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Dhruv Khullar

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What states can learn from each other on healthcare

Dhruv Khullar, M.D., writes in The New York Times about what states can learn from other states about how to improve healthcare. He concludes:

“There’s much to learn from state-level innovations, but there are also general principles that apply across states. High-performing states have competitive and accessible insurance markets; strategies for data-sharing and health information technology expansion; more value-based purchasing; greater emphasis on primary care; and strong partnerships with community organizations. They also expand Medicaid.

“It’s also important to note that many state-level policy changes do not require federal approval, and that states don’t always use their flexibility to improve population health. Proposals that allow states to weaken protections for those with pre-existing conditions, for example, could harm patients and their ability to access care.

“Greater flexibility for states is an opportunity, not a solution. The enormous variation in quality, costs and access across the nation should remind us that experiments succeed and experiments fail. Having laboratories is probably a good thing. But it depends on what they cook up.”

To read  The Times’s article, please hit this link.

For an integrated federal healthcare system


Read this proposal by Dhruv Khullar, M.D., and Dave A. Chokshi, M.D., for an integrated federal healthcare system to replace t0 rather chaotic  and contradictory one we have now.

5 ways to integrate federal health programs


This JAMA piece by Dhruv Khullar, M.D., and Dave A. Chokshi,  M.D., look at the  need for the federal government to integrate its health programs.

They note that “{t}he breadth, complexity, and incremental development of the federal health system have resulted in a fragmented patchwork, with many potential areas for integration to increase efficiency and improve care coordination.”

They suggest (in considerable detail) five ways could be improved:


  • “Minimizing overlapping service delivery and procurement.”


  • “Reducing duplicate payments.”


  • “Repurposing underutilized facilities.”


  • “Integrating information technology systems.”


  • “Expanding value-based purchasing.”


More strategies to reduce readmissions


New research now suggests multiple strategies to improve the patient  discharge process at hospitals,  such as treating it more like the admissions process and dispensing medications at that point.

Dhruv Khullar, M.D.,  a resident physician at Massachusetts General Hospital and Harvard Medical School, noted in a New York Times blog entry that at teaching hospitals in particular, junior residents usually thoroughly interview patients, often sharing any information gleaned with senior residents and the physician in charge to develop a plan of care.

Dr. Khullar recommends incorporating the attention to detail in the admissions process into the discharge process. For example, follow-up phone calls helped William S. Middleton Memorial Veterans Hospital, in Madison, Wis., cut admissions 11 percent.

Another good move is dispensing medications to patients ahead of discharge, says a study  in Pediatrics, reports FierceHealthcare. “Discharging patients with medications in hand significantly lowered the odds of readmission, leading Boston University Medical Center to add medication dispensation to its discharge protocols,  says Pharmacy Times.”

Fierce  also cites  a program to  patients manage the discharge process at home.  As part of the program, providers identify high-risk patients and implement discharge plans over a 30-day period after a “warm handoff,” according to Healio. Providers implementing the program report readmission rates of 17 percent.

Fierce adds: “Hospital design may hold potential keys to improving discharge as well; since introducing a transitional care center on the first floor of its trauma tower, San Antonio’s University Health System has reduced patients’ time spent in bed after discharge, Healthcare Design reports, with a goal of sending 30 percent of discharge patients through the unit over the course of the year.”

How long should residents’ hours be?


Dhruv Khullar, M.D., a resident physician at Massachusetts General Hospital and Harvard Medical School, asks whether physicians-in-training should work fewer hours.

He concludes with these remarks:

“The right answer on how many hours residents should work may be more nuanced than we’ve been willing to accept. It isn’t the same today as it was 20 years ago, as the complexity of caring for patients and medical technology continue to evolve. It varies by subspecialty — discontinuity may have graver consequences for neurosurgery, say, than for radiology. And it hinges more on the character of work than the length of it — I’d spend twice as long at a patient’s bedside if I could spend half as long at a computer.

“Ultimately, the answer may be as philosophical as it is empirical. What kind of doctors do we want to be? What kind of doctors do patients want us to be? And does what we can’t measure still matter in a profession that’s now judged and motivated by what we can?”


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