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Productivity and the Health Care Workforce

  • By
  • Shannon Brownlee,
  • Joe Colucci,
  • New America Foundation
  • and Thom Walsh, Dartmouth Center for Health Care Delivery Science
October 2, 2013

Guest Post: How Nonprofit Hospital Wealth Can Build Assets for Low-Income Communities

March 8, 2013
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Editor's note: This blog post was authored by David Zuckerman, Research Associate with The Democracy Collaborative at the University of Maryland. 

Study after study tell us that socioeconomic factors contribute more greatly to overall health than lack of access to healthcare. And few statistics are more powerful than the fact the zip code you live in is a better determinant of your life expectancy than your genetic code. When eight-and-a-half miles can result in a difference in life expectancy of more than 20 years, the local hospital’s quality of care is not at fault. Instead, the culprit is the lack of community wealth in the poorest neighborhoods.

To achieve their mission of promoting health, hospitals would do well to focus not just on providing acute-care services in the low-income communities they serve, but on building wealth in those communities. Policymakers, community organizers, and public health advocates should recognize the tremendous opportunity to leverage nonprofit hospitals’ reported revenues of more than $650 billion and assets of $875 billion (as of August 2012) to transform neighborhoods and build assets for residents.

Meningitis deaths could have been avoided

December 18, 2012
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This op-ed is co-authored by Jeff Borkan, Chair of the Department of Family Medicine at Brown University School of Medicine.

The media attention and Congressional investigation into the tragic epidemic of spinal meningitis in people who had injections for back pain has focused on unsanitary conditions at the compounding pharmacy that produced the medications. At last count 620 cases and 39 deaths have been confirmed in 19 states because the steroids used in the injections were contaminated with a common fungus. Yet remarkably little has been said about the underlying cause of this tragic outbreak -- the widespread overuse of an unproven procedure (epidural steroid injections) that put the contaminated steroids into the spinal cords of patients in the first place.

The procedure involves inserting a needle into the spinal canal, one of the most vulnerable parts of the human body, and then injecting steroids, which are supposed to reduce inflammation and allow the back to heal. Each year, more than 9 million Americans are treated with spinal steroid injections, and one study found that the number of Medicare recipients undergoing this procedure increased by 159 percent between 2000 and 2010.

How did steroid injections come to be performed so often? Patients assume that most medical treatments are supported by years of careful studies. They think any invasive procedure that might put them at risk of harm is performed only by trained and certified physicians with rigorous clinical oversight.

In the case of spinal steroid injections, nothing could be further from the truth. There is no widely accepted guideline for the use of epidural steroids, and the U.S. Food and Drug Administration has never specifically approved steroids for that use. There is scant medical evidence to show that the use of epidural steroids is any more effective at relieving back pain than routine, conservative care or even sham (fake) injections. There are many possible side effects of this procedure, and while the most serious complications are rare, they can be disabling or life threatening. Yet this unproven, risky treatment is routinely offered on an outpatient basis by physicians who have widely varying levels of training and expertise. While most of those physicians undoubtedly believe they are acting in their patient’s best interest, there is no escaping the fact that they are paid nicely for a procedure that takes only a few minutes to perform.

There's no doubt that regulators should go after the makers of unsafe medications. Slipshod manufacturing practices can't be tolerated when people's lives are at stake. At the same time, we need to rethink our willingness to pay for procedures and tests that have known risks and unknown benefits. Epidural steroid injections are just one of myriad examples of such treatments, and taken together, the overuse and misuse of medical procedures is costing us dearly, both in terms of wasted dollars and wasted lives. It’s time to build a health care system that serves patients rather than profits, and the first step is recognizing tragedies like the spinal meningitis outbreak for what they are, cases of overuse.

"The Waiting Room" at E Street Cinema

December 4, 2012
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E Street Cinema in DC is playing the documentary The Waiting Room, by director Peter Nicks. It profiles the emergency room at Highland Hospital in Oakland, CA, for 24 hours, profiling the patients who come in and the staff who treat them. It looks like an interesting film--check out the trailer here.

60 Minutes on HMA Admission Practices

December 3, 2012
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Last night, CBS's 60 Minutes aired a segment reporting on the allegations that for-profit hospital chain Health Management Associates (HMA) has committed widespread Medicare fraud, including by pressuring ER docs to admit at least 20% of their patients (and at least 50% of patients over 65!), and by using a computer system that automatically ordered tests before patients even saw a doctor. The company has denied the accusations, but they are under investigation by the Justice Department.

Obviously, if HMA was breaking the law, it should be investigated and punished. But it's important to note that similar questionable admissions happen all the time, at hospitals across the country, without any deliberate Medicare fraud. Supply-sensitive admissions are a huge and expensive problem that the 60 Minutes story didn't address. It doesn't matter to a patient who ends up getting an infection if they were admitted explicitly to make more money, or "just in case" and because there was a bed available. Preventing fraud is yet another reason we need much better evidence on when being admitted to the hospital is helpful, and when it just puts patients in harm's way.

CBS based the report on conversation with a large number of former HMA employees, as well as on some documents that apparently show the pressure from inside the organization. We've asked to see the documents, and will update this post to reflect anything we hear about that request from CBS.

Watch the full segment here!

Do Prestigious Residencies Mean Better Doctors?

  • By
  • Shannon Brownlee,
  • Joe Colucci,
  • New America Foundation
November 13, 2012 |

Each fall, medical students in their fourth and final year select a medical specialty and apply to residency programs. Residency, which lasts anywhere from three to eight years, is run by teaching hospitals. It's when newly minted MDs learn the hands-on, practical skills of doctoring -- how to make diagnoses, perform surgeries, order and interpret tests, etc. They also learn how to deal with patients and families, and work with other caregivers.

For Your Thursday Enjoyment: Health Wonk Review!

August 16, 2012
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Hosted this week by Dr. Jaan Sidorov at the Disease Management Care Blog, it's "A Brainy Health Wonk Review on Health Reform, the Affordable Care Act and Lots More!" Go check it out.

Health Wonk Review will be back on September 13th, hosted by Louise Norris of the Colorado Health Insurance Insider Blog.

NEJM Headed in the Right Direction on Overuse

July 26, 2012

The New England Journal of Medicine just published a great article about physician stewardship as it relates to medical spending. The piece, called "Cents and Sensitivity—Teaching Physicians to Think about Costs," discusses whether or not we should be training physicians to consider the bills patients will face when making decisions about what treatment to choose. (Aaron Carroll’s treatment of this piece is here.) The authors propose that teaching physicians to be more cost-conscious will increase their capacity to care for the whole patient, not just their symptoms:

"Whether it’s lack of time, fear of “missing something,” or simple ignorance, the incentives to do more often overwhelm our impulse to use resources wisely. Now some educational reformers are offering us an added ethical incentive. Put simply, helping a patient become well enough to climb the stairs to his apartment is meaningless if our care leaves him unable to afford that apartment. Protecting our patients from financial ruin is fundamental to doing no harm."

We agree that overtreatment is a problem, and we applaud the NEJM for addressing it. It says a lot about how far we have come from even five years ago when everyone was thumping their chests and talking about how we have “the best healthcare in the world.” But we believe that there’s an even greater reason to address the topic of overtreatment: because it is dangerous. Starting with the Institute of Medicine’s 1999 report, “To Err is Human,” the research has continued to demonstrate that more does not always mean better

So yes, physicians should consider what patients can afford, but even before that, physicians need to realize that doing nothing is often safer than putting patients at risk with treatments that don’t work. Fiscal responsibility—making sure we aren’t sending Grandpa Frank from the ICU to the poor house—will be the natural consequence.

Drug Regulation, Symbolic Votes, and Hospital Safety

July 16, 2012

Here's our wrap-up of last week's articles by our own Shannnon Brownlee and Joe Colucci:

Letting Big Pharma Review Its Own Drugs — What Could Go Wrong? (The Atlantic Health Channel):

Earlier this month GlaxoSmithKline agreed to pay a record breaking $3 billion fine for a slew of criminal and civil violations. But is a fine really enough? In a piece in The Atlantic, Shannon Brownlee and Joe Colucci argue that we need to stop letting drug companies track the post-market safety of their drugs and establish an external automatic review system. 


12 Ways Health Care Could Be Improved If the House Wanted to Hold More Than Symbolic Votes (The Atlantic Politics Channel):

In the wake of the House's 33rd vote to repeal/defund Obamacare, Joe and Shannon propose a list of 12 things the House could have done to make a better use of tax payers' dollars and actually improve health care. In the article in The Atlantic the proposals range from enacting a less intrusive mandate to funding after school programs to teach kids how to cook. Any of them would have worked better than another "symbolic vote."


Why The ‘Best’ Hospitals Might Also Be The Most Dangerous (TIME Ideas):

We've all seen them—the U.S. News Rankings of everything from colleges to cars. How do their hospital rankings look? In her latest article for TIME, Shannon argues that, based on new rankings by Consumer Reports, many top-name hospitals fail to measure up in terms of safety. Hospital rankings would be a lot more useful if they considered how medical care affects most patients, not whether a hospital performs some cutting-edge procedure on three patients per year.

Why the 'Best' Hospitals Might Also Be the Most Dangerous

  • By
  • Shannon Brownlee,
  • New America Foundation
July 11, 2012 |

Quick, name America’s three best hospitals. Many people would probably identify places like the Harvard-affiliated Massachusetts General Hospital, in Boston, and the Mayo Clinic, in Rochester, Minn., which usually top the list in U.S. News & World Report‘s annual “Best Hospitals Guide.” But are they really the best?

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