QUALITY: Dying Well Beats Dying Badly. And Expensively

As we've written a lot on end of life care, we notice when others do the same.  NPR's Joseph Shapiro this week reported on La Crosse, WI where 96 percent of the adults who die have an advanced directive. That extraordinarily high figure arises from the innovations and commitment from Gundersen Lutheran hospital. Careful, sensitive discussions by trained doctors and nurses -- they use a 12 page guide -- is time consuming. Medicare doesn't reimburse them for that time, A provision in the House health care bill would change that -- the provision that was caricaturized as a "death panel." The Senate bill doesn't contain it.

WORLDVIEW: Assume There's Morality

Not many health writers -- not many writers of any ilk, for that matter -- can match T.R. Reid's ability to bring a light, witty touch to really serious topics. Like health policy around the globe.

Tom (that's what the "T" in "T.R." stands for) was the featured speaker at the Peterson Institute of International Economics today. Not the usual venue for the book tour for his best-seller, "Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care." Before his talk, he told me he was planning to stress the moral case for covering everyone. Not the approach, perhaps, that this particular crowd was used to hearing. Go ahead, I told him. It is, after all, a roomful of economists eating a free lunch.

And that's what he did.

COVERAGE: Accidental Costs of Being Uninsured in the USA

Here is more evidence that the uninsured fare worse than the insured. Including trauma patients in the emergency room. 

The AP's Carla Johnson reported on a troubling study published in Archives of Surgery, Downwardly Mobile: The Accidental Cost of Being Uninsured She writes that "uninsured [adult] patients with traumatic injuries, such as car crashes, falls and gunshot wounds, were almost twice as likely to die in the hospital as similarly injured patients with health insurance."

Under a 1986 law known as EMTALA (Emergency Medical Treatment and Active Labor Law), anyone who shows up in an emergency room needing emergency treatment will receive treatment to stabilize him or her. That statute is intended to "prevent hospitals from rejecting patients, refusing to treat them, or transferring them to ‘charity hospitals' or ‘county hospitals' because they are unable to pay or are covered under Medicare or Medicaid."

QUALITY: The Bottom Line is Still Patient Safety. And We're Still Waiting

With all the talk of financing and mandates and public options, it's important to make sure the essentials -- that patients are helped, not harmed, by health care -- don't get overlooked. Consumers Union's Safe Patient Project held a daylong event here in DC today to help us keep that in mind.

Roughly 100,000 patients die a year from medical errors and about another 100,000 die of infections acquired in health care settings. "The status quo is not acceptable," Art Levin, director of the Center for Medical Consumers, told the forum.

Consumers Union last May marked the 10th anniversary of the Institute of Medicine's landmark "To Err is Human Report" with a report of its own called "To Err is Human - To Delay is Deadly" (Here's what we wrote about it at the time). The bottom line: not a lot of progress.

The event today highlighted some achievements; the health reform legislation does take some important steps to improve safety and quality. It also sheds a rather depressing light on how much remains to be done.

HEALTH REFORM: Necessary Nurses

If all goes well, and we have a new and improved health care system -- which will have to absorb millions of newly insured people, many of whom have been putting off needed care -- one thing we're going to need is more nurses. And once we have them, we need to use them well.

As the AARP's John Rother and RWJF's Risa Lavizzo-Mourey reminded us earlier this year in Health Affairs:

It is nurses -- of every stripe -- who will deliver, coordinate, and direct care in hospitals, clinics, and physicians' offices, and it is these same most necessary nurses who are in short supply...

Nursing has developed and implemented innovative models of care that promote the goals of policymakers for health reform: expanding access, improving quality and safety, and reducing costs, (but) extending these models of care to the general public will be difficult without action to bolster the future nurse workforce.

IN THE STATES: How Health Reform Can Stimulate Colorado Economy, Create Jobs

Talking about health care reform all over the country, I have the opportunity to see many states' health systems up close.  In particular, we spend a lot of time in Colorado -- as evidenced by our study on Grand Junction. In the context of current reform discussions, I began focusing on the state in earnest in 2006 when the Colorado Blue Ribbon Commission for Health Care Reform began trying to identify a sustainable future for the state's health care system. It was a privilege to be consulted by the Commission -- a true bipartisan and multi-stakeholder effort -- about choices they could make to cover more Coloradans, improve the quality of care while reducing health care cost growth, and make the health system economically viable in the long run. At the end of a long and impressive (but surely exhausting) process, the Commission's recommendations look prescient, in that they are structurally and conceptually consistent with the federal health reform proposals under consideration today.

IN THE STATES: Comparative Effectiveness in Minnesota

What is comparative effectiveness research? If you need a reminder: comparative effectiveness means comparing two or more treatments for the same health problem to see which one works best for patients. The question has popped up quite a bit since comparative effectiveness research showed up in the economic stimulus package alongside other common sense health reforms, such as health IT adoption. Comparative effectiveness is about giving doctors and patients more information and facts for decision-making, not about taking away their autonomy.

QUALITY: Seven Percent of Premier Hospitals Increase Lives Saved -- Can the Other 93% Follow Suit?

We're always on the lookout for health care success stories. (Even if they are smaller scale than we'd like -- but we'll get to that.) Premier, Inc., a quality improvement alliance and group purchasing organization, just reported excellent quality results from a year-long initiative. It's called QUEST, which stands for Quality, Efficiency, Safety, and Transparency.

After sharing data, adopting measures such as aspirin and beta blockers for heart attack patients (inspired by CMS's Hospital Compare), rapid response teams (inspired by IHI, a QUEST collaborator  -- and written about by our program in our Baylor case study), and giving clear instructions to patients at discharge so they  are less of a readmission risk (a cost containment target for numerous reformers), the 157 participating hospitals calculated that they saved 8,043 lives and $577 million.  That's an absolute real achievement.

WORLDVIEW: U.S. Lags In Primary Care

The U.S. lags behind other leading industrial democraties in primary care, according to a new study from the Commonwealth Fund. The report, A Survey of Primary Care Physicians in 11 Countries, 2009: Perspectives on Care, Costs, and Experiences, surveyed doctors in Australia, Canada, France, Germany, Italy, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom, and the United States. It found the U.S. falls behind significantly in access to care, the use of payment incentives to improve health care quality, and utilization of health information technology.  

Health IT. The U.S. lags behind every surveyed country except for Canada in health IT adoption. In the Netherlands, New Zealand, Norway, the U.K., Australia, Italy, and Sweden, over 90 percent of doctors use health IT, while in the U.S., only 46 percent of doctors use health IT. (It's worth noting that the U.S. has prioritized funding for health IT through economic stimulus package, and approximately $1.2 billion in grants has gone out to health IT development and implementation since data collection for this study concluded in July 2009.)

QUALITY: A Good Beginning for Better Endings

After all the sound and fury of last August, we're pleasantly surprised that the right hasn't risen again with all sorts of horror stories about the resurrection, so to speak, of the "death panels." Maybe because all that fear-mongering was finally discredited. Maybe we are finally getting just a little bit smarter.

The inevitable focus on the politics of health reform, and the disproportionate amount of attention paid to the public plan, sometimes obscures the many ways that the House and the Senate health plans are ambitious. Not perfect. Ambitious. I've heard experts, people I like and respect, say the legislation does "nothing" to advance the cause of quality of end of life care in America. They are wrong. The House and Senate bill each contain measures that would advance that cause -- not fix it completely, far from it, but they will take us important steps in the right direction. It's too soon to know which of these measures - if any -- will survive a final melding of House and Senate legislation. But let's look at them here because, except for the end of life consults which got way too much of the wrong kind of attention, they haven't gotten adequate attention. In an accompanying guest post. Dr. Ira Byock, director of palliative medicine at Dartmouth-Hitchcock Medical Center in New Hampshire, talks about what these changes can mean for his patients and their families.