Inkwell: Authors and Artists

    
Hmmm. I will see if I can get one to him. He does sound like he is
primed for this discussion.
  

    
One thing I deeply appreciate about the book is that it shows how
these changes can be self-driven (there's a cybernetics term for this,
which I can't think of at the moment)--  they don't require a master
plan for instigation, and many are already in place in certain
institutions all over the country (Kaiser, Cleveland, Mayo). That much
is a matter of self-interest and education, not legislation, is good
news, given the paralysis of our legislators at the moment. From Atal
Gawande's check lists to the "virtuous spiral," many can simply be
adopted as policy at an office or institutional level.

Meanwhile, here in England, everyone I've talked with was pleased to
hear the Supreme Court upholding of the step forward. It may not be the
central issue in larger change, but as a basic principle of civic
mindedness and decency, it's a Good Thing.
  

    
You need to get your book to Ezra Klein at the Washington Post, if you
haven't already. His team is deep into the healthcare wonkery and your
ideas are right up their alley.

<http://www.washingtonpost.com/blogs/ezra-klein/>
  

    
Good call.
  

    
Joe,

I don't have your book yet, but plan on getting a copy. In laymen
terms, how can we explain that we are already spending the money for
the uninsured when they cannot pay for themselves? Who eats the costs
of people who cannot pay? 

I good friend is an ER Doc in a small local hospital. This is a
non-profit that is barely making it. He thinks that many of the
provisions in the health-care act will give the place a fighting
chance.
  

    
> You need to get your book to Ezra Klein ...

He's already on my list, and I have emailed him. If anyone has a
better contact, please let me know.

> Who eats the costs of people who cannot pay?

All those who pay into the system do, whether they pay in premiums or
taxes or (probably) both. When people who cannot pay end up in the ED
and such, the hospital "absorbs" their costs. That means that this
unfunded care becomes part of the bottom line, and it ends up being
built into the cost of their services. Medicare and Medicaid rates are
set in ways that are quite beyond the hospital's control, though CMS
(the agency that administers Medicare and Medicaid) does set aside some
DSH or "disproportionate share" funds for hospitals that have way more
than the usual proportion of non-payers. For the rest, the hospital
negotiates the other rates with private insurance companies. So the
unfunded care becomes part of what hospitals must negotiate out of
private payers. 

But it is very indirect, just filtering through all of these thousands
of hospitals' bottom lines into demands and needs to negotiate higher
rates out of private payers. So what people see is, "Healthcare
insurance is expensive!" If they are really following the bouncing
ball, they might see that "Hospitals charge huge amounts!" What they
don't see is that hospitals are (must be) passing on the costs of very
expensive care for the uninsured.
  

    
<pspan> used to work for the Washington Post. She might know a way to
get a book to the staff.
  

    
The other point to note is this: For those uninsured who end up in the
system a lot, it would cost a lot less, on the order of half as much,
if we provided them with some form of insurance, so that they could
just go to the doctor when they needed to, or to a clinic or urgent
care center.

The entire political discussion always assumes that we are giving
something away, adding onto our own costs, if we insure the uninsured
poor. The reality is that we our costing ourselves money by _not_
insuring them.
  

    
> <pspan> used to work for the Washington Post. She might know a way
to
get a book to the staff.

I'll ask her. To be precise, though, I think Klein is a Bloomberg News
staffer whose blog gets published by the Post. He is a consistently
sensible and well-informed writer.
  

    
Thanks Joe. Interesting stuff. It seems like something we should know
in our guts, but talk circles around. Unless a person is willing to say
some people do not deserve healthcare, they should know that it is
costing THEM money right now.
  

    
> some people do not deserve healthcare

This is in fact the undercurrent of an awful lot of what regular
people say about healthcare. Some of them come right out and talk about
"deadbeats." Many conjure up the healthcare equivalent of Reagan's
"welfare Cadillac queen" myth. I have quite a section of the book
addressing the sound, sensible, fiscally responsible, not even
compassionate reasons why we should take care of people who, to the
outsider, don't seem to be taking care of themselves, and who cannot
afford care.

The short version? I have two. One is, "Show me the recreational
hysterectomy, then we'll talk." 

The other, less glib, one is: "So you have always done the right thing
and made sure you are well-insured? That's great. Let's imagine that,
right now, while we're talking, you start feeling ill. You make it to
the emergency room, there are tests. You have cancer. Maybe you'll
live, but it means a year or more of being very sick. You can't work,
so you get laid off. You pay for the very expensive COBRA insurance out
of your diminishing savings and unemployment. Six months later, that's
gone, you can't get new insurance because you are sick, all you have
left is Medicaid, if you qualify for it, and if you can find doctors
who will take it as payment. And there you are, one of those deadbeats,
coming begging to the system to help you not die.

That's the system before ACA, and ACA will only partially fix it.
  

    
A couple of years ago, I had some very memorable conversations with
the upper-middle-class parent of one of my patients:  the primary
family breadwinner had lost a job, and the child was now on Medical. 
The child was still welcome in my clinic, but their descriptions of the
circumlocutions, the long silences, the not-being-called back, and
refusals to outright say, "we can't see you anymore, please find
someone else to see your child with the crappy new insurance"--it was
eloquent and disturbing.
  

    

Time to Get Fierce!

"Putting the provider at risk, measuring quality, giving the patient the
power of a consumer: all these taken together change the landscape
completely. It's time for healthcare to get fierce about efficiency and
effectiveness, about clinical quality, and about the patient experience...

"To get fierce about efficiency and processes, you have to be able to see
into them. This not only means wall-to-wall computerization and automation,
but also means designing the system so that you can continually mine the
data it produces, continually query the system for answers to questions you
never thought of before, for patterns, outliers, and anomalies."

I am carried away by this vision, yet I wonder how solo and small
practitioners move from where they are to this exalted place in the
healthcare universe. Who develops, automates, maintains, and funds 
coordination and consistency between these providers, the hospitals, 
pharmacists, drug companies, laboratories, device makers, billing 
services, payers, IT support that they depend upon?

How does one build and pay for a seamless web for systems big, small, and 
solo?
  

    

debunix slipt.

Yes to that concern. Personally, when I had topnotch insurance, I developed
great relationships with my doctors that continued when I was both
impoverished and disabled, but still insured. I was damn lucky.

Then my PCP retired and sold his practice to a doctor who simply wanted me
gone. He refused to treat a simple bladder infection that transmuted into a
serious kidney infection. Had the hospitalist not kept me in hospital while
she cultured the antibiotics I was on after surgery, I easily could have
died from rampant, untreated infection.

I was in hospital for ten days. 
  

    
Wow. Incredible. Or I should say, unfortunately all too credible.
  

    
Yes, entirely believable.

One aspect of the seamless web is coming faster than I had suspected: 
>97% of pharmacies reportedly belong to e-prescribing networks, so my
scrip pad is soon going to vanish, and not because I misplaced it.  My
primary and secondary hospital systems are pushing to a system where I
have to enter all the info electronically which should in theory
minimize medication errors.  (I expect added inconvenience in both time
and irritation for various medication interaction data that is going
to be forced at me over and over until I'm so desensitized to it that
I'll miss the really important one.....)
  

    
> Who develops, automates, maintains, and funds 
coordination and consistency between these providers, the hospitals, 
pharmacists, drug companies, laboratories, device makers, billing 
services, payers, IT support that they depend upon?

> How does one build and pay for a seamless web for systems big,
small, and solo?

There are really two answers to this question. The first is that (as I
show in parts of the book) there are ways even for sole practitioners
or small practices to streamline their practices and make them cheaper.
The index string is "ideal medical practice."

The second, more important answer is that all these things have been
uncoordinated and full of seams and cracks and disjunctures because,
under the usual fee-for-service system, it is not to the financial
advantage of any of those systems to be well-coordinated and seamless.
When you have a system even partially based on getting paid for
results, suddenly it it massively important for systems to find ways to
be coordinated and seamless, even with doctors who don't work for
them, and to help them be more seamlessly enmeshed in the larger
system.

So you get Geisinger Health System in northeastern Pennsylvania paying
for extra nurses in independent doctors' practices whose sole function
is to track patients with chronic disease and communicate with them.
You get North Shore/LIJ in the New York area telling independent
doctors in their area: "Digitizing your practice? We'll pay half. If
you organize it (with our help) so that we can pool your data with ours
to see what works system-wide with chronic patients, we'll pay 85%"
  

    
Not to annoy anyone but I've been reading Ezra Klein since he was a
wee blogger, and he joined the WashPost before he was on Bloomberg,
though he's everywhere now.
  

    
Okay. The Post site says, "Ezra Klein is the editor of Wonkblog and a
columnist at the Washington Post, as well as a contributor to MSNBC and
Bloomberg."
  

    
I'm away from my copy of the book, so perhaps this is in there, but
isn't there another argument why we should insure everyone in addition
to the two above-- re vaccinations, herd immunity, and re general good
health, EVERYONE is better off if you don't have people with untreated
contagious illnesses, or partially treated illnesses that end up
creating resistant strains because a person can't afford the full
course of antibiotics? "Public Health," that old fashioned concept,
leads to a country free of cholera, tuberculosis, and other such
diseases that once were rampant and could be again. Health care for all
is health care for all, the wealthy as well as the poor. To not treat
the poor is akin to not treating a part of your own body, thinking that
it somehow isn't connected to your full well being.

Compassion and self interest are in alignment. 
  

    <scribbled by julieswn Mon 2 Jul 12 08:35>
  

    <scribbled by julieswn Mon 2 Jul 12 08:33>
  

    <scribbled by julieswn Mon 2 Jul 12 08:34>
  

    

Beautifully put, Jane!

When I started your book, Joe, I never imagined it would be a page-turner! I
read it before sleep. Yet, it livens me up and I have to will myself to 
put it down!

You write so clearly and well, explain the problems, build excitement 
about ideal solutions, and then bring in real world examples--it's 
being done right here and there. Why not everywhere?

Last evening I was yawning *and* my heart was pounding and my eyes were 
wide. Your book is the *best* mystery ever! We have unnecessarily broken 
and dead bodies throughout the system. Let's stop the mayhem and protect 
the living! 
  

    

Now, Joe himself slipt!