Quotes from Students Papers 2007
           University of Minnesota, School of Publice Health
           Topics in Health Economics
           Masters in Health Administration MHA 6-755 

In the United States, however, progress on investments in health maintenance has been limited and episodic, rather than broad and systematic.  This is especially apparent in the areas of prevention, which is intended to reduce risk factors that may lead to disease, and to detect and treat health conditions as early as possible to prevent more serious problems from developing.  In theory, prevention should be a primary activity for consumers and health insurers, resulting in early identification of risks and timely intervention and lower costs over time.  It should also be the result of individuals being responsible for their health and providers encouraging patient responsibility.

 A confounder is that the role of buyer and seller in the U.S. health care market are remarkably scrambled.  Most health care purchasing decisions do not involve the employer or the government, and those “buyers” are involved in decisions about coverage levels and co-pays.  The current market does not provide consumers with the information, authority, or responsibility consistent with a central role.  Thus, while health payers, including states, include coverage for prevention activities, most health plans under-fund it and instead spend far more dollars reimbursing hospitals and physicians for providing treatment.

 Mark Aeder, a physician and assistant professor of surgery for Case Medical Center in Cleveland, says that, in the current system, there are three main factors influencing the consumption of health care resources in hospitals and clinics.  First, the more unique encounters that a physician has with a patient, the greater total reimbursement the physician receives.  This applies to office visits, procedures and tests that reward the separation of each encounter.  Second, medical institutions favor those physicians who maximally use their resources, through admissions, outpatient studies, operations, and consultations with other physicians on the hospital staff.  Once in this “system” environment, Aeder notes, the providers are benefited by multiple individually reimbursable contacts for a single problem.  Third, the legal pitfalls of not having the “appropriately trained specialist” evaluate each individual complaint places the practitioner, who is probably sufficiently capable of addressing the problem, at medical risk if an unfavorable or less than optimal outcome is achieved.

 Although health system performance varies regionally in America, states with better access to care and higher rates of insurance are closely associated with better quality, according to study for the Commonwealth Fund published in 2007.  States with the lowest rate of uninsured residents tend to score highest on measures of preventive and chronic disease, as well as other quality indicators.  Conversely, states with low quality rankings tend to have high rates of uninsured.  “This cross-state pattern points to the importance of affordable access as a first step to ensure that patients obtain essential care and receive care that is well coordinated and patient-centered.  In states where more people are insured, adults and children are more likely to have a medical home and receive recommended preventive and chronic care.”

While charity care is better than no care, it is really no system of care at all.  It meets the immediate need to treat a sick patient, but it does not engage patients in the health system on the same basis as most persons.  Patients receiving charity care are far more likely to forego needed preventive care, to delay seeking needed acute care and to be more sick (and costly) when they do seek care.  They are less likely to receive the medications and treatment they need to manage chronic conditions and are therefore at greater risk of complications.

 How do we break through the politics?  We have studied health care problems in America long enough.  We are overdue for a solution to universal health coverage, and it must start with bold leadership from across the sectors — public health, public schools, cities, counties, states, non-profits, business, community leaders and health care organizations.  These groups have a common social, political and economic interest in seeing it happen, so they need to work together to get it done.

— Eric Eoloff,

Universal Health Coverage: Why can’t America get it done?

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It should be noted that the 65 years and older group had more hospital stays than any other age group in 2003. B Even though this group represented only 12% of the U.S. population, they accounted for 34.6% (13.2 million) of hospital stays annually and 43.6% of the national hospital bill (nearly $329 billion) (Russo and Elixhauser, 2003).

Another interesting finding in 2003 was that the mean length of stay for this group was 1.7 days longer and the mean hospital charges were 46% higher than for the under 65 age group.  The non-elderly had an average of stay of 4.0 days vs. the elderly had a stay of 5.7 days (U.S. Census Bureau, 2004).  The average hospital charges associated with this 5.7-day stay were $24,800.

A larger portion of the hospitalizations among the elderly were admitted through the emergency department (57.4% of elderly vs. 36.2% of non-elderly (Russo and Elixhauser, 2003).  These elderly patients tend to be quite ill, and their admissions are considered non-elective.

The proportion of elderly patients who died during their hospital stay was five (5) times higher than in-hospital deaths among the non-elderly (Russo and Elixhauser, 2003).  The patients can be more fragile, and they usually have co-morbidities when they are admitted to the hospital.  In 2003, an elderly patient was admitted with 2.2 co-morbidities, and this number is up from 1.8 co-morbidities in 1997 (Nagamine, et. al., 2006 and Russo and Elixhauser, 2003).

       In teaching hospitals, the Accreditation Council for Graduate Medical  

      Education (ACGME) placed restrictions on residency duty-hour limits.  The    

      80-hour work week limitation, which was reduced from 100-120 hours/week,

      forced some hospitals to search for alternative providers and systems for

      patient care.

       The new work hour limits at teaching hospitals placed a premium on

      improving patient hand-offs as well as teaching and supervision.  The

      resulting decrease in patient continuity for residents required greater  

      continuity and attention from supervising attending physicians.  Due to this

      situation, many academic institutions have developed non-teaching services

      managed by hospitalists who admit, care for and discharge patients without

      resident involvement.

Hospitals like to pride themselves on their ability to efficiently manage their patients while maintaining or improving patient outcomes; however, a focus on efficient management can lead to an assembly-line approach which turns each patient into a series of “do-order-call-check tasks” to get the patient out of the hospital as quickly as possible.  This approach has advantages but may also blind physicians to the scope and complexity of issues that arise in caring for the very old through the course of an illness that often extends beyond hospitalization (Landefeld, 2006).

One last point, Dr. Reinertsen, former CEO of Park Nicollet Health Services and former CEO of CareGroup and BIDMC in Boston challenged hospitalists to standardize and simplify common care processes.  At the 2004 annual meeting of the Society of Hospital Medicine, Dr. Reinertsen told hospitalists that patients (and families) are shocked when they discover how much variation is tolerated in simple processes of care, particularly when there is clear evidence that one way is better and safer than another (Gesensway, 2004).  Dr. Reinertsen’s comments are right on target based upon the first hand experiences I saw as a family member of a patient.  For example, it was unbelievable to see a large, urban hospital in the Twin Cities have a potassium protocol in place on its 4^th floor units and not have the same protocol available at its 8^th floor rehabilitation unit.

The comments of Dr. Reinertsen are significant to the older patient group under discussion here because his talk at the hospitalist conference was focused on hospitalists who could prevent needless deaths on their watches.  He indicated that more than 40% of a hospital’s deaths occur in patients who were well enough at the beginning of their hospital experience to have been admitted to non-intensive care wards (Gesensway, 2004).

Dr. Reinertsen stated, “There is so much variability in how doctors practice medicine — even how they do or don’t do simple things that evidence proves are effective — so it is a breeding ground for errors.”  As he said, “There us no argument in favor of giving physicians so much autonomy that they can make decisions that are not backed up by evidence — and that may harm and even kill patients” (Gesensway, 2004).

During a seven-day hospitalization in mid-December, one hospitalist (the PCP) treating the 86-year old man started him on IV antibiotic treatment for a possible pneumonia (this treatment lasted two days); the next hospitalist inexplicably stopped the antibiotics, even though the patient would end up staying at this hospital for another four (4) days.

 The IV antibiotic reduced the patient’s temperature from 99.1° F. to 97.8° F. so clearly it was beginning to work.  However, a hospitalist with no first-hand knowledge of the case just changed the course of treatment without explanation to the patient or family.

Again, this was the same patient who went home with a cough and a low-grade fever.  Thirty (30) days later he was being treated with IV antibiotics at a bigger hospital for pneumonia.

At this point in mid-January, the patient needed paramedic support, emergency room care and ICU observation before being moved to a cardiac unit.  Total length of stay this time was thirteen (13) days.

Addendum:  Does the hospitalist have the “carte blanche right” to change the course of treatment that another hospitalist initiated (especially when the prior hospitalist was the patient’s PCP)?

— Juliet B. Seropian,

Hospitalists and the U.S. Geriatric Patient Population . . .

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The linkage of employment and healthcare benefits is a product of another age when American Business was dominant and didn’t have to worry about competing globally (Schulte-Scott, 2007).

Every 24 hours, Americans pay a horrific price to diabetes: 4,100 people are diagnosed with the disease, there are 230 amputations in people with diabetes, 120 people will enter end-stage kidney disease programs, and 55 people will go blind.  During this same period, there will be 613 deaths due to this epidemic (Limbaugh, 2006).

There is significant evidence that preventive and care management services improve the lives of Americans and are cost effective.  According to the American Diabetes Association, the amount of funding needed to run a basic diabetes control program in all 50 states would be only $120 million compared to the current $132 billion spent in 2002 on diabetes care.  With the indication of cost effectiveness, the issue becomes one of funding.

Specifically, investing in the prevention and management of diabetes in America can improve the lives of over 21 million Americans and prevent the incidence of diabetes in another 41 million Americans.  If successful, there will be a reduction in the incidence of sometimes life-threatening diabetic complications such as heart disease, stroke, high blood pressure, blindness, kidney disease, nervous system disease, amputations and dental disease, among others.  By decreasing the cost of healthcare, business becomes less costly and theoretically more competitive in the global market.  The U.S. economy will grow as a result.

Minnesota’s fourth largest insurer, PreferredOne, recently announced a new health plan that provides incentives for staying healthy.  According to the June 25, 2007, Star Tribune, Preferred One uses biomarkers including blood pressure, body mass index, cholesterol, nicotine and glucose.  These are generally seen as indicators of people’s risks for illnesses such as diabetes and heart disease.  National Institute of Health (NIH) guidelines are the most commonly used biomarkers.  The biomarkers are measured annually, and testing can be done at a doctor’s office or at the workplace.  If a biomarker is within acceptable levels, an employee may get a $100 credit toward the deductible.  If five biomarkers make the grade, the deductible could go from $1,500 to $1,000.  It’s up to the employer to determine the biomarker values.  But it’s an incentive that experts believe is worth a look.  The PreferredOne plan meets two goals, 1) it rewards healthy employees and 2) it helps other employees detect and identify potentially debilitating conditions before they become full-blown problems.  The PreferredOne plan is a step in the right direction but only includes insured employees in the plan.  This does not address the large population of the uninsured and it does not address the consequences for not managing one’s health.

The current health system in America lacks negative personal financial consequences for poor health management.  Consumers are fairly confident that the American health care system will be there for them when they need it and if they fall ill, health care providers will make them healthy again.  The system lacks substantial negative consequences for not managing one’s health care other than the apparently minor inconvenience of seeking treatment.

— Robin Pedersen,

Diabetic Preventive and Chronic Disease Management

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Financing drives this two-tier-based system.  Louisiana is a major user of Medicaid disproportionate share funding (DSH).  In 2005, the state’s $1 billion in DSH funds accounted for nearly 20% of all Medicaid spending in the state, compared to about 6% nationwide (Rowland, 2007).  This creates a dependence on hospital care for the poor, rather than outpatient or ambulatory care settings, since DSH funds are generated through inpatient use.  Currently in Louisiana, these monies are spent primarily on the Charity/state public hospital program, managed by the Louisiana State University (LSU) system.

Rural community hospitals rely heavily on the Medicaid DSH program to offset the uncompensated care costs of providing services to uninsured patients.  Hospitals are the nation’s largest providers of uncompensated care, delivering a substantially greater volume of services to low-income patients than community health centers, local clinics or private physicians (Mechanic, 2004).  Any scenario that will require the conversion of DSH funds to health coverage rather than hospital care will have significant repercussions for the financial viability of these facilities.  Rural providers in the state, such as Jennings American Legion Hospital, are entitled to an even greater percentage of DSH funds than non-rural hospitals under the protection of the state’s Rural Hospital Preservation Act.  Yet this cross subsidization may be unsustainable.  Medicaid disproportionate share expenditures in Louisiana per uninsured person are the third highest in the nation (Mechanic, 2004).  More appropriate utilization of Medicare and Medicaid funds by all facilities will impact their ability to continue to provide services to the region.

Unbalanced financing supports excess in the private sector that produces more care than is needed, and the public sector’s lack of capacity that produces less care than is required (Price, Waterhouse & Coopers, 2006).

(Price, Waterhouse & Coopers, 2006). 

This system for provision of routine medical services would dramatically alter the current safety net system whereby emergency departments are often the access point for the uninsured and underinsured.  Funding would follow the patient rather than the facility.  This approach would combine the best of both the government and the private sector, while making individuals more responsible for their own health.

The VHA has an exceptional record of quality care, with vets faring significantly better than commercial HMO and Medicare patients in diabetic care and a host of other quality measures as reported I peer-review analysis published in recent journals, including the Annals of Internal Medicine.  In 2002, the National Committee for Quality Assurance rated the VHA tops, surpassing every major HMO on 16 of 18 performance measures (Glabman, 2007).

Studies have consistently shown that having a regular provider of care is a better predictor of care than having insurance alone, and having both makes the greatest impact on health care outcomes (Choudhry, et.al., 2007).

— Dana D. Williams,

Redesign of Louisiana’s Healthcare System

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