Yesterday we talked about how the nature of the community hospital will be changing in the next half generation. The combination of the push towards quality and bundled payments will lead to general hospitals and general specialists becoming more specialized.
the combination of bundled payments and quality accrual due to specialization is that the general surgeon and the general specialist will be declining in importance. Instead, hospitals will have emergency departments that can handle stabilization of patients and then they’ll ship the patients out to county or regional centers of excellence. If someone has a broken hip, there will be two or three hospitals in a metro area with a dozen surgeons who just do hips and nothing else. If there is a need to do a bypass, a hospital will have two bypass surgeons who do 90% of those procedures between the two of them.
A new article in JAMA lays out a framework to think about what types of non-emergency surgeries should be performed locally and which ones should be shipped out.
When's regionalization the best way to improve surgical outcomes? @jdimick1 & I @JAMASurgery https://t.co/Slqoub6RvX pic.twitter.com/tnLzDUuynh
— Karan Chhabra (@krchhabra) July 27, 2016
Low risk, high volume surgeries should be performed locally while high risk surgeries should be sent to the specialized specialists.
How does that actually work?
Does it even work in areas where the two most tightly community hospitals are forty miles apart by air and seventy by ambulance? Does it work when a patient would need to travel a day or more for the surgery?
I think it could work in reasonable proximity to major metro areas. The central academic and flagship specialty hospitals would be able to handle the extreme cases like they do now while St. Tabatha’s develops a specialization in gastric bypass but they concede colectomies to Northern Community General which does that and complex knee replacements as its core special services. At the same time Big City Hospital Chain Southern Campus gets a focus on CABG. They’ll ship patients half an hour into the city for transplants, complex and rare diseases but the community hospitals could have initial diagnosis ability, broad spectrum critical capability that is enough to get a person stabilized and then a lot of moving between facilities for the middle to high end care. System wide net utilization may be the same with significant redistribution of particular patients with particular needs compared to today’s system of everyone trying to be everything.
Does that work in Wyoming? Does that model make sense in the Dakotas? Is it feasible along most of the Appalachian spine? Does this work in areas where there is low proider density and great distances to current specialists much less in a future where specialists are even more tightly clustered?
I don’t know what that answer is. I don’t think this simple model works as well outside of major metropolitan areas but I don’t know where those critical access facilities and doctors fit in a world where specialization on procedure class produces increasing quality returns and payment reform models are driving towards comprehensive bundling where low volume systems are at a distinct disadvantage due to their inherent inability to accumulate significant experience and significant specialization to capture gains by learning.
NotMax
One hospital on the island of Maui. One.
Richard Mayhew
@NotMax: Yep, so how does this model work there? Do people take the ferry to Oahu for common(ish) things?
NotMax
@Richard Mayhew
No ferry. Air service or nothing. Commercial flights to Oahu (Honolulu) stop running fairly early in the evening.
Air ambulance is contracted out. Obscenely expensive, spotty coverage at best (weather can bring to a halt at the drop of a hat) and not even close to 24/7 availability. Also has had the contract pulled and contractors changed multiple times due to rampant corruption or general ineptitude.
All private hospitals in the state were state owned and run until recently. Maui’s is being transitioned to management by Kaiser.
OzarkHillbilly
I lived in WY briefly, the answer is “No.” In WY, there is Laramie (possibly Cheyenne too) and then you have to go out of state. My cousin was hit by a drunk driver while hauling a load of asphalt, burned over 90% of his body. They had to fly him to Salt Lake City (at night from a one horse town airstrip with cars lined up for landing lights). Not in the Dakotas either. (blew out the rear end of my truck there once- when I asked what my chances were of finding one I was told, “Well, you might find one in Pierre, or maybe in Rapid, but you ain’t gonna find one around here!” here being Murdo) If truck parts are hard to find, imagine surgeons.
Appalachia…. Maybe, kind of, sort of, depending on where exactly you are. It kind of works out here, but air ambulance insurance is the rage because we all know if you get hurt, you could well be fvcked. I have been to our local hospital on many occasions including for a # of minor surgeries, but when I got blood clots the first time they couldn’t ship me up to STL fast enough. They were all looking at me like “Nice knowing you.”
StringOnAStick
I suppose what every smaller facility will have to become even better at is the initial diagnosis in order to make sure of the treat/ship out decision process.
I had a gall bladder hit the fan, hard, while in a tiny CO mountain town 1 hour from any medical professional. The local, very small hospital did the surgery and the nurse who kept me comfortable over the night leading up to that was wonderful and very informative; I sent the hospital a sincere thank you letter for the quality of care and the attention I’d received. Granted most of their 35 beds were empty, so I was a nice distraction. Back in the big city I heard many tales of people ready for the same surgery who kept getting bumped in the OR schedule by emergencies, so I was glad Id had mine where the local surgeon got me in first thing.
raven
@NotMax: Imagine having to make the run to Hana at night!
a non mouse
I am a little wary of the hyperspecialization. Background: I am a general OB/GYN in rural mid-west. 60 minute drive to closest tertiary hospital in good weather. I am old enough to remember paper charting (Gawd, how I miss it!).
I see this as a way to decrease the care rural folks get. Many patients out here either don’t or can’t drive. I have a hard enough time trying to figure out how to get people to an oncologist or other specialists that we don’t have on staff. But to have us not do some things that we already do…
I understand the push to have some consolidation for rare cases. But for bread and butter cases…I’m seeing a way to make it difficult to HAVE care.
raven
I’m lucky I guess. I’m about 100 yards from the public hospital, 2 miles from the mackerel snapper point and there are several surgery centers between. I have hernia surgery scheduled for January. I was diagnosed over a year ago but had no issues. I finally went to the surgeon 2 weeks ago and, since I had no symptoms, decided to wait. In the last few days I’m starting to feel like I need to get it done now so I’ll call this morning. I’m over 65 but still working so I have BCBShmo. I guess I have to pay a $200 co-pay. What if I was just on medicare?
OzarkHillbilly
@a non mouse:
It’s all about the $. We aren’t worth very much.
I am close enough to STL that we get regular visits from specialists (the local hospital is affiliated with Barnes Jewish). That part works well enough (tho I now have to go see one specialist in STL because the one who travels out here is such a ginormous ass that I refuse to see him again)(and that is not an easy thing to be)
Wag
I am a general internist. I used to practice and a small mountain town in Colorado. When weather cooperated it was great to be able to chopper patients down to Denver for tertiary care, however more often than not, weather didn’t cooperate and it was faster to send the by ground ambulance. The hospital I was at provided excellent care, especially for specialty orthopedic care, however was (and still is) insanely expensive.
I am now at an academic hospital. The quality of care that we offer is extraordinary, however based on CMS and their new quality system, my hospital only rates two stars. The hospital I was at in the mountains rates four stars. Was the overall care that much better in the mountains? Absolutely not. However, as alluded to by @astringonasrick above, small hospitals that aren’t as busy have an opportunity to provide very personalized care and an excellent patient experience. That level of personalized care can happen at a large academic hospital, however sometimes it’s easy for the personalized care to get lost in the shuffle.
I’ve spent a little time perusing the CMS quality website and I have somewhat of a hard time fathoming the difference between two star and four-star hospitals. I think that it’s possible for hospitals that are hyper specialized to score higher on patient experience, but whether that experience is clinically meaningful or not is open for discussion.
Alright. Off to work.
Richard Mayhew
@a non mouse: That is my entire question — how the hell does this work in your region where the current closest specialist is an hour plus drive away with the best luck/weather and no accidents on the road and several hours away if things don’t run your way.
This model makes sense in Greater Denver, it makes sense in Greater chicago, it makes sense in NYC, it makes sense in Phoenix, it makes sense in LA, it makes sense in Eastern Massachusetts — how does it work elsewhere? Can it work elsewhere?
Richard Mayhew
@raven: you would have a deductible and a 20% co-insurance. you’re coming out ahead with your copay.
schrodinger's cat
Treating health care and education as a business, where the most important thing is the profit margin or cost reduction has lead to many undesirable outcomes.
raven
@Richard Mayhew: Cool! I re-scheduled of the 23d of August!
Mnemosyne
@Richard Mayhew:
I’m guessing it would be useful to look at Canada to see how they handle similar issues, but I’ve heard that they have a similar problem with rural care up there.
I think I’ve said a couple of times that my unexpert, uninformed opinion is that it might be helpful for states that are more rural to be able to for healthcare consortiums because sometimes the nearest “big city” is across the state line.
Believe it or not, we have some of these problems here in California because, while we have several very large metropolitan areas, we also have a lot of very rural areas, especially in northern and eastern California. Even the small metro areas in Southern and Central CA like Santa Barbara and San Luis Obispo are struggling with these issues.
Mnemosyne
@schrodinger’s cat:
Even in healthcare, you want to make sure that what you’re paying is a reasonable price and not artificially inflated. There’s always a lot of insurance and Medicare fraud every year by people looking to make a buck. But healthcare in rural areas is always going to be more expensive on a per-person basis just because there are fewer people.
OzarkHillbilly
@raven: Funny isn’t it? Soon after talking to a Doc about an issue you have that isn’t really bothering you (just kinda there- hanging over everything), it starts to bother you?
Doctor Science
It might also be worthwhile looking at how this is handled in Sweden and Norway, which (like Canada) have huge rural hinterlands where transportation is naturally difficult.
One thing that’s NOT discussed in this schema is difficulty for family caretakers. Transferring a patient to a distant hospital may create exponential difficulty and cost for the family. Who’s going with the patient, to be their advocate and comfort? Where will they stay? what about the people (children, other elderly) who stay at home?
Certainly this schema won’t work without there being a lot of rehab facilities in rural areas, for the weeks/months after a major procedure.
amygdala
I can’t see much in the way of big breakthroughs on the horizon with this. Robotic surgery hasn’t worked out well thus far, so that doesn’t look like a fix anytime soon.
It may be possible to chip away at the edges, like using telemedicine for pre-procedure and post-op care. That would decrease some of the burden of travel for patients. It can even help in more urgent situations. Friend of mine is a rural neurosurgeon and when he’s on call, he can review scans even on remote patients from his home computer, while talking to the ED doc. Sometimes that means the patient can stay where he or she is, with a plan for how to monitor. Other times it means getting the patient choppered over, and he meets the patient in the OR prep area or OR itself, if it’s really bad.
Mayo provides tertiary care a good ways away from a major city, so scrutinizing their systems of care might be a good start. They’re good at getting comprehensive workups done quickly, including having patients stay in a local hotel, rather than being admitted. The military also deals with moving patients and practitioners long distances to match supply and demand.
raven
@OzarkHillbilly: I know! Makes me nuts. (and that’s what’s starting to bother me)
CONGRATULATIONS!
I live about a quarter-mile from the nearest hospital. My wife and I both have a standing understanding that unless we in immediate danger of dying we are to be taken to the one 15 miles away. They’re both owned by the same company, even. But our community hospital is horrific and has a four-decade institutional record of being horrific. Gruesomely overcrowded and staffed largely with complete incompetents whose only goal in life is to get reassigned to the nice, much larger, only slightly overcrowded hospital 15 miles to the south.
We live in an interesting community, former ag town turned SoCal beach town, which very quickly, what with rising property values, turned into SoCal retirement community – with largely empty beaches now. I think the local hospital is still in the mindset that they’re in ag land treating Hispanic field workers for cuts and dehydration – and that’s just not the case anymore.
Kelly
Here in Oregon the way us non medical types can tell it’s serious is they send you off to Portland to OHSU. For us that’s an hour and a half drive but some folks it’s a lot further. I know the Bend hospital takes care of a vast low population area east of the Cascades. Eugene and Medford split up southern Oregon. It’s been that way for decades. There is an income divide in that folks with time and money find the best docs and travel to them. A lot of folks settle for the closest place to home
raven
@CONGRATULATIONS!: I was talking to a old guy at a beach stand at the Huntington Pier when I visited last fall. I told him I used to there in the late 50’s-early 60’s and he told me it was all butterbeans right up to the road across the street!
pseudonymous in nc
Doctors have preferences about where they want to work, especially in the earlier, more dynamic years of their professional careers. They train at med schools in metropolitan areas. They pay a lot of money to become doctors. That’s why there are agencies like the NHSC and incentives like loan forgiveness to get them to work in places they wouldn’t necessarily choose.
One of the knotty questions in the US is, in essence, what level of service people should feel entitled to when they live far away from large metro areas, and what can be practically provided them. Put aside things like museums or theatres or fancy boutiques: it’s the question of whether you should get the same mail service or have subsidies for flights from small regional airports or, in this case, top-tier medical care. Pragmatically, there are certain things that are worth paying for because they unite a nation. Practically, the Senate is always going to ensure that metropolitan America underwrites some of the costs of living in truly remote areas, because there is value in the tale of a homesteading nation.
Mnemosyne is right about the state-line issue: have an accident in Yellowstone and you might end up air-ambulanced to Idaho Falls or Billings or SLC.
In Australia, where “rural” often means “take a Cessna to get groceries”, the Royal Flying Doctor Service provides aeromedical and telemedical healthcare. It’s a non-profit non-governmental organisation.
Steve LaBonne
@pseudonymous in nc: Given the high rate at which rural voters oppose the government doing much of anything, I find that expanding public services to them is not very high on my list of priorities. I know that’s kind of mean, but at some point one has had enough.
burnspbesq
@CONGRATULATIONS!:
Oceanside?
One aspect of this looks like a problem in antitrust law: defining the relevant market. I live in central OC, and our closest general hospital, St. Joseph, is pretty good. If I were shunted off to Hoag or UCI, I’d be cool. But if you tell me I have to go to USC or Cedars-Sinai, there will be pushback. In contrast, the town in North Jersey where I grew up has a decent general hospital, but if I were told I had to go into the city, I wouldn’t bat an eye, because going into the city for stuff is ingrained in the culture.
None of this will be easy. Lots of devils in the details.
CONGRATULATIONS!
@raven: Same here. One of the few dryland crops that can be grown with no irrigation. Beans and flowers. Now it’s freeways and McMansions all the way to the Mojave desert. Am I bitter? Hell yes.
CONGRATULATIONS!
@burnspbesq: No, just a wee further south. But you’re close enough. And come to think of it, I’m not sure Oceanside has a hospital anymore!
Checked. They do, at least Tri-City still has an ER. I’d prefer not to go there either.
Jake Nelson
Here in Twin Cities metro MN, it’s pretty straightforward: use the closest hospital in an emergency, use your provider’s primary hospital for anything long-term or planned (which for my mom means going to one about 20mi away multiple times a week, which is less than ideal… but having used both, we prefer this insurer/clinic and hospital owner chain than the one that runs the hospital 2mi from us). If either find something outside what they’re comfortable handling (exotic, difficult, requires rare tools or drugs or whatever), they send it to Mayo in Rochester. Most people have someone in the family that had to have a case “kicked upstairs to Mayo”. Mayo is regarded as nigh-godly for a lot of reasons, but their recent brand extensions with satellite facilities and partnerships outside Rochester is diluting that a little.
Re: Dakotas – a lot of their complex cases end up here in MN. Stabilize and ship. It’s not that long a flight.
Jeffro
Hmm…time for an afternoon open thread yet?
IdahoFlaneuse
I wonder how this will work with the consolidation of doctor’s practices. Here in Boise most of the primary care practices have been bought by the hospitals here. I don’t have personal experience, but I think that some of the specialist practices have also been purchased by the hospitals. Seems likely to me that the doctor will send you to the hospital that owns them rather than the one that is rated the best. Will this leave the patient fighting to go to the better rated hospital or bearing a larger burden of cost if they don’t?
Richard Mayhew
@IdahoFlaneuse: yes
a non mouse
@Richard Mayhew:
In bad weather, we keep ’em until things get better. I have had to deliver micropreemies on a day when copters weren’t flying and it took me over an hour to drive in(normally a 12-15 minute drive). I honestly believe small town docs have to be BETTER than the big city docs – we have little back-up, no in-house residents, no 24 hr imaging, oftentimes the only docs in house are the ER doc and the OB doc.
We’re better off than some counties near us – the county to the east of me has a hospital with no GYNs. Think about that. Also the county to the north of that one (northeast of us). My patients can drive quite a way just to get to my group.
And to the commenter who basically said the hell with rural folks – we are more necessary than you think. Remember that the next time you eat some bacon or enjoy some popcorn (to name 2 common things raised around here).
And yes, it will be more expensive to care for these folks who live in low-density areas. Just like it was more expensive to get electricity out there. Like how we didn’t get cable tv until my junior year of high school because we lived in the boonies (although now where I grew up is developed).
I’m rambling now.