Thursday, August 13, 2009

A narrowing window of opportunity

Catching up on last week’s journals, two seemingly unrelated pieces caught my eye: one in JAMA and the other in the New England Journal of Medicine. The one in JAMA talked about how the Israeli health system deals with mass casualty-related surge capacity, and the one in the NEJM focused on how growth of corporate medicine can benefit healthcare in the US. Juxtaposing these two papers made for an interesting exercise in gap analysis.

In their JAMA Commentary, Peleg and Kellermann point to evidence from studies by the Government Accountability Office, the Institute of Medicine and the House Committee on Oversight and Government Reform, that the US hospitals lack infrastructure and resources in case of a mass casualty event. The authors then offer a formalized schema used by the Israeli health authorities to address their contingencies for disasters. Their planning, testing and enforcement functions are centralized: a government body is not only held accountable for developing and testing the systems, but also is imbued with authority to demand compliance from the participating institutions. In the US, on the other hand, the responsibility for disaster planning is divided between the CDC, Homeland Security and the department of Health and Human Services, and none of these bodies monitors preparedness and surge capacity on the ground, leaving the hospitals themselves to take them on individually and voluntarily.

Turning now to the NEJM Perspectives piece by David Cutler, a grim, albeit not unfamiliar, picture of the US hospitals emerges: ¼ of all US hospitals operate in the red, with another 11% making a less than 2% annual profit margin. In the current financial situation Medicare and Medicaid increases don’t have a snowball’s chance in hell, and private third-party payers are steadily negotiating lower reimbursements. Of direct relevance to disaster planning, emergency departments are seeing 30% more visits than they did two decades ago, and among urban centers, those most likely to be affected by a mass casualty event, two-thirds operate at or over capacity. How does one prepare in this context?

Back to Israel. Three points are critical in the Israeli preparedness plan. First, they have a concrete blueprint for de-clogging the EDs, the central point for efficient and effective management of the sick. Do we? Second, Peleg and Kellermann also remind us that centralized coordination, so well designed and executed in Israel, is possible there partly because of universal access to healthcare: hospitals do not have the incentive to see insured clients over engaging in potentially less lucrative mass casualty care. Not so here. Finally, communication and collaboration between healthcare institutions are key to the success of preparedness efforts. In the US competition precludes such collaboration.

Let’s add the threat of H1N1 to this mix. Now, I am not a catastrophist, and I do not want to be perceived as Chicken Little of the 2009 flu season. I recognize that so far this flu seems by and large to cause less severe disease than its seasonal counterpart. What I am also appreciating is that this flu is highly contagious, so, despite a relatively low frequency of complications, their volume may be vast. These predictions are based on what we know so far, and, while they may not come true, we need to be moving as if they were certainty. If we do not, and they come true, we will be caught with our pants down and suffer more than just a red face. Yet no one is at the wheel coordinating a response to this likely event. If the EDs are operating at or over capacity and have no contingency plans, how do we expect them to provide adequate care this fall? If hospitals are having to let go of essential personnel due to financial difficulties, how can we expect them to care for 30-60% more patients coming through their doors with the flu? Although the Federal Government has allocated funding for institutional preparedness, no one has overseen its implementation and the math is not adding up.

The situation poses an obvious conflict between our collective need to be prepared and our societal fear of centralization, exacerbated by the healthcare system’s financial ruin. Further, our culture of individualism is driving absurdly self-centered discussions without any regard to the reality or application of wisdom to the upcoming potential disaster: not everyone will get everything. In fact, even if we had the will to implement a preparedness schema akin to Israel’s getting all of our ducks in a row, rationing during a pandemic would be mandatory. What will things be like when tough choices have to be made under the pressure of a chaotic situation, choices that we as a society are ignoring now, when there is time to approach them rationally? Why are we engaging in hysterical lies about government-sanctioned euthanasia instead of discussing this challenging and rapidly approaching reality?

Today in New Hampshire Obama appealed to our civility and common sense as a nation in our discourse on healthcare reform. We need to heed this message, turn away from demagoguery and focus on developing a roadmap for realistic scenarios of 5 patients competing for one ICU bed, of our EDs clogged with a relentless influx of casualties from H1N1, and of having to make end-of-life choices for our critically ill grandma because asking her about her preferences when she was well would have amounted to a Nazi execution.

Both, the JAMA and the NEJM papers offer solutions to the US problem of healthcare capacity and preparedness. These solutions require time and a culture shift. But time is short, and culture change before the fall is unlikely. Yet this is a teachable moment in which we need leadership. Mainstream media should lead this conversation without attention to their ratings and in more than sound bites. Treat us, the citizens, like intelligent adults, and we will rise to the challenge; treat us like spoiled children, and we will miss this narrowing window of opportunity.

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