Tradeoff between quality of care and readiness to practice?

The following CNN Health report includes a CNN Radio report regarding new regulations limiting the lengths of shifts worked by medical interns and residents.

http://thechart.blogs.cnn.com/2011/06/14/limiting-student-doctors-hours-cuts-both-ways/?hpt=hp_bn6

The essential point is that while long shifts have been shown to contribute to medical errors that "shorter" shifts (say 16 hours at a time) will undermine the quality of the educational preparation of medical interns and residents. In a comment to the report "ramparts1815" stated that recent graduates know less and can do less than graduates five years ago. He or she adds, "And the public should realize that really good doctors and surgeons peak at 5-10 years after training."

As a university teacher I think a lot about the level of preparedness of new graduates. Something seems to be happening that is affecting the nature of the cognitive skills of emerging young professionals. Perhaps it is the cognitive overload of trying to digest so many streams of incoming information at a time. Even watching CNN television now involves continually receiving two or three news reports at the same time. Nicholas Carr suggests as much in his book, The Shallows: What the Internet is Doing to our Brains. It has been suggested that increasing rates of autism may be of environmental/chemical origin. If true, might the same chemicals be affecting the cognitive capacities/processes of all of us? Are we each losing individual cognitive capacity while our networked collective capacities are increasing?

To me, the bottom line is that if it takes increasingly long to educate physicians and surgeons and if their abilities peak and then tend to decline only five to ten years after graduation, we have problem. All things considered, if I have to be rushed into a hospital for some medical emergency I hope to be seen by people who are not so tired they cannot at that moment provide their wakeful attention. Nor do I expect when I go to a physician that others have perhaps endured medical errors in the past so as to somehow contribute to the quality of his or her education. I don't claim to have the answers here, but I wonder if there is something incorrect in the reported concern that when someone in training goes home for rest after a 16 hour shift that they do not adequately appreciate their needs to learn.

Scope of a Miracle

It is good to see photographs of U.S. Rep. Gabrielle Giffords that became available to the public today. Few people know all the details of the kinds of care she received that made possible the near miracle of her survival and recovery. There are surely many physicians, surgeons, nurses and others who together made this possible. She is alive and recovering today because of the coordination of the efforts of many professionals. In other words, it was not only the skills of individuals who saved her life and promoted her recovery. It was the timely coordination of those efforts. In this case, the "system" of care worked. I want to believe it would have worked as well for any person who suffered her injury.

As I read some of the comments received by HHS regarding proposed rules for implementation of ACOs I see the strong expressions of good people who simply do not want government agencies to attempt to rationalize the healthcare delivery system. Some people are simply opposed to "socialized medicine" and/or define the proposed changes as a loss of freedoms won on battlefields around the world. Others are open to change but do not believe that the new law and the proposed rules will work. Rep. Giffords' recent experiences with the system could be cited either as evidence that what we already have can work; or to say that we can do better. I want to believe that we can do better for at least all American citizens, including the large numbers of people entering the Medicare program. I believe that the rationalization of medical processes can reduce costs and produce more consistent quality outcomes for all patients.

It is a safe guess to say that the implementation of the new law will produce unintended behaviors among providers. The system that produced the law is a political system. Democratic political systems cannot produce scientifically rational policy designs, as in the context of operations research which is rational in a more objective way. Politics is the art of what is politically possible. As we pray and hope for Rep. Giffords' continued recovery let us continue to hope that the new law which she supported in Congress with her vote backed by her courage can be implemented successfully. "Bureaucrats" have to run with what they are handed by others.

What is the role of competition within an ACO?

I am reading the last chapter of the book Accountable Care Organizations: Your Guide to Strategy, Design, and Implementation by Marc Bard and Mike Nugent. It is well worth the time and thought to read. It appears to me that if they work, ACOs are more likely to be successful in large urban areas where there are large populations of people and large numbers of hospitals and physician groups. The idea is to scale up "production" by designing efficient and effective care pathways. In an urban setting multiple ACOs can exist and as a result there can be a constructive combination of efficiencies within ACO networks and constructive competition among multiple ACO networks. Hospitals and physician groups can "shop around" and even participate in multiple ACOs within a large urban market.

But it is not apparent to me that this is going to work well in smaller markets that lack enough population base to support multiple ACOs. If there is only one existing local hospital and no large physician groups then it appears that there is only one potential "game in town." The challenge there will be the usual one of trying to align the interests of physicians with the interests of the hospital, given shrinking revenue from government payers. But what about the situation in which there are two or three local hospitals in a city and they have a long history of unhealthy forms of competition including frequent law suits? To create an ACO governance body composed of people with long-standing local institutional loyalties is going to be difficult. I am concerned that Medicare beneficiaries and others in such places may lack adequate care because in the absence of an ACO local institutions will not have adequate financial resources to provide quality care. If long-term competitors cannot get past their issues and competitive interests they may be unable to form an ACO in small to midsize places.

Just as Certificate-of-Need legislation led to accelerated spending for costly medical technologies in the 1970s it will not be surprising if the Patient Protection and Affordable Care Act will lead to many attempts by local hospitals to buy out other local hospitals and local physician practices. Coordination that may not be otherwise possible is possible under unified ownership. But there are still laws on the books that prevent some acquisitions and that make it illegal for the very entities that should be talking about forming ACOs from discussing financial matters because such conversations would be anti-competitive. What it boils down to is, do we believe in competition or do we believe in networks based upon cooperation, coordination and trust. It seems as if we want hospitals to compete with each other while at the same time being partners within ACO structures. How can the people who govern an ACO also fulfill their responsibilities to individual institutions engaged in competition with ACO partners?

One of the things that Bard and Nugent advocate for is tightly coupled systems. Can a system be both tightly coupled and internally competitive? Is it reasonble to insist on what amounts to consolidation of institutions while at the same time forbidding hospitals and others from engaging in behaviors that are illegal because they threaten competition?

Helping Patients See the Light

Thomas Goetz of Wired Magazine spoke recently at TEDMED about the potential to leverage the voluntary compliance of patients by presenting them information that is personal, relevant and actionable. In my opinion, our nation cannot rise up to the challenge of providing quality medical care to all citizens without more effectively engaging patients as their (our) own best primary caregivers. Goetz points our that a sense of self efficacy is more effective in producing compliance behaviors (exercise more, stop smoking, and so forth) than is fear as a source of self motivation. Most people want to be healthy. Most people don't want to die a premature death. Goetz believes that "packaging" information for people is an effective way to gain compliance. I believe it is also a way to help reduce overall costs.

Direct link to YouTube video below

ACO regulation design flaw?

Paul Levy's explantion of a possible design flaw in the proposed rules by which ACOs may be regulated is worth exploration.

http://runningahospital.blogspot.com/2011/04/aco-rules-wheres-beef.html

It seems to me that the underlying problem is that many government policies intended to prevent constraints on competition just don't work well in the new paradigm of accountable collaboration. Is it possible that political realties make it impossible to achieve the needed combined goals of increased access, quality improvement and cost constraints? In light of national and global "graying," the reality is that as medical interventions become more successful people will live longer and costs will rise. It seems to me that there is an "impedance mismatch" between population-based healthcare and patient-centered medical care. On the one hand, when acute medical interventions become necessary we want assembly-line efficiencies. But on the other hand, we want to personalize care for each patient. Continuing discoveries involving DNA and genes can bridge the mismatch by allowing the creation of evidence-based protocols for very small groups of patients and even for specific individuals. But to do this the complexity of personalized diagnoses and treatments will increase dramatically, and with complexity the costs.

Yarnell Beatty Speaking on Accountable Care Organizations

Attorney Yarnell Beatty speaks here regarding what is now known and not known about Accountable Care Organizations, as outlined in the new healthcare policy.

Investigation of quality of care in Las Vegas hospitals

This is from Paul Levy's "Not Running a Hospital" blog. In the video below Brian Greenspun, Publisher and Editor of the Las Vegas Sun speaks about an extensive investigation of the quality of care delivered by hospitals in that section of Nevada by reporters Marshall Allen and Alex Richards and others. The essential message is that transparency and the willingness to face up to errors may actually reduce lawsuits and enables a hospital to learn from its mistakes.