"Please read – all the way through"

Some three years ago, Peter McGinn told his colleagues about a Canadian pilot who died from a hospital-acquired infection. He copied the man's obituary in an email sent to the management staff at United Health Services (UHS), where Peter was President and CEO.

“Someday,” Peter wrote, “we may look back at this (obituary) and say it represented a tipping point in public consciousness.” He advised his managers: “Please read this very carefully – all the way through.”

It was typical of Peter to stay in touch with his managers, to bring them relevant information that might help them understand or perform better, to bridge the human and the technical.

Last Monday Peter died at Massachusetts General Hospital from complications of amyloid disease. The disease had damaged his heart, and he was in Boston for a possible heart transplant.

On Saturday he wrote:

I learned yesterday that the amyloid disease has infiltrated my lungs. I cannot safely or successfully have a heart transplant.

In the meanwhile, I have been kept alive with high doses of heart medication and kidney dialysis. We are going to stop the treatment soon. After that, my heart is not likely to continue to work. . . .

My family is here. We’ve had a chance to talk with each other. I am at peace with what comes next. I have been so moved by the expressions of support and the outpouring of prayers that I cannot begin to convey the comfort that brings me as I go to my next step.

While in Boston, Peter kept in touch with family, friends, and colleagues using CaringBridge, a website for communications and support during illness. His first journal entry was February 21. When he died 178 days later, his journal had been visited some 9,000 times. That’s an indication of the people who were touched by his life and his leadership.

Peter was a PhD psychologist, and throughout his career at UHS and at Johns Hopkins University Hospital, he was always a teacher, a colleague, a coach, and a friend. When he retired from UHS two years ago, he formed Leadership Impact, a management consulting firm.

On Sunday his nurses organized a picnic for Peter and his family, a last time together in the sun. After returning to his room, Peter declined his medications and said goodbye to the doctors and nurses who had cared for him.

This is from the last entry in the journal, written by his wife and daughters on Monday:

When we remarked to him that we were touched by his generous spirit even now, he said the important part of being kind is to share specific, meaningful details about what people mean to you. It was one last lesson he was able to teach us.

Reforming the system

Suppose we want to reform the transportation system. Where would we start?

Would we begin with bridge repairs, fuel costs, or alternative energy? Would we consider incentives or taxes on rail, ship, airline or truck traffic? How would we reduce accident rates – by changing vehicle design or operator behavior? What about licensing criteria or insurance costs? Could we address the comparative value of different modes of transportation? What percentage of the nation's economy should be devoted to transportation?

The reform analogy, of course, applies to the "health care system." It sounds straightforward enough, but reforming the "health care" involves many different sectors – industries in themselves, really – sectors that function in technical ways and involve a web of risk, referral, production, regulation, and financing connections.

This is why the advocates (and opponents) of health care reform talk about so many different things. There are many things.

Consider:

▪ Extending insurance coverage to the uninsured ("access,” “universal health care,” and "the public option"),

▪ Aligning financial incentives involving doctors and hospitals ("quality improvement," "patient safety," and "efficiency"),

▪ Controlling the cost of government entitlements ("affordability"),

▪ Paying for additional coverage by taxing employer-paid health insurance benefits ("affordability"),

▪ Mandating insurers to cover preexisting conditions ("access"),

▪ Authorizing payments only for services proven to be clinically effective ("review board," "rationing" and "affordability"),

▪ Limiting the resources used by individuals in the final six months of life ("quality of life," "rationing," and "affordability"),

▪ Expecting lawmakers to use any public plan they create for others ("fairness" and "quality"),

▪ Increasing payments for primary care specialists ("access"), and

▪ Developing better ways to manage chronic conditions ("prevention" and "affordability").

The list goes on.

It's no wonder people are talking past one another. It is no wonder people are concerned about the feasibility of trying to do so much all at once.

All health care is local

Atul Gawande’s compelling article for the New Yorker, “The Cost Conundrum,” discussed variations in health care system performance throughout the country. Such variations are apparently related to differences in medical and hospital practices. Dr. Gawande’s point: using relatively more health care in one part of the country does not mean patients are necessarily receiving better care or experiencing better outcomes. In fact, the reverse may be true.

That’s good news if the health care legislation now being debated in Washington finds ways to improve care and costs in inefficient medical geographies without penalizing areas where medical care has already achieved greater efficiency and effectiveness.

For over two decades the Syracuse hospitals have worked together through the Hospital Executive Council (HEC) to help improve acute care services. That’s a message the CEOs of Syracuse hospitals delivered last week when we met with Rep. Dan Maffei to explain our relatively better performance within New York State.

We showed Congressman Maffei the Syracuse area's lower discharge rate. A low discharge rate means fewer patients are being cared for in hospitals – the most expensive place for care – in proportion to the overall population. The point is made by comparing the discharge rates per 1,000 population among New York metropolitan areas, based on 2007 data. [1]

You can see that Syracuse is among the more efficient medical markets, about one-fifth more efficient than top utilizing areas, New York City and Utica.

Discharged Patients per 1,000
Oneida County (Utica) – 113.3
New York City (New York) – 101.8
Erie County (Buffalo) – 99.3
Albany County (Albany) – 90.7
Monroe County (Rochester) – 82.5
Onondaga County (Syracuse) – 84.2

The Syracuse area has also done a better job in managing the time patients remain in hospitals. The mean length of stay among Syracuse hospitals -- at 5.37 days -- is about one-tenth below the highest area (New York).

Mean Length of Stay
New York City (New York) – 5.93
Erie County (Buffalo) – 5.68
Monroe County (Rochester) – 5.62
Albany County (Albany) – 5.56
Oneida County (Utica) – 5.42
Onondaga County (Syracuse) – 5.37

The combination of lower per capita utilization and lower lengths of stay gives Syracuse hospitals fewer patient days per 1,000 population. This means that aggregate hospital capacity is more efficiently utilized. By “aggregate capacity” I mean the productive resources acute care hospitals employ, such as the patient rooms, medical equipment, professional and support staffing, and medical-surgical supplies.

Compared with areas of higher capacity utilization, Syracuse hospitals are about one-quarter more efficient.

Patient Days per 1,000 Population
Oneida County (Utica) – 614.2
New York City (New York) – 603.7
Erie County (Buffalo) – 563.9
Albany County (Albany) – 504.4
Monroe County (Rochester) – 463.7
Onondaga County (Syracuse) – 452.4

Some may question with shorter hospital stays are Syracuse patients being readmitted more frequently? The answer is no.

Through the HEC, the hospitals are participating in a demonstration of new software (developed by the 3M Corporation) that examines all patient data to determine readmission rates for the portion of the patient population that is at risk of being readmitted. [2] Based on 2008 data, the readmission rate for Syracuse hospitals is one-quarter below the expected rate.

Former Speaker of the House Thomas “Tip” O’Neill famously said, “All politics is local.”

As it happens, so is health care.

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[1] Prepared by the Hospital Executive Council, the data include medical, surgical, pediatric, and neonatal discharges. Source material: the New York Statewide Planning and Research Cooperative System (SPARCS) for resident discharged patients and the New York Statistical Information System for the state population.

[2] According to the HEC, potentially preventable readmission (PPR) software from the 3M Corporation examines the numbers of patients with at least one return to hospitalization within 30 days for non-elective reasons. The readmissions are identified when they are clinically related to the initial hospital admission. The data are statistically adjusted for differences in severity among hospitals and regions.

Upcoming events

Jeans and Jewels Gala

The fall gala will be Friday, October 23, 2009 at the at Hotel Syracuse.

For more information, including ticket and sponsorship information, visit Community's website.

Auxiliary Wine and Wildlife

This new wine tasting event will be Friday, November 20, 2009 at Rosamond Gifford Zoo.

For more information, including ticket and sponsorship information, visit Community's website.

The r-word

The r-word is not “reform” as in health care “reform.” It’s health care “rationing.”

An argument for explicit rationing was made by Peter Singer in a recent New York Times Magazine (July 19). A Princeton professor and native Australian, Singer says the US should establish a treatment effectiveness review board to decide if Medicare (or any national payment system) should cover costs associated with specific medical tests and treatments.

On July 23 Peter Orszag, the White house budget director, was quoted in the New York Times as saying America needs “an independent commission that would measure the efficiency of specific medical providers and practices.”

Just the other day in the Wall Street Journal (July 30), there appeared an op-ed article by Myrna Ulfik, arguing against such a federal health review board. Ms. Ulfik, a cancer patient, said that to survive she must have “the freedom to choose my insurance, my doctors, and get the diagnostic scans and care I need.” Implicit in the freedom to choose, of course, is the ability to commit a government (or other third party) to paying the cost associated with such choice.

Ms. Ulfik argues that a government commission should not limit an individual's health care decision-making. Poignantly she says, "I am still here because my care was managed by doctors — not a government agency. My doctors do what the bureaucracy can’t: They see me as a human being.” By still "here" Ms. Ulfik means still "alive."

Ms. Ulfik's argument accords with that of the rabbi, as quoted by Dr. Singer: “if you put one human life on one side of a scale, and you put the rest of the world on the other side, the scale is balanced equally.”

"Patient-as-person will be a lost concept under the new health-care plan," writes Ms. Ulfik, "where treatments will be based not upon individual patient needs, but upon what's best for everyone."

Dr. Singer asserts that the government already weighs human life in economic terms. The Department of Transportation, he says, "sets a limit on how much it is willing to pay to save one human life. In 2008 that limit was $5.8 million." He cites a similar value set by the Consumer Products Safety Commission. I have written about the value of life in a previous post.

How does one balance the appraising decision-making of Dr. Singer against Ms. Ulfik's moral imperative? Interestingly, such decisions may depend upon the part of the brain that’s doing the thinking.

Josh Green, a Harvard professor, has studied how the brain “lights up” under MRI examinations when individuals consider specific moral questions, such as how to balance the good of many against an individual good.

Dr. Green says moral decisions apparently emanate from different brain regions. When the ethical choice is, in effect, an accounting exercise (the greater good for the greater number, as in Dr. Signer’s argument), the brain reaches its decision in the region “behind the eyebrows.” When the moral problem is resolved by asserting basic human values, the decision apparently comes from deep within the brain, involving older brain structures that we share with our primate cousins. Dr. Green talked about this in 2006 on a WNYC radio science show called Radio Lab.

Considered morally, an individual life may have infinite value. This is how the life is seen by the individual, by the family, and by caregivers. They know, and worry about, and care for the individual person. When considered from the viewpoint of the government, however, a single life may have a finite value.

The government's job is to achieve the best results from limited resources. That is why it can train and send soldiers in harm's way. That is why it can set limits on health care spending. What are those limits? That is what the debate about health care reform is all about.