health

privacy

2011-03-14T20:43:00.001-07:00

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Tough Talk helps people be gentle

2011-03-14T14:14:00.000-07:00

Some people at the University of Washington and colleagues from around the country run a wonderful website called Tough Talk: Helping Doctors Approach Difficult Conversations. They call it a "toolbox for medical educators" who want to teach about ethics and communication. Topics include:

Common teaching challenges plus tips for recovering from them • Optimizing small group dynamics • Providing effective, honest feedback • Helping clinicians develop and operationalize personal learning goals • Motivating engagement and self-assessment in reluctant participants

Look at this statement of philosophy:

Many argue that ethics and communication cannot be taught. Since these skills lie in the realm of the interpersonal, they do build on skills and practices we begin developing from our earliest interactions. However, evidence shows that practice and experience can lead to development and enhancement of these skills. This human element is where the moral work of medicine happens. We have a responsibility to attend to these skills and work to develop them, even as we strive to perfect our other core clinical skills. Quality patient care depends on it.

Teaching future medical professionals is a gift. When we interact with students, residents, fellows, or colleagues, we have many opportunities to learn and grow ourselves, in addition to promoting growth in others. We have approached this work of teaching by thinking about it as a service. We are not there to impart knowledge or impress others. We are there, working with learners, because we are genuinely interested in helping them become better doctors. Ultimately, attending to the interests of physicians-in-training will promote better patient care.

This is a nice exception from the findings made by Linda Pololi in her book about the often dehumanizing relationships among faculty in medical schools.

I was curious about how it all got started and how well it is being accepted. Here's the note I received from Kelly Edwards at UW when I asked those questions:

This project started as "Oncotalk" which has a linked site to "Tough Talk", an NCI-funded program to help prepare oncology fellows for difficult conversations with seriously ill patients. We ran two retreats a year, reaching 20 fellows each time, for four years and touched many of the training programs across the country through this program. We then received a five year grant to support a 'train-the-trainer' course to teach Oncology faculty to integrate more communication skills teaching into their clinical teaching of fellows. We have had one 20 person cohort per year for four years, and our last session is coming up in April.

Tough Talk was funded by the Greenwall Foundation and allowed us early on to study our process approach to teaching communication skills and post some teaching materials to share online. I know that our programs have impacted many practicing oncologists - and many patients in return - but we do not have specific data about the public websites that support these courses to know how many additional people find these resources.

Oncotalk was profiled in the New York Times about 5 years ago. And we have several published papers in the academic literature about our program, teaching model, and communication skills. I'd be glad to share any of these papers if you are interested.

We get emails from participants on nearly a weekly basis about how their clinical practice has been impacted by our programs. As one small sign of support, 50% of the Oncotalk alums wrote letters of support for our train-the-trainer course grant. To us, that was very moving, given how busy these oncologists are!

Other faculty-investigators involved with this program are: Tony Back (oncologist at UW, Seattle - Principle Investigator), Robert Arnold (Palliative Care physician, Pittsburgh), James Tulsky (Palliative care physician, Duke), and Walter Baile (Psychiatrist at MD Anderson). They are truly leaders in the field!

How to achieve compassionate end-of-life-care

2011-03-14T07:00:00.000-07:00

A very special report is being released right now at the Boston Public Library from the Expert Panel on End-of-Life Care, a multidisciplinary group of 41 stakeholders, including health care professionals, service providers, policy makers, health care advocates and legislators. They were appointed by the state's Executive Office of Health and Human Services, as directed by the Legislature.

The have done very good work on an important topic. It is thoughtful, practical, and compassionate.

Here are some excerpts from the press release:

Included in the report are the Expert Panel’s professional training guidelines to assist physicians with end-of-life consultations with patients who wish to discuss advanced directives.

The panel identified several essential goals toward achieving the highest quality end-of-life care:

- Inform and empower residents of Massachusetts to understand and plan for end-of-life care;
- Support a health care system that ensures high-quality patient-centered care;
- Promote and support a knowledgeable, competent, and compassionate healthcare workforce;
and
- Employ quality indicators and performance management tools to measure results.

I really like all these, especially the last one. Like all process improvements, if you don't measure, you don't achieve. I also like that the report talks about guidelines, clearly being sensitive to the preogatives of doctors and nurses in their relationships with patients.

Notable quotes from two fine people:

"Any health care system should help doctors and other caregivers ensure that patient's wishes are understood and honored, perhaps most of all in the last phases of life," said Dr. Lachlan Forrow, Director of Ethics Programs at Beth Israel Deaconess Medical Center.

“Meeting with residents throughout the state, it is clear to me they want to talk about ‘a good death,’ and how will we respect and honor their wishes at the end of life," said Jim Conway, Senior Fellow at the Institute for Healthcare Improvement. "Implementing systematically the report’s recommendations will go a long way to ensure we, as a community, do that in partnership 100% of the time.”

Why cognitive specialists lose out

2011-03-14T01:53:00.000-07:00

His father is a cardiac surgeon. His mother is an internist.

The little boy, aged 3 1/2, is asked by his girlfriend(!), "What do your parents do?"

"My father is a surgeon. He saves people's lives. My mother is just a regular doctor."

Father shamelessly promotes Florida performances

2011-03-12T04:10:00.000-08:00

For those readers in the Tampa area, here are surely excellent performances at the New Seeds Festival on March 19, 25, and 26th.

Cars, planes, and trains. And later, there are the doctors.

2011-03-10T08:40:00.000-08:00

I have great admiration for the Massachusetts Health Quality Partners. The mission is sound, and the organization uses what exists to good purpose.

But this post is about what exists, and it is not good enough. MHQP just published its annual review of primary care practices in the state, available here. You would like to think that you could use the information provided to conduct a comparative review of your MD's practice group compared to others, looking at compliance with generally accepted guidelines.

But you can't. Why not? Because the data are old.

If you review the report's technical appendix, you find that "This report provides information on the 2009 performance of Massachusetts Medical Groups on the selected HEDIS® Measure Set. ...The measurement periods vary somewhat by measure, but in general, HEDIS® 2010 measures report on performance during calendar year 2009."

What would be really useful is current information.

The data for this report come from the five major Massachusetts health plans. I have heard over and over from these insurers about the advanced information systems they have in place. So why does it take so long to collate rather simple data from that which was collected well over a year ago?

In contrast, let's look at the currency of the auto repair data provided by Consumer Reports. Here's how they do:

All our reliability information is completely updated annually. We begin sending out each year's survey in the spring. By late summer, we have collected and organized responses, and we complete our analysis and update the information online by late October. The new information first appears in print in the Consumer Reports Best & Worst New Cars, on newsstands in mid-November. ...All reliability information we publish is based on subscribers' experiences with cars in the 12-month period immediately preceding the survey.

How about airline on-times rates? Collected monthly, reported within three months. Curious about annual figures on that metric, but also many other quality metrics that might influence your choice of carriers (flights cancellations; chronically delayed flights; causes of delays; mishandled baggage; bumping; incidents involving pets; complaints about service; complaints about treatment of disabled passengers; discrimination complaints? Within two months of the end of the year.

The Boston transit system -- not always viewed as the paragon of efficiency! -- on-time rates? Monthly, published within weeks.

Don't you think we deserve more timely information about the quality of our primary care group than we can get about cars, airplanes, and commuter rail?

Patient and Family Advisors on WIHI

2011-03-10T07:15:00.000-08:00

Health Care’s Newest Improvers: Patient and Family Advisors
Thursday, March 10, 2011, 2:00 PM – 3:00 PM Eastern Time

Guests: Kristine White, RN, BSN, MBA, Vice President, Innovation and Patient Affairs, Spectrum Health System
Cindy Sayre, MN, ARNP, Director, Professional Practice and Patient and Family Centered Care, University of Washington Medical Center
Dorothea Handron, EdD, APRN, Faculty Emeritus, College of Nursing, East Carolina University; Patient-Family Advisor, University Health Systems of Eastern North Carolina
Brandelyn Bergstedt, Coordinator, Patient and Family Advisor Program, Evergreen Hospital Medical Center
Martha Hayward, Executive Director, The Partnership for Healthcare Excellence; Founder, Women’s Health Exchange; Member, Dana Farber Cancer Institute Patient Advisory Council

Not that long ago, Patient and Family Advisory Councils (PFACs), where they existed at all, were pretty much concentrated in children’s hospitals. We have these pediatric pioneers to thank for their courage and for laying the groundwork for what’s now becoming a new standard for all hospitals that are serious about patient safety and better patient care.

As PFACs gain traction and acceptance and respect, the myriad of initiatives that their members have undertaken across hospital departments is truly mind boggling. That’s just one reason WIHI Host Madge Kaplan hopes you’ll tune in to the program on March 10. Kristine White, Cindy Sayre, Dorothea Handron, Brandelyn Bergstedt, and Martha Hayward are going to describe what it’s like to engage with board members, be part of teams to redesign physical space, round with health care providers, rewrite educational materials, and much, much more. As leading patient advisors, all five guests also have valuable wisdom to share about what makes for an effective PFAC, what sort of homogeneity and heterogeneity matter, how to establish ground rules for members, and how to become more knowledgeable about quality improvement.

In Massachusetts, the creation of PFACs is mandated through legislation. But the best reason to collaborate with patients and families at your organization is because of the perspective anyone who receives care brings to the table. In other words, the most complete team to drive change at your facility is one that includes patients and families.

To find out why, to add to the picture, or to get some tips on how to start a PFAC, please join this next WIHI. Encourage a colleague or two to sign up as well!

To enroll, please click here.

Observations about the Israeli health care system

2011-03-09T09:12:00.000-08:00

As I share this view from my room in Tel Aviv after leaving the conference in Haifa, it is a good chance to consider the features of the Israeli health care system and draw some comparisons with that of the US. You can find a full description here, but let me hit the highlights as I understand them, based on discussions over the last two days.

Israel has had universal coverage for many years. It is provided by four HMOs, one with about 55% of the market, another with 20% or so, and the remaining two splitting the rest. The competition that exists is not based on price. Indeed, the cost of care is covered by a payroll tax and other government funding in the form of a capitated payment to each HMO based on enrollment. People are free to shift from one HMO to another as often as every two months, but only a very small percentage (well under 2%) shift each year.

Supplemental insurance, privately paid, is also available. However, the basic coverage offered to the population is very inclusive, and the supplement is for the small number of elective items that are not of great interest to most people.

The HMOs offer a strong primary care network and then contract with the hospitals for secondary and tertiary care. Some hospitals are owned by the HMOs, but many of the patients go to hospitals that are not owned by the HMOs. These are either government owned or are private, non-profits.

Now, as we explore transactions among these entities, it gets interesting. What is the process by which the rates for the government hospital are set with the HMOs, for the services purchased by the HMO out of its capitated budget? This is a negotiation in which the government is a participant. But recall that the government also owns those hospitals for which it is negotiating the rates with the HMOs. The HMOs are not permitted to joint together to negotiate with the government.

The government has also established uniform salaries that can be paid by HMOs to their executives and doctors. Even accounting for exchange rates and different standards of living, the salaries paid to doctors are well below those in the US. This is possible, in part, because the cost of medical education is highly subsidized by the government.

Finally, if any of these institutions -- government hospitals or HMOs -- runs a deficit, the finance ministry makes up the losses.

For those in the US hospital and physician practice world who are aghast at the idea of rate-setting, you find it here in a very interesting form. In essence, there is little in the way of market forces in place determining the level of financial transactions within or among the major entities providing health care services. And, the whole system is subject to a budget that is set, directly or indirectly, by the parliament.

Regular readers may recall observations I made a few years ago about the Icelandic health care system. There, too, the annual national budget for health care, as a percentage of GDP, was set by the parliament. I asked my Icelandic hosts the following questions and derived a conclusion:

Is this percentage based on a quantified assessment of the actual health care needs of the public, i.e., is it driven by public demand (e.g., a growing aging population)? No. Does it take into account the government's expectation for certain quantifiable levels of service quality, medical quality, or operational efficiency of hospitals and other parts of the system? No.

In essence, this appropriation by the parliament is a politically derived decision, just as it would be for any appropriation for a program of important national priority, and it therefore competes with other worthy national programs for resources.

Such is the case in Israel, too.

It is instructive to compare the differences among these systems, and it is worthwhile to understand the trade-offs that have been made in each political jurisdiction. There is no right or wrong way to do this. The system in each country is a composite societal judgment call.

It is important to recall, though, that all developed countries face similar structural challenges for the future: An aging population that is living longer and demanding more in the way of hospital service; a rapid introduction of technological innovation in diagnosis and treatment that tends to increase the cost of health care; a greater expectation on the part of the public of the "rule of rescue," i.e., devoting more and more resources to the more unusual, but emotionally charged, medical conditions; and a growing base of consumers/patients who are better informed through social media and who therefore have higher expectations of the services provided to them.

These trends intersect with the ability of a society to pay for them, and the bulls-eye for that intersection will be the hospitals. Why? Hospitals are capital-intensive and staff-intensive organizations. In essence, they are characterized by large fixed costs or by variable costs that are hard to vary very quickly. In competing for business, hospitals are prone to engage in the "medical arms race," prompted by their doctors, companies who cleverly market expensive devices and equipment, and ultimately by patients who want the latest and best -- even if clinical efficacy has not been demonstrated.

Hospitals also often have an overlay of responsibility for medical education, the costs of which cannot be easily shed, and many also engage in research for which they are not fully compensated.

In contrast, the HMOs in Israel or the multi-specialty physician practices and primary care groups here in the US have the most potential to change their ways of delivering service to get ever more clinically effective and cost-effective. For one thing, they are not burdened by high levels of fixed overhead. For another, they are better situated to use technology to deliver care more efficiently. For example, they can start to use home-based, remote reading devices to check on a congestive heart failure patient's weight and other vital signs -- or they might use other types of remote testing devices to review a diabetic patient's blood levels and other metrics. These technologies, in the hands of primary care doctors, will enable patients to get the care needed in a low-cost setting and help avoid hospitalization.

The hospitals that succeed in the future will need to do everything possible to avoid incurring large increments of capital expenditures. To do that and otherwise minimize cost increases, they will also have to learn to engage in front-line driven process improvement (whether of the Lean variety or something else) to redesign their work flows. A strong emphasis on quality and safety improvement will also be a virtue rewarded over time. These latter steps do not happen without a strong commitment to transparency: You can't improve unless you acknowledge where you are failing.

Mideast drama

2011-03-08T20:45:00.000-08:00

A storm passes through Haifa this morning (posted at 6:45 Israel time on March 9).

Hospital Governance Issues in Israel

2011-03-08T08:23:00.000-08:00

I am currently in Haifa, Israel, addressing a conference being held by the Israel National Institute for Health Policy Research entitled "Governing Hospitals." Here's the summary of the program:

As explained here, Israeli hospitals come in several varieties. An excerpt of the context:

Israel has a national health insurance system that provides for universal coverage. Every citizen or permanent resident of Israel is free to choose from among four competing, non- profit-making health plans. The health plans must provide their members with access to a benefits package that is specified within the NHI Law. The system is financed primarily through taxation linked to income (through a combination of earmarked taxes and general revenue). The Government distributes the NHI funds among the health plans according to a capitation formula which takes into account the number of members within each plan and their age mix.

The Ministry of Health has overall responsibility for the health of the population and the effective functioning of the health care system. In recent years the Ministry has developed strong capabilities in the areas of health technology assessment (HTA), the prioritization of new technologies, health plan regulation, quality monitoring for community-based care, and strategic planning to set goals for population health, along with strategies for achieving them.

In addition to its regulatory, planning and policy-making roles, the Ministry of Health also owns and operates about half of the nation’s acute care hospital beds. The largest health plan operates another third of the beds, and the remainder are operated by means of a mix of non-profit-making and profit- making organizations.

As you might expect, therefore, the questions of hospital governance in this country are complex and multivariate. It is impressive, therefore, that this conference was organized to provide the leaders of the hospitals with a chance to join together and consider future directions.

Speakers included Richard Saltman, from the Department of Health Policy and Management at Emory University, and Dr. Antonio Durán, from the Andalusian School of Public Health in Sevilla, Spain. You see them here with one of our hosts, Schlomo Mor-Yosef, Director General of the Hadassah Medical Organization. Nigel Edwards, from the UK's NHS, was supposed to attend but got busy with the issues mentioned above and sent a video of his remarks.

Professor Saltman summarized European efforts to restructure how public hospitals are governed. Starting with the introduction of self-governing trusts in England in 1991, policymakers in a number of countries have sought to design more independent decision-making capacity into public hospitals. The goal has been to generate more innovative and entrepreneurial behavior, while simultaneously preserving the social advantages that accompany publicly operated institutions.

Dr. Durán discussed the Spanish experience, noting that the country has explored various hospital self-governance arrangements over two decades. It has done so, however, via ad hoc, politically-driven, last-minute legislation, resulting in a confusing regulatory framework, with national and regional norms superseding each other. Various self-governing hospitals with different ownership status, legal characteristics, and degrees of autonomy and accountability now co-exist with traditionally managed public hospitals.

My talk was on the evolution of governance of US hospitals from a traditional focus mainly on financial management to an expanded view of a board's fiduciary responsibility, with a concern for issues of quality, safety, and efficacy of clinical care. My theme was that a well-functioning governing body can enable hospital leaders and management to harness the experience, wisdom, and judgment of members of the community to build a stronger hospital.

By the way, someone pointed out today that there is no Hebrew word for governance, making it an elusive concept here, perhaps culturally as well as linguistically. This suggests that some degree of flexibility will characterize the evolution of this concept in this country. But let's not be purists about this. After all, even in other parts of the world where governance is clearly part of the vernacular, it is not universally well executed. This conference suggests that we all can learn from one another.

Why do we need a regulatory crosswalk?

2011-03-08T03:06:00.000-08:00

In a post below, I talked about the unfortunate marketability of a book that explains The Joint Commission standards in plain English -- both for the hospitals it surveys and for its own surveyors. Now arrives another email with an ad for a $399 service called Patient Safety Monitor, that, among other things, allows you to:

Find and compare state, CMS, and Joint Commission regulations on high-profile patient safety issues such as:

Verbal Orders;
Critical Test Results;
Handoffs
Infection Control: Hand Hygiene

I don't want to get into the issue of state regulations today, but the idea that you might pay for a service to provide a "crosswalk" to help you reconcile CMS and Joint Commission regulations is troubling.

The CMS Conditions of Participation are basically the terms that make a hospital eligible to see Medicare patients, and by extension, other patients whose bills are paid by private insurers. In essence, you can't stay in business as a hospital if you do not satisfy the Conditions of Participation.

The Joint Commission has been delegated "deeming authority" by CMS to review a hospital's compliance with the Conditions of Participation.

So should there be any difference between the reviewing standards of the JC vis-à-vis that of CMS? If there is no difference, why is this service being sold? If there is a difference, we have a troubling difficult situation.

The advertised service, by the way, also provides updates in a Patient Safety Monitor Journal of new developments in regulatory review standards. As in the previous post, I wonder why there is a need for a commercial product to offer such advisories. Don't CMS and The Joint Commission offer plain English advisories and interpretations of their own regulations?

All of which reminds me, while we are at it: Whatever became of the idea of The Joint Commission making its library of best practices open to the public? Why doesn't CMS require it as part of the delegation of authority? After all, the JC acquires this information as part of its surveying function. In that sense, it should be public information, like other government sponsored work.

In good company

2011-03-07T12:22:00.000-08:00

Just in case you thought it was just the United States health care system that is facing financial issues, here comes this story about the British system from today's Financial Times: "Reforms of NHS take back seat to cash fears." (Sorry, I can't find a link to the story.) Here's the lede:

Health bosses are far more worried about keeping control of the NHS finances over the coming year than they are about implementing the government's sweeping reforms, warns the NHS confederation, the body that represents health authorities and trusts.

And later in the story:

[S]aid Nigel Edwards . . . "We are already picking up worrying signals from a number of hospitals and primary care trusts about significant money pressures emerging -- and this is before the challenging rigours of next year's tight financial settlement."

After years of sustained growth, the NHS faces a real-terms freeze in spending for the next four years.

. . . The service is being asked to make £15bn to £20bn of efficiency savings by 2014 at the same time as administrative costs are being cut by a third and management costs by 45 per cent.

It is no surprise that these pressures are emerging. The same demographic, technology, and patient care issues exist throughout the developed economies.

What is sadly surprising is that, whether in the US or elsewhere, there seems little coordinated interest in the use of process improvement to redesign work in the health care environment, which would improve quality and safety and also garner financial savings. Why can't the lessons of Spear, Toussaint, and Kaplan take hold?

Wanted: New, unblinking eyes

2011-03-06T15:17:00.000-08:00

An op-ed by Joseph Hallinan in the New York Times discusses a form of cognitive error that is worth considering in the health care environment.

Goldovsky’s experiment yielded a key insight into human error: not only had the experts misread the music — they had misread it in the same way. In a subsequent study, Goldovsky’s nephew, Thomas Wolf, discovered that good sight readers report that they do not read music note by note; instead, they rely on their recognition of familiar patterns and on their ability to organize the music into those patterns and dependable cues.

One day, a student of his was practicing a piece by Brahms when [Boris] Goldovsky heard something wrong. He stopped her and told her to fix her mistake. The student looked confused; she said she had played the notes as they were written. Goldovsky looked at the music and, to his surprise, the girl had indeed played the printed notes correctly — but there was an apparent misprint in the music.

At first, the student and the teacher thought this misprint was confined to their edition of the sheet music alone. But further checking revealed that all other editions contained the same incorrect note. Why, wondered Goldovsky, had no one — the composer, the publisher, the proofreader, scores of accomplished pianists — noticed the error? How could so many experts have missed something that was so obvious to a novice?

. . . In short, they don’t read; they infer. Moreover, this trait is not unique to musicians: pattern recognition is a hallmark of expertise in any number of fields; it is what allows experts to do quickly what amateurs do slowly.

Goldovsky’s insight offers a useful metaphor for understanding the crisis on Wall Street: Not only did hedge-fund managers, bankers and others misread the danger involved in many of their investments, but they misread them in the same way.

The author's conclusion: "These types of errors are most likely to be discovered by those who, like Goldovsky’s young student, look at the world with new, unblinking eyes."

In an earlier post, I discussed forms of cognitive bias that have been documented by psychologists and neurologists. Also, you may recall this presentation by Pat Croskerry about intuitive decision-making, and the "cognitive miser function," a tendency to get comfortable with the form of decision-making that you find most used and useful.

The application of these thoughts to process improvement in the health care setting is obvious. It is very difficult to overcome cognitive biases in the delivery of clinical care, especially when the field remains such a cottage industry, in which in which each person is expected to be an artist, relying on his or her creativity, intuition, and experience when taking care of a patient. The resulting lack of standardization -- the high degree of practice variation -- creates an environment that is inimical to process improvement based on scientific methods.

But I wonder if the some of the same types of biases are spilling over into the business aspects of hospital finance, too. In Hallinan's words, "It may be too much to suggest that we let adolescents run Wall Street.... But it wouldn’t hurt to let them check the math." Maybe it is time for some "new, unblinking eyes" among business reporters.

Essays from Ernie's students - 1

2011-03-05T04:00:00.000-08:00

Some of you will recall that about a month ago, I gave a guest lecture at Ernst Berndt's course at MIT's Sloan School, entitled "Economics of the Health Care Industries," and gave the students this essay assignment:

First, read this blog post. Then, the question is: What methodology would you propose for the allocation of an annual global payment, to divide it up among primary care doctors, community hospitals, tertiary hospitals, specialist doctors, nursing homes, etc. -- all of whom are involved in caring for a given population of patients? How would you make the transition from the current fee-for-service approach?

Those in the field will grasp the difficulty of this assignment, and it may have been unfair to pose it at the beginning of the semester. But, hey, these are MIT students, and so we should expect a lot. I said I would post the best answers, and I start with this entry. I don't have room for the entire essay, so I will take excerpts. Others will follow in three separate posts.

The first is from Joshua Copp. Feel free to offer your grade and observations, as if you were his professor, in the comment section below. Here is the excerpt:

Examining the costs in order of priority for payment, we would need to start by paying for any materials consumed in the care of the patient. Think of these as the direct costs for treating a patient...

Following direct material costs, a fixed payment will have to be negotiated between physicians groups and care centers. This contract between the physician group and the hospital or nursing home would be very similar in nature to the contract between BCBS-MA and BIDPO...

Base compensation will be a difficult policy to establish, but it is the final cost before considering any efficiency gains or bonus payments. In order to set base salaries, the physician work relative value unit established by Medicare will be the most objective and accurate way to account for training requirements, skill, and time needs. Initially, using a weighted average RVU for each specialty group (cardiologists, nephrologists, orthopedic surgeons, etc) multiplied by the PCP base salary will set that group’s base salary.

The PCP base salary is the compensation level corresponding to an RVU equal to one. For example, if a PCP base salary is $100,000 per year, and the average RVU for nephrologists is 1.2, then a nephrologists’ base salary would be set at $120,000 per year. An inherent assumption for base compensation is that the number of specialists relative to PCP’s will likely decline under the AQC in equilibrium.

Now we must consider how efficiency gains by physicians and quality bonus payments are allocated. First, with efficiency gains, this should tie directly into the direct material costs associated with patient care, and therefore one should be able to tie gains directly to physician groups. For example, if the orthopedic surgeons identify a lower-cost knee implant that saves $500 per implant, then the total savings should be allocated to the orthopedic group. However, to ensure that the least efficient groups are not being over-compensated, target efficiency gains should be normalized across all provider groups.

The next consideration is how to handle quality of care improvements. Specifically, this is targeted at the additional 10% payment available upon meeting certain quality benchmarks for the contract as a whole. First, because the hospital influences the metrics used for bonus payments, the fixed payment contracts established with the care centers should include bonus payouts if the hospital meets certain quality standards. Further, payments to the hospital should be tied to the total AQC bonus payment, ensuring that bonus payments to hospitals only happen when quality benchmarks were met by all, not just the hospital.

In order to tackle the bonus payments to physicians, consider first only those group practices which as a whole delivered on their quality improvement metrics. For those groups, the bonus payment should be divided evenly across each division, and no bonus is paid to groups who, as a whole, did not meet the improvement threshold. The next layer is the individual physician within those groups that improved. For the individual physicians, only those which delivered on their quality levels will be awarded a bonus, evenly split across all physicians who delivered on quality of care. Therefore, an individual’s ability to receive a bonus is directly tied to the ability of the team to gain a bonus, reinforcing the teamwork necessary to develop an efficient system.

The final consideration with bonus payments and incentives is how they fund and support the overall mission of the physician organization and provider network. Thinking specifically in the case of BIDPO, this is an academic institution that has a large teaching contingent. Therefore, in order to support their mission of research and instruction, all bonus payments should be ‘taxed’ at an appropriate rate each year before any distributions are made. For example, if BIDPO received $100 million in care quality bonus payments, then 30% of this is automatically set aside to fund research and training, before any consideration is given to group payouts. This tax would be used to fund research, training and continued education across the institution.

The final consideration is how to transition from the fee-for-service model to the global payment system. Two main points need to be addressed to ensure an effective transition. First, negotiations need to begin immediately with all care centers to accurately gauge the annual effective rental expense for each center, based on the mix of procedures and usage. Second, communication with specialist physicians must begin immediately. There will likely be attrition from the specialist groups as the transition is made, and as such retaining the best trained physicians will be imperative to providing the highest quality care. The key for retaining the top specialists will be to explicitly demonstrate how they will not suffer in compensation, research opportunities, or in their ability to care for the patient.

Essays from Ernie's students - 2

2011-03-05T03:59:00.000-08:00

Here is the second of the selected essay's from Ernst Berndt's Sloan School class at MIT. David Berlin is the author. Please submit your observations and grade in the comment section. There are three other essays.

The most complex question raised by the AQC is how to allocate the global payment among various care providers encountered by a patient. Evaluation of this question requires analysis of methods for data aggregation, a structure for determining the relative value of various services provided to a particular patient and a plan for implementing the change from fee-for service reimbursement to global payments.

The logistics for managing care under an AQC arrangement are significant. Providers are responsible for orchestrating the spectrum of care received by patients, and concurrently optimizing both outcomes and costs. The initial hurdle in achieving these goals is to provide reliable and consistent data to the primary care physician decision makers. The AQC relies on physicians adjusting to new incentives that incorporate costs. Therefore it is essential that physicians who choose where to refer patients are fully informed as to the costs of various referral options. If physicians are blinded from this cost data they cannot be expected to make rational decisions regarding the best locations to refer patients. Secondly, these physicians should be provided aggregated outcome data for referral sites. By pairing aggregate outcomes with the costs of services, physicians will be able to determine where patients will receive the greatest value. The data should be aggregated through the insurance provider, as they are a source of continuity between patients and therefore the only party that is privy to the totality of a particular patient’s care and cost tally. By aggregating this data through the insurance provider and distributing it to primary-care physicians, these physicians will be empowered to make rational decisions on behalf of their patients.

Determining the relative reimbursement for various services is also a major issue within the AQC model. Under the traditional fee-for-service model each service is independently reimbursed at pre-defined rates. However under the AQC model, a significant portion of potential revenue is realized through outcomes based bonuses. Were this bonus to be distributed proportional to a physician’s share of reimbursement for a given patient, the system would again incentivize the provision of high-cost services. Therefore providers should find a mechanism of distribution that links payment to the value of services received by a particular patient, as measured through outcomes. Within the physician practice network various specialties should negotiate their payment rates with the practice administration. This provides internal market forces that allow the individual practice network to determine the relative value of various services. Furthermore, since the primary-care physician is tasked with orchestrating the spectrum of care, they should be entitled to a more significant share of performance based payment than specialty providers.

The transition from fee-for-service to a global payment system creates significant changes in provider incentives, and therefore should be executed in a gradual manner to allow an appropriate market reaction. Initially it would be most reasonable to keep reimbursement rates at existing levels, with efficiencies being extracted through changes in referral volume. Over time in-network physician specialists should be required to negotiate with their practice administration to determine reimbursement rates. Should those services ultimately be priced at too high a level relative to the value provided to patients, one would expect the volume of referred patients to diminish accordingly as a result of changing referral patterns. If provided with adequate information regarding utilization and outcomes, practice administrators should recognize which physicians provide improved value to patients, and can subsequently allocate an increased share of overall reimbursement to these physicians. By leveraging these market forces, a system of continual improvement will be created with incentives for investment in both improved outcomes and efficiencies.

The objective of modifying physician incentives is both challenging and important for creating a sustainable healthcare system. The recent AQC contract between BIDPO and BCBS-MA provides an encouraging framework for modifying incentives to align with the overall value provided to patients. While the theoretical structure of this contract should provide both improved outcomes and restrained costs, the results remain to be seen. Among the challenges facing the AQC are questions regarding implementation, allocation of global payments, and uncertainty regarding the true impact of these changes on physician behaviors.

Essays from Ernie's students - 3

2011-03-05T03:58:00.000-08:00

Here's the third essay from Ernst Berndt's Sloan School class at MIT. This one is by Anna Capetanakis. Please offer your observations and grade in the comments section. There are three selected essays.

Implementing such a large and different payment system will be a challenge. Multiple ideas will have to be tested on a small scale to determine the best way to divide the funds. Below are a few ideas on how to approach this issue.

One main question is how to divide the patient budget across primary doctors, hospitals, specialists, and so on. I believe the answer entails both a technological and human aspect. The technological aspect is to analyze past data to determine the historical breakdown of treatment costs per ailment. Basing it off of data will make it difficult for the various stakeholders to refute. Once the breakdown is calculated, experts from more efficient systems (for example from the European countries) would assess where cuts could be made. These new adjusted ratios would act as general guidelines for how funds per patient should be divided amongst the various caretakers. It will be critical to make the process iterative so that as costs change, the allocation of funds shift accordingly.

Despite these general guidelines, it will be important that care be determined on a per-patient basis. To do this, the hospital organization should create a group of specialist physicians who have been trained on how to optimize the care of patients within budget constraints. These doctors will act like consultants to settle dispute, help primary care physicians adapt and make decisions, and decrease the risk associated with physicians making a decision.

In addition to this team of physician experts, it will also be critical to give all primary care physicians appropriate training on the new system. Which procedures are critical and which can be avoided? How do you communicate to your patient that his requested procedure is unnecessary? How do you solve conflicts among your patients’ caretakers? These doctors will need a support network and training to address these and other questions. These doctors have become accustomed to ordering tests rather than decide based on their intuition, so they will need support to make decisions. The group of experts will be invaluable to break the primary care physicians’ habits, increase their risk tolerance, and help them share some of the risk that comes with determining a patient’s critical procedures.

Another revolutionary but potentially very rewarding solution would be to completely revamp the hospital organization. Quite often we find in the business world that companies will piece together arcane IT systems rather than create one new, overarching system, resulting in a more inefficient, cumbersome, and expensive system than if the company had just started from scratch. With respect to hospitals, the hospital organization has evolved to support the fee-for-service system. Why not completely overhaul the system? Create a central database to track all patients. Change the relationships between departments in order to increase communication. For example, for common ailments like a heart attack, have a team of cardiac team (a radiologist, a cardiologist, etc) work together on the patient – essentially realign departments according to the payment scheme. It sounds farfetched, but why not try it? There would certainly be huge organizational resistance, but as we see in business, organizational change can be painful but it can pay off too.

Essays from Ernie's students - 4

2011-03-05T03:55:00.000-08:00

Here's the last of the four chosen essays from Ernst Berndt's MIT class at the Sloan School. As above, please offer your observations and suggest a grade in the comments below. This one was written by Ramesh Chandra. I include the entire essay, as it was the only one to include an alternative payment and patient care mechanism. There are three other selected essays.

Do AQCs solve the U.S. HealthCare System’s Woes?

1 Introduction

It is widely accepted that the U.S. health-care system is highly inefficient, with estimates of up to 30% inefficiency. The important causes of this inefficiency are considered to be: (i) fee-for-service payment methods that result in over prescription of care by doctors even when there is no significant benefit [6] (ii) lack of coordination in care delivered to the same patient by different doctors (iii) overuse of care by patients due to moral hazard, driven by the perception that more care is better care, and (iv) relatively little attention to prevention and wellness programs compared to treatment programs (also a fallout of the fee-for-service payment policies.)

One solution suggested to address these issues is to have care providers have more “skin in the game” by using global payment schemes. The idea is to allocate a fixed annual budget per patient and have the care provider manage it to deliver the care required by the patient, with bonuses awarded to the provider if it efficiently manages the budget.

In this essay, we study a specific type of global payment scheme designed by the BCBS of MA, called the Alternative Quality Contract (AQC). We look at the AQC model’s goals and analyze it to understand its limitations. We also briefly look at an alternate design, which we believe works better than the AQC in practice.

2 Overview of the AQC model

The salient features of an AQC are as follows:

1. The contract is between BCBS and provider organizations with primary care physicians (eg: HMOs, POS) for a period of five years.

2. Each patient that the provider organization provides primary care for, is allocated an annual budget. All health care expenses for the patient come from this annual budget, even if care is provided by a different organization. If the expenses are lower than the budget, the provider organization gets to keep the savings; if the expenses exceed the budget, the provider is liable for the extra cost.

3. To incentivize providers to take care of their patient’s health (and not optimize for the short term by denying care), they are paid an additional bonus of up to 10% if they hit certain health quality measures for their patients.

4. The first year’s budget is determined by the patient’s prior year’s medical expenses. The rate of increase of the budget is also negotiated based on trends.

5. Patients are unaware of whether their PCPs are part of an AQC.

The goal of the AQC is to contain the ballooning costs of health care, and it plans to achieve that by making providers more “accountable” for the costs of their primary care patients. At a high-level, it appears that the AQC’s design is aligned with its goals—Ideally, the annual budgets would motivate physicians to reduce spending on unnecessary care, while the performance bonuses would motivate them to keep their patients healthy, thereby not skimping on necessary costs.

Accountable Care Organizations (ACO) are similar in concept to the AQC, and are designed for Medicare; the main difference appears to be that the provider is not liable if expenses exceed the budget, but receive rewards for reducing costs and meeting quality improvement markers.

3 Will the AQC model work in practice?

To understand the AQC model better, let us consider a simple thought experiment. Imagine that the entire healthcare system consists of Reliable Insurance Corp. (RI) and Expert Medical Center (EMC). Let us further assume that the only illness that patients acquire is backache. EMC operates in two states, A and B, with one primary care physician and five orthopedic surgeons per state (ratio consistent with current ratios of PCPs vs specialists). Assume that 1000 patients get backache each year in each state, out of which 100 need surgery, 800 can be cured in 2 weeks by getting ergonomic chairs, and the remaining 100 are the “indeterminate” group—they can either be operated on or can be cured in 2 months by getting ergonomic chairs. A new chair costs $100, whereas back surgery costs $10K, of which $5K goes to the surgeon and $5K to EMC.

Now, to keep the example simple, assume that all orthopedic surgeons in state A recommend chairs for the patients in the indeterminate group, whereas surgeons in state B recommend surgery. Correspondingly, EMC has over the years built enough facilities to accommodate 100 surgeries in state A and 200 surgeries in state B. Thus, the total annual healthcare costs for the entire system are $3.17M, out of which $990K could be saved with no change in outcome.
Let us say RI wants to realize these savings by entering into an AQC with EMC. Would it succeed? Let us look at it from each party’s perspective. (here we assume that all parties are rational and that earned income is the motivating factor):

1. Will EMC be motivated to enter into a contract? If so, at what annual budget? Since EMC already built the facilities needed for doing 300 surgeries per year, it cannot forgo the $500K it gets for the 100 surgeries in the indeterminate group. So, it needs the annual budget to be at least $2.18M + $500K = $2.68M

2. Will the orthopedic surgeons agree to enter into the contract? If so, at what budget? The orthopedic surgeons in state B lose half their income if surgery is not done on the indeterminate patients. So, they would resist the AQC, unless their $500K of salaries is incorporated into the budget and EMC assures them that their income will not be adversely affected.

3. Will the primary care physicians want to enter into the contract? In this example, PCPs won’t see any difference to their income levels and so would be fine entering the contract. However, they may ask for additional perks to “sweeten” the deal.

4. Will RI be able to realize these savings by entering into an AQC with EMC? From the above analysis, we see that in practice, RI will not be able to realize the savings. In fact, it may cost RI more, due to the administrative overheads, and because each of the other parties may expect perks for the inconvenience of getting involved in the contract.

The above example is arguably simple, but gives a flavor of the challenges involved in implementing AQC. We believe that the points made above would hold in real world scenarios. Consider the following examples:

• It is widely agreed that there is 30% waste in the system. However, the current AQC contracts that BCBS entered into start above the current spending levels. This seems to be tacit acknowledgement that this waste cannot be recovered.

• In addition, it appears that BCBS “has offered physician groups and hospitals sky-high reimbursement rates to persuade them to sign up for a new type of health care plan," which contributed to its loss in 2009.

• Some ACO providers in Medicare “want to avoid being financially responsible for patients who go outside for care”, they want to be able to “pick and choose” patients, or have asked “to limit quality measures” [2]. All of these point to providers trying hard to protect their income sources.

The above trends validate our simple thought experiment. The take-away point is that one man’s expense is another man’s income. In other words, the waste in the health care system is income to a significant portion of the providers, and it is natural that they will only enter into contracts (or try to mold the contracts so) that their income is not jeopardized. This would run against the grain of efforts to reduce waste in the system.

There are two other issues with the AQC, which we briefly discuss below:

1. The AQC, as it is currently structured, is more of a risk-transfer mechanism from the insurance provider to the care providers. This makes the provider organizations more like insurance companies. This means that they get more complicated and they need finance/insurance personnel who can negotiate AQC contracts, purchase reinsurance, manage budgets etc., This increases the already high administrative costs in hospitals. More importantly, this further detracts hospitals and doctors from their primary job—practicing good medicine.

2. Another key issue with the AQC is the glaring lack of any role for the patient in it. The fact that the AQC participation of PCPs is hidden from patients can make them distrustful of their PCPs and the AQC model, and lead to perceptions that care would be withheld from them.

The above fundamental issues can jeopardize the success of AQC in achieving its goals, and instead result in a more expensive and more complex system, with more dissatisfaction and distrust among the different parties. Given these limitations of AQC, we believe it would have a difficult time succeeding in its current form, regardless of the allocation of resources among care providers.

4 Is there an alternative?

The AQC suffers from poor system design (as does the rest of the healthcare system), as it does not account for human behavior. Given that the current health care system is a supply-driven market, it is rather difficult to negotiate with the suppliers to agree to restrict supply, unless they are promised no reduction in profits. This fundamental conflict works against the AQC/ACO model’s goal to reduce waste.

So, what is the alternative? We look to the end user/patient for a solution — one whom the AQC model ignores. We feel that the end user is likely the only party with enough wherewithal to provide the required counterbalance to excessive supply — after all, the entire system exists for the end user. But for that to happen, we need to have informed patients who have a basic understanding of healthy living, understand how to navigate the health care system, and have the confidence to not blindly go along with whatever their doctor recommends. Let’s go through the above thought experiment again with informed patients in the mix.

Imagine that our informed patients have full knowledge of all the past procedures done by the orthopedists. It would be apparent to them that the outcomes of treatments by all the orthopedists is the same, but that orthopedists in state A do fewer percentage of surgeries than those in state B. Also, our knowledgeable patients understand that surgery can have long-term ill-effects. So, when a patient is recommended surgery by a orthopedist from state B, she would solicit a second opinion from an orthopedist from state A. If the opinion differs, she may (i) ask her original orthopedist for the reason for difference in opinion, and/or (ii) use an ergonomic chair for 2 months to see whether her condition improves. Once enough number of patients realize that they can be cured without surgery, the orthopedists in state B would be “pressured by the market and the cause of science” to revise their treatment procedure, to avoid falling out of favor of their customers (or worse to avoid getting sued). This leads to much better outcome than RI trying to negotiate an AQC with EMC. Note that the care providers are still paid on a fee-for-service basis.

So, how can RI get its users to be more informed? Here’s one potential design: RI can encourage the formation of a health advisor organization, whose sole charter is to guide consumers through the health care process and keep them healthy. RI can compensate the health advisor with a minimal fixed fee per user and tie the majority of compensation to the health care savings of its users (with compensation spread over several years and weighted by the health of its users to avoid short term optimizations). A health advisor itself does not perform any procedure and does not offer medical advice. Its users are not bound to take procedural advice it offers—the only leverage it has with its users is mutual trust. Also, to avoid conflict of interest, it cannot obtain revenue from any other sources. Given these constraints, the health advisor can only increase its revenue by (i) chasing down major waste in the system (ii) finding ways to mitigate this waste while maintaining user health (or even better, improving it, as in the case of avoided surgeries) (iii) gaining user trust, and (iv) convincing them to do things that are good for their health, which also happen to reduce waste. We can imagine several ways in which the health advisor organization can do this (collect effectiveness metrics on healthcare providers; gather scientific studies on effectiveness of various procedures; suggest users take second opinions; run ads to convince customers to practice prevention; build health IT systems to take care of customers—reminders for pills, for appointments, preventive care etc.,) If we reflect on the the above thought experiment again, it is easy to see how these steps of a health advisor would map to the actions of informed patients.

If the guidance of health advisors convinces customers to reduce consumption of health care services, that acts as a market signal to providers to throttle expansion of unnecessary services, achieving the desired result of reducing waste.

5 Concluding remarks

In this essay we analyzed AQC, a global payments proposal to contain health care costs, and show that its design suffers from a fundamental challenge — convincing suppliers in a supply-driven market to reduce their revenues. We outlined an alternate consumer-centric mechanism that instead focuses on educating and guiding consumers on how to be healthy, while at the same time reducing consumption of unnecessary medical care, thereby reducing demand. We believe that a consumer-driven approach provides the right counterbalance to the supply glut. The limited size of this essay does not permit a more detailed discussion of this approach, and the rationale behind the arguments against current approaches; however, we end with a
note on the wider applicability of the consumer-driven approach, by pointing out how it applies to the Indian healthcare scenario. The health care system in India is also increasingly suffering from a supply-driven approach. Modern hospitals are outfitted with expensive equipment, and doctors are prone to prescribing procedures to put this equipment to use. Furthermore, the fee-for-service approach leads to more focus on treatment than on prevention. Patients are typically timid, rarely question their doctor’s analyses, and do not generally seek second opinion. All this, even though most patients pay for their medical expenses out of their own pocket. We believe that a health advisor organization, as proposed above, would also work well in that scenario.

JetBlue's Dave in the air

2011-03-04T14:23:00.000-08:00

Back in April, 2008, I wrote about JetBlue's use of homesourcing:

The idea is simple and elegant. For some staff functions, those relying mainly on computers and telephone, why not allow people to work from home and avoid the mess of commuting? Also, people who are otherwise tied to home for physical or family reasons can be active members of the workforce and get better jobs if they are permitted to work from home.

We tried a variant of this at our hospital, and while it could not be expanded to the full extent of the reservations assistants at Jet Blue, the concept showed some promise for the health care sector.

Anyway, because of this and other things, I had always admired Dave Barger, JetBlue's President and CEO. What a pleasure, therefore, to run into him on a flight earlier today and have a chance to extend my appreciation in person.

Based on my conversations with the staff, he is very well regarded as a CEO, displaying a real concern and affection for the people who work in all capacities in the firm, and joining in to help out as a flight progresses and on the ground. You see him here with Kiwi flight attendant James Harbour.

Update from Cape Verde

2011-03-04T08:07:00.000-08:00

You may recall a post from November, in which I described a mission from BIDMC to Cape Verde. Well, I had the story a bit backwards. I thought it was initiated by the doctor, but the impetus actually came from one of our interpreters. In any event, these wonderful people together did good for the community. It is a lovely story.

Here's a video update. If you can't see the video, click here.

Time for the wisdom of the crowd

2011-03-03T06:25:00.000-08:00

On the post below, "nonlocal MD," a regular contributor, asks:

I would next like to see a series on how you think all this could be done better, perhaps drawing on your international experiences.

And Barry Carol says:

As I understand it, the German population is generally satisfied with their healthcare and health insurance system. However, people can opt out and access more comprehensive private insurance if they want to and can afford to. About 10% of the population chooses the private system. One way or another, the wealthy and upper middle class will always be able to trade up creating, in effect, a two tier system. Personally, I don’t have any problem with that as long as what’s available to the bulk of the population is widely perceived as “good enough.”

Here is my reply, to you and to her:

Dear nonlocal,

It is not a question of doing better: It is the political imperative at work. My purpose in writing about all this was to describe the natural sequence of events.

As Barry suggests, people are generally content with this kind of system. The broad base of the population, the voters, gets security and a plan that is "good enough." The wealthy buy the "upper tier" plan.

It's the same as coach and first class on airplanes; Ford and Lexus in cars; McDonald's and luxury restaurants.

For years, we have rationed primary care in the US based on income. Now, like Europe, it will be reversed: We will ration high-end care based on income.

An underlying problem remains: There is little about the new order here in the US nor the European system that has dealt with the need to improve quality, safety, transparency, and promote continuous process improvement. And so demographic cost pressures will continue to build on both sides of the Atlantic. Governments and other payers will try to use the hammer of rates and regulatory changes to accomplish the kind of process improvement that can truly create better value for the population. That will fail. Those changes should come from the medical profession, but that profession has been recalcitrant and engaged in denial. We have seen that over and over: "The data are wrong" or "Our patients are sicker."

Changes are most likely to come as a result of strong advocacy from patients who are more and more empowered because of the internet and social media. In health care, the future is Egypt -- if and when the patient advocacy community gets its act together.

Places like Institute for Healthcare Improvement and the Joint Commission will finally succeed at their jobs when they facilitate the engagement of those thousands of people throughout the country. But you can not "own" those individuals or prescribe the approach that should be taken: You have to cede control of the agenda to let the wisdom of the crowd come through.

Paying more for the amenities you may never need

2011-03-03T02:53:00.000-08:00

Let's continue our discussion about the future of employer-based insurance products in the US. We have talked about a general shift of employer-based plans to insurance exchanges and Medicaid; about a shift of retiree health benefits away from employer-based plans; and a move to reallocate risk away from insurance companies and towards doctors and consumers. What's left?

Well, as the commercial insurance pool shrinks and as subsidies for government-chartered or government-paid insurance products diminish, the norm for the general public will be a "dumbed down," lowest common denominator kind of insurance. With accountable care organizations and a move to bundled or capitated payments, limited networks will come into play. Deductibles and co-pays will rise to discourage people from using health care services. Likewise, if you choose to go out of network for your care, you will see higher personal charges.

But the potential for market segmentation never disappears. What will you do if you are an employer who wants to retain an insurance plan to attract workers in competitive fields? The answer may be to provide your staff with a "privileged access product," something that we have seen in Europe. (There, government-sponsored insurance can leave out a lot of items that are routine in the US, and rationing by congestion of high-end services is more commonplace.) The idea of this kind of privileged access product is to address the insecurities that people of means may have about the new environment. They want to assure themselves rapid access to the services they want, including the latest technological advances. They also want extra amenities like private rooms and other concierge type services.

It is a recognized phenomenon that people, especially people of means, are willing to pay more for amenities they may never need. So, look for such high-end specialized product offerings, especially in companies where well-paid workers in demand by competing firms represent a significant share of the workforce.

So, when you put this all together, we will likely see a move towards a more egalitarian (government provided or government-influenced) offering of insurance products for the majority of the workforce, combined with a less egalitarian offering of premium services for those with higher incomes. As I suggested years ago and reiterated last year, expect a convergence of the US and European models:

I predict . . . that the systems will start to look more and more alike over time. Pressure in the US for a more nationally-determined approach. Pressure in Europe for more of a private market approach. It shouldn't surprise us to see this convergence. After all, the countries are dealing with the same organisms, both biologically and politically.

Latke vs. Hamentashen, The Great Debate

2011-03-02T06:29:00.000-08:00

There's serious work that goes on at MIT. And then, thankfully, there is not.

A debate was held to determine which is superior among two traditional Jewish foods: The latke (a potato pancake served during Hanukah) or the hamentashen (a prune-, poppy seed-, or apricot-filled triangular pastry).

(Wow, you should have seen what the Blogger spell-check suggested for some of the words in that sentence! Latte, larked, Hank, lamentation, fomentation, emendation, among others.)

Back to the debate. Six of the world's greatest scientists joined Rabbi Michelle Fisher, executive director of the MIT Hillel, to offer their "proofs" that their assigned food was superior to the other. It was heartening to see the degree to which academic credentials and principles of scientific discovery were applied to this high purpose. One participant was Robert Weinberg (Course 7*), a Founding Member of the Whitehead Institute, and a pioneer in cancer research most widely known for his discoveries of the first human oncogene — a gene that causes normal cells to form tumors — and the first tumor suppressor gene. "Trust me, I am an expert," he noted. When facts faltered, character assassination was brought to bear. Said Weinberg of the other side: "Remember, in debates like this your opponents' motives are ultimately vastly more important than the arguments they make."

The other participants on Team Latke were Sanjay Sarma (Course 2) and Allan Adams (8). Team Hamentashen comprised Steve Wasserman (20), Shaoul Ezekial (16), and M. Fatih Yaniak (20).

A secret ballot was held at the end. Not a paper ballot. Audience members promised to bend their heads down and look at the floor as Rabbi Fisher asked people to yell, first, if they liked latkes, and, then, if they liked hamentashen. You can see the result in the video below.

A reception followed the debate, with samples of both treats.

If you cannot see the video, click here.

--
* Unlike other colleges, MIT departments are called "Courses." Courses are called "classes." All Courses have an English name, of course, but are usually known by their number. To make it trickier, the designations have changed over the decades.

Power -- er no, risk -- to the people!

2011-03-02T03:10:00.000-08:00

What will be the biggest trend in the health insurance business over the coming years? A tendency to shift risk from the insurance companies to the public.

How fitting for a sector that was created to manage risk to do this.

Why is it happening? Even before the recent health care legislation in the US, insurance companies were looking for a way to shift the rising cost of medical care to others.

This trend will grow because of provisions in the new law for benefit mandates, floors on medical loss ratios, guaranteed issue, and medical underwriting represent a challenge for payer balance sheets. Insurers will want to shift those risks away.

And -- as we have discussed -- so will employers, who will want to shift their insurance obligation for current employees and retirees to others.

Who's left? Ironically, it is the participants in the health care marketplace who are most unsuited to bear risk -- individual doctors and consumers. This will come in the form of global payments, higher deductibles, and higher co-pays.

These will be portrayed as means to greater efficiency and consumer-directed health care. And perhaps they are. But they are also a veneer that hides the fact that a large portion of the actuarial risk of care will be shifted to individuals. The insurance industry was designed with reserve requirements and a capital structure that acted as a shock absorber for the vicissitudes of risk. Consumers and doctors do not have that back-up.

Alan MacDonald, head of the MA Business Roundtable, makes this shift clear in a discussion about Governor Patrick's proposed legislation:

Up until now, where the insurer in the health plans accepts the risk of making sure the payment is there to cover the expenses. When we have a global payment, a payment is made to the organization, and that accountable care organization is responsible for the care. They've received the payment already, and so the risk is that more care is required than is covered by the global payment, so they would have to have a reserve to take care of that. (Dig Boston, Volume 13, Issue 8). Emphasis added.

There has been no talk of reducing the capital requirements of insurance companies in return for this shift in obligation to individuals. Are they going to be permitted to maintain large capital reserves, on which they earn money, while their liabilities diminish? Who will ensure that the savings that insurers gain from these changes will be passed through in lower rates to consumers?

On a lighter note, comedian Brian Donnelly is quoted in the same newspaper -- perhaps displaying greater insight that he knows:

I've been looking at the new health care proposal and I'm not sure what's going on. Most of it feels like that part in the "Star-Spangled Banner" where no one knows what it is and you sort of mumble through. I feel like there could be magic involved.

Spreading knowledge that matters

2011-03-01T08:15:00.000-08:00

Back in January, I wrote about a great example of a locally produced, informative and engaging newsletter produced by Samantha Riley, Head of the Quality Observatory at NHS South East Coast, and her colleagues. The latest edition has just been published.

There is a nice article by Roger Halliday about self care, with the following introduction:

When people take an active role in managing their health, this tends to lead to them having better health, better experience of care and using fewer healthcare services. This finding seems intuitive and indeed is backed up by a significant body of research. The challenge is how to make this happen. If you are struggling with this challenge, this product may be something to help.

This free to use product gives local commissioners the likely demand for, costs, cost savings and patient benefits of self care education, tailored for their area. It makes the business case for you and indicates the best value spend on this theme given local circumstances. It uses the latest national and international research combined with local data, though you can change the assumptions to explore options.

Again, I offer it as an example of the good work that can come out of a dedicated cadre of people seeking to improve the quality of care and the work environment at a hospital.

Shifting retiree health benefits

2011-02-28T19:50:00.000-08:00

In a post below, I discuss the possibility that the new health care law many entice many employers to drop their company-provided health insurance plans and send their staff over to one of the new health insurance exchanges or Medicaid. Such a strategy, I noted, depends on a firm reaching a conclusion that having company-sponsored health insurance is not important to attract and retain workers.

But there is a group of people who are served by company-provided insurance whose competitive employment choices are no longer of any concern to the firm: Retirees.

Post-employment health benefits are an expensive drag for many companies. Even if the full provision of health insurance ends upon Medicare eligibility, there is the cost of covering retirees during an intervening period. This could easily be 10 years or more, since people can often retire in their mid-50s.

Hewitt Associates seems to be on top of this trend. The company conducted a survey last year of 245 U.S. companies that offer medical benefits to 1.3 million retirees and their families and "learned that six out of ten employers intend to evaluate their long-term retiree medical benefits strategy in the near future, and nearly half of these companies have already begun the evaluation process."

Look at this finding:

While the second option seems more drastic, the first option is intriguing because it still allows a company to gain financial stability with regard to the retiree health care costs. You set an annual amount that you are prepared to spend per person and let the former employees go shopping. Nothing says you have to increase that amount each year, or, if you do increase it, nothing says that you have to do so at the rate of inflation of health care costs. This could remove a huge liability from the balance sheet of many corporations and transfer the risk of future cost increases to the former employees.

A counterbalance focused on quality

2011-02-27T16:20:00.000-08:00

Ascension Health, the largest chain of Catholic hospitals, has joined forces with Oak Hill Capital Partners, a private equity firm, "to form Ascension Health Care Network (AHCN), a joint venture that will provide an alternative funding source for the acquisition of Catholic hospitals and other healthcare provider entities. AHCN will offer these entities access to financial, operational and clinical resources."

Ascension Health is renowned for its quality and safety programs and also its commitment to the efficient and profitable operation of the hospitals in its non-profit network. Further, Ascension operates under a distributed leadership model, designed to ensure a strong local presence in all communities that are served by the national system.

The announcement is short on details as to how the business arrangement between a non-profit chain and a private equity firm will work. But this move seems to be a direct challenge to other private equity firms with little or no hospital experience. Ascension seems to be saying to hospitals in distress: "Before you sell out to someone with no track record and no demonstrated commitment to the long run, call us."

Gentlemen, start your engines . . . .

Come on in any time!

2011-02-27T08:40:00.000-08:00

Winchester Hospital, a 229-bed facility just north of Boston, has announced that it has eliminated defined visiting hours, effective immediately. With some exceptions -- operating rooms and for clinical reasons including infection concerns for the patient or visitor, safety, clinical care and interventions, or if the patient needs rest -- people visiting patients can do so whenever they wish. "We recognize the value of emotional support during the healing process," said Kathy Schuler, vice president of patient care services and chief nursing officer at Winchester Hospital. "We hope this new policy will benefit all patients."

This is good stuff and a nice contrast to the story below. It would be interesting to know whether the initiative was driven by the staff or whether it came out of consultation with a formal patient advisory council. At BIDMC, it was the latter, as described here, after our ICU Patient and Family Advisory Council suggested to the MDs and RNs that it would help accommodate family members who work late and allow loved ones to visit at their convenience, rather than at ours.

No way to run a hospital

2011-02-27T06:05:00.000-08:00

A friend reports on her recent experience in a New York City hospital, where her husband was undergoing a hernia repair.

They were about as un-user friendly as one could be. They called 5 times to tell him to come in between yesterday and today, all the time seeming to change the information. They gave him the wrong pick-up info to give me, so when I came up the K elevators to an empty reception area, I only figured it out by barging into the patient bay area where there was a lone nurse at the station. She told me to go back down and come up the A elevators. When I did, I couldn't find the recovery area (no signs) and had to ask somebody at the blood bank window, who pointed me to the right doors -- which were locked. You couldn't open them by pushing on the door release button and nobody answered the intercom.

So I called Sam on his cell phone, and he gave me to a nurse who couldn't seem to understand the problem: "The door is locked, can you please have some one let us in?" (There was another woman there trying to pick someone up by then.) "We're very busy right now." So we got in because some staff person opened the door with a card key and let us in, too. (He probably shouldn't have: How did he know who we were?). I felt badly for the other woman because she was old with a cane. The nurses couldn't seem to focus on talking to her, whereas they were suddenly wanting to help me.

And the elevators barely work and were crowded as hell. If we had put Sam in a wheelchair like they suggested, I think we would still be there. Of course he was walking slowly, having just had his abdomen repaired, so I basically had to body-check the elevator doors (and they were brutal) to get him in.

ObamaCare Shift

2011-02-25T03:16:00.000-08:00

A colleague pointed this out to me recently, and I think he has it right: While more people will have health insurance as a result of the federal health care reform act, a side effect will be to reduce the number of people insured through the employer-based insurance plans that have characterized the US health care system. These people will either be insured as individuals through the state exchanges that are to be established or, if eligible, through Medicaid. There are three aspects of economic hydraulics that are likely to lead to this result.

First, the penalty to be assessed against employers for not offering coverage -- $2000 per year -- is dramatically below the cost of providing insurance. If you are an employer and can save, say, $5,000 by paying $2,000, why wouldn’t you do that? And the $2000 is not even indexed to inflation, while the annual charge for an employer-sponsored plan is likely to go up over time. Hence the differential will grow every year.

In the past, the provision of a health care benefit was viewed as competitive factor in hiring and retaining a firm's work force. But for the vast majority of businesses, that may be a less important factor than saving a few thousand dollars per employee and being able to offer a portion of those savings in higher wages and/or improving the profitability of the firm. Sure, some businesses might still want to attract workers by having their own semi-customized insurance benefit, but the power of that is likely to diminish over time.

A second factor is that the so-called “Cadillac” tax will make employer-sponsored health care even more expensive if you have a plan with generous benefits. Health coverage in excess of $10,200 for individual plans and $27,500 for family plans will be hit with a 40 percent excise tax on the amount in excess of the floor. The tax is indexed for inflation plus 1 percent.

Finally, to help avoid the excise tax, employers are going to “dumb down” plan designs by raising deductibles and co-pays. As they do so, the substantive difference between their own plans and the ones that will be offered through state exchanges or Medicaid will diminish. Even if you have a residual concern that your workers may want an employer-based plan, their desire might be diminished as you make your plan less attractive, so you lose little in competitiveness by referring them to the non-employer based plans.

There are those who believe that there was an ideological basis for this construct, that the Administration and a majority of Congress wanted people to move away from employer-based health insurance as part of an eventual movement to a federally chartered single-payer regime. Others say that it is just a natural extension of a bill that created important protections -- benefit mandates, a floor for medical loss ratios, guaranteed issue, restrictions on medical underwriting -- all of which act to increase the cost of insurance products.

Whatever the reason, we should expect that the world of employer-based health insurance that was created in the 1940s in the United States will rather rapidly move away from that system to one in which government-controlled insurance exchanges and direct government pay (Medicare and Medicaid) will rule. On the latter point, I have have now heard a couple of people estimate that the percentage of the US population covered by government payers can be expected to rise from the current mid-30s% to about 50% over the coming five years or so, abetted by the factors mentioned above but also by expanded income eligibility for Medicaid.

Snake oil, still available

2011-02-24T11:04:00.000-08:00

While many in the health care industry are betting their strategic plan on some combination of accountable care organizations, limited networks, and global payments, there is clearly a segment that is going the other way. These are hospitals that seem to be betting on the discretionary, luxury market for care, and especially cancer care.

These hospitals advertise to a national audience in media of general circulation. I saw a few recently in an airline magazine.

What is striking about some is the modern equivalent of snake oil that they are peddling. Preying on the fear of cancer, their verbiage and offer of amenities overshadows the fact that their proposed combination of therapies has no proven efficacy greater than that found in oncology centers in communities throughout the world.

Here’s one. I am NOT making this up.

Built in Accordance with Nature

Built to Outsmart Cancer

Vastu, the ancient Indian science of architecture and building, works in accordance with the natural laws of the universe – Earth, Water, Air, Fire, and Space. A building designed to Vastu standards ensures that these elements exists harmoniously, which in turn balances the energy of the building itself. A Vastu designed building, therefore, positively affects the overall well-being of all who enter.

…[W]e are able to provide what no other cancer center in the world can offer – a healing atmosphere for any and all ailments while enhancing the spiritual, emotional, and mental aspects of the human being.

(After more of this, we find a list of services offered. Like a midrange restaurant that is trying to make its menu appear to be haute cuisine, they use capital letters on normal words to give the appearance of something special. I am especially taken with “Clinical Lab with Pathology”!)

Medical Oncology • Hematology • Radiation Oncology (Including the World’s Most Advanced Robotic Radio Surgery, The CyberKnife™ • Surgical Oncology • State-of-the-Art Imaging & Radiology, Including PET/CT, CT, MRI, Digital Mammography & Nuclear Medicine • Dedicated breast center with Genetic Counseling • Clinical Lab with Pathology • Mind & Body Medicine • Naturopathy • Skin Cancer and Dermatology Center • Clinical Research

We can laugh at this, but it feels obscene when there remain millions of people without access to health care. It also feels obscene when there is so much work to be done on reducing waste and improving the quality and safety of care in clinical settings.

This is not a revolution in North Africa

2011-02-23T19:17:00.000-08:00

I have discussed the futility and absurdity of not permitting staff in hospitals to have access to social media like Facebook, but let us now consider the cruelty of not permitting patients and families to have access to it on the public wireless network that is made available to them. Such is apparently the case in this pediatric setting: "[T]he hospital network has decided I can’t get on Facebook anymore." Earth to hospital administrators: This is not a revolutionary setting in North Africa.

Orthogonal, towards MIT

2011-02-23T17:14:00.000-08:00

Walking along the Charles River on the Cambridge side late this afternoon, I glanced southeast towards Boston across the river and was blinded by the glare of sunlight reflecting off the ice. How can the setting sun attack from the southeast?!

The riddle is solved when you see that the stainless steel roof structure and/or windows at 111 Huntington Avenue had caught the rays of the setting sun from the southwest (see shadow on the buoy in the river) and reflected them at a right angle towards MIT.

Rick Gilfillan on WIHI

2011-02-23T10:34:00.000-08:00

The Newest Innovator on the Block: Center for Medicare and Medicaid Innovation
Thursday, February 24, 2011, 2:00 PM – 3:00 PM Eastern Time

Guest:
Rick Gilfillan, MD, Acting Director, Center for Medicare and Medicaid Innovation

Health reform in the US has a lot of moving parts, and sometimes it’s difficult to sort out the political ups and downs from the on-the-ground changes and challenges facing those in the trenches, seeking to make health care delivery safer, more patient-centered, better coordinated, and cost effective. As WIHI tries to keep its eye on the ball of innovation and new designs so badly needed to pave the way, it’s a sincere pleasure to welcome to the program the man behind the country’s first-ever government center dedicated solely to figuring out what works...and what could be spread widely.

Dr. Rick Gilfillan, the Acting Director of the Innovation Center at CMS, has a track record of thinking outside the box. He helped design a bundled payment system – coupled with a guarantee of quality care – for the Geisinger Health System in Pennsylvania, long before others were willing to take the notion seriously. Now Dr. Gilfillan is working hard with his staff in Washington to roll out opportunities for others to tell him, and to tell the country, about other payment models that are needed for health care. What’s the accountable care organization (ACO) model that’s good for patients as well as the bottom line? Where are providers walking the talk of the Patient-Centered Medical Home and reinventing primary care?

Join WIHI host Madge Kaplan to get the latest from Dr. Gilfillan about the Innovation Center’s plans, priorities, and programs that will enable health care providers to test new ways of delivering care and sharing the learning more broadly. There will be plenty of time for your questions and comments and we look forward to your participation!

To enroll, please click here.

Expand and acquire to prepare for the IPO

2011-02-23T02:53:00.000-08:00

Today's story that Cerberus Capital Management has offered to buy the financially troubled Jackson Health System in Florida is consistent with an own-it-flip-it approach to investment in hospitals. Part of the business strategy is to create an organization with a larger revenue stream for when it comes time for the initial public offering in a few years. This simply creates a greater sales multiple when the IPO occurs. As we have seen in other sectors in the economy, this phenomenon is remarkably independent of the actual sustainability of the business as an operating entity in the long run. Capital markets flock to size during an IPO.

This is the same strategy being employed by Vanguard Health Systems in buying the financially troubled Detroit Medical Center. Each deal is likely to be highly leveraged, and as long as the cash flow from Jackson/DMC is positive for a few years, the strategy has the potential to yield an excellent return to the investors in the private equity fund.

By the way, you wonder why the newspaper doesn't check its own recent story on Cerberus to make sure it gets its fact right. Today's story says:

Cerberus . . . spent $895 million to buy the Caritas hospitals, including St. Elizabeth’s Medical Center in Brighton and Carney Hospital in Dorchester. As part of the deal, Cerberus agreed to assume $260 million in pension liabilities for workers and pledged to spend $400 million on new emergency rooms and surgery wards.

The one from two weeks ago, however, reports:

Cerberus paid $495 million for the Caritas system, a sum that funded its pensions and retired most of its outstanding debt. It also committed to pumping another $400 million in capital improvements into the system over the next four years, although de la Torre acknowledges that those funds may come from hospital revenues in coming years, rather than from Cerberus itself.

The dummies' guide to The Joint Commission

2011-02-22T12:44:00.000-08:00

I received an email advertisement, and it left me saddened. It is for a book entitled The Joint Commission Survey Coordinator's Handbook. This was the text of the email:

Packed with expert advice, best practices, and sample tools and tracers, this book saves you from having to research and manage Joint Commission accreditation activities on your own.

Now in its 12th edition, this fully updated book by Laure L. Dudley, RN, MS, interprets The Joint Commission’s standards in practical, straightforward language that removes the guesswork for you. Discover what has changed in the past year, what you need to know about the standards, and what you need to do to comply.

So, I figured that this was the dummies' guide to the Joint Commission's standards. I was saddened to think that those standards are so abstruse that there is a need to translate them into "practical, straightforward language."

Then, I clicked on the book's image in the email and was taken to the real advertisement. Upon further review, I figured out that the book is not the dummies' guide only for hospital folk who are about to be surveyed by the Joint Commission. It is as much a guide for the surveyors themselves! The ad includes the following in addition to the text above:

Benefits:

Find answers to all of your Joint Commission questions in one resource
Remove the guesswork and hunting for the latest Joint Commission changes
Gain confidence in your role as survey coordinator
Become an effective communicator with staff and leadership

What’s new:

Joint Commission Standards and CMS: Much has changed in the Joint Commission standards following the organization’s deemed status application. Find out how this affects survey preparation as The Joint Commission aligns closer to the CMS Conditions of Participation.
The clarification process: One of the most nerve-wracking components of a Joint Commission survey is clarifying requirements for improvement. Find tips and suggestions for getting the most out of your clarification process.
Insider perspective: This year the Handbook is written by a former Joint Commission employee and contains guest commentary by several other former staff, offering readers a distinct insider’s perspective.
Updated Life Safety Code® for the non-engineer: Written by safety expert Brad Keyes, CHSP, discover how the Life Safety Code® is accessible to survey coordinators and other non-engineers.

I don't know if the book is an officially authorized publication of The Joint Commission. That point is blurred a bit, as there is an endorsement in the advertisement from someone putting herself forward as a surveyor. If it is authorized, it should say so. If it is not, it does not seem appropriate for a JC employee or contractor to endorse a publication by a third party.

Beyond this point, though, what does it say about hospital accreditation standards if there is a need for them to be translated or interpreted in this manner? What does it say about the training of surveyors if they need CliffNotes to do their job confidently?

Maybe this is just a clever company trying to make money from both hospital safety and quality folks and from JC surveyors. On the other hand, it is the 12th edition, so the book seems to have some staying power. And the author is a former executive director of The Joint Commission.

For years, I have been proclaiming the importance and value of JC surveys, having great appreciation for the dedication and expertise of the surveyors who visited our hospital, and noting:

I have often said that, if the Joint Commission did not exist, we would want to invent it. An objective outside review of this sort is extremely helpful to a hospital as it strives to provide better and better care to the public.

Each time I said that, though, observers from other hospitals would skeptically respond by saying that the accreditation standards are often recondite at best, but also sometimes in conflict with good clinical practice. Some of that is inevitable, and I am confident the JC is involved in its own process improvement efforts on those fronts. But, wouldn't it be nice if the 12th edition of this book were the last because it just wasn't needed any more?

Shared decision making

2011-02-22T05:22:00.000-08:00

Along the lines of the video below, please read this article from the Health Affairs Blog by Jessie Gruman about shared decision making. The key excerpt is below, to which I would only add an equally important point demonstrated in the Dave-Danny case: Knowledge and information go both ways in a truly participatory process, not just from provider to patient.

It is important to have (and to promote) a step-by-step process to present us and our families with evidence that helps us understand the trade-offs of health decisions and to thus prepare for productive discussions with our physicians. And it is important to know that most individuals and physicians who go through this formal process find it feasible and satisfying.

But it is the values that this model embodies that justify the focus, energy and investments in it. Those values are that:

…Information and evidence about tests and treatments is a critical component of many health care decisions.

…Patients and caregivers can understand evidence and can use it to help them weigh their options.

…Providers can discuss available evidence – what is known, where it is lacking and what it means – with patients.

…Patients are explicitly invited to participate in the decisions about their care (even if that participation consists of delegating decision-making to a caregiver or physician).

…The opinions and preferences of patients – informed by their understanding of the evidence –shape and determine the tests they take and the treatment they undergo.

Dave and Danny on the big screen

2011-02-22T03:20:00.000-08:00

Regular readers may recall that I wrote about a grand rounds presentation by Dr. Danny Sands and e-Patient Dave deBronkart. It was an impressive and moving exposition about the power of patient involvement in the delivery of health care.

Dave and Danny did a reprise of this session at the IHI Annual Forum in December, and IHI has generously made it available for public viewing. I offer it here for you. It is about an hour long, but well worth your time. (You can play it in the background while you catch up on the long weekend's emails today!)

Danny and Dave are now both active in the Society for Participatory Medicine, spreading the word and publishing research in support of "a cooperative model of health care that encourages and expects active involvement by all connected parties (patients, caregivers, healthcare professionals, etc.) as integral to the full continuum of care."

If you cannot see the video, click here.

IHI Forum 2010 Session A1: How Patient-Provider Engagement Can Transform Healthcare from e-Patient Dave deBronkart on Vimeo.

2 kidneys versus 100,000 lives

2011-02-19T05:00:00.000-08:00

This story about a kidney transplant mix-up in California is bound to get lots of coverage. It is these extraordinary cases that get public attention. I am sure it will lead to a whole new set of national rules designed to keep such a thing from happening.

Of course, such rules already exist, and it was likely a lapse in them that led to this result.

Nonetheless, we will "bolt on" a new set of requirements that, in themselves, will likely create the possibility for yet a new form of error to occur.

This kind of coverage and response is a spin-off from the "rule of rescue" that dominates decisions about medical treatment. We find the one-off, extreme case and devote excessive energy to solving it. In the meantime, we let go untreated the fact that tens of thousands of people are killed and maimed in hospitals every year.

Those numbers are constantly disputed by the profession. To this day, many doctors do not believe the Institute of Medicine's studies that documented the number of unnecessary deaths per year.

And you never hear anyone talking about this 2010 report by the Office of the Inspector General, which concluded:

An estimated 1.5 percent of Medicare beneficiaries experienced an event that contributed to their deaths, which projects to 15,000 patients in a single month.

As the IOM notes, “Between the health care we have and the care we could have lies not just a gap, but a chasm.”

There is an underlying belief on the part of policy makers and public and private payers that the focus on quality is best addressed through payment reform. Let me state as clearly as I possibly can: That is wrong. It is a classic example of the old expression: "When you have a hammer, everything looks like a nail." Changes in payment rate structures, penalties for "never events," and the like can cause some changes to occur. Their main political advantage is that they give the impression of action, and their major financial advantage is a shift in risk from government and private payers to health care providers.

But these are gross tools and will have unintended consequences. More importantly, they do not get to the heart of the problem, the manner in which work is organized in the highly complex environment of hospitals and physician practices. This is an environment in which ineffective work-arounds -- instead of front-line driven process redesign -- are the usual answer to obstacles in patient care.

They do not address the unmet education needs of doctors-in-training, training that is a throw-back to a cottage industry in which each person is expected to be an artist, relying on his or her creativity, intuition, and experience when taking care of a patient. The resulting lack of standardization -- the high degree of practice variation -- creates an environment that is inimical to process improvement based on scientific methods.

They do not address the documented advantages of engaging patients in the design and delivery of care, nor the power that such engagement brings to both doctors and patients.

Add to this the sociology of dehumanization in medical schools documented by Linda Pololi, and you have a stewpot of well-intentioned people destined to kill and maim others.

It is up to the medical profession, not the politicians or the insurance companies, to change this. First, though, they have to be willing to acknowledge that problems exist, that the current level of harm is not a statistically irreducible amount. The need to put aside the usual responses -- "the data are wrong" -- "our patients are sicker" -- "our care is the best in the country" -- and have the intellectual modesty to recognize that the real work has just begun.

To the extent the medical profession continues to abdicate responsibility, the more will step in politicians, regulators, and payers to do it for them. If you are a doctor and already feeling a lack of control over your professional life and your relationship with your patients, just wait.

I have previously quoted experts on this field, but the most cogent imperative remains the one provided by Ethel Merman:

Now what kind of an attitude is that, 'these things happen?' They only happen because this whole country is just full of people who, when these things happen, they just say 'these things happen,' and that's why they happen! We gotta have control of what happens to us."

The infrastructure chronicles -- Volume 4

2011-02-18T11:52:00.000-08:00

Back to our occasional series about infrastructure. This one is about a part of infrastructure that, oddly, often tends to be invisible: Signage.

Designing effective signs is important. After all, if there is a need for the sign in the first place -- for safety, convenience, or efficiency -- why not post one that solves the problem? But, we often see the opposite, a sign that actually makes things worse. It is at that moment that a sign becomes invisible.

In a previous post, I presented the dangers of sign congestion in a hospital. In another, I presented an example of one from the Postal Service that provides guidance that is unhelpful because it requires a person to detect the difference between 12 ounces and 13 ounces in a letter s/he is about to mail.

Here's one that demonstrates simple clutter and a bureaucratic point of view. It is posted on the "Fare Array Hut," a small structure at many MBTA transit stops that is not designated as a "Fare Array Hut." So, to start with, you might look at the sign and say, "Where's the Fare Array Hut?"

Then, you wonder, "Do I have to validate my card in the manner set forth?" The answer is no. It does make it easier to enter the train in one of the back doors, but you can also validate upon entering through the front door.

And then, you see things on the poster that simply have no relevance for you, like "Ensure all revenue is properly collected and recorded."

By the way, it turns out I am not the first person to notice this problem. After writing this post, curiously searching Google for the term "Fare Array Hut," I came upon this post by another blogger, who nicely describes the situation.

It all comes back to cost and choice

2011-02-17T11:09:00.000-08:00

Those watching the implementation of national health care reform are advised, again, to keep an eye on Massachusetts, which began many of the same programs several years ago. As will be evident eventually at the national level, after you provide universal access to health care by creating a more broad-based insurance program, you then need to focus on two areas: cost and choice. (Remember that President Obama tried to present the case that access, lower costs, and choice were mutually consistent public policy goals. 'Taint so. Eventually, you have to deal with the other two to have a sustainable solution.)

Governor Deval Patrick today offered his legislative proposals in this arena. The key elements are control over provider rates; encouragement for capitation and bundled payment regimes; creation of integrated delivery systems; and transparency of prices and medical outcomes.

I was especially intrigued with the rate-setting aspect of his plan. For some time, I have been suggesting that a return to administrative rate-setting for rates paid to hospitals and doctors was inevitable in a state in which market power had for so long dominated the methodology for establishing those rates. This has been mightily opposed by most industry observers. My point was that rate-setting already existed, but it was in the hands of unaccountable insurance companies.

So the Governor now proposes rate-setting, admittedly through the back door, but substantively so in any event. How will it work? We will not appear to regulate rates paid to providers, except that an insurance company's premiums will not be approved unless the underlying rates paid to providers meet certain conditions. Here's the relevant excerpt from the press release:

This legislation clarifies the [Insurance] Commissioner’s authority to reject premium increases where the underlying provider rates are excessive. Specifically, the Commissioner may disapprove rates that contain provider increases inconsistent with the following criteria:

The rate of increase in the state’s Gross Domestic Product;
The rate of increase in total medical expenses in the region as reported by the Division of Health Care Finance and Policy;
A provider’s rate of reimbursement with a carrier, especially in relation to the carrier’s statewide average relative price;
Whether the carrier and a contracting provider are transitioning from a fee-for-service contract to an alternative payment contract.

So, whether you call it six of one or half a dozen of another, we are back to rate-setting.

On the choice front, the Governor adopts the religious dogma of pricing discussed here earlier, stating that "the existing fee-for-service payment system is outdated in the medical field." He apparently understands that doing so is inconsistent with consumer choice and thus he "encourages the formation of integrated care organizations (commonly referred to as Accountable Care Organizations or 'ACOs')". As discussed in the last two paragraphs of this post, insurers and providers better tread carefully here. Unless consumers are confident of getting the same or better quality of care from the restricted network serving them, there will be extreme negative feedback in the future. Transparency of outcomes will definitely help, but the power of habit and reputation is long-lasting.

So congratulations to the Governor for taking steps that are consistent with the state's policy of universal access. The key to legislative adoption of these proposals, unfortunately, is likely to be an attempt to minimize discussion of what they would mean for individuals and families, and for doctors and hospitals. Otherwise, they will be viewed as bitter medicine, even if they are in the service of an overall policy objective -- universal access -- that is clearly the right direction.

MIT Sloan BioInnovations Conference 2011

2011-02-17T08:40:00.000-08:00

Here's an interesting conference in a couple of weeks, offered by the MIT Sloan Healthcare Club, for those of you in the Boston area:

The 8th Annual MIT Sloan BioInnovations Conference, taking place on March 4th at 8:30 A.M in the Boston Marriott Cambridge, brings together thought leaders from industry and academia to discuss important topics applicable across the health care industries.

Steve Rusckowski, CEO of Philips Healthcare, and Peter Hecht, CEO of Ironwood Pharmaceuticals will deliver keynote speeches in addition to our panel discussions about the challenges of regulatory uncertainty and R&D productivity as well as the opportunities of next generation technologies and emerging markets. Our panelists come from the top companies across pharma, biotech, medical devices and support services including Pfizer, Genentech, Merck and Genzyme, and innovative emerging firms like SmartCell and AMAG Pharma.

This year's BioInnovations conference promises to be an insightful discussion on the topics at the center of health care.

For full details on panel speakers and to register, click here.

Is this part of the death of trust?

2011-02-16T14:41:00.000-08:00

A short time ago, I wrote with concern about the blurred boundaries between news and opinion in the lead stories of major newspapers. I did not think I would have to worry about blurred boundaries between front page stories and advertising, but this front page story in the New York Times has me wondering.

The story is about Bernard Madoff and statements he has made from his jail cell. It is strange enough that the Times would give upper right hand front page placement to comments made by Mr. Madoff. As the story notes after the page turn: "Mr. Madoff’s claims must be weighed against his tenuous credibility."

But beyond that judgment about newsworthiness, note this paragraph on the front page:

Both the interview and the e-mail correspondence were conducted as part of this reporter’s research for a coming book on the Madoff scandal, “The Wizard of Lies: Bernie Madoff and the Death of Trust,” for publication this spring by Times Books, a division of Henry Holt & Company.

Did we just see a commercial posing as part of a news story? First, who cares if the interview was conducted as part of research for a book? The interview rises or falls on its own. Second, why is the full name of the book given, along with the publisher's name?

If this was meant to be some kind of disclosure, it could have been written to make that clear. As it now stands, the only surprise is that the on-line version of the article did not have an embedded link to Amazon.

Are you taking those pills yet?

2011-02-16T13:33:00.000-08:00

Over a year ago, I wrote about entrepreneur Eran Shavelsky, CEO of MedMinder, who has created an electronic, cell-phone connected pillbox that can help people remember to take their prescription drugs. As I noted at the time: "The pillbox has an embedded cellular phone that can send reminders by phone call, text message, or email. It also has lights that blink and sound alerts that beep. You can program it to send reminders in any or all of these formats -- but not just to the patient. The reminders can also go to a trusted family member and/or the provider. These can be easily programmed on the company website. You load up a month's worth of medications, and on you go. Or, if you forget to load up the medicines, you can have an alert about that."

I visited Eran today, curious as to how things were going. The design of the pillbox (now called Maya) has been upgraded, and it is now for sale in some retails outlets as well as through some insurers and providers. He reports that adherence to medication regimes for patients using the device averages about 92%, well above that reported by people in the pharmacy benefit field.

Eran has also developed a portable medication holder/reminder (lower picture), which also works off of cell phone signals, for when people are away from home for a short period of time.

I have no financial interest in this product or company, but I do have a personal interest as someone who wants to improve the management of patient care. It seems to me that this kind of elegant device would especially be of interest to those physician groups that have signed global or other risk contracts. The relatively modest cost of the pillbox and its cellphone service would be recovered many fold by enhancing the likelihood of adherence with prescribed drugs, avoiding the much higher cost of hospital admissions and readmissions.

Catharsis is not policy-making

2011-02-15T13:33:00.000-08:00

If you ever needed an indication of why the public remains confused about the issue of health care costs and insurance premiums, look no further than a story in today's Boston Globe entitled, "Insurers seeking smaller rate hikes." It is not that the reporter has done a poor job. Quite the contrary. The structure of the piece is good, and the story is fair and accurately reported. It is just that the current exigencies of newspaper production make it impossible to devote sufficient space in a daily story to portray the whole picture. So, in an understandable effort to give equal time to divergent viewpoints, the story ends up as a "he said-she said" exposition, leaving out underlying facts and context that might help the public understand why we are where we are.

So, let's deconstruct and expand the story to give more insights.

When the undersecretary of consumer affairs and business regulation sets forth her view of the rightness of the Governor's intervention in the rate-setting process, she neglects to mention that the intervention was arbitrary and found to be legally deficient by appellate boards in the state government. In essence, she attempts to proclaim economic and regulatory virtue in actions that fundamentally had a political origin during the last gubernatorial campaign.

She fails to mention that the underlying costs of providing health care have not changed very much. So insurance companies, bowing to political pressure, have been forced to come down hard on those providers whose contracts happen to have come up for renewal. These have often not been those with higher reimbursement rates. In essence, the administration's intervention succeeded in increasing the payment differential between the have's and have not's among the providers, contributing to the very factors disclosed by the Attorney General that lead to higher, not lower, health care costs.

When she says that the answer to the world's problems is to move to global payments, she makes no commitment to the idea that payment disparities among providers will be eliminated as part of this move.

When the Blue Cross Blue Shield spokesperson says that the proposed premiums are inadequate to cover costs, he leaves out the fact that this insurer has systematically overpaid certain providers, relative to other providers, for their services. These divergent payments are reflective of market power, as opposed to higher quality or other measurable factors, and, as noted, are a major contributor to the cost of health care in the state. He also leaves out the fact that early contracts to persuade or reward providers to sign the company's new global contract regime were particularly generous, especially in the early years of those contracts, increasing the company's costs.

When the head of the association of health plans (which does not include BCBS) continues her long-standing practice of blaming providers for all the problems, she not only neglects the contribution of the inefficient administration of her members, but she too fails to distinguish between those providers who enjoy above-market rates and those who are paid less. Why? Because her members, too, have been forced by market power concerns into paying some providers more for no net benefit to society.

In short, the entire story consists of each party passing blame to another or inappropriately taking credit for something that deserves no credit. Over the nine years I was running a hospital, I came to see the debate often set forth in this manner. It has some cathartic value for the insiders, but it offers little to the public that is helpful. It suggests to the medical profession, too, that the people who move money around to pay for health care have little or no understanding of the underlying demographic and societal factors that are determinative of health care costs, or of the manner in which process improvement and transparency could help bend the cost curve and improve clinical outcomes and the public health.

--

Aside: Some recent developments in which insurers are attempting to introduce products based on tiered networks, or charging different copay's rates based on which provider you visit, are good news. But without publicly available date on clinical outcomes, these efforts run the risk of failure because the (undeserved) reputational advantages enjoyed by certain providers will trump the price differential in people's minds. You can get a sense of that in many of the comments on this story.

It took years after the introduction of low-cost long distance service by MCI and others in competition with AT&T for the latter's market share to drop below the 60th percentile, and the service provided was identical. People's habits die hard, even in the face of accurate information. How much more so when no information is offered to demonstrate that a move to a lower cost provider will result in service of equal or better quality.

Breathing more easily

2011-02-14T14:00:00.000-08:00

Do you remember this post from 2009, where I praised Children's Hospital Boston for an asthma intervention program that provided advice and assistance to families? The summary:

Using a combination of interventions (e.g., counseling about drug dosages, HEPA filters for vacuum cleaners, rodent control measures), they dramatically reduced the number of asthmatic incidents for the children in several of Boston's neighborhoods. A subsidiary benefit was a huge reduction in the number of emergency room visits.

Well, now comes the business issue, summarized in an excellent article by Cheryl Clark at HealthLeaders Media.

It costs about $2,600 per child, but avoids $3,900 in hospitalization costs over a two-year period, hospital officials say. Elizabeth Woods, MD, who directs the hospital's initiative, says cost analyses point to a 1.46 return on investment. The hospital has papers in press that illuminate its progress.

So, where's the problem?

"That's a saving to society, not to the hospital," Woods says.

So here's a great program, but one whose success could hurt the hospital's bottom line, one that costs money and reduces business.

This, of course, is the argument for bundled payments for chronic illnesses and/or capitated payments for all medical service. In this article, Atul Gawande leaps to that conclusion. And there is something to be said for that.

But the short term business analysis sometimes fails to account for all of the items that inure to the benefit of a hospital for doing "the right thing."

Here's a sample of that broader view, the reduction in ventilator associated pneumonia and other hospital acquired infections in a hospital's intensive care units. As above, the direct result was a reduction in costs to insurance companies, Medicare, and Medicaid, and a commensurate reduction in revenues to the hospital. But, and this is a big but:

On the business front, it has contributed to a reduction in length of stay in our ICUs. We were able to avoid the multi-million dollar capital cost of expanding our ICU capacity. Indeed, we were able to create capacity out of the existing facilities and improve throughput.

Hospitals today often face limitations on their ability to raise capital. Avoiding a new fixed expense like that, while effectively creating capacity, can make business sense even if some short-term revenues are lost.

Also, some hospital costs are variable, not fixed. Some of that $3900 saved at Children's Hospital, for example, is certain to be related to supplies that will no longer need to be purchased. Likewise, some portion of nursing and respiratory therapy resources can either be reassigned to other cases, or if the trend is long-lasting, simply avoided by having fewer staff people over time.

And, of course, as noted by the CHB official, "Some of the losses might be made up by not providing worthless or futile care."

So, before we make the leap to a new payment regime, let's be a bit more complete in our analysis.

I was not skeptical enough

2011-02-13T14:06:00.000-08:00

A recent webinar held by Day Pitney LLP made me wonder if my previous post may have understated the skepticism that should be applied to private equity purchases of hospitals.

The session was held on February 9 and was entitled, "Recapitalizing Not-for-Profit Hospitals with For-Profit Equity Capital." It had excellent and lucid presentations by Sandford Steever, Editor of The Health Care M&A Monthly; Wayne Ziemann, Managing Director of Alvarez and Marsal Healthcare Practice Group; and Lori Braender and Bruce Boisture of Day Pitney. The slides are here.

The theme of the day was that health care reform activities over the coming years will require massive capital investments to comply with the new federal law and associated regulations and to create accountable care organizations. This is a problem for not-for-profits, which are are often locked out of capital markets or have difficult access to such markets. In contrast, for-profits have an easier time raising capital.

One panelist then reported, though, that for-profits and not-for-profits have generally earned virtually identical after-tax profit margins. He also noted that equity holders demand a high return, in the range of 25 to 30 percent.

These remarks led to a series of questions from the audience: If for-profits are identical to not-for-profits with regard to after-tax profit margins, how can those puny margins be sufficient to justify investment by equity markets? Or putting it another way, if equity holders are demanding a 25-30% return, how do they earn that return if after-tax margins are the same as not-for-profits. Does this depend on flipping the properties in an IPO or to another private equity firm?

The initial reply was startling, "It is an apparent contradiction occurring in the market today."

Expanding on that, it was noted that private equity entry in this field is different from the for-profit hospital companies that have purchased properties in the past. "Private equity firms envision exiting, and not in the far future. Betting that there will be a buyer at some time in the future is the exit strategy. It is quite a gamble. They are banking a lot of health care reform and consolidation in the industry. Beyond that there is not much that is well defined."

Beyond that, there was a suggestion that the play in the marketplace right now is a "bet on a business plan" -- hoping that access to strategic capital will give these companies a competitive edge in the marketplace and grow market share. It is a bet on a transformation in the health care industry -- different payment models, being a low-cost, efficient provider, and wringing out inefficiency and overtreatment. "It is a heck of a bet to make," noted one panelist.

We were reminded that for-profit investors believe that community-based governing bodies lead to poor business decisions by not-for-profits. (This thought parallels the "stale bologna sandwiches" comment noted in my earlier post.) This belief, though, is interesting in light of a comment by one panelist who noted that not-for-profits have done better than for-profits with regard to building integrated networks of care and coordination of electronic health records.

Finally, though, there were two sobering comments from the panelists. The one: "It is kind of like the gold rush in years past."

The other was worse: "A third possibility beyond an IPO or sale to another investor is that the firm will simply shut down."

It was on this point that I concluded last week: Investors may come and go, but the community depends on its local hospital to provide high quality service. It is the residents of the community who are left holding the bag if the hospital corporation reaches the conclusion that ownership is not financially viable.

Ropeik takes on risk

2011-02-13T05:37:00.000-08:00

My colleague and friend David Ropeik takes on a risky subject in this op-ed in the Washington Post, and he gets it right. He points out the flaws in an EPA proposal to give more weighting to death from cancer than from other diseases. Here are some excerpts:

Wouldn't it make more sense to be more afraid of what's more likely to kill you?

Yes, but that's not how we perceive risks. Risks have psychological and emotional characteristics that make some feel scarier than others, the probabilities notwithstanding. A long, painful cancer death may not be any worse than a long, painful heart disease death, but we think it would be, and feel we can't control it, and that makes cancer more feared.

That is precisely what a new proposal at the Environmental Protection Agency is trying to acknowledge. When assessing whether a new regulation would be worth the money, the agency projects how many lives it would save vs. the costs of implementing it. But now, the EPA suggests that death by cancer is so frightening to the public, cancer deaths should carry greater weight in its calculations than deaths by other causes.

This is an approach that may have some ethical and emotional appeal, but it carries serious dangers for us all.

. . . Under its "cancer premium," the [value] of lives saved from cancer would be 50 percent more than that of lives saved from other causes of death. So this premium would incorporate our greater fear of cancer into the analysis of whether regulations are worth the cost. That may seem pretty democratic: Cancer is scarier, and shouldn't our government protect us from the things we're more afraid of?

. . . It would give an advantage to regulations to control carcinogenic chemicals in the air, for instance, and disadvantage rules to control particulate air pollution, which contributes to cardiovascular deaths - which are far more common but, we think, less scary. As unpleasant as it may seem to argue against the cancer premium, it could increase the overall environmental death toll in America.

. . . We need to recognize that, just as there are physical risks that we study and try to manage, there are very real risks from the perception gap that also need to be recognized, studied and accounted for in policymaking. Getting risk wrong is risky.

We use tools such as toxicology and epidemiology and economics to identify and analyze how to deal with those physical threats. We should also use neuroscience and psychology and sociology and economics to recognize the dangers posed by our misperceptions and to analyze those threats the same way we analyze and manage any others.

That can help us handle the gap between the facts and our feelings about the facts.

We didn't start the fire

2011-02-11T18:19:00.000-08:00

This was forwarded by a friend. If you are of a certain generation, you are bound to like it.

Whether you are a Billy Joel fan or not, you probably remember his great song, "We Didn't Start the Fire."

Here it is, set to pictures. It's a neat flashback through the past half century. I never did know all the words. Turn up volume, sit back and enjoy a review of 50 years of history in less than 3 minutes! Thanks to Billy Joel and some guy from the University of Chicago with a lot of spare time and Google.

Top left gives you full screen. Top right lets you pause. Bottom left shows the year. The older you are, the more pictures you will recognize. Anyone over age 65 should remember over 90% of what they see. But it's great at any age.

We didn't start the fire.

Missing news from friends on Facebook?

2011-02-11T04:12:00.000-08:00

A Facebook post by Kellie Mairs:

Have you noticed that you are only seeing updates in your newsfeed from the same people lately? Have you also noticed that when you post things like status messages, photos and links, the same circle of people are commenting and every……one else seems to be ignoring you?

Don’t worry, everyone still loves you and nobody has intentionally blocked you. The problem is that a large chunk of your friend/fan list can’t see anything you post and here’s why:

The “New Facebook” has a newsfeed setting that by default is automatically set to show ONLY posts from people who you’ve recently interacted with or interacted the most with (which would be limited to the couple of weeks just before people started switching to the new profile). So in other words, for both business and personal pages, unless your friends/fans commented on one of your posts within those few weeks or vice versa – you are now invisible to them and they are invisible to you!!

HERE’S THE FIX: Scroll down to the bottom of the newsfeed on the homepage and click on “Edit Options”, click on “Show Posts From” and change the setting to “All Of Your Friends and Pages”

Simply posting an update about it won’t do any good because lots of your friends/fans already can’t see your posts by default. You’ll either have to send out a message to everyone on your list (which I’m not even sure business pages can do and is a rather tedious method) or post an event explaining the situation like this one and invite your entire fan base and/or friend list. You can also tweet about it hoping that most of your fellow facebookers are also on Twitter.

Shame on Facebook for altering the default setting and not telling people about it!

Huge barriers to effective relationship formation

2011-02-10T14:51:00.000-08:00

During Ernie's class at MIT, the students and I were discussing why it is so hard to implement process improvements in clinical settings. I suggested that one aspect of the problem was that doctors, no matter how well intentioned, were not trained in such matters. Further, I suggested that there is very little in the career advancement pattern of successful doctors in academic medicine that rewards attributes that are so important in most other fields of endeavor, i.e., interpersonal skills and teamwork.

Well, along comes Linda Pololi, an MD who has been doing research at the Women's Studies Research Center at Brandeis University, who today conducted a seminar about her new book, Changing the Culture of Academic Medicine. (Dartmouth College Press.) The book is mainly about the perspectives of women faculty in medical schools, but it also has observations from men. It is based on extensive surveys and interviews with faculty members from a number of prominent medical schools.

Not only did Linda confirm my hypotheses, she provided thorough documentation of a pattern among the faculty of medical schools that can hardly fail to have an impact on those trained in the system.

Here are some excerpts:

Our data show that the way medical schools are structured and the norms of behavior among faculty can create huge barriers to effective relationship formation . . . a medical school environment that could at times negatively impact patients and our system of health care as a whole.

Problems with personal interactions in the academic medical culture emerged as a central theme in our interviews. . . . Comments about relationships tended to arise spontaneously rather than be elicited by the interviewer. . . [and] both women and men spoke similarly about relationships in the interviews.

Two fundamental worrisome experiences . . . were a sense of disconnection and having few trusting relationships with colleagues and supervisors.

Interviewees described an intensely individualistic, competitive environment where rewards usually went to individual accomplishments. . . .[I]ndividuals and institutions tended to function on behalf of their self-interest, making decisions and choices that benefited themselves rather than contributing to the common good -- and sometimes came at the expense of the common good.

The system is designed to create barriers at all levels to collaboration and collegiality.

Numerous faculty complained of not being recognized as a person beyond their professional role. No attention was paid to what people were feeling. . . . [T]his refusal to engage them as individuals had a depersonalizing effect. The culture seemed to ignore the qualities that made them able to address human needs and show compassion and sensitivity to others.

We found little indication that medical schools cultivated appreciation of people's efforts. Rather, the focus was on finding fault.

Now, let's draw the connection between all this and patient care. It is obvious that process improvement is hampered when there is a lack of trust, collegiality, and collaboration among the medical staff. But sadder still, consider the implications for those being treated. Linda notes:

There is a parallel between disconnection and emotional detachment among medical school faculty and ineffective communication between doctor and patient. If faculty feel disconnected and cannot communicate among themselves, they are less likely to create good relationships with students and patients. Similarly, in a culture where faculty and administrators themselves do not receive consideration and compassion, it is less likely that they will treat students and patients with compassion.

And what about improving quality and safety and reducing harm to patients?

Research shows that physicians remember for decades mistakes they have made, feeling guilty and humiliated and isolated in their shame. Only by creating transparency, so they can discuss mistakes openly, can these destructive feelings be relieved. Equally important, open discussion enables the physician and others to learn from these mistakes and prevent them from recurring.

If the training ground of American physicians works against this common sense view of the world, is there any doubt as to why we have such problems in patient care? Clinical and administrative leaders in hospitals must strive to undo the culture that is embedded in these centers of learning and help those who have devoted their lives to alleviating human suffering to start, first, to alleviate their own suffering and sense of loneliness and isolation.

At Ernie's class @ MIT

2011-02-10T08:55:00.000-08:00

I was a guest lecturer last night at Professor Ernst Berndt's course at MIT's Sloan School, entitled "Economics of the Health Care Industries." The students represent a variety of backgrounds, and we had great discussions about a full range of issues in hospital management.

I added a new weapon to my arsenal in the Socratic method -- a promise that anyone who made a particularly insightful comment would be featured here on this blog. You see them in the accompanying pictures.

I also had an opportunity to suggest the first of four essay topics for the class. These will be turned in on Monday, and I promised to print the best ones here. Stay tuned for those next week.

I gave them a very tough topic, but it is quite timely and represents an actual problem facing provider groups here in Massachusetts and elsewhere. Here it is:

First, read this blog post. Then, the question is: What methodology would you propose for the allocation of an annual global payment, to divide it up among primary care doctors, community hospitals, tertiary hospitals, specialist doctors, nursing homes, etc. -- all of whom are involved in caring for a given population of patients? How would you make the transition from the current fee-for-service approach?

This is investigative reporting

2011-02-10T02:22:00.000-08:00

The Las Vegas Sun conducted an extensive investigation of the quality of care delivered by hospitals in that section of Nevada. It took two years of research by reporters Marshall Allen and Alex Richards, along with help from lots of support staff. They made use of hundreds of thousands of pieces of information. The material was presented in a multi-part series through 2010. Here is the video summary offered by Brian Greenspun, publisher and editor.

This series exemplifies the potential power of the media in focusing public attention on one of the country's major public health hazards -- being treated in a hospital. To a greater or lesser extent, a similar story could be written in most American cities. But it would take a commitment to write stories that go beyond parroting corporate press releases or believing the advertisements of self-satisfied medical institutions. Perhaps a little less coverage about the weather would free up reporters to dig through a different kind of snow job.

Congratulations to the Las Vegas Sun for showing the way.

If you cannot see the video, click here.

Pauline Chen on WIHI

2011-02-09T10:20:00.000-08:00

A Legible Prescription for Health Care
Thursday, February 10, 2011, 2:00 PM – 3:00 PM Eastern Time
Guest: Pauline W. Chen, MD, Columnist, The New York Times; Author, Final Exam: A Surgeon’s Reflections on Mortality

Have you heard the one about the backlash to Accountable Care Organizations (ACOs)? Actually, there’s no such thing...yet. But there could be, suggests Pauline Chen in her latest “Doctor and Patient” column, if ACOs take off without fully appreciating that patients have to buy into the concept. And that won’t happen if they’re not part of the discussion and the design, and offered more than legal lingo.

Anyone interested in a bridge between patients and practitioners and health care reform has no better voice these days in a major media outlet than Dr. Pauline Chen. WIHI host Madge Kaplan is pleased to welcome Dr. Chen to the program on Feb 10 to discuss the issues she brings to light with her writing, often drawing on her own day-to-day experiences seeing patients and conversations she has with other colleagues. On this edition of WIHI, Dr. Chen wants to spend some time talking about language, especially the words doctors use with one another when describing patients; the unintended barriers created the more doctors and nurses don protective, infection-protecting garb; the mounting weight of patient satisfaction surveys; and more.

Pauline Chen says the more she delves into tough topics, the more her own habits have changed. Perhaps that’s the effect her writing has had on you, too. Come join a timely discussion with someone who often reminds us that it’s human beings who either uphold the status quo or change the dynamics in health care, no matter how many good, prescriptive ideas are out there. We look forward to your participation on this next WIHI!

To enroll, please click here.

Jubilee presents Beautiful

2011-02-09T04:51:00.000-08:00

Here's the latest video from the Jubilee Project. As always, when you view it, a donation will be made to a charity, in this case Becky's Fund.

If you cannot see the video, click here.

Ethical blinders?

2011-02-09T03:48:00.000-08:00

Is this a case of ethical blinders?

Today's New York Times has an important story about the ineffectiveness of removal of lymph nodes for certain women with breast cancer. That is a significant result of clinical research. But read this:

Experts say that the new findings, combined with similar ones from earlier studies, should change medical practice for many patients. Some centers have already acted on the new information. Memorial Sloan-Kettering Cancer Center in Manhattan changed its practice in September, because doctors knew the study results before they were published.

And they felt no need to spread the word quickly to other hospitals and to breast cancer patient advocacy groups and help women across the world avoid the surgery and its after-effects? (As noted in the article, "It can cause complications like infection and lymphedema, a chronic swelling in the arm that ranges from mild to disabling.")

La gala del nadar es saber guardar la ropa

2011-02-09T03:01:00.000-08:00

A December article in Scientific American by Dr. Alvaro Pascual-Leone, "Get Better at Math by Disrupting Your Brain," makes some fascinating observations about brain function. It is short and worth reading. A few excerpts:

We tend to believe that our brains work as well as they can.

Being better in math does not mean being smarter at everything. But we assume that, at least within a given domain, better behavioral performance implies superior brains, because we take it for granted that the brain is working as well as it can to optimize behavior.

However, a growing number of instances in clinical neurology and a growing body of research in cognitive neuroscience reveal that this assumption is incorrect. . . . For example, if the brain optimizes behavior, disruption of normal brain activity ought to lead to a loss of function, and never to enhancement. And yet, in some instances, disruption of brain activity . . . can result in a paradoxical behavioral improvement.

Behavior after damage, or after the modulation of activity in a given brain area, reflects the capacity of the brain and its networks to adapt to the disruption. The final behavioral consequence of a brain injury may be worsened performance, but also, paradoxically, improved performance, or even recovery from the deleterious consequences of a pre-existing insult or disease.

Read the article to understand the title of this blog post!

Is this the image you want to portray?

2011-02-08T13:19:00.000-08:00

Is anybody else put off by the fact that this newsletter from the American Medical Association takes advertising from drug companies and displays it so prominently at the top of the front page and on the right side of that page, also?

Teach the doctors, please!

2011-02-07T11:55:00.000-08:00

If you read the Boston newspapers, you would think that the most important thing going on in health care is a proposal to move from one kind of insurance payment scheme to another. Reporters seem willing to accept relatively unsupported and undocumented assertions that global payments are working. You have to be persistent to find these sentences in this story:

But other doctors and health care executives cautioned against drawing definitive conclusions from the insurer’s early results. They have not been independently reviewed and may not be easily reproduced statewide.

If it is working, why do reporters not demand more transparency to demonstrate it? Why this instead?

Blue Cross did not release specific performance results for doctors groups.

Why no mention in these stories of alternative approaches being taken by other insurers?

Why hold off, too, on this really important statement until after the page turn and deep at the end of this story?

Both supporters and critics of global payment agree that any mandate should be flexible, and phased in slowly, so patients and providers can adjust. Thomas A. Croswell, chief operating officer of Tufts Health Plan, suggested a five-year transition.

Much is often made of Atul Gawande's superb writing about the use of check lists and other quality and safety process improvements. If you read carefully, though, you will see that he seldom mentions progress in the medical schools with which his and other Boston hospitals are affiliated. While we wait five years or more for the new pricing regime, why don't the insurers, the state government, and other stakeholders put pressure on the region's four medical schools to introduce and emphasize the science of process improvement in their curriculum?

Local readers might be interested to know that the process improvement world is alive and well in other regions, irrespective of insurance payment regimes. Two of the heroes in this arena, Brent James and Bob Wachter, recently had a conversation about how to teach quality and safety improvement.

Dr. James gave some history of his efforts at Intermountain Health. Dr. Wachter asks:

[Y]ou and others have written about the culture of medicine being so individualistic. It sounds like we came into this with a culture that you would expect would create tremendous variation from doctor to doctor.

Dr. James replies:

Looking back, that's absolutely true. Of course it came to be called the craft of medicine, a cottage industry, where it's based on purely personal expertise, personal perfection, if you will. Speaking as somebody out of a surgical background—that concept is so central to what it means to be good, I mean for your patients, the best you can be. You don't want to lose that personal dedication. But you start to extend it a step further. Where it ended up for us was a form of Lean.

And later, he relates:

We did other things that were really important. The first is that we built firmly on the foundation of medicine. By that point, we'd understood that there's a whole bunch of jargon with improvement, but you didn't have to use any of it; you could describe the whole thing in the language of medicine. So rather than asking the natives to learn quality improvement jargon, we spoke the language of the native. The second thing was that in order to graduate you had to complete a successful improvement project. Our aim was to get hands-on experience that was real. And boy did that ever turn out well.

Here is an article about a system clinical safety and effectiveness (CS&E) course taught at the University of Texas. An excerpt:

Unfortunately, most front-line caregivers complete their professional training with almost no exposure to even rudimentary QI concepts or methods....

The University of Texas MD Anderson Cancer Center began such a course in 2005 ... and its success led us to implement courses in four of the six health campuses in the University of Texas system....

The purpose of the CS&E course is to provide physicians, other key clinicians, and administrators the skills and knowledge required to lead breakthrough change initiatives. After initial success at UT MD Anderson Cancer Center, all presidents of the UT System health care institutions approved a proposal in 2007 to develop and implement CS&E programs on their own campuses. A UT CS&E Steering Committee with representatives from each campus was established to provide oversight for the course expansion, and in 2008 the University's Regents provided funding from the UT System's malpractice liability reserve fund.

We are very quick to find a rivalry between Texas and Boston in other fields. Let's start one here, where lives hang in the balance.

Is the "greater fool" theory alive in the hospital world?

2011-02-05T18:45:00.000-08:00

In the last four decades, we have witnessed a series of investment "bubbles" that have all collapsed. It seems that there is no end to the number of people with cash who will be intoxicated by a good story line, even when there is little substance to back it up. All of these stories depend on the capital markets to bolster the price of investments, counting on the "greater fool" theory: There is always someone who will take on a bad investment at just the wrong time, providing a good return to those who are lucky enough to escape before the crash.

In the early 1990s, ENRON was entering the market with a new electricity trading division. A business partner of mine was asked by one of the largest government pension funds to evaluate a proposal to invest $250 million in the start-up. He came to me a few weeks later, saying that he was having trouble evaluating the deal. They could not give a substantive answer to the basic questions: How will each transaction make money? What will be your competitive advantage in this business? What do you expect your market share to be? When he would ask the ENRON guys for a business plan, their answer was, "We did it in natural gas. We can do it in electricity. Trust us."

My friend advised the pension fund not to invest. It did so anyway, apparently because of personal relationships between the fund managers and people at ENRON. As we now know, the fiction behind ENRON's financial plan eventually led to its collapse.

A bit later, Bernie Ebbers was building a telecommunications company called WorldCom. His approach was to play on the stock market's desire for growth by acquiring other long distance phone companies. As the market capitalization of the company grew, its stock price rose -- notwithstanding a surplus in long distance capacity in the country and declining profit margins. The thing that finally stopped Ebbers was that the government would not let him continue to acquire companies (for antitrust reasons). Then, finally, he had to run the business as a business and make a profit, and he could not. Collapse followed.

More recently, we have all witnessed the subprime debacle, the sale of unsecured insurance products, and the like. As above, these were examples of money chasing money, of stated valuations with no inherent relationship to the actual value of the business enterprise.

What is the next bubble? Might it be private investment in hospitals and hospital systems?

I have discussed above the rationale for and some of the financial techniques involved in private equity acquisitions of hospitals. These acquisitions also tend to have great political support: A financially troubled hospital system will have a more secure pension plan, pay taxes to municipalities and the state, and the like. The private equity firm rescuing the system is seen as a "white knight" and makes commitments that sound very persuasive.

As time goes along, some of those early statements are quietly modified. This Boston Globe article, for example, reports that one private equity firm "also committed to pumping another $400 million in capital improvements into the system over the next four years, although [its CEO] acknowledges that those funds may come from hospital revenues in coming years, rather than from [the private equity firm] itself."

We also learn that strong commitments to local involvement can diminish. At a recent conference, one private equity official derisively talked about the inadequacies of local lay leaders eating their "stale bologna sandwiches" at Board of Trustees meetings, to draw a contrast with the unsentimental businesslike behavior of a board chosen by his firm.

Those seeking to regulate the behavior and financial decisions of for-profit hospitals will find that their post hoc authority will likely be insufficient to protect the public interest from a depletion of plant and equipment and from a plan that is mainly meant to burnish the pre-tax and pre-depreciation short-term earnings of the firm so that it is ready for the initial public offering or resale to another private equity firm.

Who gets hurt if these deals go bust when the next generation of owners takes over and discovers that creating the margin to generate the expected return is very hard in the hospital world? Well, that very last set of investors, the "greater fools." But, as we have seen in the examples above, the hurt goes much further. Hospitals, though, are in a special category. Investors may come and go, but the community depends on its local hospital to provide high quality service. It is the residents of the community who are left holding the bag if the hospital corporation reaches the conclusion that ownership is not financially viable.

Perhaps I am being too pessimistic, but this feels very much like those conversations I had in the 1990s. Let's hope that I am wrong. So in the meantime, enjoy the Super Bowl and root for the good guys to win.

Power outages foil criminal behavior

2011-02-04T12:28:00.000-08:00

As we head into the weekend following a week of snow and power outages, it is diverting to consider the latest "stupid crook" story, this one from Silver Spring, MD. The essence:

As the burglar was rifling through the rooms in that house, the homeowner's son arrived and startled him. The burglar jumped out a window and fled. The son called police, who searched the house. They were stunned at what was found: a cellphone, charging in an electric socket, that didn't belong to the homeowner. The phone led police to Cody Wilkins, who is now charged in 10 burglaries. Police say that Wilkins's home lost power in the storm and that he needed a place - anyplace, it seems - to charge his phone. In his haste to flee, he left it charging.

Blurred boundaries between news and opinion

2011-02-04T04:04:00.000-08:00

Is this happening with your home town newspaper? It used to be that there was a separation of news and opinion columns. I am not saying that editorial and personal biases were ever missing from news stories; but I am saying that columns containing opinions were clearly labeled as "opinion." That seems to be gone now. We are presented with news stories that subtly present the reporter's opinion as part of the news.

Here is an example from today's New York Times and Boston Globe (the same story by Anthony Shadid):

The Egyptian government broadened its crackdown of a 10-day uprising that has shaken its rule yesterday, arresting journalists and human rights advocates across an edgy city, while offering more concessions in a bid to win support from a population growing more frustrated with a devastated economy and scenes of chaos in the streets. (This part is news.)

The campaign was a startling blend of the oldest tactics of an authoritarian government — stoking fears of foreigners — with the air of sincerity of a repentant order. (This part is opinion.)

And another from the Globe:

US Representative Barney Frank announced yesterday that he plans to seek another term, increasing the possibility of a battle — the first in 30 years — between two sitting Massachusetts congressmen over a single congressional district. (News.)

Frank, 70, an irascible (opinion), liberal (news) Newton Democrat....

I am not saying either opinion is wrong. (I don't know Mubarak, but the characterization of Barney is dramatically understated.) What I am saying is that you would expect the newspapers of record to be better about separating reporting from opinion on their front pages. In my view, the story should tell the story, leaving readers to form their own opinions. Opinions should be clearly set forth in stories labeled as opinion or analysis, whether on the front page, the editorial page, or the op-ed page.

How to get into Chuck E. Cheese when you are middle aged

2011-02-04T03:33:00.000-08:00

For those of you not familiar with Groupon, it is an internet-based discount coupon service, targeted for individual cities throughout the country. An offer is sent out, and if enough people sign up for it, the discount is awarded. Groupon is known for its humorous descriptions of the service or commodity being offered.

Today's Boston offer has the most clever description I have seen. Will 20 people snow-struck people who have spent weeks trapped in their homes looking in the mirror sign up? Health care experts advise me that this most assuredly is not covered under the Blue Cross Blue Shield global payment plan! Here goes:

Med-Spa Treatment from Boston Plastic Surgery Associates in Concord. Three Options Available.

Maintaining a youthful visage helps get you into hip nightclubs, such as Chuck E. Cheese's, where sentient mice dance wildly in rooms entirely filled with balls. Live it up at the club with today's Groupon to Boston Plastic Surgery Associates in Concord. Choose from the following options:

$175 for 50 units of Dysport (a $300 value)
$129 for three laser hair-removal treatments (up to an $800 value)
$129 for a photofacial skin-rejuvenation intense-pulsed-light treatment (a $450 value)

Dr. Brooke Seckel of Boston Plastic Surgery Associates is a medical Ponce de Leon, immersed in a perpetual quest for age-defying noninvasive and nonsurgical therapies to keep his patients budding and boisterous. The photofacial rejuvenation treatment gives hardened mugs a science-fiction makeover via beams of intense pulsed light, thought to gently remove pigment, brown spots, blood vessels, and shrink enlarged pores. Worry lines are whisked away with Dysport injections, which are similar to Botox injections, smoothing out the area between the brows for clean lightning-bolt-scar application. Patients can also punish their naughty shampoo-stealing pelts with three laser hair-removal treatments on either the lips, chin, sideburns, front of neck, back of neck, underarms, feet, hands, or ears (a $500–$800 value per area for three treatments). All prospective baby faces need to call ahead for an appointment.

Shaw got it right

2011-02-03T14:20:00.000-08:00

George Bernard Shaw wrote The Doctor's Dilemma, Preface on Doctors in 1909. It is fun to read some excerpts:

It is not the fault of our doctors that the medical service of the community, as at present provided for, is a murderous absurdity. That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity. But that is precisely what we have done. And the more appalling the mutilation, the more the mutilator is paid. He who corrects the ingrowing toe-nail receives a few shillings: he who cuts your inside out receives hundreds of guineas, except when he does it to a poor person for practice.

Scandalized voices murmur that these operations are necessary. They may be. It may also be necessary to hang a man or pull down a house. But we take good care not to make the hangman and the housebreaker the judges of that. If we did, no man's neck would be safe and no man's house stable. But we do make the doctor the judge... I cannot knock my shins severely without forcing on some surgeon the difficult question, "Could I not make a better use of a pocketful of guineas than this man is making of his leg? Could he not write as well—or even better—on one leg than on two?"

Why doctors do not differ

The truth is, there would never be any public agreement among doctors if they did not agree to agree on the main point of the doctor being always in the right. Yet the two guinea man never thinks that the five shilling man is right: if he did, he would be understood as confessing to an overcharge of one pound seventeen shillings; and on the same ground the five shilling man cannot encourage the notion that the owner of the sixpenny surgery round the corner is quite up to his mark. Thus even the layman has to be taught that infallibility is not quite infallible, because there are two qualities of it to be had at two prices.

But there is no agreement even in the same rank at the same price. During the first great epidemic of influenza towards the end of the nineteenth century a London evening paper sent round a journalist-patient to all the great consultants of that day, and published their advice and prescriptions; a proceeding passionately denounced by the medical papers as a breach of confidence of these eminent physicians. The case was the same; but the prescriptions were different, and so was the advice.

Now a doctor cannot think his own treatment right and at the same time think his colleague right in prescribing a different treatment when the patient is the same. Anyone who has ever known doctors well enough to hear medical shop talked without reserve knows that they are full of stories about each other's blunders and errors, and that the theory of their omniscience and omnipotence no more holds good among themselves than it did with Moliere and Napoleon.

But for this very reason no doctor dare accuse another of malpractice. He is not sure enough of his own opinion to ruin another man by it. He knows that if such conduct were tolerated in his profession no doctor's livelihood or reputation would be worth a year's purchase. I do not blame him: I would do the same myself.

But the effect of this state of things is to make the medical profession a conspiracy to hide its own shortcomings. No doubt the same may be said of all professions. They are all conspiracies against the laity; and I do not suggest that the medical conspiracy is either better or worse than the military conspiracy, the legal conspiracy, the sacerdotal conspiracy, the pedagogic conspiracy, the royal and aristocratic conspiracy, the literary and artistic conspiracy, and the innumerable industrial, commercial, and financial conspiracies, from the trade unions to the great exchanges, which make up the huge conflict which we call society. But it is less suspected.

Statistical Illusions

Public ignorance of the laws of evidence and of statistics can hardly be exaggerated. There may be a doctor here and there who in dealing with the statistics of disease has taken at least the first step towards sanity by grasping the fact that as an attack of even the commonest disease is an exceptional event, apparently over-whelming statistical evidence in favor of any prophylactic can be produced by persuading the public that everybody caught the disease formerly.

Thus if a disease is one which normally attacks fifteen per cent of the population, and if the effect of a prophylactic is actually to increase the proportion to twenty per cent, the publication of this figure of twenty per cent will convince the public that the prophylactic has reduced the percentage by eighty per cent instead of increasing it by five, because the public, left to itself and to the old gentlemen who are always ready to remember, on every possible subject, that things used to be much worse than they are now ... will assume that the former percentage was about 100.

Flame throwers would work nicely

2011-02-03T06:37:00.000-08:00

Now, why didn't I think of this, instead of suggesting that we throw the snow in the Harbor?

Sixty three years ago Boston received so much snow that then Mayor James Curley took a look at it and began pleading with then MIT President Dr. Karl Compton for help. “I am very desirous that [MIT] have a competent group of engineers make an immediate study as to ways and means of removing the huge accumulation,” he wrote, “…be it by the use of flame throwers or chemicals or otherwise.”

Courtesy of the MIT Alumni Association.

Our patients are sicker

2011-02-02T06:23:00.000-08:00

What more do we need to know? The British Medical Journal published a study showing that Peter Pronovost's program to reduce central line infections in Michigan saved lives.

A new study finds that a safety checklist program developed by a Johns Hopkins doctor has reduced patient deaths in Michigan hospitals by 10 percent, in addition to nearly eliminating bloodstream infections in health care facilities that embraced the prevention effort.

The research, published in the British Medical Journal, is the first to show a drop in patient mortality in hospitals using the Hopkins program. Previous studies have found major reductions in bloodstream infections from using the checklist when inserting catheters or central lines to give patients medication, fluids or nourishment.

Well, duh. But I guess it is important to have scientific verification. But I can almost hear the comments from some places: "That wouldn't work here. Our patients are sicker."

So, how long will it take for this approach to be used across the country? This study is based on work from nine years ago. If this is like other innovations in medical care, it will take a decade and a half more to spread.

Here's my proposal to jump-start it. Publish the monthly rate of central line infections for all hospitals on a public website. CMS, IHI, the Dartmouth Atlas group or some other organization could do this in a nano-second, creating a voluntary website, giving each hospital a password through which it could enter its own data. There is no need to audit the figures. We can trust people to be honest.

And, at the bottom of the website, the host could list the hospitals that have chosen NOT to publish.

Then, you would see the power of transparency.

Lessons from Cairo

2011-02-01T15:47:00.000-08:00

I think most of us would be hard-pressed not to be inspired by the moral power of the crowds in people in Egypt as they throw off a form of government that they find repressive. But, it is about the US reaction to all this to which I turn today. It is the subject of New York Times columns by David Brooks and Nicholas D. Kristof.

Both authors noted the ham-handed manner in which the United States deals with authoritarian regimes and with popular movements for freedom.

Brooks notes,

The . . . thing we’ve learned is that the United States usually gets everything wrong.

Policy makers always underestimate the power of the bottom-up quest for dignity, so they are slow to understand what is happening.

Then their instinct is to comfort the fellow members of the club of those in power.

Then, desperately recalibrating in an effort to keep up with events, they inevitably make a series of subtle distinctions no one else heeds.

Kristof says,

Yet one thing nags at me. These pro-democracy protesters say overwhelmingly that America is on the side of President Mubarak and not with them. They feel that way partly because American policy statements seem so nervous, so carefully calculated.

The upshot is that this pro-democracy movement, full of courage and idealism and speaking the language of 1776, wasn’t inspired by us. No, the Egyptians said they feel inspired by Tunisia — and a bit stymied by America.

Everywhere I go, Egyptians insist to me that Americans shouldn’t perceive their movement as a threat. And I find it sad that Egyptians are lecturing Americans on the virtues of democracy.

Brooks provided a broader context for all of this:

I wonder if sometime around 50 years ago a great mental tide began to sweep across the world. Before the tide, people saw themselves in certain fixed places in the social order. They accepted opinions from trusted authorities.

As the tide swept through, they began to see themselves differently. They felt they should express their own views, and these views deserved respect. They mentally bumped themselves up to first class and had a different set of expectations of how they should be treated. Treatment that had once seemed normal now felt like an insult. They began to march for responsive government and democracy.

You will excuse me if I draw the connection to health care. I hope you don't think it inapposite.

I do not think that it has been a fifty year trend in health care, but a more recent one. Patients and families have decided that they should be equal partners in the process of diagnosis and treatment. They believe that they have a right to the information that can represent life or death, health or suffering. As Brooks would put it, "treatment that once seemed normal now feels like a insult." Opinions from trusted authorities no longer carry the weight they used to. Questions are being asked. Answers are being demanded.

A few weeks ago, author Charles Kenney asked the question, Isn't there a compelling -- perhaps even overriding -- moral component to transparency?

I responded,

The answer, of course, is yes. Doctors and others pledge to do no harm. How can you be sure you are living by that oath if you are unwilling to acknowledge how well you are actually doing the job? As scientists, how can you test to see if you are making improvements in evidence-based care if you cannot validate the "prior" against which you are testing a new hypothesis? At the most personal, ethical level, how can you be sure you are doing the best for people who have entrusted their lives to you if you are not willing to be open on these matters?

But transparency threatens the status quo. In the medical world, status quo confers power, influence, prestige, and money on those who have had a reputational advantage. A close friend and colleague put it this way:

Transparency in self-interested institutions who are making fortunes by deluding themselves and the public that they and only they know what the community wants and needs is a very dangerous concept.

The agents of change in this battle will be the same people who are turning things over in Egypt. Normal people who have experienced pain and suffering, or even just disrespect, in the health care system are starting to find their voice. Like the US in the international arena, the powers that be in the government and their agents, having been captured by the powerful forces of the medical and hospital profession, are slow to react and are protective of the status quo.

Policy makers always underestimate the power of the bottom-up quest for dignity, so they are slow to understand what is happening.

Then their instinct is to comfort the fellow members of the club of those in power.

Then, desperately recalibrating in an effort to keep up with events, they inevitably make a series of subtle distinctions no one else heeds.

Tectonic forces at work

2011-01-31T19:01:00.000-08:00

We are about to witness the clash of two tectonic plates in health care. The creation of Accountable Care Organizations, combined with a movement towards capitated and other types of bundled payments, will be forces towards integration of care across the continuum. From primary care to tertiary care to skilled nursing and rehabilitation, principles of care management will combine with financial incentives to create ever more concentration in the health care market. Proprietary electronic medical records systems and "captive" doctor organizations will work towards reducing consumer choice in this new environment.

You already see health care companies engaged in this and advertising it as an attribute. Here, for example, one company notes: [Q]uality care is not just about the care in one institution – it’s what happens between institutions. And if we don’t pay close attention to those gaps – which means measuring and acting to improve the information flow – the patient will suffer. (And, you already see health care companies engage in deceptive behavior with regard to referrals, too, like here.)

Yet, at the same time, patients and their advocates will be demanding more choice. Fully trained in consumerism in other fields, they will expect the same in health care. They will want internet-based transparency of clinical outcomes, along with tons of disease-specific information, so they can seek out and obtain the best possible care for themselves and their loved ones. They will press captive doctors to allow them to be referred to out-of-network health care companies that appear to provide better, safer, and/or more compassionate care.

How will this crash of the tectonic plates be resolved? One answer is to ignore consumer preference and rely on monopoly-like organization of care. We know from other fields, however, that this not only results in monopoly pricing, but it slows down innovation. Think of the Bell System in years past, which provided integrated service, from telephone instruments to long distance calling. Many people alive today do not know that the Bell System conspired to limit people's choice to the extent that you were not allowed to connect a non-Bell telephone in your house. The company argued that doing so would cause irreparable harm to the network and knock out telephone service for miles! You could not buy your phone. You had to rent it for a monthly fee, payable forever (see below). Actually, it was even worse than that. Your bill also included a fee for every extension outlet in your house, even outlets that did not have telephones attached.

And, if you wanted to make a long distance call, there was only one provider, AT&T Long Lines, the one affiliated with your local Bell operating company. You paid by the minute: There was no unlimited service based on a fixed monthly fee. Why? Because they could.

Eventually, the government broke up the Bell System when upstart competitors wanted to sell telephone sets and other companies wanted to offer long distance service. Standards were established that allowed anyone to use the local network and get access to dial tone. Eventually, even that monopoly was broken when other telephone companies and cable companies were permitted to string wires into the neighborhoods. And then, even those technologies faced competition from cellular networks and voice-over-internet.

Is there a lesson from all this for health care? You bet.

The heart of the problem in health care has two dimensions. First, electronic medical records are often based on proprietary systems, limiting interoperability between health care networks. Second, doctors are captive members of a provider network, often one controlled by a region's major hospital or health care company.

As computer guru John Halamka would note, the first problem is gradually going away, in a technical sense. With the advent of national data standards, it will be easier and easier to electronically connect patient records across multiple providers. There are already clear demonstrations of full integration in place, where two or more organizations have found it to be in their mutual interest. But we can expect geographically strong networks to resist this. It will take government action to enforce interoperability.

The second problem, though, requires a Bell System-like solution. As long as physician groups are owned by or otherwise financially affiliated with hospitals, the doctors in those groups will not have the freedom to refer folks to the facilities that are optimal for patients. We can make all the claims we want about the need to have a closely tied physician network to provide integrated health care delivery, but those claims are vacuous. Such systems tend to be driven by -- and serve -- the hospitals and the specialists in them rather than the community-based physicians.

Ask this question to any primary care doctor you know who is part of a hospital-based network: "Do you feel you have the freedom to send a patient to a hospital in another network? " At best, they will say, "If I really feel strongly about it, I can do so." But, if they are honest, they will say, "I don't dare do that very often, if at all. My continued participation in the contracting benefits of my network depend on sending my patients to affiliates in that network."

It is time to break this system wide open and prohibit corporate affiliations between community-based providers and hospital-based health care delivery networks. Let's free up the community doctors to make referral choices based on publicly available data about clinical outcomes, quality of service, and other items that matter to their patients. If global payments become the norm, the PCPs should "own" the payment and then apportion it among secondary and tertiary providers who best serve their patients. Let the marketplace decide which hospitals rise or fall in this environment.

Short of that, we will retain Ma Bell in health care. Then, the answer will be the one given by Lily Tomlin (aka, Ernestine, the telephone company operator):

"Next time you complain about your phone service, why don't you try using two Dixie cups with a string. We don't care. We don't have to. We're the Phone Company!"

If you cannot see the video below, click here.

Should there be a billing code for compassionate care?

2011-01-30T13:45:00.000-08:00

Back in 2009, Dr. Amy Ship gave a moving acceptance speech when she received the annual Compassionate Caregiver Award from the Schwartz Center.

The most memorable tag line from the speech was, "There is no billing code for compassion." This resonated with so many of us -- patients and providers -- in part because it set forth the proposition that compassionate care should be an inherent aspect of medical services. The idea that some portion of a doctor's or hospital's payment should be tied to such an essential human value seemed ludicrous.

Or is it? A recent survey conducted by the Schwartz Center, entitled "The state of compassionate care in the United States," indirectly raises the issue. Those patients and doctors surveyed were overwhelmingly in favor of the idea that compassionate care was important to the successful treatment of patients. They agreed, too, that compassionate care makes a difference in how well a patient recovers from illness. Indeed, they believed that good communication and emotional support can make a difference in whether a patient lives or dies.

But there was a gap between what patients said was most important to them, in terms of compassionate care, and what they actually experienced during recent hospitalizations. And, looking forward, both patients and doctors are worried that the changes being made in our health care system will make it more difficult for providers to offer compassionate care.

Now, if we remove the word "compassionate" from the above discussion and instead insert "safety," "quality," "avoiding hospital acquired infections," or the like, our immediate response would be that we need to change the system of hospital and physician payments to provide financial incentives to change things for the better. Whether we might propose a pay-for-performance approach or some kind of global payment to encourage improvement, the current environment seems very comfortable with using the payment system to nudge behavior in the right direction.

So, why not pay for compassion? Surely, we can name those aspects of care that are most closely tied to compassion, and we can likewise document whether they occur.

While I will let this debate play out in the comments below, let me start it off by saying that I believe this would be a mistake. So many discrete aspects of medical care are already monetized that is hard to imagine a payment regime that would actually focus sufficient financial attention to motivate a doctor along the spectrum of less-to-more compassion. Beyond that, the idealist in me is offended by the idea of paying someone to, in essence, be more humane. In my view, this is not a matter of remuneration. It is a matter of societal values and a training program and ongoing supervision that imbues practice with those values.

But, let's hear what you have to say. Should there be a billing code for compassionate care?

Unguarded waterfront

2011-01-30T07:40:00.000-08:00

An important warning at Walden Pond, in case you were thinking of swimming yesterday.

Throw the snow in the Harbor!

2011-01-30T03:27:00.000-08:00

As I was walking home last night, I saw this scene on Arlington Street in downtown Boston. I was reminded of a story I heard the other day on WBUR's Radio Boston about the problems being faced by Boston and other communities as they engage in snow removal from municipal streets. One aspect of the problem is that state environmental officials have prohibited Boston and other coastal communities from disposing of street snow in the Harbor.

Now, I don't think anyone can contest my environmental bona fide's. After all, I ran the agency that accomplished the Boston Harbor Cleanup, one of the world's largest environmental remediation projects. But this is one rule that I just don't understand.

Yes, I know that snow on city streets picks up all kinds of chemicals and pollutants from the city environment, and I know it also picks up salt and chemical de-icers during its residence time.

But, instead of dumping this snow in the harbor, it gets trucked -- using thousands of gallons of fuel which create all kinds of air emissions -- to inland locations. What happens there? It melts, and those same pollutants enter the ground water system. Or they go into city storm drains, where they end up where? Boston Harbor.

Perchance some of the melted snow goes down storm drains that empty into the city's combined system, which sends the wastewater to the Deer Island sewage treatment plant. In that case, such contaminants that are captured are concentrated in the sludge at the plant, which is eventually made into fertilizer, from which the chemicals leach out onto farmland somewhere. The contaminants that are not captured in the sludge go out through a tunnel 9.5 miles long with the plant's effluent to Massachusetts Bay, the receiving water for . . . Boston Harbor.

I just don't see the point. Why don't we save the extra expense so Boston and other coastal communities can use that money for things like environmental education in the local schools?

When snow falls from the sky, it goes directly into the Harbor. Let's follow Nature's lead.

Standard of review

2011-01-30T03:01:00.000-08:00

A comment by an eight-year-old girl, exiting last night's tap dance performance by Savion Glover: "That was better than American Idol!"

Cleaning for a Reason

2011-01-29T05:13:00.000-08:00

From a friend:

If you know any woman currently undergoing chemotherapy, please pass the word to here that there is a cleaning service that provides free housekeeping -- once per month for four months while she is in treatment. All she has to do is sign up and have her doctor fax a note confirming the treatment.

Cleaning for a Reason will have a participating maid service in her zip code area arrange for the service. The organization serves the entire USA and currently has 547 partners to help these women.

Be a blessing to someone and pass this information along.

Website for parents

2011-01-27T19:44:00.000-08:00

I'm taking a step away from health care for a moment to offer something that might be of interest to parents. One of my former soccer players, Dr. Alexis Lauricella, sends the following note.

But first this question: How can someone who in my mind is 14 be a Ph.D? Of course, as was always the case, I am really proud of her.

Here's the note:

I just wanted to let you all know that I started a website for parents about child development. I have always felt particularly frustrated by the fact that there are very few services and very little information available to help parents become the best parents they can be. This is only the beginning, but I wanted to create a website/resource where parents can learn about basic child development and parenting information. If you know anyone who is a parent, who may become a parent, or in anyway may benefit from basic child development resources (e.g., teachers, nurses, pediatricians, etc) please feel free to pass along this website and the Facebook page (See below for links) and please feel free to sign up yourselves! The website has resources and a few blog posts and I tend to post articles and interesting resources daily on the Facebook page.

PlayLearnParent Website
PlayLearnParent Facebook Page
PlayLearnParent Email: playlearnparent [at] gmail [dot] com
PlayLearnParent on Twitter: ARL@playlearnparent

I would really appreciate help getting this out to people, so please feel free to pass this along to anyone. And thanks to everyone who has already "liked" PlayLearnParent on Facebook or has taken a look at the website!

Global warming in the extreme?

2011-01-27T05:51:00.000-08:00

Hmm, perhaps the headline writer on Boston.com needs a chemistry lesson.

At least it feels that way!

2011-01-27T05:39:00.000-08:00

Actual image of commuters in Boston this morning after the recent series of snowstorms.

Residency Work Hours on WIHI

2011-01-26T18:06:00.000-08:00

New Models for Residency Work Hours
Thursday, January 27, 2011, 2:00 PM – 3:00 PM Eastern Time

Guests:
Christopher P. Landrigan, MD, MPH, Director, Sleep and Patient Safety Program, Brigham and Women’s Hospital

David B. Sweet, MD, FACP, Program Director, Internal Medicine Residency, Summa Health System

James F. Whiting, MD, Surgical Director, Maine Transplant Program and Surgical Residency Program Director, Maine Medical Center

Donald Goldmann, MD, Senior Vice President, Institute for Healthcare Improvement

If you survey the American public on efforts to restrict the number of hours medical residents can work without sleep or time off, there’s overwhelming support for new rules and regulations. The relationship between lack of sleep and the increased likelihood of impaired judgment and medical errors seems like a no-brainer to most patients. The bigger challenge is to convince residents themselves – and, perhaps even more, those who teach new physicians – that work hour limits make sense...and can be implemented without compromising continuity of care or interfering with education and training. Still, a growing number of residency program leaders are discovering that the only way to move this debate forward is to dig in and start innovating and doing things differently.

David Sweet and James Whiting are two such program directors who will be joining WIHI host Madge Kaplan on January 27 to describe what residency training can look like in systems grounded in patient safety, greater teamwork, better handoffs, increased supervision, and educational redesign. The changes at Summa Health System (16-hour limits are the norm for all residents) and Maine Medical Center are noteworthy; they join a growing number of residency programs not just doing the bare minimum to comply with Accreditation Council for Graduate Medical Education (ACGME) rules, but seeking to create new and better models of care.

Christopher Landrigan’s research on sleep deprivation and patient safety, along with Don Goldmann’s knowledge of hospital improvement and the goals of residency training, will deepen the conversation and round out what is sure to be a rich discussion. Both Drs. Landrigan and Goldmann appreciate the challenges residency programs now face to institute critical changes, but reform also opens up all sorts of possibilities. We hope you’ll join us on the next WIHI.

To enroll, please click here.

Reminders of Art Buchwald

2011-01-26T06:05:00.000-08:00

I cannot locate the article, but I think it was Art Buchwald who once wrote a humorous piece about competition between the two airlines who ran shuttle services between New York and Washington, DC. It went something like this:

The piece opens with a phone call to the US Airways agent. "I see you just raised your fares to New York."

"Yes, we did that to compete against Pan Am. They just raised their fares."

"Wait, I thought the idea of competition was to lower prices."

"Why would we do that? If we lowered our fares, and they followed suit, it would be a race to the bottom. We would both lose money."

Recently, Tufts Health Plan (730,000 members) and Harvard Pilgrim Health Care (1 million members) announced a plan to merge here in Massachusetts. This would leave two major insurers in the state, along with Blue Cross Blue Shield (3 million members).

Not surprisingly, the leaders of the two suitors have said that the merger would cut health costs in the state. Rob Weisman and Kay Lazar at the Boston Globe summarize that view in this article, but in this one, Lazar raises an opposing view:

The bargaining clout of a larger company could help it negotiate better prices from hospitals, but one less major insurer might also mean consumers would have less choice and end up paying more, said officials of leading consumer and business groups.

“Like a town with two gas stations versus four gas stations,’’ said Jon Hurst, president of the 3,000-member Retailers Association of Massachusetts. “Two can copy each other with gas prices, but if you have four, someone is always going to be looking for the edge.’’

Has Mr. Hurst landed on an important distinction? It is one thing to assert that the merger will reduce health costs. That is certainly likely if providers have only two insurers with whom to negotiate payment rates. It is another thing altogether to argue that a merger will reduce premiums. Why?

Well, in a duopoly, as noted by Mr. Buchwald, there is a tendency for the two market participants to fix prices. That is especially the case if one participant is much larger than the other. The dominant player sets the price ceiling and enjoys what economists call "monopoly rents." The secondary player needs only to use that ceiling to establish its prices, at a level just below that of the dominant firm, but also at a level that is higher than would be possible in a truly competitive market, a contestable one that would be characterized by free entry.

Let's think about it this way. If you are on the Board of Tufts or HPHC, why would you merge? The first reason, and the one that I think motivates this decision, is survival. Most observers think an insurance company needs about 2 million subscribers to compete. You need this many to have sufficient economies of scale to drive down transaction costs. You also need that scale to have sufficient access to capital. And, you also need that scale to participate in the national insurance market that now characterizes the needs of large business customers.

Beyond survival, the Board members have to believe that the financial results for the combined entity would be greater than for each one standing alone. Some improvement in that regard can come from eliminating redundant positions and otherwise reducing administrative costs, and some can come from economies of scale in electronic processing of claims and payments. Some would likely come from increased leverage over providers, who will no longer be able to play off one firm against the other.

But what is to prevent some improvement from being derived by the market power of a duopoly, an improvement that would be solely based on extracting more from consumers than would otherwise be the case?

The answer here, as in other industries, must be state regulation. As a former regulator, I will tell you that state regulation is a crude alternative to competition. It is inherently ex post in nature, and it is extremely difficult to get the facts and data you need to do a thorough job.

Nonetheless, with diligent, expert staff, a regulatory agency can do a pretty good job. In this situation, however, the ability of regulators to do well will be dramatically enhanced if the public is let into the process by having total transparency of the accounts of the insurance companies, the premiums they are setting, and the payments being made to the providers.

In essence, the insurance companies in the state have now positioned themselves as public utilities. The secrecy of rates, charges, premiums, actuarial methodology, and the like that have characterized the system have no place in a duopoly environment. To extent current law does not permit this kind of openness, the state should act to make it a condition for the future.

Defining a defect

2011-01-26T00:34:00.000-08:00

From Charles Kenney's book Transforming Health Care, about Virginia Mason Medical Center's journey:

Implementing the program was not a simple matter. Defining a defect in a medical setting presented a challenge.... [D]octors pushed back. The argued that many instances of harm -- ventilator-acquired pneumonia, for example -- should not be considered an error because these things happened in medicine. Complications, they argued, were inevitable.

This is a typical assertion, based on a belief that there is a statistically irreducible amount of harm that must occur in medical settings. There may be such a statistically irreducible amount, but most hospitals are not close to the potential minimum. As Gary Kaplan and his team showed, and as shown at BIDMC, setting an audacious target of zero defects and organizing work to reach that target can enable the people in a organization to reach or get mighty close to that target.

Joseph Gavin strived for such a goal in space flight. Others are doing so in medicine.

Real transparency is a concomitant of success in such a transformation. You cannot improve what you do not acknowledge to be flaws. That is why I pound away below as to its importance and as to why misuse of transparency is unethical.

In her humorous way, Ethel Merman tried to show us the way when she decried the view that "these things happen." But this is deadly serious. Those who stand in the way are causing death and injury as clearly and directly as those who wield weapons.

If you cannot see the video, click here.

Transparency is not marketing

2011-01-24T17:52:00.000-08:00

When is transparency not transparency? Answer: When it is marketing.

A recent ad campaign by a well known hospital system suggests that you are better off going to one of its hospitals if you have a stroke because they have a speedy rate of administration of an anti-clotting agent. It is true that rapid administration of this drug is very important.

But the data offered by this hospital system are old, based on the period 2006-2008. According to the Boston Globe, "State officials said that when data for 2009 and 2010 are released next year, they expect the gap between hospitals will have narrowed because of improved care."

Look, no one will argue that you don't get excellent care at this hospital system. Quite the contrary. But to suggest that you will get better care, based on old data, just isn't right. It might even raise unnecessary concern among patients or their families. Imagine, for example, that a loved one is having a stroke and you ask the ambulance to go to a hospital that is farther away because you think that the patient will get faster treatment. The extra time spent in the ambulance might add danger itself.

Also, selective use of clinical outcomes for marketing purposes is a slippery slope. Let's review the issue, for example, of "door-to-balloon" time. The Joint Commission has set a standard for opening blocked arteries with catheterization (percutaneous coronary intervention) within 90 minutes of presentation at an emergency room in a hospital. The hope is to achieve this goal at least 90% of the time.

But one member of this same hospital system only accomplished this standard about 60% of the time for part of 2009. I don't recall a marketing campaign back then that referred to this result.

You cannot be selective about transparency. You have to post the good and the bad. See the VA story below. If you use it for marketing purposes when the numbers are good, you rightfully open yourself up to attack for selective use of statistics.

Let's just accept that transparency is about holding ourselves accountable to a high standard of care and learning from one another, rather than attempting to use it as a marketing tool.

VA stands for "very accountable"

2011-01-23T19:50:00.000-08:00

A mutual friend recently introduced me to Scott Gould, Deputy Secretary of the Department of Veterans Affairs, who informed me that VA has recently posted the performance data for all 153 medical centers at Veteran's Health Administration on the web. Here's the introduction from the website:

Welcome to the VA Hospital Compare web site. This site is for Veterans, family members and their caregivers to compare the performance of their VA hospitals to other VA hospitals. Using this tool, Veterans, family members, and caregivers can compare the hospital care provided to patients.

Imagine that. They are actually inviting people to make comparisons of clinical quality in their hospitals. I am guessing that this kind of transparency gives people in the individual hospitals an extra incentive to do well. As I have often said about transparency, its main value is in holding ourselves accountable to the standard of care we say we believe in.

This is clearly exemplified by the VA. See below for more from the website. I say bravo and congratulations!

The Secretary of Veterans Affairs (VA) and the VA’s Under Secretary for Health are committed to transparency − giving Americans the facts. The Veterans Health Administration (VHA) releases the quality goals and measured performance of VA health care in order to ensure public accountability and to spur constant improvements in health care delivery. The success of this approach is reflected in our receipt of the Annual Leadership Award from the American College of Medical Quality.

Raising the bar for the 21st century healthcare
Much of the data in LinKS and ASPIRE are simply not measured in other health systems – VA is raising the bar. When available, VA uses outside benchmarks but often sets VA standards or goals at a higher level. VA scores hospitals more than 30% different from the goal as underperforming or red and those only 10% different from the goal are shown in green in ASPIRE. But a red site within the VA might be a good performer compared to outside counterparts. The scoring system is designed to move VA forward. ASPIRE is not about finding fault but about helping VA to target opportunities for improving performance.

Post volcano

2011-01-23T03:15:00.000-08:00

Many of you expressed interest in my earlier two posts about the impact of the Iceland volcano on air traffic in Europe. There is a follow-up article on aerospace-technology.com about this period of time and lessons learned.

Here's an interesting excerpt:

In response to claims that operators should have allowed airlines to fly, Haines states: "It would have been unthinkable to abandon the current international guidance without the necessary evidence - when you are dealing with peoples' lives it is not enough to just make up a less restrictive standard. You have to agree on a new standard based on robust evidence and data."

New standards and new procedures have been researched and developed since April 2010 - including ash measurement, ash location, charting and operational planning.

I'll leave you to read the rest of the article on your own, but I will observe that the airline industry and its regulators seem much more adept than the health care industry in systematically studying adverse and unexpected events, rigorously drawing lessons from them, sharing safety lessons even among competitors, and applying industry-wide solutions quickly.

Plum Island scenes

2011-01-21T15:17:00.000-08:00

An aerial view of a river system? Not quite. It is just a pattern on a winter beach at Plum Island, north of Boston.

Even the walkway to the beach has a special presence on a crisp and cold winter day earlier this week.

Help on sepsis

2011-01-20T17:20:00.000-08:00

Dr. Jim O'Brien, Assistant Director, Medical Intensive Care Unit at the Center for Critical Care at Ohio State University Medical Center, writes with this news and a request:

I sit on the Board of Sepsis Alliance. Our data suggests that only 1 in 3 Americans has heard the word “sepsis” and because of a lack of an organized approach to sepsis care – that is, care consistent with the Global Sepsis Alliance proclamation at the Merinoff Symposium (“recognize sepsis as a medical emergency requiring the administration of fluids and antibiotics within one hour of suspicion”) -- as many as 50% of septic patients die needlessly. That is approximately 100,000 deaths/year in the US alone.

If you have a chance, check out our website and the video we created. We would love any thoughts/ideas you have. This is a disease whose natural history could be changed within the next five years – with therapies we already have.

Religious dogma

2011-01-20T02:14:00.000-08:00

One aspect of religious dogma that has entered the medical world is that fee-for-service pricing of medical services is bad and should be replaced by a capitated, or global, arrangement that establishes an annual budget for care for different risk groups of patients. Like other religious beliefs, this is often offered without rigorous analytic support. Some insurance companies are particularly pleased with this approach because it shifts risk from insurers to providers and makes it easier for the insurers to create budgets and price their products.

Don't get me wrong. This may be the right way to go, but the topic is worth more time and discussion than it has received.

It may be illustrative to think about other sectors of our economy and see which of them are characterized by global payments. Not many. Sure, there are products like cellular phone service that are sold in monthly fixed dollar amounts. But that is because it is a high fixed-cost product, where the marginal cost of additional phone calls is essentially zero. Fixed prices offer revenue stability to the vendor and a way to recover those fixed costs.

But most other goods and services in our economy are sold on a piece-work basis. Think of groceries, automobiles, electricity, gasoline, televisions, and clothing. Why is fee-for-service pricing appropriate for these? Or, in economists' terms, why does such pricing lead to a reasonably efficient solution? The answers are pretty straightforward. Other markets are characterized by open entry and exit and by transparent information concerning quality, value, and pricing. Consumers can make more or less knowledgeable choices based on that publicly available information. New firms enter the market when they see an opportunity. Successful firms grow. Other firms fail.

In contrast, medicine is characterized by friction. Doctors are trained as radiologists, pathologists, or other specialists. The only thing they can do for a living (more or less) is sell their services as specialists. As the people at the Dartmouth Atlas have noted, this leads to supply-driven treatment patterns. If there are more radiologists in a given community, the usage of imaging will be greater than in less well staffed communities.

Likewise, hospitals generally do not come and go. They, too, represent huge investment in fixed costs, and they stay in the marketplace for decades.

But in addition to this, the main attribute of the practice of medicine is opacity. You and I as consumers (patients) have no idea what a given service costs because it is covered by insurance, and the actual rates paid to doctors and hospitals by each insurer are confidential. You and I also have no metrics by which to judge the quality of the service being provided. You have every incentive to request or demand more service for your medical problem.

If you are an insurance company holding a hammer, every problem looks like a nail. What is the most direct thing you try to do to influence levels of care that might be excessive? Design a pricing system that shifts risks to providers and is subject to an annual budget.

But, that is not the only solution. In the post below, I discuss the path being taken by Harvard Pilgrim Health Care. It is good for Massachusetts that two of the largest insurers are trying different approaches. It establishes the possibility of comparing results across the two populations.

Now, though, let me let you in on a little secret with regard to capitated care. Underneath the global budget, there is still a fee-for-service arrangement establishing the transfer prices among the providers in a network. That GI specialist will still get paid for each colonoscopy. The big thing to work out in this system is the allocation of any surplus or deficit in the annual budget among the various specialists.

Unless that allocation is skewed heavily towards primary care doctors, decisions about the level of care given will not change. But, if the allocation is skewed too heavily towards the PCPs, there is no real income signal for the specialists, leading to a danger that they will not feel invested in the end result. Unless the system is accompanied by intensive, real-time reporting, along with clear penalties for excessive care, it will not work.

Did I say penalties? You bet. Without those, there is no enforcement of the global budget. But with those, global budgets are likely to raises hackles and resentment among specialists. I predict that the biggest issue facing physician groups in the coming years is the perceived interference by the global payment risk unit in the clinical decisions made by specialists.

If we were designing the health care system from scratch, I am guessing that the HPHC approach would be more likely chosen than a global payment approach. It would be accompanied by a shared savings mechanism, where physician groups and hospitals that beat an annual budget target would get a cash reward. It would also have a hefty dose of transparency with regard to clinical outcomes, so that the pricing levels charged by each provider would be accompanied by meaningful medical information that could help consumers make more rational choices. In short, a lot of the opacity of the health care delivery system would be eliminated.

That does not solve the problem of friction with regard to market entry and exit by doctors and hospitals. But global payments are weak on that front, too. Such friction may be an inherent characteristic of this sector for some time to come -- unless, as appears likely, overall payment rates for Medicare, Medicaid, and private insurers fail to keep up with the cost of living. In that case, the future will belong to the efficient, hospitals and doctors who implement Lean or other front-line driven process improvement.

Dear JC, give everything away for free

2011-01-19T02:04:00.000-08:00

An article by Nina MacLaughlin in the Boston Phoenix entitled "Unlocking Knowledge" reminded me of the extraordinary step taken by MIT a decade ago -- a decision to offer course materials online, free to the world.

Here are the introductory excerpts:

Back in 2000 . . . the MIT faculty had to answer two questions: how is the Internet going to change education? And what are we going to do about it?

Distance learning was about to take off, and there was money to be made. Some MIT professors were already in the habit of posting their course materials online so that students could access them informally. But when monetizing this practice became a possibility, people got concerned that the business model ran counter to the school's mission — a commitment to generate, disseminate, and preserve knowledge.

So they took a step back. "We said, 'Let's stop thinking about money," says Stephen Carson, the director of external affairs of MIT OpenCourseWare, "and start thinking about what we can do to create benefit.' " They asked themselves: what's the Internet good at? (Spreading information widely.) What's MIT good at? (The classroom experience.) The faculty drew up a 10-page report making a case for why the conventional distance-learning model wasn't the right route to take. On top of that report — a one-page memo with a bold statement: let's give everything away for free.

Wow. The result was OpenCourseWare, the Web-based publication of virtually all course content from the graduate and undergraduate subjects taught at MIT. Notes MacLaughlin,

The site now welcomes an average one million visitors per month with the tagline: "Unlocking knowledge, empowering minds. Free lecture notes, exams, and videos from MIT. No registration required." It's a system that means Kunle Adejumo, an engineering student at Ahmadu Bello University in Zaria, Nigeria, can supplement and complement the materials and experience he's getting at his own school, which has limited resources and computer access.

It also means that any interested human can click on the course offerings — pick, say, "Problems of Philosophy" — and select whatever lecture topic might be of most interest.

Let's now view a contrasting approach. The Joint Commission, the main accrediting body for hospitals, recently created a Leading Practice Library. This is an outstanding idea. As the commission conducts its accreditation surveys, it encounters many excellent practices in the hospitals it reviews. The idea of the library is to share these stories more broadly.

But read this description and note the implicit exclusion:

The Leading Practice Library is a complimentary tool available to organizations that are currently accredited or certified by The Joint Commission. The documents in the Library are real life solutions that have been successfully implemented by health care organizations and reviewed by Joint Commission standards experts. The Library was built from solutions that organizations have contributed that support patient safety and quality health care. By accessing the Library link, which is located on each accredited organization’s extranet page, users can browse through specific topics of interest related to their own organization and browse as many documents and topics as needed at any time.

Did you catch it? You have to be a subscribing organization to get access to these helpful stories. Why not, like MIT, open them up to the world? If the library would be of value to accredited hospitals, wouldn't it also be valuable to individual patients and consumers who are involved in their own care or who are working as advocates to improve the health care system in general? Would it not also be useful to private practice physicians who refer patients to hospitals, so they could ask possible referral sites if they have considered these best practices? And, of course, wouldn't it be of value to the thousands of doctors, nurses, lab techs, rad techs, trainees, and others in subscriber hospitals who do not ordinarily know (or even know to ask) the password needed to get into the JC's website.

Also, these case studies could provide fodder for fascinating academic work on process improvement. You could imagine the Joint Commission creating alliances with medical schools and the like to have professors and student study them and write journal articles or white papers that elicit even more interesting things from the cases.

Having met a number of the JC surveyors, I know that this work is an outgrowth of what they have been doing informally for a number of years--sharing the best practices they themselves observed or heard about from their peers. I would guess that the surveyors would be pleased to know that the results of their work are being more broadly distributed.

If that were not enough reason, let us recall that the JC does its work on behalf of the federal government, serving as the accreditation body for Medicare. As such, it is not just a private organization. It is more quasi-public in nature. How could we justify limiting the accessibility of government-sponsored work products in an era of transparency?

Finally, on the business front, when it comes to quality and safety, broader distribution of ideas and programs would also add value to accredited bodies for the fee they pay the Joint Commission. Look at Institute for Healthcare Improvement, with its absolutely free Open School, which gets tens of thousands of viewers. It has not hurt and has probably helped IHI's programs that are revenue producing.

So dear Joint Commission, take a leaf out of MIT's book. Give it away for free. Make it easy for anyone to read.

And if you really want to be social media savvy, check out this last thought from the Phoenix story:

What MIT OCW offers is the content. The school is now pairing with the social learning network OpenStudy, which offers the interactivity to create opportunities to engage with other learners. So when you're scratching your head over a single-variable calculus problem, you can connect with others taking the same course and puzzle through it together.

Imagine the potential!

Henna relief for Xeloda patients

2011-01-18T05:47:00.000-08:00

Here's an excellent article by Roni Caryn Rabin in the New York Times by about living with metastatic breast cancer. Hidden in the middle is an excerpt about one patient:

When they find a drug their tumor responds to, they can achieve a remarkable degree of stability. Pat Strassner, 61, of Severna Park, Md., had breast cancer that spread to her lung and hip in 2007, but she has had success with a chemo pill called Xeloda for the past three years. The drug has side effects, including drying out the skin on her hands and feet so much that they crack and bleed....

What a shame that Ms. Strassner did not know about a simple treatment for that syndrome, published by Monique Doyle Spencer, author of The Courage Muscle.

What a bigger shame that she and others have not been told by Roche Pharmaceuticals about this approach, presumably because of some corporate fear of running afoul of FDA regulations.

HPHC goes its way, thoughtfully

2011-01-18T02:27:00.000-08:00

Lots of people are thinking about the form of payments between insurance companies and providers for health care services, but it is also important to think about how each such approach would be marketed as an insurance product to the population.

The payment model that gets the most attention is capitated, or global payments, combined with accountable care organizations. In this environment, an average annual budget is established for each person served by an integrated health care delivery system (ACO), and that budget is shared among the providers according to some mutually agreed upon arrangement.

But the insurance product that would accompany this kind of payment scheme is often left without much of a description. As I have talked with insurance executives, they often fail to explain how they would offer consumers a desirable choice for a product based on this payment plan. Instead the main focus seems to be on shifting risk from the insurer to the providers, reducing the amount of unnecessary expenses, and sharing the benefits of those changes between the insurance company and the providers. Over time, the theory goes, the cost curve is slowed and premiums go up less quickly. But, it remains unclear what the role is for consumer in this scheme.

Eric Schultz, the CEO of Harvard Pilgrim Health Care, is offering a different view. I heard him give a talk the other day and have read some of his company's materials. I will try to offer a fair representation here.

Eric recognizes that changes in the payment and insurance system will have to evolve over an extended period. Noting that the current system has been in place for decades, he views that time frame as being well over five years, and more like ten. He seems to be advocating a step-wise plan, one that allows time for consumer and provider education and one that envisions mid-course corrections when the inevitable unintended consequences emerge. He is keen to avoid the kind of consumer and physician misunderstanding and resentment that characterized previous adventures in capitation.

His approach is exemplified in two new product lines being offered by HPHC. The first is called Focus Network and is described here.In essence, this is a plan that offers consumers less choice, relying on service from lower cost providers, and it enables HPHC to offer a premium that is 10 to 14% below the standard product.

How is it sold? While the Focus Network offers less choice, the consumer gets a clear choice between it and the standard plan. In a side-by-side comparison, a subscriber can see the difference clearly. Very importantly, HPHC advises its corporate customers to offer employees a defined dollar contribution towards their health care benefit. Doing it this way, rather than offering a defined percentage, ensures that the price differential between the two plans is not watered down in the eyes of the subscribers.

The second product line is a tiered network, where providers are grouped according to their cost. Well, not cost -- price -- i.e., the negotiated rates between HPHC and the providers. Physician groups (not individual doctors) are to be put in a tier based on the total medical expense of their patients (including hospitalization costs.) Hospitals will be specifically tiered based on their own expenses. Then, consumers get to choose their site of service, knowing that their personal co-pays and deductibles rise or fall depending on the tier chosen.

Under both schemes, the fee-for-service payment regime remains in effect, with a healthy dose of pay-for-performance incentives. In other words, global payments are not viewed as being necessary to change practice patterns or to influence consumer choice.

As I see it, Schultz is willing to bet that his approach will bend the cost curve with potentially less public outcry and backlash than might occur with others. I also am guessing that he wants to maintain HPHC's reputation among consumers as an excellent HMO, something that is important as employers choose between HPHC and other insurers. He is doing so in a way that engages and educates consumers -- and offers elements of choice -- rather than imposing a new system that will appear to some as taking it away.

Nifty fellowship opportunity

2011-01-17T14:30:00.000-08:00

Here's a great fellowship opportunity in biomedical imaging being offered by the Madrid-MIT M+Visión Consortium program. Applications are welcome from people of all nations, and with a variety of backgrounds. Here is an excerpt from the description:

With a focus on accelerating innovation in biomedical imaging, promoting translational research, and encouraging entrepreneurship, the Madrid-MIT M+Visión Consortium is currently recruiting bright young talent from all over the world – engineers, physicians, scientists, and entrepreneurs interested in biomedical imaging who are in search of a career-enhancing experience and want to make their mark on the world.

Over the course of a one- or two-year fellowship in Madrid, Spain, and Boston, Massachusetts – supported by a generous stipend and travel expenses – you will be part of a team that will accelerate cutting-edge research in imaging, translate that research from bench to bedside, and establish new enterprises to enhance and enrich Madrid's biomedical research community. Your knowledge, skills, network, and career track will all be enhanced from this remarkable experience.

Ten fellowships will be awarded. The deadline is January 25. To apply visit this site.

Let freedom ring!

2011-01-16T04:36:00.000-08:00

As we celebrate the memory of Martin Luther King, Jr., in the US this week, it is moving to revisit his August 28, 1963, "I have a dream" speech. This is oratory at its absolute best. There are gems in virtually every sentence -- a use of metaphor that is unparalleled. And a construction of the entire speech that is incredibly powerful, with a rhythmic repetition of key themes that builds in intensity and beauty.

View it as a great speech, but also view it as a lesson that needs to be reinforced regularly. Please take the 12 minutes and watch the whole thing.

If you cannot view the video, click here.

Weather-appropriate attire

2011-01-14T11:30:00.000-08:00

Seen in the Prouty Garden at Children's Hospital Boston.

I just hadn't reached a conclusion

2011-01-13T12:01:00.000-08:00

It is not soccer season -- certainly not with a blizzard here in Boston -- but reminders abound. Yesterday, I ran into one of my former players as she was heading home from sledding with a neighbor, and I was reminded of her remark one day during practice in 2009.

Me to 12-year-old girls: I want you to try to remember to think about what you are going to do with the ball before it gets to you. If you wait until it arrives, you will be under too much pressure to do the right thing.

Next: Ball arrives at Margaret's feet, and she boots it away to nowhere.

Me to Margaret: Margaret, you weren't thinking about the ball before it got to you.

Margaret: Yes, I was thinking about it. I just hadn't reached a conclusion.

Management lesson. People think at different speeds.

Washington hospitals lead again

2011-01-12T19:29:00.000-08:00

What is in the water out there in Washington? I have written before about the leadership displayed by the Washington State Hospital Association with regard to transparency and process improvement. Now they go and win the annual John M. Eisenberg Patient Safety and Quality Award from the Joint Commission and the National Quality Forum.

According to this release, "This organization is recognized for its Safe Tables Learning Collaborative program. The program provides the infrastructure for Washington hospitals to share experiences and learn from one other and from patient safety experts."

Bravo and congratulations!

WIHI on Specialty Care

2011-01-12T12:01:00.000-08:00

The Institute for Healthcare Improvement offers another engaging webcast. Here are the details. Click here to sign up for this free program.

The Power of Specialty Care – and the Necessity to Use It Wisely

Thursday, January 13, 2011
2:00 PM – 3:00 PM Eastern Time

Featuring:

Neil Baker, MD, IHI Faculty and Improvement Advisor; Improvement Consultant, Neil Baker Consulting

Lawrence Shapiro, MD, Managed Care Medical Director, Palo Alto Medical Foundation

Here’s something most clinical and quality leaders agree with: a lot of specialty care isn’t always necessary or beneficial. What’s more, there’s tremendous variation across the US in the use of specialist services -- variation that tends to be driven by the volume of what’s available, not the health needs of a community’s residents. Meanwhile, in the trenches of decision making and with state-of-the-art interventions available to diagnose and treat diseases of all sorts, doctors and patients want what’s best, and potentially lifesaving. We applaud the oncologist who’s carefully helping a patient with cancer weigh treatment options; we respect the cardiologist who’s prescribing someone who’s had a heart attack the best medications to prevent a recurrence; we want the C-section for the pregnant woman who might lose her baby otherwise.

It’s in this context that Doctors Neil Baker and Lawrence Shapiro and others are hard at work creating a framework to help providers get closer to an appropriate use of specialty services – to reduce unnecessary health care costs and to deliver better care to patients. Neil Baker is the co-author of a 2010 IHI White Paper, Reducing Costs Through the Appropriate Use of Specialty Services, that lays out a six-step process for generating good data about current practice patterns, analyzing the information, and making agreed-upon changes. In this model, physicians (including those making referrals to specialists) are partners and problem solvers in their areas of expertise, not passive recipients of external rules. Just ask Lawrence Shapiro. The work that’s been underway at the Palo Alto Medical Foundation is case in point of what’s possible -- and he’ll be on hand, along with Neil Baker, on WIHI to tell you about it first-hand.

Improving when, why, and how specialty care is tapped also intersects with robust work going on across the country, and globally, with shared decision making—where patients, too, better understand their options and the benefits, or not, of obtaining specialty care. WIHI host Madge Kaplan welcomes this opportunity to delve into a topic that is not rocket science in terms of solutions but deserves plenty of attention and requires the best minds, and experiences on the ground, in order to make the right kinds of changes. Please join us on January 13, the first WIHI program of 2011, and be sure to invite your colleagues to join, too.

Truth or consequences

2011-01-12T06:54:00.000-08:00

While we are on the topic of medical errors, let's see how doctors feel about disclosing them when the patient has not been harmed. Medscape recently surveyed doctors on this question and published the results in a provocative article by Gail Garfinkel Weiss entitled: 'Some Worms Are Best Left in the Can' -- Should You Hide Medical Errors?" (A subscription is required, but it is free.)

To the doctors reading this, into which camp do you fall? To the patients reading this, what would you expect of your doctor in this kind of situation?

Some excerpts:

In response to the question "Are there times when it's acceptable to cover up or avoid revealing a mistake if that mistake would not cause harm to the patient?" 60.1% of respondents answered "no," and the remaining respondents were almost evenly divided between "yes" (19%) and "it depends" (20.9%).

Professor Margaret R. Moon, MD, MPH, a pediatrician and faculty member at the Johns Hopkins Berman Institute of Bioethics at Johns Hopkins University, is squarely in the "no" camp. "Physicians have a duty to put the patient's well-being first -- specifically, before their own," she says. "If patients don't believe the physician will do that, the whole doctor-patient relationship falls apart. In some circumstances, a physician might believe that the disclosure of error might harm the patient more than benefit the patient. But because it's difficult to know ahead of time how much a reasonable patient would want to know, erring on the side of disclosure makes the most sense."

Among the comments on the "yes"' side:

If there is a mistake that would have no medical effect but would cause extreme, uncalled-for anxiety, then yes.
Why make a mountain out of a molehill if it will cause the patient more emotional upset than not saying anything?
I see no benefit in revealing mistakes of no consequence, like giving a patient Tylenol 650 mg instead of 325 mg.
Why shake the patient's trust in the doctor for something that is irrelevant?

A somewhat different question about medical errors -- "Are there times when it is acceptable to cover up or avoid revealing a mistake if that mistake would potentially or likely harm the patient?" -- drew an almost unanimous response. A whopping 94.9% answered in the negative, 1.6% said "yes," and 3.5% said "it depends."

Some "yes" respondents hedged their bets, with one saying, "I would contact an attorney first." Another, who had no such hesitation, said, "If the mistake has not progressed to harmfulness, then it's essentially a non-issue. Treatment correction takes place and you move on." Ditto for the respondent who endorsed nondisclosure "if the mistake appears in no way possibly significant now or in the future."

What do medical errors cost your state?

2011-01-12T01:43:00.000-08:00

GE Healthcare offers this calculator, based on data from the Society of Actuaries, to show the cost of medical errors for a given population. I inserted the population of Massachusetts from the most recent US Census to see what would pop up. Here is the result.

I suspect this figure of $260+ million is actually an underestimate because there is a lot of preventable harm that does not get counted as such. For example, we reduced our rate of ventilator associated pneumonia at BIDMC considerably over the last three years by rigorous application of the VAP bundle. Likewise at Cooley Dickinson Hospital in Northhampton, MA.

As best as I can tell, VAP is not included in the statistics above. Chances are those cases previously would not have been counted as medical errors. They were just part of the mentality of "these things happen," a belief by many that the current level of harm caused by hospitals is a statistically irreducible number.

Notice that I say "caused by hospitals," and not "occurring in hospitals." Until we take ownership of the fact that a great degree of harm that occurs in hospitals is caused by failures in the manner of delivering care, we will not make progress.

Jubilee presents 50 People, 1 Question

2011-01-11T12:53:00.000-08:00

I have written below about the Jubilee Project, a non-profit that that harnesses the power of Internet videos and the spirit of philanthropy. Here's their latest video. I think it is compelling. Enjoy!

If you cannot see the video, click here.

Tsokos takes on Lupus

2011-01-11T10:51:00.000-08:00

Fellow riders on my Moroccan bike ride a couple of weeks ago would often ask about BIDMC's clinical specialties. Without giving much thought, I would say, "The usual -- cancer, cardio-vascular disease, GI, orthopaedics, infectious disease, diabetes." But upon return, I realized I had shortchanged some of my colleagues. So it is time to set that aright, at least in part.

I just visited with George Tsokos, chief of our Rheumatology Division. In the short time since his arrival here in 2007, George has built Boston's largest Lupus clinical program. Systemic lupus erythematosus is an auto-immune disease that mainly strikes young women. It can be seriously debilitating. Its course is unpredictable, and treatment currently is focused on resolving symptoms, not reversing the disease itself.

George's group also has the region's largest research program. He and his colleagues study the cellular and molecular mechanisms of the disease and the mechanisms that lead to tissue injury. His aim is to identify molecular therapeutic targets and disease activity biomarkers.

He has plans to join with Martin Pollak, our chief of Nephrology, to create an interdisciplinary clinic. Why? Well, about 60% of people with Lupus show symptoms related to the kidneys.

George was recruited by Mark Zeidel, our Chief of Medicine, who saw a need for the Boston metropolitan area to focus on this disease. Interestingly, this was a humanitarian goal, as the reimbursement rates for physicians in this field are not very attractive. Diagnosis and treatment do not to involve procedures, so there is no significant gain for the hospital, either. When Mark approached me with this idea, I wholeheartedly supported it.

This is an important aspect of academic medical centers that is worthwhile for policy-makers and insurance companies to remember. While there are aspects of our clinical services that are well paid and produce a margin, there are others that make no money or lose money. But, for a young woman with Lupus, having a place to go and be seen by one of the world's specialists is very important. Mark and George make a persuasive case that this is sound thinking, even if it is not good business.

Knowledge Matters in the UK

2011-01-11T02:49:00.000-08:00

Whilst (hah!) at the IHI Annual Forum Poster Session, I had a chance to meet some delightful folks from the United Kingdom. (See minute 5:25 in the video on that blog post.) Samantha Riley, Head of the Quality Observatory at NHS South East Coast, later wrote me to say:

I thought that you might be interested to see the latest edition of our newsletter - Knowledge Matters. We produce this every two months. It provides a range of articles on measurement, analysis and quality. Back issues of the newsletter can be viewed at this website.

She added,

The next edition will be February. As you will have hopefully seen, we aim for the newsletter to be fun but informative. We do have a very wide circulation across our region (the three counties of Surrey, Sussex and Kent), also across the UK and we have a few international subscribers (which will hopefully increase if you write about Knowledge Matters on your blog!) The newsletter is produced totally in house by my team - we're now nearly into our fifth year. We started with four pages and the December edition was up to 24 pages!

If people would like to subscribe the best way to get in touch with us it to e-mail quality [dot] observatory [at] southeastcoast [dot] nhs [dot] uk.

Take a look. This is a great example of a locally produced, informative and engaging newsletter. Others may want to consider a similar approach and/or may just want to subscribe to this one.

Accountability? Heaven forbid!

2011-01-10T10:06:00.000-08:00

At a recent talk, Dartmouth's Elliott Fisher facetiously remarked that we cannot yet be sure whether accountable care organizations (ACOs) will actually be accountable, caring, and organized. Well, if some providers have their way, they certainly won't be accountable.

This story by Jordan Rau in the Washington Post relates comments being made as Medicare writes its rules governing the ACOs. Here are some quotes:

[S]ome prominent doctor and hospital groups are pushing for features that some experts say could undermine the overall goal - improving care while containing costs. They're seeking limits on how the quality of their care will be judged, along with bonus rules that would make it easier for them to be paid extra for their work and to be paid quickly.

Here's the one I like best:

The Federation of American Hospitals, representing for-profit facilities, goes further, urging that ACOs be allowed to choose their patients. "Providers are better positioned than CMS to determine which of their patients would be appropriate candidates," the federation wrote.

So, we are happy to be held accountable, but only if we get to choose which patients are part of our network.

And, how about this from the American Medical Association?

The medical association doesn't want surveys of patient experiences to be used in evaluating ACOs.

Right. What do the patients know, anyway?

And from my soon-to-be-former hospital association:

In the dispute over financial incentives, the American Hospital Association is pushing CMS to let providers collect bonuses early on and in full rather than having some of the bonuses deferred as an added incentive to keep up the good work.

Collect bonuses before you earn them? Of course.