If it aint working...

The Commonwealth Fund reported their State Health Rankings in June, 2007.  To view your individual state's performance, go here. 

They study re-iterates two well known principles:

1. Higher quality does not mean higher costs.
2. Better access is associated with better quality across states; insurance matters.

My current home state of Louisiana owns the following dubious ranks:

• Overall : 46
• Access: 33
• Quality: 41
• Avoidable Hospital Use & Costs: 51
• Equity^*: 28
• Healthy Lives: 50

What particularly bothers me about working here in an outpatient free clinic in New Orleans is the abject failure of the local public hospital - Charity Hospital/University Hospital (MCLNO) -  to provide any meaningful outpatient access to patients.  The hospital maintains so few outpatient clinics and allows such inflexible access that patients end up going to the ER for even the simplest medical task: medication refills, lab checks, etc. 

Patients, in turn, having no access to primary care, reflexively treat the ER as their medical home.  The ER staff at MCLNO, while excellent in emergency care (by definition!), don't provide optimal routine and preventive health care.  Since by law they can't 'dump' patients, they tend to minimally treat the patients who show up at the door.  The patients now 1) satisfied by this minimal care and 2) realizing they can't get into the outpatient clinic, simply wait until the next time they need medications, feel chest pain, have an asthma attack, etc, and the vicious downward spiral continues.

How to improve this system?  I don't know, yet.  I'm currently grappling with

• the desire for a re-vamped, simple city/state/national health care system akin the the VA healthcare (single-payer, single-provider) versus
• the lack of political viability of such a system and moving on to an already forming ad hoc free/low-cost clinic system. 

Comments

[carrie]

Ironically, Louisiana is already working on "revamping" the system through what they call the "Louisiana Health Care Redesign Collaborative" (http://www.hhs.gov/louisianahealth/) where they will establish medical homes and insurance for everyone. I don't know anymore details than this, but I got this information from respected individuals like Tony Keck (health management prof at Tulane and former board chair at St. Thomas Clinic) and Micheal Keiser (started the first pediatric HIV program in New Orleans, currently forget his exact title). We didn't necessarily say these were good things or go into much detail other than to say that many people are comprimising to reach agreement in a largely Republican state.

If people have any more constructive thoughts about the plans in Louisiana and New Orleans, this would be awesome. To my understanding, the hesitancy to reorganize it all is a big reason for not reopening Charity.

I personally favor off-the grid health care and can clearly envision the day when the free health care system which is forming in New Orleans is united and follows suit to clinics like St. Thomas Clinic. If a free or affordable system can unite and prove that they will utilize federal money in a positive way, then that should work. In addition, if we can not pressure the state of Louisiana to unleash those 6 or 8 or so trailers parked out back of Charity for the purpose of primary health care, I have doubts about our ability to change the system from the inside out.

I propose:
1) A direct action to cut the chains around those trailers. We invite willing patients and loads of medical personnel to immediately start using them for the purposes of clinical care and hold a press conference on the spot stating the immediate concerns.

2) A more united front of free health care delivery where we agree on objectives and beliefs of care, support the needs to grow, and demand for expansion of services so that clinics can offer more specialty care. Make Hutchinson something important so they can agree to support it all and demand that this is the answer and we will make it work. On another note, there is currently a Health Service Corps grant giving massive signing bonuses to staff willing to commit to 3 years of full-time employment to hospitals. Can the clinics have some of that money too? With the bonus I was just offered at Tulane, we could hire one nurse for a year...

[Ben]

A -
Better access to Appropriate Care, may be key to the quality and cost dilemmas. Even in a system with a single payer and universal coverage, quality will only rise to the extent that those who receive services get the services that they actually need: nothing more, and nothing less. Appropriateness of care delivered for a given disease (like Coronary Artery Disease - CAD) varies widely. Some people with CAD who have access to the healthcare industrial complex receive too little care, some people receive the wrong care, some people receive too much care, and some receive exactly the right care. The result of inappropriate care is harm to the patient and waste of limited resources, despite basic access. My point is that while I agree that access is important, given the political climate regarding access and the baseline poor quality of care being delivered across the country (see Steve Asch and Elizabeth McGlynn's NEJM articles on quality of care delivered nationally; and Robert Brook's contributions on Appropriateness of Care; also the Dartmouth Healthcare Atlas led by Jack Wennberg), it can be argued that we would do more to improve health by focusing our energies to improve the quality of care actually delivered.

C -
The LA Healthcare Redesign Collaborative, which emphasized expanding access by insurance vouchers and quality through a fuzzy medical home model, lost momentum and foundered in the rising tide supporting the new $1.2 billion LSUHCSD Charity Hospital. This hospital may open by 2016, if things move quickly.

The signing bonuses and other incentives for providers are available for work in clinic settings, such as through the GNO health service corps, and not just hospital settings.