In our first “bonus episode,” Dr. Alessi further explores some of the relevant topics from his conversation with Dr. Andrew Agwunobi, UConn Health CEO and executive VP for health affairs, such as patient safety, the per-capita cost of health care in the U.S. compared to other parts of the world, how aligned incentives might address that, and electronic medical records.
Watch for periodic “deep dives” released as bonus episodes as Dr. Alessi brings in more guests throughout the year.
Submit questions for Healthy Rounds With Dr. Anthony Alessi:
HealthyRounds@uchc.edu
Dr. Andrew Agwunobi:
https://www.uconnhealth.org/about-us/leadership
UConn Health:
https://www.uconnhealth.org
Support from UConn Health Orthopedics and Sports Medicine:
https://www.uconnhealth.org/orthopedics-sports-medicine
Grant support from Coverys:
www.coverys.com
Welcome to the Healthy Rounds Podcast, where we provide you with up-to-date timely medical information from national and international leaders in their fields. This podcast is brought to you by UConn Health, with support from the Department of Orthopedic Surgery and a grant from Coverys. Our podcasts here are not designed to direct your personal healthcare, which should only be done by your physician.
I’m your host, Dr. Anthony Alessi, and today we’re going to do something a little bit different. Our first episode last week was with Dr. Andrew Agwunobi, the Chief Executive Officer for UConn Health and the Executive VP for Health Affairs.
And, in our discussion with him, he brought up several topics and you know, we only have 20 minutes or so to have the conversation, but he brought up many topics and I think this is going to be happening as we do more and more of these interviews because they provide topics for us to really take what we’re going to be calling the “deep dive”.
And that being these topics that we discussed really provoke further thought and the need for further explanation. So, I thought we’d have some fun with that by looking at some of the topics he brought up and maybe looking at them a little more carefully.
Among the things he talked about were research, education, things that UConn can be doing to improve the stature of the university and you know, I guess we expect research and education to be part of it. But he also talked about patient safety, patient satisfaction, improving the patient experience. You know, when I first heard the term patient safety, I thought it was an odd term because you think right away, “well, I’m in a hospital, I should be safe.”
But years ago, and I would say about 20, 30 years ago, we started looking at the entire hospital system and how we deliver care from the standpoint of industrial engineering. For those of you familiar with industrial engineering, it’s a way of looking at a process and finding a way to make it more efficient.
So, you look for the weak points in that process and make corrections. So, in the case of healthcare, we looked at a lot of different things and I guess probably the most relevant change came in the operating room where we now have a timeout that’s mandatory. So, before surgery begins, when everyone who’s involved is in the room, they take a timeout to make sure we’ve identified the right patient by their armband, make sure we’ve identified what side or what procedure we’re going to be doing and where it’s going to be done. We also make sure we have all the proper equipment in the room.
So basically, you have a checklist. And that brings me to a book called The Checklist Manifesto by Atul Gawande. Dr. Gawande is a surgeon and a famous author, but he looked at the use of checklists in medicine. Much like a pilot, right, before a pilot takes off, they go through a whole checklist to make sure various things are working, we know who’s available, what they should do, but they go through a checklist of all their buttons and dials before they even initiate taking off.
So, medicine took that same, those same practices and applied it to really every procedure we do. If I’m giving an injection, say a nerve block, right, part of what I have to do is make sure that I’ve identified the procedure I’m doing, what side I’m doing, how have I marked my landmarks, and what I’m using. So again, a checklist to do a procedure. And that is to really help patient safety, and that’s just one example.
We’re going to get Dr. Scott Allen on the show. Dr. Allen is an internist who is really the guru here in the state of Connecticut when it comes to patient safety and quality, and he won a great award last year from the Connecticut Hospital Association, so, I look forward to having him on as a guest as well and talk a little bit about that.
One of the other things Dr. Agwunobi brought up was the per capita cost of care in the United States versus Europe. We spend twice as much as everyone else in delivering healthcare.
The cost in the United States per capita is $14,000 per year, as opposed to Europe where that same cost is only $7,000 per year. That’s a big difference. Now, you might say, well, it’s worth paying more if you’re getting a better result. But the interesting part is when you look at us compared to Europe, they live longer. They’re living longer and getting better care.
So we talked about how the fact that the United States is second to no one in developing new technology, but it’s finding out how to deliver that technology that’s been a real obstacle. And one of the solutions we discussed was that of aligned incentives, meaning that all the constituents to the process of delivering healthcare have to have an aligned incentive, the same incentive.
In our discussion I actually brought up the example of the Veterans Administration and I thought it would be worthwhile to really talk a little bit more about The Veterans Administration and how it all started. The Veterans Administration and the Department of Veterans Affairs as we know it today actually started 150 years ago.
It was back on March 3rd in 1865, it was called the “National Asylum for Disabled Volunteer Soldiers”, and the first branch of it was established in 1866 in Augusta, Maine, and the idea was established by President Lincoln to go out and find a way to care for volunteer soldiers, union soldiers who fought in the Civil War.
In 1917, it started branching into other things like life insurance, disability compensation, and now instead of being called the “Veterans Administration”, it’s the “Department of Veterans Affairs” because it’s so all-encompassing. But our discussion was based on the fact that in a VA system of medical care, all the incentives are aligned.
And basically, the incentive is to deliver the best care. There are no financial incentives, right? A doctor isn’t getting paid more or less based on the number of procedures or the complexity of the procedures. Pharmacies are not making more money because there’s a fixed rate for medication. So, there is a formulary that is the federal formulary, the federal list of drugs that are made available for free to veterans or at nominal cost. So again, pharmacies are aligned. And the hospitals themselves, there’s no incentive for upcharging, right, to find new ways of charging money because it’s all paid by the federal government and it’s paid in the same system.
What’s also interesting about the VA system is that many of the hospitals became aligned with universities. For example, here in Connecticut, the West Haven VA is really an arm of Yale University. Where I worked in Ann Arbor, Michigan the Ann Arbor VA was part of an arm of the University of Michigan, and you’ll see that throughout the country.
But one specific example I brought up and discussed with Dr. Agwunobi was the electronic health record. So, the goal of an electronic health record was so that someone’s chart, someone’s medical information, would be easily accessible. The VA was the first to really design that and put it into practice.
Where a veteran who may have had an x-ray here in Connecticut and spends his or her winter in Florida, when they went to a VA there to get follow-up care, their x-ray, the reports, their medications were instantly available. It wasn’t a paper record that needed to be mailed down there or tracked down.
And we were able to do that because it was a national system. So, with that, part of the Affordable Care Act was to push electronic health records further, and it was a great plan. The problem was that there were so many electronic health records, they didn’t all talk to each other. Now we’re starting to get away from that and there’s a lot more communication, with Epic and Cerner and other companies, but, we had so many different companies, so many different electronic health records that didn’t speak to each other. It really was an obstacle. And the VA, some 30 or more years ago, got around that. Unfortunately, the VA really hasn’t been able to keep up with it, their own designed record, and I’m sure they’re now using a commercial system.
A couple of the other topics that we discussed with Dr. Agwunobi included primary care incentives. Really, primary care physicians are probably the least paid of physician specialists, and how to get them more, how to encourage more people to go into primary care and especially rural care. We also talked a little bit about home care and shifting the focus of care from institutions like skilled nursing facilities or hospitals to the home.
And there’s been a big push for that, and I think we all agree that we need to do that more.
So with that, I hope you enjoyed this deep dive and have given you some food for thought. If you’d like to get back in touch with me about any of these topics or if you have ideas for future shows, reach out to me at healthyrounds@uchc.edu.
Many thanks to Jennifer Walker, who’s the Executive Producer for the Healthy Rounds Podcast, as well as Chris DeFrancesco, our Studio Producer, who is kind enough to put all this together. I hope you’re enjoying the podcast, and next week we’re going to be chatting with Dr. Manisha Juthani, who is the Commissioner for the Department of Public Health here in Connecticut, and I know you’re going to enjoy that conversation.
Until next time, this is Dr. Anthony Alessi. Please stay healthy.
