Sunday, October 28, 2007

New York City Public Hospitals drop managed care plans. Alligning patient interests with financial incentives is key.

Early in the week I heard from some of our staff physicians that the New York City Health and Hospitals Corporation (NYCHHC) had decided to drop all of its Medicaid, Child Health Plus and Family Health Plus programs - save three - Metroplus (owned by HHC), Healthfirst (owned by a consortium of hospitals) and HIP (which covers many hospital workers). Within the first week our community health centers were getting calls from people who had other health care plans but who used NYCHHC facilities as their primary care provider. They were scrambling around for a new primary care provider - not an easy task with the shortage of primary care providers that exists today in our city and throughout the country.

I am sure the motivation behind this came from the recognition that managed care is dependent on a sophisticated primary care delivery system and is supposed to focus on prevention, keeping people healthier and keeping them out of the hospital. Since NYCHHC "owns" their primary care delivery system then keeping people healthier and out of the hospital cuts into their inpatient revenue and actually does harm to the economics of the entire system. Any money saved is saved by the insurer and is of no benefit to the hospital or the primary care providers.

There is one critical exception - and that is if NYCHHC also owns or has stake in the insurer. In that case, saving money on hospitalization reduces their inpatient revenue but at the same time increases profits to the managed care company that they own. So if you own the hospital and the primary care system you must also own or have stake in the insurer or better care means less revenue.

So NYCHHC I suppose is gambling that patients, hearing about the drop of the formerly affiliated health plans in which they have no financial stake - will find another health plan that NYCHHC participates with and will join that plan to keep their doctor. But managed care plans don't like to lose members and while this is happening they are contacting their members who have primary care providers at HHC facilitites and encouraging them to switch to another provider for their primary care. This will cause the physician - patient relationships in many families to be disrupted severely and will surely increase health care costs in the short run as well as threaten the quality of care those members recieve.

**Please click "comment" below for a very articulate explanation of this issue written by Al Aviles, President of the New York City Health and Hospitals Corporation.**

Thursday, October 25, 2007

Teaching kids how to save lives... Subtitle: Does anyone remember what the principle export product is of Austria?

It was miserable last night - one of those foggy, drizzly nights when all I want to do is curl up in front of the fireplace with the family. But my schedule had me running from a cocktail party on 5th avenue honoring one of the true heroes of the public hospital system in NYC - LaRay Brown - to Marina Del Rey in the Bronx where Mt. Hope Housing Corporation was honoring Congressman Jose Serrano and State Senator Jose Marco Serrano Jr. I was 2 hours late and dinner had been served already. My table was all the way in the back and since I was quite late I walked right up to the front table where Jose Serrano was seated and kneeled down beside him. Not two minutes later Shaun Belle, President of Mt Hope housing grabbed me suddenly by the arm and pointed me to a woman at the next table over who was choking. The woman, formally dressed in her 30s was standing, grabbing her throat and a man behind her was trying to administer a Heimlich maneuver. He was unsuccessful. As I approached he moved away and I could easily see that the woman had an airway that was completely obstructed. She was struggling to breathe and tears were running down her cheeks. It took three tries for me to clear her obstruction with a properly (I guess) administered Heimlich.

So I went home and talked to my son Conor - 15 years old. Told him the story and watched him doing an English project. He was fascinated and surprised when I explained to him what happened. He had learned the exports of all the major countries in the world (who cares?), could name the capital of every state in the US (who cares?) but wasn't (and won't) be taught a simple technique that could, some day, help him save a life. Neither has he - or my other boys who are older - been taught anything about health (except for watching those old movies about "venereal disease") or the major diseases that effect Americans.

Today we sit in the center of epidemics of diseases that are related to health behaviors - what we eat, how we exercise (or don't as the case may be), how we use (or abuse ) substances such as alcohol and tobacco and medications. Shouldn't every child learn as much about their bodies as they learn about the planets? As much about maintaining healthy behaviors as about religion? As much about first aid and the many ways they can help in an emergency as about baseball or football?

The woman whose life I saved last night was lucky that a doctor was nearby. None of the other dozens of people who surrounded her knew what to do. Those that tried to help her failed because they were doing the Heimlich maneuver the wrong way. A tragedy was averted. But by too close a margin. If the traffic had been just a bit slower, if I had stopped for gas when the warning light went on on my dashboard, or sat at my table at the back of the banquet hall - the outcome might have been very different.

If we taught people in school adequately about first aid, health and disease, preventive care of themselves and their families - there might have been twenty other chances for her life to have been saved. Instead she was saved by good fortune and, perhaps, some intervention from above.

After the comment posted by Dr Eric Gayle below of the Institute for Family Health, I have added the following information on the Heimlich Maneuver - figures are from website. Learn these techniques and you may have the chance to save a life.

Figure 1. For Infants

Figure 2. For Children

Figure 3. For adults

Figure 4. You can also do a Heimlich Maneuver on yourself if you have some food lodged in your windpipe.