies, nursing homes

What journalists should know about hospital ratings (Liz Seegert, Covering Health, Association of Health Care Journalists, 6-24-16) "Journalists should take hospital ratings with a healthy dose of skepticism, according to experts at a recent AHCJ New York chapter event. Simply looking at an institution’s overall rating is just the start. Reporting that without understanding what’s being rated and how ';success' is measured does a disservice to your audience."

What quality measures can tell us about nursing home ratings (Liz Seegert, Covering Health, AHCJ, 7-27-16). "Nursing home star ratings are misleading and disingenuous, according to a recent analysis comparing ratings with quality measures alone. More than a thousand nursing homes nationally with high overall ratings had only one or two stars in quality measures, which could point to some serious health implications for residents."

Donabedian’s Lasting Framework for Health Care Quality (John Z. Ayanian, M.D., M.P.P., and Howard Markel, M.D., Ph.D. N Engl J Med 2016; 375:205-207July 21, 2016DOI: 10.1056/​NEJMp1605101) In a landmark article published 50 years ago, Avedis Donabedian proposed using the triad of structure, process, and outcome to evaluate the quality of health care. That triad, along with his eventual seven pillars of quality, continues to inform efforts to improve care. "Health care is a sacred mission . . . a moral enterprise and a scientific enterprise but not fundamentally a commercial one. We are not selling a product. We don't have a consumer who understands everything and makes rational choices -- and I include myself here. Doctors and nurses are stewards of something precious . . . " With thanks, as so often, to Norman Bauman for links and references.
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Improving health care practices

ECRI Institute Announces Top 10 Health Technology Hazards for 2015 . Alarm hazards, electronic health record data integrity issues, and infusion line mix-ups top the list, available now for free download.) Topics on the 2015 list include:
1. Alarm hazards: Inadequate alarm configuration policies and practices
2. Data integrity: Incorrect or missing data in electronic health records and other health IT systems
3. Mix-up of IV lines leading to misadministration of drugs and solutions
4. Inadequate reprocessing of endoscopes and surgical instruments
5. Ventilator disconnections not caught because of mis-set or missed alarms
6. Patient-handling device use errors and device failures
7. “Dose creep”: Unnoticed variations in diagnostic radiation exposures
8. Robotic surgery: Complications due to insufficient training
9. Cybersecurity: Insufficient protections for medical devices and systems
10. Overwhelmed recall and safety alert management programs

Further to point 2, read the brief 3 reasons why health care IT will always be terrible (Suneel Dhand, MD, Kevin MD, 2-15-17) IT caters to hospital administration, not to doctors. It's a monopoly once installed. And doctors have allowed themselves to be turned into data-entry clerks without demanding major change.

Genetic testing fumbles, revealing ‘dark side’ of precision medicine (Sharon Begley, STAT: Reporting from the frontiers of health and medicine, 10-31-16) 'Enthusiasm for precision medicine, from the White House down to everyday physicians, is at an all-time high. But serious problems with the databases used to interpret patients’ genetic profiles can lead to “inappropriate treatment” with “devastating consequences,” researchers at the Mayo Clinic warned on Monday....“This is the proverbial dark side of genetic testing and precision medicine,” said Ackerman. Because databases that companies use to interpret DNA tests are riddled with errors, “we’re starting to see a lot of fumbles,” with patients told that a DNA misspelling is disease-causing when it actually isn’t....That raises the very real concern that some people treated with “precision” approaches will be misdiagnosed and given useless or even harmful treatment.'
Genetic test costs taxpayers $500 million a year, with little to show for it (Casey Ross, STAT, 11-2-16). Unnecessary medical care is estimated to cost the United States between $750 billion and $1 trillion dollars a year, accounting for nearly a third of its overall spending on health care. Wasteful testing is one of the primary drivers of those costs. In the case of inherited thrombophilia, said Dr. Christopher Petrilli (a University of Michigan hospitalist who coauthored the study cited), doctors appeared to be complicit in the waste — possibly due to fear of litigation or simply a shared desire to get the answers for their patients. “You can explain to them that getting a test is not going to change therapy and that it’s just going to lead to more anxiety, unclear results, and more testing,” said Dr. Nitin Damle, president of the American College of Physicians.
One Hospital Tells Bronx's Sick: You Call Us, We’ll Call You (Amanda Aronczyk, WNYC, ) A patient's "accountable care manager" helps him coordinate his complex health care procedures and visits.

Choosing Wisely (aimed at teaching physicians to think more carefully about default screening options--at eliminating unnecessary or overused procedures)

• Community paramedicine. Beyond 911: State and Community Strategies for Expanding the Primary Care Role of First Responders
Development of Community Paramedic Programs (Discussion paper for Joint Committee on Rural Emergency Care (JCREC), National Association of State Emergency Medical Services Officials, National Organization of State Offices of Rural Health. Rural EMS systems should be able to respond in a timely, appropriate manner whenever serious injury or illness strikes someone in need. The concept of community paramedicine represents one of the most progressive and historically based evolutions available to community-based healthcare and to the Emergency Medical Services arena. By utilizing Emergency Medical Service providers in an expanded role, community paramedicine increases patient access to primary and preventative care, provides wellness interventions within the medical home model, decreases emergency department utilization, saves healthcare dollars and improves patient outcomes. Planning for a system in which the role of EMS providers is expanded role as part of a community-based team of health services and providers.

The Essential (Before I Kick the) Bucket List (Amy Berman, Health AGEnda, John A. Hartford Foundation, 8-30-12) Diagnosed with Stage IV inflammatory breast cancer in October 2010, Berman decided instead of making a personal bucket list of things to do before she dies to make a health care bucket list (for the system). Read about the five things she listed:
1) Care centers on the patient;
2) Care addresses the needs of the family;
3) Care is better coordinated;
4) Care focuses on quality of life and patient goals;
5) End of life care is more compassionate and driven by preferences.
The Doctor Who Championed Hand-Washing and Briefly Saved Lives (Rebecca Davis, Morning Edition, NPR, 1-12-15) It's not enough to discover an important way to improve health care--one has to convey it in an acceptable manner, suggests this story of a Hungarian doctor named Ignaz Semmelweis.

N.C. Program A Model For Health Overhaul? (Rose Hoban, North Carolina Public Radio, Morning Edition, NPR, 10-15-09). The state Medicaid program in North Carolina is helping people stay healthier--and saving the state money. Medicaid (not the clinics) pays nurses and social workers to do case management. They're placed in clinics and sites that see lots of patients and their priorities are those of the state, not the clinic managers (who might be interested in churning to create revenue). See also this policy profile of Community Care of North Carolina (Kaiser Commission on Medicaid and the Uninsured, 2009).CCNC's website has links to more stories and information.
The Checklist Manifesto: How to Get Things Right by Atul Gawande, who argues persuasively that medicine has become so complex that without a checklist for medical teams to work by, medical professionals will inevitably make fatal errors or omissions.

The Simple Idea That Is Transforming Health Care (Laura Landro, WSJ, 4-16-12). A focus on quality of life helps medical providers see the big picture—and makes for healthier, happier patients. Focusing on well-being might seem like a basic idea, but it is a departure from the traditional approach, especially with chronic-disease sufferers.

The Radical Rethinking of Primary Care Starts Now (Dan Diamond, The Health Care Blog, 3-7-13)

Safety-net clinics adopt medical home model (Mike Sherry, Health Care Foundation of Greater Kansas City, 1-10-13). Health care reform advocates cite patient-centered medical homes as a best-practice in providing comprehensive primary care while reducing the need for costly treatments.
And the federal Department of Health and Human Services has set a goal of having 25 percent of the nation’s community health centers certified as medical homes in fiscal year 2013, which ends Sept. 30. Proponents say certification ‘more than just paperwork,’ it’s a better model for practicing medicine.

Sharing Psychiatric Records Helps Care (Nicholas Bakalar, Well column, NY Times, 1-7-13)

A doctor's touch (Abraham Verghese's TED Talk, July 2011). Verghese describes our strange new world where patients are merely data points, and calls for a return to the traditional one-on-one physical exam.

Checking Boxes (Regina Harrell, Pulse, 10-18-13). A primary-care doctor who makes house calls in and around Tuscaloosa, Alabama, could spend more time caring for frail elders in their home if she didn't waste so much time filling in irrelevant boxes on computer forms so that she'll get paid.

U.S. Preventive Services Task Force (recommendations for, against, and for a specific number of various screening procedures).
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The costs of neglecting the mentally ill


Cost of not caring: Nowhere to go (Liz Szabo, in excellent series in USA TODAY, ). The financial and human toll for neglecting the mentally ill. First story: A man-made disaster: A mental health system drowning from neglect. “We have replaced the hospital bed with the jail cell, the homeless shelter and the coffin” (Rep. Tim Murphy, R-Pa.) States have been reducing hospital beds for decades, because of insurance pressures as well as a desire to provide more care outside institutions. Tight budgets during the recession forced some of the most devastating cuts in recent memory, says Robert Glover, executive director of the National Association of State Mental Health Program
Mental illness cases swamp criminal justice system (Kevin Johnson, USA Today) On America's streets, police encounters with people with mental illnesses increasingly direct resources away from traditional public safety roles. Chapter 1: Hordes of inmates are ill. Fractured system plagued by problems. “They end up here (the criminal justice system), because we are the only system that can't say no.” ~Cook County sheriff Tom Dart. Chapter 2: Taken away in cuffs. Exhausted cops transport those needing help all over the state. Chapter 3: A gunshot, and a teen dies. Not all officers are trained to deal with mental patients. Chapter 4: Lessons from a fatal shooting. A call goes out for special officer training. Chapter 5: A call for help, then Navy Yard. Aaron Alexis and the 'vibrations' in his body
Cost of not caring: Stigma set in stone (Liz Szabo, USA TODAY) Mentally ill suffer in sick health system. Chapter 1: A separate and unequal system. People with mental illness face legal discrimination. “'There is no other area of medicine where the government is the source of the stigma.' ” Rep. Tim Murphy, Rep. PA. Chapter 2: Lost in darkness. Many wait nearly a decade for treatment. "“'If someone had listened to me the way that psychiatrist listened to me in jail. I think maybe my illness wouldn't have gotten that far.'” Chapter 3: Working for change. Advocates chip away at discriminatory policies. “'Every parent I know has to fight for treatment for their child.'” Chapter 4: Overcoming the shame: Speaking up heals old wounds. “'Where we are at is where the cancer community and HIV community were 25 years ago.'” NFL player Brandon Marshall
The Fortunate Mother: Caring for a son with schizophrenia (Rick Hampson, USA TODAY) The lucky one: Despite hardships, a mother knows it could be worse. For the mentally ill, relatives are the last to leave.
Early intervention could change nature of schizophrenia (Liz Szabo, USA Today) Programs aim to prevent psychosis or halt a patient's decline.
Solutions to woes of mentally ill exist but aren't used (Liz Szabo, USA TODAY) Millions could be helped if programs were put into place.
Substance abuse treatment often impossible to find (Larry Copeland, USA Today) Promising strategies gather dust: 'It's hard to get anyone to pay attention until it happens again.' Joan Ayala now works as a mental health clinician trying to help others avoid her decades-long ordeal.
Mental disorders keep thousands of homeless on streets (Rick Jervis, USA Today) Thousands with mental illness end up homeless, but there are approaches that can help out. Dorothy Edwards hugs her 8-year-old dog, a shepherd-pit bull mix that helped protect her when she lived on the streets.
40,000 suicides annually, yet America simply shrugs (Gregg Zoroya, USA Today) There's a suicide in the USA every 13 minutes.

Navy SEAL Loses Battle with PTSD (Here and Now, WBUR, 1-14-13). For a Navy Seal, getting help for PTSD disqualifies you for security clearance, and in this case, Rob Guzzo, who served in Iraq, went for help too late. "For a SEAL, if you don’t have a security clearance, you don’t go on secret classified missions, therefore you’re not a Navy SEAL.”
• You can watch Michael Moore's documentary, Sicko online. You can hear on Bill Moyers' interview with Wendell Potter how the insurance industry planned to defuse reactions to Moore's documentary. As Potter states: "The industry has always tried to make Americans think that government-run systems are the worst thing that could possibly happen to them, that if you even consider that, you're heading down on the slippery slope towards socialism. So they have used scare tactics for years and years and years, to keep that from happening. If there were a broader program like our Medicare program, it could potentially reduce the profits of these big companies. So that is their biggest concern." Potter himself says of the documentary, "I thought that he hit the nail on the head with his movie. But the industry, from the moment that the industry learned that Michael Moore was taking on the health care industry, it was really concerned."
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Organizations serious about improving U.S. health care



Alliance for Health Care Reform provides tools for journalists to cover health reform, which are equally useful to ordinary citizens.
Agency for Healthcare Research and Quality, including Center for Outcomes and Effectiveness and Centers for Education and Research on Therapeutics
Association of Health Care Journalists (AHCJ) , an invaluable organization for journalists covering health care and health care reform. Core topics at September 2013 conference include health reform, aging, oral health, and medical studies. Topics to be covered in future include insurance, health insurance, health professionals, and health information technology. Many of the resources listed here I learned of from AHCJ, which also provides special informal toolkits for members. The annual conference is excellent and very helpful at keeping members up to date on what's happening in the health care field. See Health Reform resource links and Topic overview. Any journalist covering health care reform should belong to this organization.
http:/​/​healthjournalism.org/​core-topic.php?id=1&page=overview

CDC's National Center for Chronic Disease Prevention and Health Promotion
CDC's Center for Emergency Preparedness and Response
Cochrane Database of Systematic Reviews (CDSR--systematic reviews of primary research in human health care and health policy -- the highest standard in evidence-based health care). See, for example, the top 50 reviews (The Cochran Collaboration).
C-Span
Commonwealth Fund's health reform resource center , including a timeline for an overview of the Affordable Care Act's major provisions and a "Find Health Reform Provisions" tool to search for specific provisions by year, category, and/​or stakeholder group. Also see related Commonwealth Fund content and links to regulations as they become available.

e-patients.net (because health professionals can't do it alone). See particularly e-Patient Dave on BMJ's evaluation of online symptom checkers: Evaluation of symptom checkers for self diagnosis and triage: audit study ( BMJ 2015;351:h3480)

Find Help (SAMHSA's links for substance abuse and mental health services)

Get Health Care (HRSA links to free and inexpensive care)

Health Affairs, including its blogs and health policy briefs.
HealthCare.gov. Official site of Affordable Care Act.
HealthFinder.gov, U.S. government database/​encyclopedia of information and interactive tools. See Health Topics A to Z, find services near you, and check out the gazillion other helpful topics.

Medicare.gov
Medicare Rights Center, national nonprofit consumer service organization, National Helpline: 1-800-333-4114. Counselors are available Monday through Friday, and are happy to answer your questions about insurance choices, Medicare rights and protections, payment denials and appeals, complaints about care or treatment, and Medicare bills.

Medicine (Science Blogs)
Medline Plus makes available information from the National Library of Medicine (NLM), the National Institutes of Health (NIH), and other government agencies and health-related organizations. Provides access to medical journals and extensive information about drugs, an illustrated medical encyclopedia, patient tutorials, and health news.


NAIRO (National Association of Independent Review Organizations, dedicated to protecting the integrity of the medical review process)

Physicians for a National Health Program (supports single-payer national health insurance)

Reporting on Health (USC Annenberg)
Reports from the Institute of Medicine (National Academies)
Rural Health Information hub (RHIhub) (formerly the Rural Assistance Center, U.S. Dept. of Health and Human Services) 1-800-270-1898. See online library. Helps rural communities and stakeholders gain access to wide range of programs, funding, and research.


Smokefree.gov , links to resources for people who want to quit smoking.
Society for Participatory Medicine (a movement in which networked patients shift from being mere passengers to responsible drivers of their health, and in which providers encourage and value them as full partners)
SurgeonRatings.org (Consumers' Checkbook's new website lists surgeons Checkbook has identified as having better–than–average outcomes -- covers 15 types of surgery, but only lists surgeons significantly above average on 90-day mortality, readmissions, and same-stay complications_
Surgeon Scorecard. ProPublica's website shows death and complication rates in eight types of surgery, showing results on all surgeons, good or bad. with 20 or more surgeries in a category. See USA Today story 'Surgeon scorecard' measures docs by complications.
Paul Burke compared methods for the Checkbook and ProPublica rating systems (Globe1234). Globe1234.com provides all kinds of data a patient might/​should want to have
SurveyUSA News Poll on Health Care Data (showing public opinion on various aspects of the health care debate, by gender, race, party affiliation, ideology, level of college education, income,region, and age)

Organizations linked to by Alliance for Health Care Reform (an amazingly huge and helpful list)
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