Improving Care Means Doctors Must Make Changes

[Morzh]

---

Members do not see this ad.

http://www.nytimes.com/2010/10/04/opinion/04orszag.html?ref=opinion

Another politician out to 'punish' greedy, overpaid, under-worked, and unfairly exempt from government's regulating tentacles (wtf? yeah right..) doctors.

The only semi-legit sounding thing he said was that care may be slightly compromised in some patients who are admitted on the weekends vs during the week. But I still don't know which hospitals were looked at in that study.. the trauma center I work at keeps every immediately necessary (elective procedures are by definition not immediately necessary) department running at full capacity 24/7.

 

[Rollo]

Interestingly, the patients that were used in the study all came from non-federal hospitals and nursing homes in New Jersey. And if you read under Methods below, it says patients from federal hospitals were excluded. Why?

The one big problem I see with measuring quality is it will turn into a numbers/statistics game. What could happen is if hospitals adopt this quality measure, then it will start setting incentives for physicians who achieve a certain statistic. This will make physicians cut corners in order to achieve these target numbers. Which can only mean lower quality of care for patients in the long term.

Frankly, I don't see either of the two suggestions being implemented widely anytime soon.

 

[Rborda]

http://www.nytimes.com/2010/10/04/opinion/04orszag.html?ref=opinion

Another politician out to 'punish' greedy, overpaid, under-worked, and unfairly exempt from government's regulating tentacles (wtf? yeah right..) doctors.

The only semi-legit sounding thing he said was that care may be slightly compromised in some patients who are admitted on the weekends vs during the week. But I still don't know which hospitals were looked at in that study.. the trauma center I work at keeps every immediately necessary (elective procedures are by definition not immediately necessary) department running at full capacity 24/7.

Didn't read the article. But there is evidence that doctors aren't taking appropriate preventative actions concerning their individual patients. I was unaware of this until I had a bioethics discussion with doctors over physician-patient incentive systems.

 

[Perrotfish]

http://www.nytimes.com/2010/10/04/opinion/04orszag.html?ref=opinion

Another politician out to 'punish' greedy, overpaid, under-worked, and unfairly exempt from government's regulating tentacles (wtf? yeah right..) doctors.

The only semi-legit sounding thing he said was that care may be slightly compromised in some patients who are admitted on the weekends vs during the week. But I still don't know which hospitals were looked at in that study.. the trauma center I work at keeps every immediately necessary (elective procedures are by definition not immediately necessary) department running at full capacity 24/7.

Alright, I don't think we read the same article, and there was nothing about government regulation in there. This was bascially about process engineering, and it made some pretty reasonable points about how hospitals aren't adequately considering the capital investment they put into their physicial plant and diagnostic equiptment when they shut down for the weekend. This isn't a new concept: private practice Family Physicians (who don't survive on government subsidies) have know this for years, which is why they do things like work out timeshare argreements with mutiple clinics to make sure that expensive diagnostic equiptment never idles. It's not unreasonable to ask why hospitals aren't doing the same.

Also I don't know what your trauma center consders a 'necessary' department but I've rotated through the richest and largest tertiary care center in Louisiana and they still didn't do MRIs on weekend unless someone from the Saints got hurt. A lot of other departments are 'running' but significantly understaffed. It's a serious problem, and they've done internal studies showing that codes increase steadily throughout the weekend and peak on Monday morning. And of course even those patients who actually don't need anything immediately but just have to wait around the hospital for a non-urgent procedure/test should be a legal/reimbursement concern, since they're charging the patients full hospital prices for beds despite the fact that they're only offering skilled nursing services. If I go to a restaurant on Sunday night and they tell me that on that night they only serve rice and water it is not reasonable or legal for them to then bill me $50 for the meal because they usually serve steak and lobster.

 

[Pons Asinorum]

Interestingly, the patients that were used in the study all came from non-federal hospitals and nursing homes in New Jersey. And if you read under Methods below, it says patients from federal hospitals were excluded. Why?

I'm pretty sure you know why federal hospitals weren't included in that study. There's nothing to see here. Keep moving...

 

[boggvir]

Good stuff. Makes sense. If you can't measure it, you can't improve it. The best thing to happen to newborn care was the Apgar score. Just having a score that you reported or kept track of improved the quality of care by many fold. It encouraged competition, innovation, adoption of standardized practices, etc.

It's a good thing.


Federal hospitals weren't included because they work on a different model. Duh. The data would not be representative of the care (one way or another) that most hospitals provide. If they wanted to make hospitals look bad, and if your assumption is that the federal hospitals are worse, than including them in the data set would be beneficial to them, wouldn't it? Since it would result in even worse overall outcomes.

 

[Rollo]

Apgar score is a diagnostic tool.

Measuring quality of patient management is not.

Two completely different concepts.

 

[gravitywave]

Also I don't know what your trauma center consders a 'necessary' department but I've rotated through the richest and largest tertiary care center in Louisiana and they still didn't do MRIs on weekend unless someone from the Saints got hurt. A lot of other departments are 'running' but significantly understaffed. It's a serious problem, and they've done internal studies showing that codes increase steadily throughout the weekend and peak on Monday morning. And of course even those patients who actually don't need anything immediately but just have to wait around the hospital for a non-urgent procedure/test should be a legal/reimbursement concern, since they're charging the patients full hospital prices for beds despite the fact that they're only offering skilled nursing services. If I go to a restaurant on Sunday night and they tell me that on that night they only serve rice and water it is not reasonable or legal for them to then bill me $50 for the meal because they usually serve steak and lobster.

the weekend rule boils down to this. agree that it's ridiculous for the author to blame doctors for skipping weekends when it's the hospitals that are running departments with skeleton crews. I'm pretty certain that if one were to stratify these data, it would become apparent that the deficits in care were due more to high pt/nurse ratios and a lack of skilled techs than to doctors at the golf course.

it's not the nurses/techs fault - its the hospital being unwilling to pay them the weekend shift differential for a part of the schedule that is typically less profitable (not many lucrative elective procedures on weekends)

shame. fyi, orszag is not a politician, he was Obama's first director of the OMB. very bright guy, but this is subpar.

 

[tabascosauce]

Great article! We need quality control.

 

[45408]

This is laughable. Doctors need to work MORE? Really? Because I wasn't operating all day on Sunday with our staff surgeons on emergency cases. Oh wait, yes, I was!

The limitation on weekends is gettings techs, nurses, and equipment. Tell the hospital to pay them to come in, and we'll be all over it.

 

[alwaysaangel]

The one big problem I see with measuring quality is it will turn into a numbers/statistics game. What could happen is if hospitals adopt this quality measure, then it will start setting incentives for physicians who achieve a certain statistic. This will make physicians cut corners in order to achieve these target numbers. Which can only mean lower quality of care for patients in the long term..

Exactly.

According to the government "quality measurements" the VA hospitals provide the "Best Care Anywhere." If you call one of them their hold information music will even tell you so.

If you've ever set foot in a VA you know how terrifying this is. There are some quality measures that every makes sure are covered and then nothing else gets done. The nurses are unionized and never get fired for anything and a lot of the doctors are basically tenured.

The terrifying things I've seen at VAs versus other hospitals is repulsive when they call themselves "the best care anywhere."

Look at our schools under "No child left behind" - they have gotten infinitely worse in the past decade with "quality measures."

Worst idea ever.

 

[Rollo]

The limitation on weekends is gettings techs, nurses, and equipment. Tell the hospital to pay them to come in, and we'll be all over it.

Really? That is interesting. I didn't think of the ancillary staff factor.

So what happens...hospitals are staffed with less than 50% of regular ancillary staff on weekends?

 

[naus]

This Peter Orszag is a Class A douchebag who never worked an honest day's living outside the government's tit.

The best part was his arguing for Saturday elective surgery. He must have used up his sick days.

Can we actually get a real physician to manage health care and not douches like Orszag and Sebelius (trial lawyer)?

 

[Morzh]

Also I don't know what your trauma center consders a 'necessary' department but I've rotated through the richest and largest tertiary care center in Louisiana and they still didn't do MRIs on weekend unless someone from the Saints got hurt.

Immediately necessary = ED, radiology, on-call surgeons of every specialty your trauma center status requires, staffed inpatient wards, especially ICUs, and a couple other things I'm forgetting.

For example: I was working the night shift this last Saturday night and at 1:00am a 20 something year old male came in with sudden onset sharp headache and whatever else would warrant an MRI (I'm not clinical staff, I do registration in the ED). They had one done within an hour so, and the MRI suggested the possibility of a cerebral aneurysm, so they called the on-call neurosurgeon in to do a cerebral angiogram (I think thats what he did) because they said if what he experienced was a "mini-aneurysm" it was too much risk to wait until Monday because he could have second, worse one. All of this happened between 12:00 and 4:00 am Sunday morning.

But my point was better articulated by Sacrasm who said this is an issue with hospital ancillary staff and not something that will me improved by adding more paperwork, government oversight, and risk to the ridiculously hectic lives of these good physicians who are already more than willing to work weekends and nights when they are needed.

 

[Musclemass]

The limitation on weekends is gettings techs, nurses, and equipment. Tell the hospital to pay them to come in, and we'll be all over it.

Yeah right, there are getting to be far too many techs and nurses with God complexes and entitlement attitudes.

Who do you expect to come in without getting paid?

 

[gravitywave]

Really? That is interesting. I didn't think of the ancillary staff factor.

So what happens...hospitals are staffed with less than 50% of regular ancillary staff on weekends?

not that bad, but i don't have numbers either. it's that the overflow capacity isn't as great, and as someone above me said, some areas aren't operational at all.

think of it this way: say a hospital has four rooms in the cath lab. they plan to staff them all fully M-F because the work is there (not just emergent ACSs but also the less emergent diagnostics, the folks who threw clots during surgery, etc). on weekends, when the additional sources of demand for cath lab services aren't there, they might only fully staff two rooms (which would still require >50% of staff). now, if it's a busy Saturday and you are the fifth STEMI to come in this afternoon, your wait time will be longer and your outcome likely worse.

before anyone who works in a cath lab jumps on me, i'm grossly oversimplifying here. nurses and techs take call a lot of places just like doctors do. but the concept is there.

 

[gravitywave]

Yeah right, there are getting to be far too many techs and nurses with God complexes and entitlement attitudes.

Who do you expect to come in without getting paid?

you missed the point entirely. Prowler was saying that the lower standard of care on weekends is due to the hospital making a financial judgement that the ROI isn't there to pay the ancillary staff to be there.

 

[Parts Unknown]

According to the government "quality measurements" the VA hospitals provide the "Best Care Anywhere." If you call one of them their hold information music will even tell you so.

Did you pull that from Phillip Longman's 2005 article on the efforts to improve the VA system?

Do you have specific criticisms of the methodologies or findings of the quality assessment studies that have been done to date, such as the seminal NEJM article, the RAND Corp. report, or any of the other published reports?

 

[Musclemass]

you missed the point entirely. Prowler was saying that the lower standard of care on weekends is due to the hospital making a financial judgement that the ROI isn't there to pay the ancillary staff to be there.

Not at all. Prowler missed the point and suggested it was a staff problem, which is a laugh. There was an implied assumption that since s/he (as a resident) was doing emergency surgery on Sunday, any doc or any needed procedure would equally be available for other patient needs. It ain't the case.

Read the article and listen to the interview.

 

[gravitywave]

Not at all. Prowler missed the point and suggested it was a staff problem, which is a laugh. There was an implied assumption that since s/he (as a resident) was doing emergency surgery on Sunday, any doc or any needed procedure would equally be available for other patient needs. It ain't the case.

Read the article and listen to the interview.

No. You're being obtuse. The point was that if you can get the staff in to support the procedures, you'll like as not be able to find a doctor to do what needs to be done. Prowler's perspective likely comes from the fact that s/he is a resident and needs to come in for emergency situations whether s/he likes it or not. That's the case for many attendings as well. They don't have a choice: someone has to take weekend call. The difference with the ancillary staff is that for them working weekends is often voluntary: sure, the hospital can (and does) offer triple time to people who want to come in to cover open shifts on weekends - but if nobody opts for the OT, the quality of care suffers. Docs aren't going to just show up if the hospital doesn't make a commitment to staffing the facility.

Again, I'm not blaming the RNs/techs for this situation: they didn't sign up for a 24x7 career. And it's true that some of them have to take mandatory call, too. But, at the systemic level, it's a choice that has to be made by hospital management whether or not they are going to try to close this gap. If they hire more full-timers and assign them to scheduled weekend shifts, then some of the problem goes away - but that drives costs way up (you have to pay people benefits). Hospitals would rather offer overtime and hope that someone picks it up - even at 3XOT, it's cheaper that way.

Nowhere in the article or the interview were data presented singling out doctors vs. staff as being the group responsible - in fact Dr. Lee consistently referred to them collectively, as a team. Now, I do have experience with weekend cath lab activations, and Prowler is a resident. What basis have you got for your as-yet-unsubstantiated claim that staff problems aren't an issue?

 

[45408]

Really? That is interesting. I didn't think of the ancillary staff factor.

So what happens...hospitals are staffed with less than 50% of regular ancillary staff on weekends?

Oh, yeah. You have to call in the OR staff to get coverage at night or on the weekend.

Not at all. Prowler missed the point and suggested it was a staff problem, which is a laugh. There was an implied assumption that since s/he (as a resident) was doing emergency surgery on Sunday, any doc or any needed procedure would equally be available for other patient needs. It ain't the case.

Read the article and listen to the interview.

Can't read good, huh? I wasn't even making an implication. I made an outright statement that there aren't enough nurses and techs to fully staff ORs, cath labs, and do diagnostic/interventional studies and tests on the weekends or late at night. It's a completely true statement that we (the physicians) often sit around waiting for a tech to come in to perform some study at night or on the weekend.

This idiot Orszag is making it sound like the doctors are out golfing on Saturday and can't be bothered to come in and take care of patients at a fully-staffed hospital.

Doctors, like most people, don’t love to work weekends, and they probably don’t enjoy being evaluated against their peers. But their industry can no longer afford to protect them from the inevitable. Imagine a drugstore open only five days a week, or a television network that didn’t measure its ratings. Improving the quality of health care and reducing its cost will require that doctors make many changes — but working weekends and consenting to quality management are two clear ones.

What an idiot. Physicians are available every day, every night, every weekend, and every holiday of the year. I'm on call this Christmas. If you need surgery, I will be there.

Guess who won't? Not a damn office worker in sight, that's for sure. He can cry me a river, because there are thousands of empty office chairs that are going unused 128 hours/week. WE CAN'T AFFORD TO PROTECT THEM FROM THE INEVITABLE. What an idiot.

 

[Parts Unknown]

In case anyone is interested, here is the June 23rd news brief from the medical center that is attempting this project:

As part of NYU Langone Medical Center's commitment to providing patient-centered care, the Medical Center now offers evening and weekend hours for many non-emergency services. Traditionally, most non-emergent services have been only offered during normal business hours. Expanded hours recognizes and accommodates today's patients' busy schedules, allowing them more convenient and flexible access to care including, for example, scheduling a screening mammogram in the evening, an elective C-section on a Saturday or an elective cardiac catheterization on a Sunday.

"We are committed to putting our patients at the center of all that we do," said Robert I. Grossman, MD, dean and CEO of NYU Langone Medical Center. "By eliminating the nine-to-five care barrier, we are able to deliver more convenient care, and more importantly, better care to meet our patients' medical needs. This is an important step on our journey to become a true seven-day-a-week hospital for all patient needs."

"For some patients, the ability to access care nights and weekends means not only higher satisfaction, but greater compliance. If they don't have to take off from work, for example, they are more likely to schedule that important screening test rather than put it off," said Bernard A. Birnbaum, MD, senior vice president and vice dean, chief of hospital operations. "For others, such as those receiving chemotherapy, the ability to receive care on a weekend will allow them to receive the most optimal course of treatment."

In addition to accommodating patients' individual schedules, these changes are expected to alleviate hospital congestion by decreasing wait times and providing more balanced service and appointment options. Moving forward, the Medical Center expects to offer expanded service hours for additional clinical services.

 

[Musclemass]

Can't read good, huh?

Thanks for the clarification, Prowler, you've confirmed my earlier comment.

Somehow these two NYU deans (and the department heads who are on-board for the initiative) think they're doing something new and different to eliminate obstacles to patient care. You need to let them know there is no weekday/working hour barrier for non-emergency care.

 

[Long Dong]

tl dr

Someone summerize the link for me.

 

[MisterVeil]

tl dr

Someone summerize the link for me.

Bad stuff happens and/or is happening in the world of medicine and/or health policy.

The end.

 

[Cleavername]

Bad stuff happens and/or is happening in the world of medicine and/or health policy.

The end.

i hope it doesn't lead to pay cuts or more work hours, other than that, its all goods🙂.

 

[45408]

Thanks for the clarification, Prowler, you've confirmed my earlier comment.

Somehow these two NYU deans (and the department heads who are on-board for the initiative) think they're doing something new and different to eliminate obstacles to patient care. You need to let them know there is no weekday/working hour barrier for non-emergency care.

No, they've identified a possible source of more income, and they're moving to exploit it. If they call it good patient care, then they can charge extra for it.

 

[Parts Unknown]

No, they've identified a possible source of more income, and they're moving to exploit it. If they call it good patient care, then they can charge extra for it.

What's the CPT code for good patient care?

 

[45408]

What's the CPT code for good patient care?

LOLROTFLMAOZOMGSOFUNNY

You can bill twice as much for two CPT codes as you can for one. Increasing volume by pretending to be interested in the patient's needs rather than your own bottom line is a good way to go about it.

 

[Musclemass]

Increasing volume by pretending to be interested in the patient's needs rather than your own bottom line is a good way to go about it.

Being dismissive of others while pretending to be authoritative, when really one is just cynical and self-righteous, is another approach

 

[45408]

Yes, I'm being cynical in that I think NYU is doing this because it will make them more money, not because they're doing this out of the goodness of their hearts. Self-righteous? Go fish.

 

[oar2386]

Yes, I'm being cynical in that I think NYU is doing this because it will make them more money, not because they're doing this out of the goodness of their hearts. Self-righteous? Go fish.

Do you have any fives?

 

[Parts Unknown]

LOLROTFLMAOZOMGSOFUNNY

Not trying to be funny, but thanks.

Increasing volume by pretending to be interested in the patient's needs rather than your own bottom line is a good way to go about it.

These notions are not mutually exclusive, particularly in the consumer-driven system we work in.