Re: “CDC Urges Hospitals to Act on Antibiotic Stewardship” by Paul Barr in H&HN Daily, Aug. 13

What you are saying about the need for stewardship over antibiotic use makes sense — lots of sense. But that may be part of the problem.

What is a physician to do when a patient presents with bronchitis and demands an antibiotic? The physician knows full well that only 5 percent of bronchitis is bacterial. Yet, 73

percent of the time he or she will prescribe an antibiotic.

Why? Well, explaining that viral bronchitis will not respond to antibiotics and that overprescription of antibiotics will lead to drug-resistant strains and ... takes time (which the physician does not have, and is not paid for) and the patient will probably not be convinced.

Not that hospitals should do nothing, but the problem lies in both incentives for physicians and our inherent bias to do something.

— Douglas E. Hough, Ph.D.

Associate Scientist & Associate Director

Master of Healthcare Administration Program

Department of Health Policy and Management

Johns Hopkins University

Bloomberg School of Public Health

Baltimore

Is Direct Contracting a Good Idea?

Re: Ian Morrison commentary on the need for affordability in health care, H&HN Daily, Sept. 2

Heath care providers have been "under the gun" for several decades now, with private industry making much the same demands 20-plus years ago. Providers, on the other hand, are tired of seeing insurers raise premiums 15-plus percent per year and increase payments to providers by 2–3 percent. Perhaps going for a direct contracting model is a good idea. I wonder what happens to the small employer who doesn't have thousands of employees?

— Bob Marquardt

Or, Is Capitation Better?

Re: Ian Morrison commentary on the need for affordability in health care, H&HN Daily, Sept. 2

There is only one way to drive the kind of change desired in this article: capitated payments. Taking whole populations — not [only] employed or Medicaid, but whole communities — and providing a reimbursement dollar [amount] per person that the health system must live within. No centers of excellence with a handful of quality measures, but a real incentive to use quality and system improvement to drive down production costs and per capita spending. Anything else just guarantees another generation of financial wizards that will be employed to manipulate the system.

— Ed Gamache

Two Obstacles to Telehealth

Re: “Remote Technology to Manage Chronic Conditions for Patients at Home” by John Morrissey, August H&HN

This article highlights two key issues with telehealth for chronic care patients: the "last mile" issue and the "provider desert" issue. The first issue reflects the difficulty of enabling busy physicians and staff to properly use telehealth technology. This is usually a function of reviewing and adjusting clinical workflow in the office or unit, but does require systematic attention and allocation of resources.

The second issue involves those patients who don't have an assigned physician. In the absence of a receiving node, all the telehealth technology is a waste.

Proactive providers fully committed to telehealth will address these predictable problems at the start of their projects and ensure a higher probability of project success.

— Les D

The Kind of Docs We Want

Re: "Bedside Manners" by David Ollier Weber in H&HN Daily, Aug. 26

Consumers are tired of having to choose between competent and nice doctors. We want and expect both. Anything less will result in a poor experience either clinically or emotionally. Health care organizations must expect providers to deliver competent and collaborative care in partnership with patients and the rest of the care team. The word "value" in value-based purchasing is evaluating on both and so is the consumer.

— Kristin Baird