Monday, October 31, 2005

A Boutique Hospital?

A Boutique Hospital? - Boutique or concierge medical practices have received quite a bit of criticism for limiting access to healthcare in a time when the number of uninsured is on the upswing. This article in the New York Times recaps the familiar debate. There is no doubt that boutique practices create a two-tiered system, where the "haves" get special service and the "have nots" don't, but there is something rational about this rebellion from the norm. When it comes to our health, people would naturally want special attention. Kaiser Permanente hit the nail on the head with their TV commercial featuring a man being followed around by a team of physicians. Surely, many physicians would want to practice this way as well - lighter case loads, deeper relationships, a more thorough understanding of the etiology of their patient's conditions, better service. In fact, it is an artifact, however necessary, of the current healthcare system that "boutique" isn't the standard of care. The economics of our current financing system simply don't allow physicians to provide this level of service (though I am sure that they would argue that they are providing at least adequate care outside the boutique model). In the end, it is a matter of degree and supply. There are probably not enough physicians to provide this level of service to everyone.

So could there ever be a boutique hospital? And what would it look like? Certainly, we could envision a hospital with a higher level of service. The concierges would welcome you to the hospital, orient you to its amenities, and walk you to your room, where you would be met by your personal nurse, who would take the time to discuss your stay and schedule your facial in between your MRI and physical therapy. There are, no doubt, individuals that could pay for such hotel-like services in a hospital, but, as one might guess, this is not a model that would work for the larger healthcare system. Whereas physicians are more of a personal resource, something that people consume individually, hospitals are by nature a community resource, something that is shared. As with all other shared resources, hospitals must operate in a way that is not cost-prohibitive for its users.

So there probably aren't boutique hospitals on the horizon. While hospitals can provide great service, the economics of the current system simply don't allow for highly individualized hospital services, like personal nurses. Nevertheless, we can imagine what boutique hospital care would look like, and as we raise the bar for quality and customer service, we will be brining that vision to everyone.

Monday, October 24, 2005

Genetics is Here?

Genetics is Here? - I was quite surprised today to find Sciona, a company that sells direct-to-consumer genetic testing. Apparently, you can purchase their kits in select pharmacies, swab your mouth, and send in the sample. In a few weeks, Sciona will send you a report with nutritional and lifestyle recommendations based on your genetic makeup. This a remarkable turn of events. When, in the history of medicine, has bench science (here the Human Genome Project) skipped over the medical establishment and been made available directly to the public? There is, of course, much ado about the scientific legitimacy of such products (see the story in the Denver Post), but if Sciona can prove its products' validity and utility, it could further enable consumers to manage their own health sans physician.

If Sciona is not careful, it is this disconnect of physician and medical information that could be its own downfall. The medical establishment, and physicians in particular, are significantly vested in being the gatekeepers of medical information (they didn't go to medical school for nothing!). So you can bet that anything that removes the physician from the mix is going to meet with some resistance. The case in point here is total body scans. A year or two ago everyone (hospitals and physicians) was worried that imaging centers would steal all our business by offering total body scans without a physician referral (this was for out-of-pocket payment of course). The fad eventually died a natural death because the medical establishment made a concerted argument that total body scans didn't statistically lead to better health outcomes. While this argument may work again against Sciona, it may also wear thin on a public that is increasingly interested in managing their own health.

If Sciona is successful, this product could truly ease us into the age of genetics in medicine. Without much difficulty, one could imagine primary care physicians adding genetic screens to their H&Ps. Among other uses, hospitals could use the information to increase the efficacy of pharmaceuticals. Now there is no doubt that there are significant ethical issues surrounding the use of genetic information, particularly how it is communicated and kept private; nonetheless, we appear to be entering a very exciting era of medicine even sooner then most of us expected.

Monday, October 17, 2005

Instructions not Included

Instructions not Included - Judy Foreman, a freelance writer for the Boston Globe, LA Times, and other newspapers, wrote a great article recently entitled A Visit to the Doctor. The article advises patients to, among other things, prepare questions, take a friend, and leave with a plan of action. As a provider of services, the article reminds me of how complicated we have made healthcare.

As I was leaving the hospital today, I saw a patient in our radiology waiting area holding our patient's rights form newspaper-style, just inches in front of his face. I couldn't help but wonder if any of the 8 pages of small-font, HIPAA jargon made any sense to him. These aren't the only hospital documents that befuddle our patients. Hospital bills continue to live in infamy over their mysterious codes, subtotals, and "descriptions". Just last week an article in the New York Times compared deciphering hospital bills to confronting a Kafka-esque faceless bureaucracy (I can't say that I am a Kafka exert, but it is a dramatic analogy). Fortunately, the good people at the Patient Friendly Billing Project have been trying to simplify and standardize hospital bills for some time now, but the shear complexity of medicine (DRGs, ICD-9, HCPCS codes) and dated technology have kept many hospitals from making bills easier to understand.

The most unfortunate aspect of our complex healthcare system is that it places an additional burden on patients that are already struggling with illness. Hospitals should always be aware of this and make concerted efforts to ease our patients into and through the system. If we can't make the system less complex, then we can at least provide a more palatable experience for our patients. And maybe some instructions.

Monday, October 10, 2005

CDH is Coming

CDH is Coming - According to this year's group health insurance survey by the Millman organization (press release), 93% of insurance carriers in the U.S. will offer some form of consumer driven healthcare (CDH) plan in the coming year. That is more than twice the number of insurance companies that will offer tiered provider networks (44% in the survey) based on cost and quality. The message is clear. Health Savings Accounts (HSAs) are coming. Will physicians and hospitals be ready to serve these customers?

I don't think so. I haven't seen near enough chatter amongst hospital folk about how they will respond to CDH plans. I think hospitals are still trying to figure out 1) how this is all going to work and 2) is it good for us? We have invested millions of dollars to set up electronic data interchanges with the payers and we are just now getting proficient at it (remember that was part of HIPAA too). So even if we were good at collecting money from individuals, which we are not, then hospitals would have to figure out how to charge these patients something that even resembles a market rate for services. Many hospitals couldn't tell you what a MRI scan actually costs them; their charges have departed from the true cost of the service many moons ago through across the board increases to the chargemaster. My guess is that hospital CFOs see market driven prices cutting into the revenues they depend upon for cross-subsidization.

The slow response from hospitals will delay the adoption of CDH plans, but it won't stop them from coming in the long run. Without a sufficient and open provider market, patients will not be able to shop around for the best deal. In California, hospitals have been required by law to make certain charges public, but the information is far from user-friendly at this point. Hospitals can bet that this information is going to become more public and easier to compare. It did for quality data. Indeed, hospitals need to remember that these patients will also shop based on quality and, whether we think it is valid or not, there is plenty of that kind of information available for consumers already.

Monday, October 03, 2005

More Than a Hotel

More Than a Hotel - Many hospitals have pursued hotel-quality customer service and amenities. This makes sense. Fine hotels excel at making their guests feel "at home" or "like royalty" or "away from it all". Hotels capture these themes and every aspect of your stay creates the particular experience that the hotel is selling. Hospitals could really use a dose of this philosophy. If we could just get our admitting clerks to buy-in to our holistic, spiritual, total person, healing environment, care experience!

I think part of the problem is that we don't really know what these themes mean ourselves. We have a sense what holistic is. We can certainly tell what it isn't. But what is a healing environment? Again, I have to give props the folks at The Center for Health Design. They can provide hard, demonstrable research on which environments promote healing. But I still think there is more. I believe we have confined ourselves by the concept of the hospital or hospital room. Putting a plant in each patient room is nice, but it doesn't "bring nature to the bedside". Good design can certainly go a long way. If your hospital room looks more like a hotel than a scene from One Flew Over the Cuckoo's Nest, then you are in good shape. In fact, I believe that good design will separate the hospitals of choice from all the rest.

But these is more work to be done. All a hotel has to do is sell you their experience for your one night stop over or your one week vacation. A hospital is where you must go for healing, for restoring what was once whole in your life. I won't accept that that has to take place in a sterile room...where you sit for hours or days...watching television. A truly healing environment will provide tranquility and rest, but it will also engage the person. So you might be tied to an IV pole, but at least you could be looking at beautiful art or strolling through a meditative garden or writing a letter to your best friend telling her that you have decided to live. When we figure out how to engage the patient in healing, through the physical space and the experience, then we will have created a healing environment.