Stories about: Health care reform

Toward better care models for medically complex children

boy with cerebral palsyThe start of what promises to be a lengthy, multi-part endeavor has begun unfolding on Capitol Hill. It’s an attempt to reform the Medicaid program so that children with medical complexity (those with a single, serious medical condition, or multiple chronic conditions) can receive higher quality care with fewer emergency department visits and fewer hospital admissions.

When you think of medically complex children, think of children living with conditions such as spina bifida or cerebral palsy, children dependent on ventilators or feeding tubes, or children with genetic disorders. They represent just 6 percent of the 43 million children on Medicaid—yet they account for about 40 percent of Medicaid’s spending on children. Their care is often fragmented and poorly coordinated.

The reform effort, led by more than 60 participating pediatric hospitals and supported by the Children’s Hospital Association (CHA), focuses on Medicaid because it’s the single largest insurance provider for children. The backdrop is a cost-conscious Congress that’s the most politically polarized ever, passing the fewest bills ever.

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A closer look at readmission rates for pediatric hospitals is needed

One-size-fits-all metrics dont appear to fit children's hospitals.
One-size-fits-all metrics don't appear to fit children's hospitals.
Government agencies in charge of determining what constitutes efficient, quality health care have taken to looking at hospital readmission rates. On the surface, this makes perfect sense: If patients are continually being readmitted to a hospital, that hospital must not be doing enough to treat patients appropriately on the first go-round. But new research indicates that relying too heavily on readmissions as an efficiency metric may wrongly put some health care institutions—particularly pediatric hospitals—at a disadvantage.

At the American Academy of Pediatrics (AAP) meeting this week, a team led by James Gay, MD, medical director of Utilization and Case Management at Monroe Carell Jr. Children’s Hospital at Vanderbilt, presented research involving more than 1 million patients cared for at children’s hospitals across the country. The team, which also included Boston Children’s Mark Neuman, MD, MPH, posed this question: If hospital ratings are going to be tied so strongly to readmission rates, shouldn’t that rating system recognize the difference between potentially preventable readmissions (PPRs) and those that are unavoidable?

Currently, some state Medicaid programs use software such as 3M PPR, developed for this exact purpose. Like the basic idea that inspired it, the 3M PPR system works well on principle. However, according to Gay and colleagues, it doesn’t capture all the nuances of what makes a readmission preventable or not.

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Affordable Care Act: ‘There’s no going back’

Affordable Care Act of 2010Signed into law by President Obama in 2010 and upheld as constitutional by the Supreme Court in 2012, the Affordable Care Act (ACA) is withstanding yet another assault. Efforts to repeal or at least delay implementation of the complex, multi-part ACA are entangled with the current government shutdown. However, because many parts of the ACA rely on mandatory spending, the act is moving forward as planned. In fact, the health insurance exchanges called for under the bill opened last week.

John McDonough, DPH, MPA, of the Harvard School of Public Health, briefing clinicians at Boston Children’s Hospital just before the shutdown, maintained that Americans are “just three months away from a fundamental turning point in U.S. health care policy.” Efforts to derail the ACA, he said, are the “death throes” of the anti-Obamacare movement.

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It’s the system, not the parts, says Gawande

Gawande-InnovationSummit0889-K CohenWrapping up the National Pediatric Innovation Summit + Awards on Sept. 27, emcee Bruce Zetter, PhD, who runs a lab in Boston Children’s Vascular Biology program, remarked, “I thought I was going to learn about technology. What I learned about was communication.”

Surgeon, writer and public health researcher Atul Gawande, MD, MPH, laid bare this often overlooked element of medicine in his closing keynote. He eloquently made the point that communication—and more specifically systems—is where innovation is most needed and where it can have the most impact.

“We have emerged from the century of the molecule to the century of the system,” Gawande said.

Right now, these systems are broken, seemingly everywhere. Gawande recounted the sad tale of Duane Smith, a patient who survived a severe car crash that ruptured his spleen, only to lose his fingers, toes, nose and job from an ordinary strep infection.

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Reforming health care: 11 uncomfortable challenges

Facing the Giants (ForeverMan724)
Facing the Giants (ForeverMan724)

Does clinical medicine have the courage to lead health care reform? A former pediatric resident at Boston Children’s Hospital recently asked this question before a standing-room-only audience during the hospital’s annual Blackfan Lecture. I’m talking about Donald Berwick, MD, MPP, FRCP—co-founder and president emeritus of the Institute for Healthcare Improvement (IHI) and Administrator of the U.S. Centers for Medicare & Medicaid Services (CMS) from July 2010 to December 2011.

Berwick, who may run for Massachusetts Governor in 2014, didn’t just ask physicians and hospitals to embrace health care reform, as they’ve come to embrace quality improvement programs and checklists. He urged them to lead. To rescue health care.

In 1998, the Choluteca Bridge was one of the few in Honduras to withstand Hurricane Mitch. Unfortunately, the river beneath it had moved, leaving a bridge spanning dry land. “This,” Berwick declared, “is American health care.”

So why can’t we move the bridge to the river? Following Gloria Steinem’s advice to name a problem before trying to tackle it, Berwick outlined 11 uncomfortable challenges—11 “monsters under the bed” that need to be faced.

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Redesigning behavioral health care: The time is now

(TheReapersApprentice/deviantART)

Richard Antonelli, MD, is a primary care pediatrician and medical director of Integrated Care and Physician Relations and Outreach at Boston Children’s Hospital.  He also co-chairs the Task Force on Care Coordination for Children with Behavioral Health Needs, a group within the Massachusetts Child Health Quality Coalition. Laura Chandhok, MPH, Physician Partnership Liaison at Boston Children’s Hospital, contributed to this post.

The recent shootings in Newtown, Conn., have revived the long-standing debate about gun control in the United States and rightly put a spotlight on media and video-game violence. Importantly, this tragic event has also raised questions about the adequacy of our nation’s behavioral health system and whether troubled children, adolescents and their families have access to needed diagnostic and management services.

These questions aren’t new. And as care delivery models evolve in response to the demands for better care at lower costs, we have an opportunity to improve our behavioral health services.

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Pediatric complex care: A day in the life

Afraa Bakhit, from the Middle East, is among the hospital’s most complicated patients. Her disorder is unknown.

This is the first post of a two-part series on children with complex medical needs. Details on some patients have been changed for privacy reasons.

This morning, as every morning, the Complex Care Service (CCS) team huddles in a tiny office deep inside Boston Children’s Hospital. They have 14 patients to discuss, each with a mix of problems that involve multiple clinical departments. Many of them are repeat visitors.

The team begins tackling each case in decreasing order of difficulty. “It seems to be the best way to prioritize the patients with the most immediate needs,” says Mindy Morin, MD, MBA, who’s the attending physician this week. Also on the team are two nurse practitioners, a clinical nurse educator and two resident physicians.

Two-year-old Afraa Bakhit from Dubai tops the list for the sheer number of departments consulting on her case: Genetics, Cardiology, Immunology, Infectious Disease, Rheumatology, Pulmonology, Anesthesia and now a specialist from the Vascular Anomalies Center.

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Innovation opportunities from healthcare reform

President Obama signs the Patient Protection and Affordable Care Act, March 23, 2010 (Pete Souza/Wikimedia Commons)

National healthcare reform, including President Obama’s Affordable Care Act of 2010, is being driven by widespread dissatisfaction with the high cost and limited accessibility of care. Although we’ve yet to feel the full impact of these national reforms, the reform experience in Massachusetts indicates that mandated universal coverage, by itself, has failed to drive down costs.

So, in Massachusetts, we’re now in the next phase of healthcare reform, focusing on how to control and cut costs while still providing nearly universal access to high quality services and care. The need to bring down costs is stimulating healthcare innovation in three major areas – perhaps offering some lessons for the nation as it moves toward universal care.

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Reducing unnecessary care: The SCAMPs manifesto

Can we reduce health care costs without rationing? (Image: Fibonacci Blue via Flickr)

We all know the problem: The cost of health care needs to come down. About five years ago, pediatric cardiologists at Children’s Hospital Boston realized it was critical to practice more cost-effectively. “Most of the money that is going to be removed from the federal budget to reduce budgetary deficits is going to come from health care in one fashion or another,” cardiologist-in-chief James Lock told an audience of senior Children’s physicians last month. “There’s no question we were under a tremendous amount of pressure.”

Seeking to eliminate unnecessary care and testing, Lock’s team first turned to clinical practice guidelines, or CPGs, a tool meant to standardize “best practices.” But it soon became clear that CPGs were ineffective, giving no insight into how to improve care or how to deal with unexpected findings. Even worse, over time, many mandated CPGs have been shown to be wrong by subsequent data.

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Can we tackle the health care system’s ills with learned optimism?

You’ll almost never hear innovators say, ‘Can we do something?’ You will sometimes hear them say, ‘How can we do something?’

I heard this last week from Kim Smith, a founding team member of Teach For America and founder/CEO of Bellwether Education Partners, at MIT’s Innovation in Healthcare Symposium. It reminded me of the innovators at our hospital, whose problem-solving visions we try to push toward real products.

Solving problems in the health care system itself seemed a far more daunting task. I arrived at the symposium thinking about the entrenched interests keeping current systems in place — the way doctors are trained, the way companies in health care create competitive barriers to information sharing, the pharmaceutical industry’s business model, the fact that insurance companies are incentivized not to cover sick people. The list goes on.

But I left this gathering feeling uplifted and inspired.

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