By LYNLY JEANLOUIS
Health insurance companies are standing
in the way of many patients receiving affordable, quality healthcare. Insurance
companies have been denying patient claims for medical care, all while increasing
monthly premiums for most Americans. Many of the nation’s largest healthcare payers
are private “for-profit” companies that are focused on generating profits
through the healthcare system. Through a rigorous approval/denial system, health
insurance companies can dictate the type care patients receive. In some cases,
this has resulted in patients foregoing life-saving treatments or procedures.
In 2014, Aetna, one of the nation’s leading healthcare companies, denied coverage to Oklahoma native Orrana Cunningham, who had stage 4 nasopharyngeal cancer near her brain stem. Her doctors suggested she undergo proton beam therapy, which is a targeted form of radiation that can pinpoint tumor cells, resulting in a decrease risk of potential blindness and other radiation side effects. Aetna found the study too experimental and denied coverage, which resulted in Orrana’s death. Aetna was forced to pay the Cunningham family $25.5 million.
In December of 2007, Cigna Healthcare, the largest healthcare payer in Philadelphia, denied coverage for Nataline Sarkisyan’s liver transplant. Natalie was diagnosed with leukemia and had recently received a bone marrow transplant from her brother, which caused complications to her liver. A specialist at UCLA requested she undergo a liver transplant, which is an expensive procedure that would result in a lengthy inpatient hospital stay for recovery. Cigna denied the procedure as they felt it was “too experimental and outside the scope of coverage”. They later reversed the decision, but Nataline passed away hours later at the University of California, Los Angeles Medical Center.
Given the attention now paid to implementing national health reform, the bulk of which is now upon us as 7 million new individuals now have health insurance, one important issue remains largely ignored by policy makers and industry leaders–health care workers are very unhappy.
A 2012 national survey of 24,000 physicians across all specialties found that if given the choice, just over half of these doctors — only 54 percent — would choose medicine as a career again. Fifty-nine percent of physicians in a 2013 survey could not recommend their profession to a younger person, and forty-two percent were dissatisfied in their jobs. Forty percent of physicians in another 2013 national survey self-identified as burned out.
Nursing has gained the moniker of one of the least happy jobs in America, with nurses traditionally experiencing high rates of job dissatisfaction, burnout, and turnover. Some of the reason for this malaise among our highest status health professionals has to do with the stressful, uncertain nature of health care work.
But it also is an outcome of the everyday worlds in which all health care workers now find themselves: a world drenched in paperwork, packed patient schedules, and decreased control. In short, the new world of health reform.
We are in the midst of a technological and business revolution in health care delivery. We are also on expanding patient demand in ways not seen in generations. But we are not meeting the needs of health care workers, who are expected to produce at a higher level than ever before.
Writing in the Wall Street Journal (WSJ) Dr. Daniel F. Craviotto Jr. an orthopedist, made a plea to physicians to declare independence from third parties and emancipate themselves from servitude to payers, mandates and electronic health records (EHR).
As rants go, this was a first class rant. But its effect was that of a Charles de Gaulle’s whisper to Vichy France rather than a Churchillian oratory at the finest hour.
The article went viral (it has been tweeted nearly 3000 times), though with little virulence. And it is not WSJ’s paywall to blame.
The author might have assumed that most the healthcare community in general and physicians in particular wish to be free from regulations. I have serious doubts that this assumption is correct in the aggregate. The relationship between regulators and physicians is more complex and symbiotic than it first appears.
Some physicians believe in bureaucracy. Rationalism will march us out of our healthcare wilderness. This belief in scientific managerialism, faith in technocracy, is the new theism. The rationale of the new theists is that regulations fail not because they are inherently useless but because there are so few of them, and even fewer that are actually smart.
Like the first religions started with polytheism, the new believers want more agencies, more alphabet soups, more gods.
Quality improvement (QI) and patient safety initiatives are created with the laudable goal of saving lives and reducing “preventable harms” to patients.
As the number of QI interventions continues to rise, and as hospitals become increasingly subject to financial pressures and penalties for hospital-acquired conditions (HACs), we believe it is important to consider the impact of the pressure to improve everything at once on hospitals and their staff.
We argue that a strategy that capitalizes on “small wins” is most effective. This approach allows for the creation of steady momentum by first convincing workers they can improve, and then picking some easily obtainable objectives to provide evidence of improvement.
National Quality Improvement Initiatives
Our qualitative team is participating in two large ongoing national quality improvement initiatives, funded by the Agency for Healthcare Research and Quality (AHRQ). Each initiative targets a single HAC and its reduction in participating hospitals.
We have visited hospital sites across six states in order to understand why QI initiatives achieve their goals in some settings but not others.
To date, we have conducted over 150 interviews with hospital workers ranging from frontline staff in operating rooms and intensive care units to hospital administrators and executive leadership. In interviews for this ethnographic research, one of our interviewees warned us about unrealistic expectations for change: “You cannot go from imperfect to perfect. It’s a slow process.”
While there is much to learn about how to achieve sustainable QI in the environment of patient care, one thing is certain from the growing wisdom of ethnographic studies of QI: buy-in from frontline providers is essential for creating meaningful change.
Frontline providers often bristle at expectations from those they believe have little understanding of the demands of their daily work.
Aspiring healthcare entrepreneurs could be forgiven for assuming our most significant challenge is the need to reduce the cost of care. Investors and policy wonks alike seem to agree on the overriding need to focus on innovations that will improve efficiency and take costs out of the system.
The appeal of this approach is easy to understand: rising healthcare costs are a real problem, and business process improvement feels like something we already know how to do. Large companies like GE and Oracle are thrilled by the opportunity to apply their process methodologies to healthcare. Management journals love the idea of improving healthcare through operational excellence. An increasing number of foundations have also joined the fray, focused explicitly on supporting innovations that reduce the cost of care.
Yet, as much as operational improvements are urgently needed, they should not represent the primary goal of healthcare innovation.
If we’re truly interested in high value healthcare, we’d do well to keep in mind that for many, if not most serious or chronic diseases, at least in the absolute sense, high value care simply isn’t an option. We have embarrassingly few therapeutic approaches that can really do much to restore the lives of these patients. Sufferers afflicted with Alzheimers Disease, pancreatic cancer, brain tumors, and so many other conditions desperately require transformative breakthroughs, not the mucking around the edges that passes for treatment today.
Make no mistake: it’s critical we do the very best we can to provide compassionate, evidence-driven care for patients who are sick right now, and innovations that contribute to the identification and humanistic delivery of the best available care are vitally important.Continue reading…
“This GAO report sheds new light on the behavior of physicians reaping personal gain by referring patients to services at locations where they have an ownership interest. The analysis suggests that financial incentives for self-referring providers is likely a major factor driving the increase in referrals for these services. As Congress looks to reign in unnecessary spending, my colleagues and I should explore this area in greater depth,” Rep. Waxman said.
Explore you should, Representative Waxman. For if you look beyond the GAO’s conclusions, you will find that what we really need are bundled payments and a regulatory environment that supports, not inhibits, innovation to improve high-value health care.
Just because physicians have come together to manage their own futures doesn’t mean that their intent is to collude and increase costs. Could it not also indicate that health-care professionals have joined together to provide better care in a more efficient manner that reduces waste and unnecessary services to save the system money?
Patient-centered care and patient engagement have become central to the vision of a high value health delivery system. The delivery system is evolving from a fee-for-service transactional payment model to a value-based purchasing model using outcome data and quality improvement and attainment. The Centers of Medicare and Medicaid Services (CMS) and private payers have spurred delivery redesign of networks that focuses on a set of clinical quality measures and patient care experiences along with efficiency measures.
However, the questions we ultimately really care are: “Did I get better? Am I healthier?”
With the advent of Facebook, PatientsLikeMe® and Avado, consumers and patients are sharing their healthcare experiences openly with their support system and strangers with similar illnesses. Our delivery system has yet to leverage the power of patient/consumer reported data in feeding back to care deliverers in the quality improvement cycle.
Clinical quality measures have traditionally consisted of process or surrogate measures and centered on providers and hospitals. As we move toward a system based on value, the measurement system must shift as well. Part of this movement will be utilizing outcomes directly reported from patients and their caretakers and incorporating these outcomes into quality improvement initiatives and payment models. The widespread adoption of standardized and validated patient-reported outcomes measures (PROMs) would accelerate the development of a patient-centered health system. However, new standards; patient-friendly, digitally-enabled instruments; secure portals; and more research will be required to facilitate adoption.
So much media and journal space has been devoted to financial conflicts of interest, particularly within and related to pharma and device manufacturers, that to write any more about it may be redundant. On this site we have also intermittently addressed COI from other perspectives, such as financial interest of the members of the American College of Radiology in maintaining mammography screening status quo, thinly veiled in its own version of the pernicious “death panel” language. We have also spoken a bit about the non-financial COI. And even though we are so very much aware of COI’s potential to lurk around every corner, there are still some surprises.
Take the sacred cow of “quality improvement” in healthcare. Even the name, much like the “pro life” moniker, suggests that it is untouchable in its purity and nobility of purpose. So necessary is it because of the epic magnitude of morbidity and mortality attributed to healthcare itself, that the billions of dollars spent on it seem unquestionably justified. Indeed, much like our public education system, the QI movement garners higher and higher allocations simply due to the sheer face validity of the assumption that more of it is better.