Wednesday, July 29, 2009

First, Make No Mistakes -

In the health care debate, there is one thing we can all agree on: the importance of reducing unnecessary deaths in medicine. Medical error causes tens of thousands of deaths each year that could be prevented by known techniques and technologies. And all errors, even those that are not fatal, are costly: 10 years ago, the Institute of Medicine estimated that the effects of medical error accounted for $17 billion to $29 billion in domestic health care spending, and the error rate has not declined since then.

What makes the problem all the more frustrating is that we could address it with little cost to the American taxpayer. Because American medicine accepts error as an inevitable consequence of treatment, our hospitals, insurers and government do little to respond to unnecessary deaths. If we are to address the problem in a serious manner, we must first change this culture.

As a former chairman of the National Transportation Safety Board, I am familiar with the deadly consequences of human error. However, because that agency views every transportation death as a preventable occurrence, our roads, rails and skies enjoy an unparalleled level of safety. After any significant accident, the board undertakes an extensive investigation, and makes recommendations to the parties involved to ensure that such an accident never recurs. While the transportation safety board has no regulatory authority, its recommendations are viewed by the industry and the public as unbiased and therefore credible, and federal regulators usually act with haste to address them.

Such an investigative body could substantially improve the safety of medicine in the United States. While it surely could not investigate every individual instance of error, it could address many well-known maladies. Hospital-acquired infections, for instance, affect millions of Americans each year. A National Medical Safety Board would collect regional data on the problem, paying particular attention to hospitals with high incidences of infection. It would then determine preventive measures and make recommendations to state and federal regulators, hospitals and health care officials.

When such a board discovered new solutions to old problems, their advice would have the credibility that comes with independent investigation. In some cases, the board might recommend practices that doctors are already aware of, but for some reason do not employ; the public awareness that would follow would pressure hospitals to do better.

These benefits could come at a minuscule cost to taxpayers. The National Transportation Safety Board costs each citizen approximately 25 cents per year. This is a small price for an agency that has eliminated midair plane collisions, persuaded Americans to put children in the back seats of cars instead of the front and prevented deaths in every category of transportation. Given health care's notorious struggles with rising prices, this is a cost-saving opportunity the industry cannot afford to overlook.

An overhaul of our national health care system is at hand and with it a crucial opportunity to improve medical safety. The Obama administration should take a lesson from the transportation safety board's successes and establish an independent agency charged with identifying and eliminating the causes of medical error. Such a move would save money by saving lives and would ensure that our nation's health care system is equipped to provide the safest medical care possible.

Sunday, July 26, 2009

Hospital Savings - Salaries for Doctors, Not Fees - Series -

Visiting the Cleveland Clinic this week, President Obama held up that well-known hospital as a model for the rest of the country. But for most of the nation's nearly 6,000 hospitals, copying the Cleveland Clinic would be like asking the Durham Bulls, a minor league team, to copy the New York Yankees.

A more accessible example is a hospital that sits a bit more than a home-run blast from the Baseball Hall of Fame here. Called Bassett Healthcare, this modest hospital of 180 beds delivers high-quality care at low costs in the face of federal reimbursement policies that discourage many of its best practices.

Changing those policies is crucial to the success of health care reform, economists say — something Mr. Obama said that he would do. "Our proposals would change incentives so that doctors and nurses finally are free to give patients the best care, not just the most expensive care," the president said Thursday in Ohio.

But almost nothing in proposed legislation that has so far emerged in Congress would encourage the creation of similar hospitals.

Bassett looks like a small liberal arts college, with ivy-covered fieldstone buildings connected by a warren of passageways. But what really sets it apart is the way the system pays its 260 doctors.

Doctors in the United States are usually paid fees for each service they provide. The more procedures and tests they order, the more money they pocket. There is widespread agreement among health policy analysts that many of these procedures are unnecessary, raising costs in ways that often do nothing to improve patient health.

By contrast, Bassett — like the Cleveland Clinic and a small number of other health systems in this country — pays salaries to all of its doctors. No matter how many tests or procedures are performed, they take home the same amount of money. Medical costs at Bassett are lower than those at 90 percent of the hospitals in New York, while the quality of care ranks among the top 10 percent in the nation, surveys show.

Dr. William F. Streck, the longtime president of Bassett, said the hospital paid salaries that were competitive with the money earned in a fee-for-service setting. Some fee-dependent physicians, though, either by working hard or by providing excessive treatments, can make more, an ability doctors trade associations have long defended.

"Everyone knows that the Bassett model is the right model," said Senator Charles E. Schumer, a New York Democrat involved in negotiations over health care legislation. "The question is, How do you get from here to there?"

It is a question that has plagued lawmakers and medical experts for nearly a century. As early as 1910, Abraham Flexner wrote a landmark report that argued teaching hospitals should be staffed only with salaried doctors. In 1970, the Carnegie Commission released a report calling for drastic improvements in rural health care, and highlighted Bassett as a model.

Many doctors who work at Bassett believe deeply in its mission. Bassett has opened 13 clinics in schools around the region. The clinics lose money, but Bassett is considering opening 14 more.

"I was in private practice for years in New Mexico," said Dr. Philip A. Heavner, the chief of pediatrics at Bassett, "and there was no interest in doing anything like this because people thought it would take volume away from their practices."

Dr. Randall Zuckerman, an attending surgeon at the Hospital of St. Raphael in New Haven, left Bassett a year ago because his wife wanted their four children to grow up closer to family. Since many of his patients see fee-dependent doctors, Dr. Zuckerman said in an interview, their care is more disjointed than was common at Bassett.

"They get a lot of different consultations, some necessary and some not," he said. "They are always missing parts of their medical records because the information is coming from multiple private offices."

Generation B - Worry Over My Heart Messed With My Head -

I'D always hoped I had my mother's heart. She died a few years ago, at 92, in good physical shape almost to the end.

On my father's side, hearts were weak. Dad had his first heart attack in his mid-50s, and died from his third, at 65. Dad's older brother, Ben, died of a heart attack at 50; his younger brother, Carl, had open heart surgery in his mid-50s.

Through my 40s I gave little thought to my mortality. With four young children, our house was full of life. I was in good shape and had lots of energy; my only medical procedure — arthroscopic knee surgery — was a result of being overactive.

About the time I hit 50, my primary care physician, a cardiologist, noted I had elevated cholesterol: a little over 200, nothing terrible. When six months of trying to eat better made no difference, he suggested a statin, which lowered my cholesterol to good levels.

This was the first indication that I might not have Mom's heart, and that played with my head. I started reading the obituaries more closely, particularly ones about men in their 50s dropping dead. The worst were about men who dropped dead while running or biking. For years, I've jogged four miles regularly, and reading the obits quickly dispelled any notion this would save me.

For about a year, I was nutty about this. I thought too much about my chest. Any twinge, any pain, I wondered, "A symptom?" As a boy, the only time I remember seeing my father cry was when he told me his brother Ben, a doctor, was dead.

I was now older than Uncle Ben.

A few times in that year of living nuttily, if I felt chest discomfort, I stopped by my doctor's office to check my blood pressure.

It was fine, they said.

During a summer vacation trip to Michigan, I was out early, climbing sand dunes with the kids, and felt a heaviness in my chest. Soon after, I experienced persistent nausea, lightheadedness and a cold sweat. By then I was well versed in symptoms. I went to a nearby emergency room.

I was fine, they said.

When I got home I told all this to my cardiologist. He suggested, given the recurring symptoms, that maybe it was time for a coronary angiogram, which is done at a hospital. A thin tube is inserted through a blood vessel from the arm or groin area up to the heart, allowing a dye to be injected so a complete picture can be taken of the coronary arteries.

The angiogram showed some plaque buildup, but no blockages.

And that ended my year of living nuttily. I came to understand that my body was middle-aged, and I had to listen to it differently than I had as a younger man. If the first mile of my jog felt uncomfortable, I accepted this as normal and waited for adrenaline to kick in. I remembered something the E.R. doctor in Michigan had said (undoubtedly aware I was a nut case): If you run, it's like giving yourself a daily stress test; if there's a problem, you'll feel pain.

I decided my family history might not be so ominous. My father and uncles did not have the benefits of today's public health campaigns. They had smoked two packs a day for 20 years, and I have never smoked. While I don't eat perfectly, my father was part of the pastrami generation — he was considerably overweight and didn't exercise until after his first heart attack.

Over the next five years, I saw my cardiologist regularly and, except for adding a blood pressure pill two years ago, all was good. I had lots of energy, exercised daily, felt great.

About a month ago, my cardiologist, Dr. Michael Chesner, suggested a stress test. My vitals were all good, but it had been five years since the last one.

I didn't want to do it. I repeated the quote from the Michigan doctor; I explained that my family history was probably misleading.

A precaution, he said.

The stress test was easy. I had no trouble keeping up with the treadmill, and felt the same at the end as at the start.

He called the next day, and right away I could tell something was up. The nuclear scan indicated less blood flow to the inner lining of the heart after exercise. "You're not having symptoms?" he asked.

"Not really," I said.

"Not really?"


Was I?

Instead of another coronary angiogram he suggested a less intrusive diagnostic tool, a CT angiogram, which could rule out a blockage. Until then, he said, walking might be better than jogging.

The day before the test, the obituaries page featured Michael Martin, the graffiti artist, and Billy Mays, the TV pitchman, both dead of apparent heart attacks at 50.

The morning after the test, my cellphone rang a little before 8. I was finishing a brisk four-mile walk on the beach. The scan showed three possible blockages, though a coronary angiogram might still show none were significant.

Several days later, the coronary angiogram showed two were nothing, but a third was an 80 percent blockage in the circumflex artery, which the doctor cleared, before implanting a medicated stent.

It has been a little over two weeks, and I feel great. Of course, I felt great before. I'm also confused. I've had so many advantages my father's generation did not — medication, diet, exercise, not smoking — and yet, my first heart episode came at almost the same age as Dad's.

I asked Dr. Alice Jacobs, a professor of medicine at Boston University, the director of cardiac catheterization at Boston Medical Center and a past president of the American Heart Association, why I hadn't done better.

"You're ahead," Dr. Jacobs said. "You haven't had a heart attack," which does irreversible damage to the heart.

Innovations that boomers like me have benefited from — cholesterol drugs (20 years); blood pressure medication (25 years); stress test/nuclear scan (25 years); stents (15 years); medicated stents (5 years) — have all most likely contributed to improved mortality rates, Dr. Jacobs said.

In 1950, according to the Centers for Disease Control and Prevention, 587 Americans per 100,000 died of heart disease; by 2006, the number was 200.

In contrast, the mortality rate for cancer is little improved, from 194 per 100,000 in 1950 to 181 in 2006.

But on the micro level, individual by individual, it's more fuzzy. "You can modify the major risk factors, but you can't modify family history," Dr. Jacobs said. The presence of coronary disease in a close relative younger than 55 for men increases heart disease risk.

The fact that I had no symptoms? A minority of people don't, she said. Or possibly I missed them.

More than a million Americans a year get stents. Will mine prolong my life? Unclear. For stable patients like me, studies comparing mortality rates over a five-year period with a single stent and taking medication, versus treatment with medication alone like blood thinners and a statin, show no difference in outcome.

The science gets better, but life remains inscrutable.

With my doctor's permission, the weekend after the procedure I drove my daughter to a softball tournament three hours away in the Poconos. A few days later, we flew to Michigan, where I sent her off to band camp.

About a week ago, over a breakfast of low-fat yogurt, fruit and granola, I read the obituary of Christopher Hipp, a groundbreaking computer designer who collapsed and died at 47, while biking.

Then, my wife and I and two of our sons walked up to the beach.

It was a perfect summer day, the water was warm, the waves strong. I took my first swim since the stent, and though it was never spoken, I think Sam and Ben, both lifeguards, stayed with me just to keep an eye out. In an hour of bodysurfing, I caught a couple dozen great rides. As I walked back to my towel, the water dripping off me, the sun warm on my back, I couldn't help thinking it was wonderful to be alive.