Sunday, July 1, 2012

Process and Thought Reprinted from Google Plus post

Process and Thought
The big news today is the announcement by the Supreme Court of their decision on the Affordable Care Act (ACA) or ObamaCare as it is referred to.  I write this before knowing the result of that decision and while certainly important, whatever the decision is a person in need will still need a thinking, caring professional to care for them and be with them when they are in need.  For me, the more interesting story this week is the story of two children in Tacoma, Washington who were severely sunburned when a school official would not let them use sun block when they were on a school outing.  The school officials were following a law and a process dictated by that law that did not allow the use of sun block by children without a written prescription by a physician. The school officials in question, by following the policy and process in place insisted they had done nothing wrong.  At the same time, the children were subject to severe sunburn that, in the case of one of the children, was dangerous in that the child had a form of albinism and extreme sun sensitivity.

  Whatever the decision made, our health care is influenced and defined by laws, policies, procedures and statutes. While the laws may change, their presence is a constant.  While laws and procedures are usually put into place with the best of intentions, the consequences of those laws are often unexpected and may be counter to the intent of the “rule makers” whether they are legislators or managers.

The fact is that laws, procedures and statues all can have unintended consequences.  The state legislators in Washington State truly thought they were protecting children from possible allergic reactions to elements of sunblock when they passed that law.  The school officials truly felt that they were being good education professionals by following the law.

 In a recent web first article in Health Affairs, Mary Naylor of the University of Pennsylvania and her co-authors looked at some aspects of the Affordable Care Act (ACA) that are designed to improve transitional care and prevent readmission to the hospital.  The authors found that the incentives built into the act to encourage hospitals to lower readmissions, could instead encourage them to limit access to people with multiple illnesses who are at most risk for readmissions.  The authors also pointed out that the bundled payments that are part of the national pilot program do not include long term care so that the health systems involved could withhold services and “push” them into long term care to create improved finances.  A third part of the ACA calls for community based care transition programs however access to these programs require a hospitalization and often people can be very ill with multiple illnesses but not require hospitalization.  Thus many of those in need would not be eligible unless they were hospitalized which could increase hospitalizations as caring physicians admitted people to help them gain access to the program elements.

The fact is that health care is broad and involves more than just isolated illnesses, insurance contracts and laws.  Health is psychological, social and spiritual. A specific illness or issue is rarely found in isolation but is part of a person who has a unique set of genetic material and unique biologic characteristics often including other illnesses.   Health is a family affair that affects people beyond the patient. Thus no rules, laws or procedures can address every possible person and every possible issue. Thought and judgment are needed by all health professionals and not only rules, policies and procedures.  No matter what the rule or law, a school official should never allow a child to be in danger from the sun, and a health professional should never let a law dictate an intervention that can cause harm or prevent an intervention that can help one in need.  
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Unintended Consequences Of Steps To Cut Readmissions And Reform Payment May Threaten Care Of Vulnerable Older Adults »
Abstract The US health care system is characterized by fragmentation and misaligned incentives, which creates challenges for both providers and recipients. These challenges are magnified for older adu...