CHW Healthcare Blog

The Language of Health Care Reform

The language of health care reform was the subject of a workshop at the recent Catholic Health Association Assembly in San Diego. As reported by Nancy Frazier O'Brien for the Catholic News Service, several speakers at the workshop explained that a common understanding of the language used in the health care reform debate is critical to the discussion.

"Language counts and context counts," said Wade Rose, vice president for external and government relations at Catholic Healthcare West in San Francisco.

He said San Francisco Mayor Gavin Newsom was able to achieve a universal health care program for the city by focusing on the need for a "medical home" for every San Franciscan. The term means that each person would have a place to go for health care when he or she needed it.

"It was an image that people understood," Rose said. "So the plan had 86 percent support right off the bat."

But the average American does not necessarily understand concepts that might be commonplace to Catholic health care administrators, he said.

"It's hard for us to have a good understanding of how the public thinks about hospitals," Rose said, suggesting the administrators could get an idea about the information gap if they consider "the way you think about utility companies."

Jennifer Tolbert, principal policy analyst at the Kaiser Commission on Medicaid and the Uninsured in Washington, said that even use of the words "health care reform" can mean different things to different people, depending on their party affiliation.

Kaiser surveys have found that when Republicans think about health care reform they usually mean ways to combat rising costs, while Democrats think primarily about the growing number of uninsured people, she said.

How we engage one another in the reform debate will certainly shape the discussion. But how can we establish a common language for health care reform when meaning and context change with ideology or political affiliation?

Affordability is Critical to Health Care Reform

Reinforcing the need for comprehensive health care reform, a recent survey indicates that Americans, even those with health insurance, increasingly delay or forgo medical care due to cost concerns.  This survey, conducted by the Center for Studying Health Systems Change, is the latest indication that affordability is key to any approach to reform.

Indeed, this report confirms the findings of CHW’s 2008 Health Security Index which found that 24% of Americans have had to choose between paying for basic necessities (such as groceries or heat for their homes) and health care. 

Sarah Rubenstein describes the report from the Center for Studying Health Systems Change in her article for the Wall Street Journal.

An increasing array of Americans, many with health insurance, are delaying or forgoing medical care because of concern about cost, according to a report from the Center for Studying Health System Change.

About 20% of the respondents in a 2007 survey of 18,000 people said that they had put off or gone without needed medical treatment at some point in the year earlier, up from 14% in a 2003 survey.

That jump came after relative stability in patients' access to care from 1997 to 2003, according to the center, a nonpartisan policy-research group in Washington that receives funding from the Robert Wood Johnson Foundation, the Kaiser Family Foundation and the federal government, among others.

Of those who said in the 2007 survey they had scrimped, 69% cited concern about cost as a reason.

Moreover, Rubenstein shares a vivid example of the impact that delaying care can have on Americans.

Tom Wirt, 65 years old, is among the insured who has delayed care.  Mr. Wirt, a small-business owner in Hutchinson, Minn., was told in 2005 that he needed surgery on his arthritic hip.  Fearing that his share of the costs would add up to thousands of dollars, he decided to wait -- and limp -- until he became eligible for Medicare coverage.  Mr. Wirt had the surgery in December and said he paid about $800 out of pocket.

Peter Koerner, a store owner in Carbondale, Pa., didn't have insurance when he accidentally sliced off half his thumb with a hydraulic wood splitter in late 2006.  When he as told that he would have to be flown by helicopter to another hospital to have it reattached, Mr. Koerner said that he knew "there's no way I could be responsible for that kind of a price tag" for the flight.  Instead, Mr. Koerner said, "they basically cleaned up the wound a little bit, pulled some skin across the open wound and stitched it up." The family has so far paid nearly $1,400 of about $5,100 in bills.

These people in these stories are real.  Their problems are real.  The implication is clear: rising costs resulting from the American health care system force decisions that potentially threaten the well-being of thousands, if not millions, of Americans.  What role do providers (doctors, hospitals, insurance) have in addressing this issue?  What role do patients have?  Does the government have a role to play?

Are We Letting Down our Nation's Veterans?

Yesterday, a federal judge in San Francisco dismissed a lawsuit filed by veterans’ groups that alleges the Department of Veteran’s Affairs is not providing adequate mental health services to veterans. In a nutshell, the judge found that, although many of the claims made by the veterans’ advocates are, in fact, a reality, it is outside the court’s jurisdiction to change the system or compel the federal government to act.

According to the San Francisco Chronicle, U.S. District Judge Samuel Conti confirmed that:

The VA is understaffed and takes an average of nearly 4 1/2 years to hear veterans' appeals of benefit denials, and a long-range improvement plan the agency adopted four years ago is still mostly in the pilot stages, the judge said.

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But Conti said, "The remedies sought by plaintiffs are beyond the power of this court and would call for a complete overhaul of the VA system.

Is a complete overhaul of the system really necessary to provide adequate services to veterans?  The Chronicle goes on to report that Paul Sullivan, executive director of Veterans for Common Sense, one of the plaintiff organizations, chose to look on the bright side of the ruling.

Conti "confirmed many of our allegations" and issued "a huge alarm bell for Congress and the VA to take action now," said Sullivan, a Gulf War veteran.

Hopefully, this ruling will impel our nation’s leaders to work to ensure veterans receive mental health care services they need and deserve.

How Can Hospitals Better Serve the Mentally Ill?

An interesting issue that rarely gets discussed is the mentally challenged population’s experience in the healthcare system. These patients continue to get care that does not meet their needs, even in a government-run system like Canada's, where one in every 11 visits to ER is for a mental-health issue. So is one in every seven hospital admissions, and, because these patients stay much longer, they account for an astounding one-third of all hospital time.

Andre Picard captures this frustration in his article for Canada's Globe and Mail from all sides of the equation, including patients, caregivers and advocates.

[Patients with mental health problems] can wait years for a bed in a long-term care facility or a spot in supportive housing, so they end up as detested “bed blockers” or sometimes on the streets. In the community, family doctors do the bulk of treatment by default, but they are rarely equipped to deal with the complexity of care required by patients with severe depression, bipolar disorder or schizophrenia. Often, they just prescribe drugs.

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“The system is in chaos,” said Donald Milliken, former president of the Canadian Psychiatric Association and a practitioner with nearly 40 years of experience. "The fundamental trouble is not necessarily a lack of money or a shortage of beds but a lack of organization."

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What many patients need is stability – a place to live, a basic income, assistance with daily activities, monitoring of their medication. When these are not available, illness can flare up and hospital visits follow.

“Hospitals are just trying to ‘deal' with this – and I use that word in its most Spartan sense,” said Pamela Fralick, executive director of the Canadian Healthcare Association. She said health-care professionals are compassionate people, but “these are cuts that can't be sutured in hospitals.” Also, while most people recover from bouts of mental illness, a minority of cases are simply intractable.

Picard exemplifies one center that has taken on the task of meeting the challenging needs of this community, the The Archie Courtnall Centre. One notably success is the increased privacy that patients experience.

The centre is a big bright place with a dozen La-Z-Boy chairs and four short-stay beds where psychotic or suicidal patients can remain until a crisis passes. “This is a safe place, where patients get treated with respect,” said Rivian Weinerman, the site chief for psychiatry.

In particular, there is more privacy than in the general ER waiting room, where a person weeping uncontrollably, muttering loudly about conspiracies, going through withdrawal, or wearing leg irons and handcuffs is bound to draw a lot of unwanted attention.

Highlighting that something as easy as providing additional privacy in the waiting room could go a long way, the question begs to be asked “In what other ways can hospitals and other centers become friendlier for mentally challenged patients?”

Governor Pledges Reform at CHA Assembly

California Governor Arnold Schwarzenegger was in attendance at the Catholic Health Association of the United States (CHA) annual assembly to congratulate Lloyd Dean, CHW President/CEO, on his appointment as Chairperson of the CHA Board of Trustees. As the Catholic New Service (CNS) points out, the yearly meeting of the nation's Catholic health care leaders was also an opportunity for both the Governor and Mr. Dean to pledge their commitment to health care reform. According to the CNS, the Republican governor, who is a Catholic, said that:

"Even if it takes praying 20 rosaries a day, every day I will be on my knees praying the 20 rosaries and we are going to get the job done." Calling the current situation "a moral crisis," "a health crisis" and "an economic crisis," Schwarzenegger said that "this is why we will not rest until the job is finished." "With two and a half years left in my office, I'm as committed as ever to leaving California a health care system that is affordable, that is accessible and that works for everyone," he said.

Below are additional highlights from the CNS coverage of the event:

Calling Dean "an action hero," the governor said he took over a system that "was posting deep financial losses" and balanced the books within two years, "while maintaining the compassionate and high-quality service that defines your hospitals."

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In a speech accepting his new post as CHA board chairman, Dean said this is a moment "of opportunity for Catholic health care every bit as rich and urgent as any in our history" because of the coming health care reform debate.

"For too long, the health care reform debate has been ill-defined, in my opinion," he said. "For too long, the measure of health care reform has been its cost, its fiscal impact. But health care -- the laying on of hands, the act of caring for others, the gift of healing and comfort -- has at its heart the instinct for compassion."

"The proper measure of a health care system should not be the size of the 'doughnut hole' in the Medicare prescription program, should not be on casting blame for mistakes in billing, should not be on creating ever more complex pricing formulas and more complex payment methodologies," Dean added. "The proper measure is the ability to support and deliver compassionate care."

The Governor also took a few swipes at Senate Democrats, blaming them for the demise of his universal health care plan in January. But what's more important is that he emphasized that this is a moral issue and not just an economic one. Too often in the reform debate, the discussion is focused only on cost and share of responsibility, rather than the right of everyone to receive quality, compassionate health care. The full text and video of the Schwarzenegger's speech is available on the Governor's website.

"Healthcare Court"

A couple of days ago we discussed the current focus of the healthcare reform movement, cost, and the potential to ‘rethink’ this approach to include a broader perspective.  Although that post focused on changes in patient behavior, in his blog Robert Gallagher discusses the issue of malpractice in today’s healthcare system.  He argues that both physicians (through expensive malpractice insurance) and patients (through the lengthy legal process) are negatively affected by the inadequacy of the legal system as it pertains to healthcare malpractice suits.

While only 2 percent of injured patients seek legal compensation today, those that do often seek millions of dollars in pain and suffering. Juries often times award millions of dollars to these injured patients as if they are lottery-winners.

In addition to the expensive nature of these suits, Gallagher highlights the issue that the current legal system is ill-equipped to handle medical malpractice cases due to the lack of guiding principles and standards.  However, he also offers a suggestion for improvement mirroring the worker’s compensation system.

A healthcare court would create precedents by following the worker’s compensation system. A healthcare court would first have a schedule of benefits to compensate patients for medical injuries. Second, injured patients would receive consistent compensation based on previous awards.

The healthcare court would also refer to a guide of malpractice scenarios, using Accelerated Compensation Events (ACEs). Consider, for instance, a patient who requires additional care because of bleeding after heart surgery; this injured patient would not have to prove medical malpractice because bleeding following surgery is a documented error on behalf of the surgical team. Trivial cases would be dismissed by the review board without backlogging the healthcare court system.

As healthcare reform continues to be a hot topic, it will be interesting to see to what extent factors (outside of cost) are assessed.  With additional areas of focus the push for reform could become muddled and harder to manage, or it could potentially provide the comprehensive change needed to ‘fix’ the healthcare system as we know it.  Either way, the question remains ‘Is it all about cost?’

A Champion for Covering the Uninsured

It seems the call for universal health care has another vocal champion. In addition to leaders in business, government and academia, Dr. Nancy Nielsen, the American Medical Association's (AMA) newly appointed president, is making headlines as a strong advocate for covering the uninsured. According to the Chicago Tribune:

She vowed at its annual meeting last week in Chicago to use "all of the power" of her presidency and the clout of the AMA "to let the nation know that we must cover America's uninsured."

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Nielsen practiced primary-care internal medicine for more than two decades, was a medical director for a Buffalo health plan until last year and today is senior associate dean at the State University of New York at Buffalo School of Medicine and Biomedical Sciences.

As the Tribune points out, we can be hopeful that Dr. Nielsen will be able to use both her role as AMA president and her background as a health plan executive to bridge the divide between health plans and physicians -- in particular on quality report cards and pay-for-performance initiatives.

Nielsen says she endorses the use of report cards by health insurance companies but wants physicians to be involved in what is rated.

"Instead of issuing that report card on what percent of my patients didn't get a mammogram, tell me the names of those patients so I can verify the data and reach out to each one," Nielsen said. "To be fair, some health plans have been fairly innovative and collaborative. But it's time for all of them to be."

Congratulations to Dr. Nielsen and we applaud the AMA's advocacy for the uninsured.

Training New Physicians to Be Compassionate

For Canada’s Times & Transcript, Dr. Preston Smith overviewed the International Conference on Community Engaged Medical Education in Northern Ontario. Representing the Dalhousie University Medical Education Program, he provided his thoughts on the highlights of the program, in particular the emphasis on training and selecting doctors to be community-focused, compassionate care providers.

"These changes are in response to the need to train more doctors; train the right doctors for our communities; enhance recruitment of doctors and finally take advantage of the economic development opportunities that go with medical schools.

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"By training doctors in the community they will see and choose career paths that are needed, and by being closer to the patient and the community they will learn the compassionate patient-centered skills we all want in our doctor."

As compassionate care becomes front and center in health care discussions, to what extent will training and education of physicians incorporate this priority?

Is It Really About Costs?

It is a common theme in the debate about health care reform that costs are the main issue. Rahul Parikh, MD, takes a step back and suggests that the problem might be in our use of the system as a whole:

From my vantage point as a primary care doctor, there's a bigger problem than just dollars and cents. We need to look deeper into the incentives of health care. We need to examine our motivation to go the doctor and my motivation to see you. The fact that health care appears to be all about treatment is the crux of the problem, and one that won't be fixed no matter who's paying and who's being covered.

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We also seem too casual in our acceptance that medical breakthroughs will help us live longer, and too quick to forget that there are things we can do to prevent us from needing those breakthroughs (and their expensive price tags) in the first place. It would be better if our health insurers reimbursed us for buying healthier groceries or taking laps in the swimming pool at the local Y instead of paying for heart bypass surgery or the Lipitor we take just before we go out to eat a double cheeseburger and fries.

We've been discussing the same issues, taking a step back from the more detailed problems to see things from a broader perspective. In a compassionate society, how would a national health care system function and what should it accomplish? We offer three important questions:

1. How can individuals be better empowered to maintain their own health and prevent disease, especially considering the economic disparities and barriers that exist?
2. What should we expect from the delivery and insurance system? What should the experience be of the individual moving through the system?
3. What role should society play in ensuring that an effective and compassionate health care system is maintained? What is the government's role? What is the best use of society's finite resources?

We're interested in your thoughts on these questions. Post a comment or send us an email.

Mind Your Manners

Julie Salamon observed life in a major urban hospital for a year. She discusses some of what she saw in a Los Angeles Times editorial. What stood out the most for her was how important, and how difficult to practice, common courtesy was to the overall flow of the hospital:

The way hospital workers treat one another sets the tone for how they treat patients and their families, who are often frightened and fragile. The simplest form of human communication -- a harsh or caring tone, abrupt or attentive behavior -- can be healing or destructive.

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The craving for respect is a palpable part of hospital life. Nurses and technicians feel underappreciated and underpaid. "I have nursing attendants who make $28,000 a year working elbow to elbow with these attending doctors who come into work in Jaguars," a senior nurse told me. "I think what beats them down is the hierarchy, the respect they're given or not given. Everyone beats down on the one below."

And patients can feel the reverberations of these wounded feelings.

Usually, when we talk about compassion in health care, we're focused on how health care providers are treating patients. But the way we treat each other is just as important, and indeed has a ripple effect on the patient experience.