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Juxtaposition — our son's finger and our car's battery

January 19, 2010
by Joe Bormel
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Juxtaposition – our son’s finger and our car’s battery

Yesterday. Two real events, one healthcare delivery-related, the other, the diagnosis and treatment of a car battery problem. Those two events coincided with my completing reading a worthwhile, 17-page article by David Goldhill, “How American Health Care Killed My Father. The relevance of Goldhill’s article was striking. First the healthcare event.

Emergency Department and Post-acute Surgical Care

Our eight-year old son was unfortunate enough to have had his finger crushed in a door at school. It was an accident, unrelated to the intentional or avoidable behaviors of anyone. It was very scary, and will likely become only a sad memory. Thanks to careful, cautious and competent work by the emergency department at a community hospital, and follow-up with a hand surgeon, our son is likely to have a functionally and cosmetically normal finger within a few months. What about the quality and costs issues?

The costs, coordination and follow-up care issues were typical of U.S. healthcare. We were told in the ED that the follow-up surgeon, scheduled for the next day, would be covered by health insurance. When we arrived at his office the next morning, we were told that wasn’t true. The office was in no way connected to either our pediatrician’s office or the emergency department (relationships or shared records text, or radiographic images), or any sort of system that would help organize and convey the management, costs and follow-up issues.

The surgeon was in another state, and according to Google directions, an hour away accounting for known traffic. This is in a major metropolitan area with a high density of doctors, academic medical centers, and the NIH (across the street from the hospital). That said, surgeon-in-another-state’s skill and the surgical outcome of the re-implantation to date are superb. We are truly grateful, although we had no real discretion to make a choice, assess price or other options.

We had no real choices in this situation, other than to follow a guild-based referral that was costly, inconvenient, and fragmented. See my post on selecting an orthopedic physician for our daughter in the post Relativity and Reality . In that instance, it took sophisticated consumer parents and four medical opinions to arrive at a clearly superior option – an option that factors in over a decade of Comparative Effectiveness Research that’s already completed but not locally valued. With our daughter, we had the luxury of time and a huge measure of parental energy. Conversely, the quality of the opinions for our son was objectively limited and the costs incurred were significant.

DieHard Battery Care

Contrast all of that with my DieHard battery experience. I’m thinking about apologizing for the not-so-subtle slight to the U.S. healthcare system by even making this comparison. But I’m not ready to apologize. I'm also eager to acknowledge that surgical skill cannot be compared adequately to commodity automotive service ... at least not superficially.

I needed to jump start my eight-year old car (jumper cables to another car’s battery) a few weeks back after a cold snap, combined with a child leaving an interior light on in the vehicle's backseat. The car seemed back to normal after the jump, but then seemed a little questionable over the ensuing weeks. So last night after work, I pulled into the local Sears automotive center, conveniently three miles from home.

We were quickly triaged. Two minutes later, my car was inside their large garage, the battery was attached to a test rig, and the same agent was completing my registration process. This included reviewing my car’s service record while the battery was being tested, automatically, against simulated loads. No more than ten total minutes from my arrival and I was told, “Your battery needs to be replaced, and the prorated price, with service will be $48.” I signed the printed history and physical document that included an assessment, detailed plan and estimates for length of stay and final, negotiated price.

My daughter and I went to dinner, came back, and found, in addition to the set expectations, there was a print-out of a comprehensive check-list for this problem, and results of performing the checklist attached to the bill. In other language, there was a clinical discharge summary that was complete to a best-practice standard of battery care. The alternator and other electrical things had been tested and documented to be okay.

My take-home lessons:

• My juxtaposed experiences served to support Goldhill’s conclusions. Pouring more reform money into a healthcare system that uses the government and others to pay for care will not improve quality, access or the cost dynamics of care delivery. Neither emergent care or episodic.

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IA,
Thanks for the insight. I especially liked the part about how other industries deal with false SSN numbers -ie the more reliable payer!.

"Say you are the electric company and someone tries to set up service using a Social Security number that already exists in your database and is clearly borrowed, bought, or stolen. What do you do? Most utilities go ahead and set up the account, because to them what counts is whether the new customer will actually pay that bill and it turns out that people operating on such borrowed numbers are more reliable bill payers than the rest of us. "

You wrote "Organizing our healthcare system around payers and not consumers [is detrimental]". Note that Sears' system is also structured around the "Payer"/Provider Sears. In contrast, if I had gone to Sears, they'd have an empty record on my car. I'm lucky to live in a community (Madison WI) with an EMR from Epic, and so my health record is already more consumer-centric. I wouldn't, however, expect the government to step in an turn our regional EMR circumstance into a national one.

Joe,
You should check out Uwe Reinhardt's commentary yesterday, titled "A Good Start". He points out that the track record for consumers using healthcare information wisely is poor:

(http://online.wsj.com/article/SB1000142405274870467510457500110141958848...)

"... Unproven Theory

Critics complain that the bill does not do enough actually to bend the cost curve down in the foreseeable future, or to assure greater cost-effectiveness.

Many of these critics believe that presumably savvy American patients know what they want from our health system and that they would become powerful agents in the quest for greater cost-effectiveness in U.S. health care, if only they were given information on the cost and quality of the care rendered by different doctors, hospitals and other providers. They would like the bill to have forced Medicare to take the lead in providing such information.

But it has yet to be demonstrated that typical American patients actually will use such data if they are presented with it. I harbor serious doubts that they will."

Do you share Goldhill's confidence that the average consumer can effectively manage a Health Savings Account?

Joe,
Regarding your statement "The whole patient-identifier challenge . . . could it have actually been more of a hoax then I was led to believe?" - You might find value in reading this:

http://www.cringely.com/2010/01/predict-me-im-from-the-government/

Cringely is making the point that that today, whether at Sears or a Bar in Mongolia, your identity and credit worthiness can be established, around the world, in an instant. His point is that Homeland Security's identity change is, objectively, not a technical one: (here's an excerpt the whole article is worthwhile and expands upon the challenge.)

"Instead of just complaining, let's take a look at the issue from another angle. Contrast these three situations: 1) you are sitting in a hotel bar in Mongolia and want to use your Visa card to buy a round of drinks for your friends, and 2) your Mom is at the check-out counter at a Sears store when the clerk asks her if she wants to apply for a Sears credit card and save 10 percent on her order, and 3) a possible terrorist with a dubious travel record and suspected al-Qaeda connections is standing in line at a European airport waiting to board a flight to the U.S. that leaves in an hour. What happens in each of these cases?

In Mongolia the bartender takes your card and authorizes it in seconds across a 12,000-mile round-trip. At the Sears store the transaction is not only authorized in less than a minute, but a new account is created and both your Mom's identity and her creditworthiness are established and calculated on the spot, along with her discount. Meanwhile the airline, airport, local security, European police, Interpol, Transportation Security Administration, Department of Homeland Security, Customs Service, FBI, CIA, and NSA can't between them figure out in an hour whether this guy standing in line in Holland should be allowed on the plane or not.

How is it that we can run our credit card operations so well and our national security so poorly?"

Mickey,

Thanks for your comment.

I think it's great that you're health system is providing a consumer-centric access. I would suspect that is associated with a larger, local commitment to provide integrated care between ED, in-patient, community providers and services.

In other communities where that's the case, it's possible to get your care from a non-government entity that can provide the integrated record (that Sears exemplifies). For example, today at eHI, Dr Ronald Paulus of Geisinger Health System described how they can and do provide that for some patients in their geography.

In my neighborhood, the regional providers aren't there yet. I think Goodhill's argument is consistent with your point (if I'm reading your comment correctly), which is non-governmental entities can provide services with a consumer-centricity; reform that doesn't address current payer-centricity will have trouble improving cost and quality features of the current model.

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Joe Bormel

Healthcare IT Consutant

Joe Bormel

@jbormel

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