Tuesday, January 28, 2014

Assignment 3 for my students - The plot thickens

My personal learning network fed me many ideas recently. Tonight President Obama will make his annual State of the Union address. We will certainly hear more calls for cooperation between the political parties in Congress, particularly as related to healthcare reform. The major provisions of the Affordable Care Act are taking effect now. CMS (Centers for Medicare and Medicaid Services) and the Department of Health and Human Services (HHS) are quite fully engaged now in efforts to implement the new law.



This article in Modern Healthcare helps scope out the issues right now.



The heat is on. Physicians and other providers are under financial pressure, legal requirements, and the need to integrate information technologies. People will begin to experience the new "system" as patients very soon. There will be problems. Anything this big and complex is going to have problems. Many states, including Georgia, are not expanding Medicaid coverage. Doing so was part of the "magic," but the Supreme Court ruled that the federal government cannot force the state governments to expand Medicaid, even if most of the money comes from the federal government.

Students, in commenting to this post, please review the information in this post (including the links above) and address at least one aspect of what is going on right now. Watch or listen to the President's address if possible. It will be available on YouTube. The President's concern has to be that a sufficient number of Democrats in Congress and going to get "cold feet" and begin to side with Republicans on some of these issues. It is difficult to "see the entire picture." At least take one aspect of it and comment about how you see things here, please.

Tuesday, January 21, 2014

Assignment Blog 2 for my students

"Modern Healthcare" recently reported the closure of Interfaith Medical Center in Brooklyn, New York. Interfaith Medical Center, like Grady Memorial Hospital in Atlanta, is/was a large "safety-net" hospital. Interfaith primarily treated patients on Medicaid and uninsured patients. It has been in financial strain for some time.


The question, of course, becomes, where will those patients now received needed medical care. At least two things catch my attention in this regard. The first is that this hospital may have survived had "Obamacare" been implemented sooner. In other words, by participating in the exchanges and tapping federal revenues available to help people afford health insurance, the patients served by Interfaith would have had more resources to be spent for medical care. Also, the hosipital itself apparently could have sponsored its patients by paying their premiums for insurance under the new laws and policies.

The article notes that hospitals with high debt, low occupancy and less acutely ill patients are more likely to close. Well, under the new law, if Interfaith Medical Center had become part of an Accountable Care Organization, perhaps more of its revenues whould have come through capitation and its low occupancy rates would not have been a major problem.

This bring up the question of the role of hospitals (and safety net hospitals in particular) in the future of healthcare delivery in the United States. Many people see hospitals as the "hubs" of Accountable Care Organizations (ACOs). Others see a more fluid situation in which ACOs are not dependent upon hospital systems as "hubs."

It seems to me that to effectively protest the closing of a major safety net hospital requires more than a wish to return to the past. An effective protest, I think, requires an understanding of the future of healthcare delivery in the United States. Without that understanding, then it is not possible to anticipate how existing institutions can fit into the new realities and survive.

Students, please see what you can find regarding safety net hospitals and Accountable Care Organizations and then reflect upon the situation reported in this recent article in Modern Healthcare. Comment here, as before.

Wednesday, January 15, 2014

New Post 1 for my new students

There was a report issued in Modern Healthcare yesterday titled, "AMA fears privacy loss as Medicare moves to reveal Doc pay." I became aware of this because my own personal learning network brought it to my attention this morning.


In the article Joe Carlson discusses the balance between the privacy interests of physicians and the value of transparency regarding the incomes that physicians receive for services provided to their patients who have Medicare benefits. When values are in competion with each others reasonable people can certainly disagree about the nature of the "balance" between or among the values. The following statement in the news report caught my eye.

"The American Medical Association is warning that the Obama administration could violate physicians' privacy rights if it poorly implements its new policy for informing the public how much money Medicare pays to individual doctors."

The part of that statement that I notice in particular is the, "if it poorly implements" its new policy.

There is, of course, wide-spread and strongly felt opposition to the entire policy commonly known as "Obamacare." Some of that opposition is grounded in personal philosophies about the nature of freedom and the role of government. There is a substantial fundamental mistrust of central government that goes back to prior to the founding of our nation. A part of that is a pervasive belief that large governments do not have the capacity (ability and competence) to implement complex programs. Even those of us who generally favor what the new Affordable Care Act intends have concerns about the ability of "bureaucrats" to make it work well. The clumbsy roll out of the healthcare.gov website is an example that for various reasons government agancies often appears to be able than other kinds of organizations. Basically, what I see is a vicious cycle of public mistrust creating constraints upon agencies which cause agencies to appear inept that then feeds back into public mistrust and perceptions that government employees are less than fully competent.

The facts are that policy implementation is often very difficult and that implementation of "Obamacare" is a minefield of challenges because of its complexity.

I honestly don't know how to balance the privacy concerns of physicians with the need for the system to be "transparent." I do think that to the degree that being a physician is becoming more "bureaucratic," physicians are opting for early retirements. I am concerned that going forward the shortage of physicians is likely to increase.

I am here asking my students to repond to this post by sharing their opinions and insights about these things. How do the competencies of administrators affect the ability of medical providers to deliver care to large populations of people? Is it possible that "Obamacare" is so bold an initiative as to be impossible to implement effectively? I ask that my students include a link in their reply to some other relevant online resource.

Sunday, September 22, 2013

Post assignment 5 for my students

It will be interesting soon to see how people (and employers) respond to the opening of the insurance exchanges soon. It is evident that even with financial help for those who really cannot afford even the cheapest plans, some people will not participate. Some people will not participate for ideological reasons; making a decision to go without medical insurance rather than becoming part of something they oppose for political, philosophical or, perhaps, for religious reasons. Others may not sign up because they don't know what is happening and may simply fail to respond, for lack of knowledge or, perhaps, lack of literacy.


To my students: do you think some hospitals and other medical care providers may pull back on providing care (beyond what they are legally obligated to provide, such as under the EMTALA law), to people and families that have decided to pay the fine rather than to buy insurance? Will it become more "ethical" or acceptable to say "no" to individuals with no insurance under the new circumstances? There are people and families who use emergency departments of hospitals as their primary care providers and do not pay for the services they continue to receive in emergency departments, by choice. Do you think the availability of the insurance exchanges will change the point at which hospitals say, "no more" to those without insurance?

Friday, September 20, 2013

Module 4 assignment for my students

I am finding that using a blog as a way to create assignments for you, my students, is a bit challenging. The nature of most blog posts is to write reflectively, as if in one's own personal diary. Creating assignments is something else. :-) In one case, the issue is when an idea seems "ready" to be expressed. The other case is a matter of the calendar and the clock. I am a little behind in posting assignments right now, which suggests that this is still a blog, which is good.

I read a lot and our course is the theme of most of what I am currently reading. I have recently discovered Joseph S. Bujak as an author. He is a physician who has become an administrator. I am learning from the insights he has derived from his experiences. I often don't like what he has concluded, but the world is not necessarily what I would like it to be and I find his perspectives thought provoking. I am, perhaps, too much a idealist. As a physician who has become an administrator he, perhaps, has a "license" to say or suggest some things that those who are not physicians cannot say or suggest.

The gulf between hospital administrators and many physicians is frequently reported. Policy experts seem to be of the opinion that the only way Accountable Care Organizations may work is if they are led by administrators who are also physicians. I am sure that there are instances in which administrators and physicians have good and constructive relationships. But I question that administrators who are first physicians necessarily have a greater ability to work with other physicians. I read somewhere that the gulf is about the battle of the apostrophe. In other words, administrators by training and dispostion are primarily concerned about patients' interests; while physicians by training and disposition are concerned primarily about the interests of particular patients. In my idealism (a luxury of teachers) I want to believe that people can change and that it is possible for people of good will to learn from each other's perspectives. I want to believe that even as people age they can remain pliable. Yet in professional cultures (such as medicine and higher education) people cling tightly to the values acquired during training and years of practice. I believe that Bujak somewhere wrote, "Everyone is always 100% in agreement with his or her own perspective." That is especially true of professionals, including physicians and professional administrators. In the classroom I have the luxury of pretending to "see" everyone's perspective. In life, as a professional I see things from "where I sit" and who I am.

In the book Leading Transformational Change: The physician-executive partnership Bujak and Atchison include the following parable.

A scorpion wants to cross a pond and asks a frog for its help. The scorpion asks to ride across the pond on the back of the frog. The frog initially does not trust the scorpion not to bite him. But the scorpion explains that it would not be in his own interest to sting the frog because doing so would kill the scorpion. The frog agrees. Half way across the pone the scorpion stings the frog. Before dying the frog asks, "Why did you sting me? Now we will both die." The scorpion replies, "I am a scorpion. I have to sting you -- it's my nature!"

Ouch! The authors go on the write that effective leaders accept that they cannot change people; that effective leaders find ways to build upon what people already are and by helping others become more of what they already are. That parable haunts me because it challenges what I want to be true. And yet I expect that there is some truth or wisdom in it; otherwise it would not remain in my mind.

Okay, my students. What do you make of this? If it is true that one cannot easily modify professional cultures, then what are the implications for leadership in perilous times? Can we only trust others to be their essential selves? Are notions of personal and organizational learning just empty exercises in academic idealism? Please take whatever you can of this, reflect upon it, and share your journey as a comment to this blog post.

Thursday, September 12, 2013

Module 3 assignment for my students

This is in response to a post by Dr. Kimberly Manning of Grady hospital. I believe she is a hospitalist at Grady Hospital in Fulton County, Georgia. In other words, like many other modern physicians she is employed by the hospital to provide primary care for patients while they are in the hospital. This frees up community physicians with admitting privileges from having to come to the hospital frequently. It is part of a management strategy that may work for everyone involved. It is not the "old days" when your personal physician came to see you in the hospital every day.

http://www.gradydoctor.com/2013/08/dr- no.html

I have been following Dr. Manning's posts on her blog occasionally for several years. A surprising number of health care professional (and hospital administrators) have blogs. Dr. Manning posts frequently and share a lot about her experiences at work and with her family. She really writes well.

In this particular post she reports an event relevant to the cultural environment of medical care. It is no secret that many patients are dissatisfied with their care in part because of cultural insensitivities. There are so many potential barriers including, for examples, languages and religious differences. Hospital administrators and medical care professionals have always faced such challenges. Patients are not always reasonable. Under new policies financial revenue flows will be linked directly to patient satisfaction scores, because patient satisfaction is a proxy measurement of quality of care.

Please reflect on the situation Dr. Manning faced with this patient. Did she handle it well? It is easy to "blame" patients who may appear irrational or unreasonable. In your opinion, is the use of patient satisfaction scores "fair" to hospitals and physicians in the assessment of quality of care? Include a working link to another web page or video that is relevant to your thoughts.

Tuesday, September 3, 2013

Module 2 assignment for my students (and for other readers)

The usual notion regarding market competition is that in the long run it will result in the efficient production of goods and services as "better" companies win out over "not so good" companies in the marketplace. While some scholars argue that competition is the solution to rising costs and the need for higher quality in medical care, others say, "no," medical care is different.

A medicine that I take daily became available in a generic form recently. I use the pharmacy at Walmart on Ledo Road. They informed me that they were out of the generic form and that I had the choice of waiting a few days for the generic, going across town to the Walmart on the East side for the generic, or getting the version that is not generic for an out-of-pocket cost of $30, compared to out-of-pocket for $10 for the generic version. I asked what the non-generic form would cost my insurance company for 30 days. The answer was $186. I drove across town to get the generic in order to save both myself and my insurance company some money.

Here are my questions of you. Was my behavior rational? How many people (as patients) would have cared in the least what a prescription costs their insurance company? Why do we have the complicated system at all? Why not just charge patients the cost of things and not bother with government agencies and insurance companies at all? What would you have done in my situation? How "should" people make economic decisions about medical care? Based on your reading of chapter 2 of our textbook by Marcinko and Hetico do you think competition alone is the solution to the quality crisis and rising costs of medical care?

I am looking for at least one solid paragraph as a reply to this post. You don't have to answer every part of the question. Please remember to include a link to a relevant Web page or YouTube video.