Quality

Even author-recluse Don DeLillo knows the value of a good internist. In White Noise, he observed that:

In New York ... people ask if you have a good internist. ... "Who's your internist?" someone will say in a challenging tone. The question implies that if your internist's name is unfamiliar, you are certain to die of a mushroom-shaped tumor on your pancreas. You are meant to feel inferior and doomed not just because your inner organs may be trickling blood but because you don’t know who to see about it, how to make contacts, how to make your way in the world.

Post-modern angst aside, we'd have to agree with DeLillo about the value of a good internist. Primary care is the foundation of our health care system, and strengthening that foundation can lead to better outcomes at lower costs.

But what exactly does an internist or primary care physician do that makes them so important? The Happy Hospitalists has a good explanation today about of what it takes to be a "doctor's doctor." He writes:

We wouldn't expect Duncan, Oklahoma—the birthplace of Halliburton and Ron Howard—to be a bastion of pay-for-performance, which is why an article in Saturday's Tulsa World, caught our attention.

Four years ago, Duncan was in a bind, unable to control the rising costs of providing health care to city workers. Enter, Jeff Greene, CEO of MedEncentives with a program to improve health care and reduce costs by aligning the incentives between patients and doctors.

Last night's town hall presidential debate gave voters a chance to ask the candidates about the issues they care most about. Not surprisingly, health care was a top concern. Below is one of the longer exchanges on health care. For a complete transcript of the event click here:

Trella: Senator, selling health care coverage in America as the marketable commodity has become a very profitable industry.

Do you believe health care should be treated as a commodity?

Obama: Well, you know, as I travel around the country, this is one of the single most frequently asked issues that I get, is the issue of health care. It is breaking family budgets. I can't tell you how many people I meet who don't have health insurance.

If you've got health insurance, most of you have seen your premiums double over the last eight years. And your co-payments and deductibles have gone up 30 percent just in the last year alone. If you're a small business, it's a crushing burden.

So one of the things that I have said from the start of this campaign is that we have a moral commitment as well as an economic imperative to do something about the health care crisis that so many families are facing.

Here's a classic half-full, half-empty health care scenario.

Some hospitals and communities are vastly improving the way they take care of seriously ill patients.

Some aren't.

The Center to Advance Palliative Care and its close collaborator the National Palliative Care Research Center recently completed a "report card" complete with interactive maps on palliative medicine nationwide. Despite the growth of palliative medicine as a field in recent years, they found large variation in access and quality. Only three states—Montana, New Hampshire and Vermont—got an "A." Overall, the country got a "C." Generally speaking, the South and portions of the West lag in palliative care. In Mississippi, for instance, less than 10 percent of hospitals have a palliative care program; in Vermont every single hospital has one. Big hospitals are more likely than small hospitals to have palliative care, for-profit hospitals were less likely than nonprofits (even though these two research groups have found that palliative care is cost-effective), and safety net public hospitals which serve large numbers of the uninsured also tend to lag.

Our uncle Rich—who for our 21^st birthday gave us his law firm's card—once told us that the only people who hate their jobs more than lawyers are doctors. At the time, we found it hard to believe—after all, doctors actually help people...

But, we remembered our legal counsel's words while reading Dr. Benjamin Brewer's column in the Wall Street Journal this week. Brewer is a primary care physician, whose work has drawn our attention in the past. We don't always agree with Brewer's positions on policy, but we certainly appreciate his perspective as a primary care physician working directly with patients.

His latest post reveals a frustration familiar to many doctors "waging health battles by fax;" trying to get patients approved for a treatment while fixing a three-year-old girl's finger instead of fixing their lunch. Brewer writes:

What would you do with $700 billion? (Aside from buying the fabric ($2.10 a yard) needed to make 3.6 billion golden parachutes.)

Here at the New Health Dialogue, we like to talk about how a quality health care system will actually save us money. But while watching the ups and downs of the Wall Stree bailout plan all week, we couldn't resist indulging in a little health care spending fantasy. So we asked our director Len Nichols how he might spend $700 billion.

Yesterday we wrote about three physician-innovators awarded MacArthur "genius" grants, whose work we knew quite well. Today we want to draw your attention to a fourth physician, Wafaa el-Sadr, whose work was less familiar to us. She is both an infectious disease physician and a public health expert, who works both in Africa and Harlem. Reading about her work on HIV/AIDS, TB and other infectious diseases we were particularly intrigued by her ability to blend state-of-the-art pharmacological expertise with insight into how broader social and economic factors impact the course of an epidemic and the fate of an individual.

This year's MacArthur "genius" grants included three extraordinary physician-innovators. All three are practicing physicians, taking care of patients. All three are also showing us how we can improve the whole system, not just for a handful of patients lucky enough to have exceptional doctors. Diane Meier is a pioneer in palliative care, illustrating how we can dramatically improve care for the seriously or terminally ill—and save money while we're at it. Regina Benjamin provides primary care to the poor in unbelievably difficult conditions in rural Alabama. Peter Pronovost is a critical care physician who has shown hospitals simple, inexpensive ways to prevent lethal infections. What's really phenomenal—and different—is that if you try to talk about some of these concepts to policymakers in Washington, at least some of them will know what you are talking about. That wasn't as true just two or three years ago, and I think it shows a growing awareness that health reform has to do more than cover people. It has to cover people in a health care system that is both more efficient and more compassionate.

Quality is too often Jan in the Brady Bunch of health reform issues. The media and public tend to focus on the Marcias of cost and the Cindys of coverage. But New America's Health Policy Program has been dedicated to promoting an informed discussion of the entire family of issues. Today's event (video here) helpedto illustrate that improving quality must be central to any sustainable health reform.

Christine Bechtel, Vice President of the National Partnership for Women and Families, began the discussion with a broad overview about why we care about quality and what we can do about it. Bechtel noted that we spend nearly $1.3 trillion dollars a year on health care, of which nearly 30 percent is wasted on poor-quality care. Medical errors are the eighth leading cause of death in the U.S. and, in general, patients have only a 50 percent chance of receiving the right care. Bechtel stressed the fact that issues of cost, coverage and quality are fundamentally related and must be addressed as a package.

Today New America's Health Policy Program is hosting an event on the serious quality problems in our health care system.  From medical errors, to overburdened ERs to disparities in health care outcomes, the event will illustrate the connections between quality issues and the larger health reform debate. Moderated by New America's health policy program director Len Nichols, the event will also feature commentary from New America's physician adviser Guy Clifton,  on potential solutions. It's on the Hill, 485 Russell, 10:00 a.m. We'll try to post later today, if not check us out on Monday....