Thursday, March 31, 2011

Crowdsourcing for his book

Mark Graban, an expert on the use of Lean process improvement in hospitals, has opened up his own process as he prepares revisions of the "Visions of a Lean Hospital" ideal state chapter in his book, Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction.

He notes on his blog:

I’ve shared the first chapter of the book for those who signed up on my book’s site. Now as I’m making revisions, I’d like to get your input and ideas around the final chapter – “A Vision for a Lean Hospital.” I think the chapter has some good ideas, but given my audience here, I’m not going to pretend I have all the answers for hospitals. So I’d like to hear what you think in the comments for this post, or email me. What’s missing? What’s confusing? What’s wrong?

Here's your chance to be a ghost writer!

How the veterans are winning the war

At a seminar last night at the Center for Public Leadership at Harvard's Kennedy School, one of the students asked a question along the lines of, "How do you know when you have done too much with regard to transparency?" My answer was that the question presupposed the wrong approach to transparency, that it was being driven by the CEO without proper attention to the efficacy and appropriateness of what was being measured and disclosed. Instead, I suggested that it should be driven by the leadership of the organization, but based on metrics that were viewed as useful and appropriate by the clinical staff. In such an instance, transparency serves the function laid out by IHI's Jim Conway, as summarized here in an article discussing the BIDMC experience:

[P]ublic reporting created what management guru Peter Senge calls creative tension, a key in getting an organization to change. Announcing a daring vision — the elimination of patient harm — combined with honestly publicizing the problems, fuels improvement, he said.

I expressed the concern last night that the general recalcitrance of the medical profession about engaging transparency will inevitably lead to fiats about disclosure from government regulatory agencies. The problem with those fiats is that they will be grossly constructed and force hospitals and doctors to focus on the wrong things, in a manner not consistent with widely established principles of process improvement. (See, for example, this approach in Maryland.)

Now comes the Veterans Administration, proving the case with panache! You may recall my complimentary post on the VA back in January. Thomas Burton's article this week in the Wall Street Journal -- "Data Spur Changes in VA Care" -- documents this in more detail. Some excerpts:

Hospitals serving U.S. military veterans are moving fast to improve care after the government opened a trove of performance data—including surgical death rates—to the public.

The information was released at the urging of VA Secretary Eric K. Shinseki. Among other things, it presents hospitals' rates of infection from the use of ventilators and intravenous lines, and of readmissions due to medical complications. The details have been adjusted to account for patients' ages and relative frailty.

"Why would we not want our performance to be public? It's good for VA's leaders and managers, good for our work force, and most importantly, it is good for the veterans we serve," Mr. Shinseki said in an emailed statement.

At VA hospitals in Oklahoma City and Salem, Va., the rate of pneumonia acquired by patients on ventilators was shown last fall to be significantly higher than the national VA average. The Salem hospital says a relatively low number of patients on ventilators skewed its infection rate higher, but staff members at both facilities say the numbers prompted action.

Seeing the data helped, says the Salem hospital's chief of surgery, Gary Collin, because "you can become kind of complacent."

In contrast, notes the article:

This unusually comprehensive sort of consumer information on medical outcomes remains largely hidden from the tens of millions of Americans outside the VA system, including many of those in the federal Medicare system.

And, as I reported last month,

A November 2010 report from the Health and Human Services inspector general concluded that one in seven Medicare patients is harmed by medical care, nearly half of those avoidably.

Conway is right. Senge is right. The veterans have figured out how to start winning the war for patient safety and quality and process improvement. The rest of the profession is in retreat and is letting the wrong people design the battle plan.

Wednesday, March 30, 2011

Conversation at the Center for Public Leadership

Many thanks to the Center for Public Leadership at Harvard's Kennedy School for inviting me to meet with the Zukerman and Dubin Fellows tonight. The Zuckerman Fellows are graduate students or professionals from the fields of law, business, or medicine who are pursuing a second degree in health, education, or public policy in order to broaden and deepen their understanding of public sector issues. The Dubin Fellows are master's degree students at the JFK School who have demonstrated strong character, academic excellence, the ability to thrive and lead in the face of adversity, and a commitment to making a transformative impact on the communities they serve.

My topic was about lessons from leadership positions, with a particular focus on engaging front-line staff in process improvement, building constituencies in the complex environment of academic medical centers, and the importance of transparency in both clinical and administrative matters.

I promised to post the pictures of those who asked especially good questions, but everyone did! I don't have room here for all, but I include a few. Special thanks to Laura Burke (bottom right), a resident in Emergency Medicine at BIDMC, for her role in organizing tonight's event.

Tuesday, March 29, 2011

It's not "nothing" -- Accepting gratitude

A friend and I were discussing the point that effective communication is most likely to occur when the other person feels that you understand his or her situation. This is an underlying premise of negotiation theory: You are more likely to be successful at a negotiation when you understand the other person's underlying interests and when you make it clear to that person that you do. To do otherwise, whether in negotiations or other settings, is likely to lead to speaking at a person, rather than to the person. Not because you mean to, but because the other person will not value what you say, compared to when they think you really "get it."

One of the things I learned in my hospital days was how to accept gratitude. A hospital can be an uncomfortable place for patients and family members. It is a strange physical environment, where people are anxious because of feared or actual medical conditions or forthcoming procedures or tests. In that situation, when you do something kind for someone, the person is truly grateful. It can be as simple as offering directions, or picking up a fallen object, or something much more serious.

When I started working in the hospital, when someone would say "Thank you" to me, I would often answer, "It's nothing," or "No problem." Wrong! I was taught that such an answer devalues the gratitude that the other person is feeling. A more appropriate response is, "It is my pleasure," or "I am so pleased I was able to help." That indicates that you understand their feelings.

Over the years, I trained myself to do this. Lo and behold, once I got rid of the "It's nothing" conversation stopper, people would jump in and continue the conversation even further. I was able to learn so much more about people's fears, expectations, experiences, and hopes and then help translate those into improvements in the clinical environment.

Try it. It's not "nothing."

Monday, March 28, 2011

A mentor hospital

The Institute for Healthcare Improvement gives the following update. How impressive! And how generous of Columbia Regional to offer to share what they have learned. What a shame that The Joint Commission has not followed this lead by making its best practice library available to all.

Mentor Hospital Goes 5 Years Without a VAP

Columbus Regional LogoStaff at Columbus Regional Hospital in Columbus, IN, recently celebrated an amazing accomplishment. They have gone five years without a single incidence of a ventilator-associated pneumonia (VAP). These deadly pneumonias used to be considered an unfortunate reality in ICUs. As a participant in IHI's 100,000 Lives and 5 Million Lives Campaigns, the hospital took aim at reducing VAP by implementing the IHI Ventilator Bundle, evidence-based care guidelines that, when reliably applied, can drastically reduce and even eliminate these infections. One of the enduring legacies of the Campaigns is a robust registry of mentor hospitals, facilities that have outstanding track records in improvement in Campaign-related topic areas that have generously agreed to provide support and clinical expertise to hospitals seeking help with their implementation efforts. Columbus Regional has been a mentor hospital since 2006 for the topics of VAP, Rapid Response Systems, the Central Line Bundle, and Heart Failure Core Processes. IHI congratulates Columbus Regional on their tremendous achievements.

Saturday, March 26, 2011

Please nominate for Schwartz Center Award

I am pleased to post this at the request of the Schwartz Center. Please see below and consider people or groups of people who might be worthy recipients of this award:

Nominations Open for Schwartz Center Compassionate Caregiver Award®
New England Caregivers Sought Who Demonstrate Extraordinary Compassion for Patients

Boston, MA (March 22, 2011) – The Schwartz Center for Compassionate Healthcare, a nonprofit organization dedicated to strengthening the patient-caregiver relationship, is seeking nominations for its 2011 Schwartz Center Compassionate Caregiver Award®. For the first time since the program began in 1999, caregivers from all six New England states are eligible.

The winner will receive $5,000 and be honored at the Kenneth B. Schwartz Compassionate Healthcare Dinner on November 17th at the Boston Convention Center. Last year’s event attracted more than 2,000 attendees. Four finalists will also be recognized and receive $1,000 each. Nominations are due April 22, 2011. Information on how to nominate a caregiver for this prestigious award is available on the Schwartz Center’s website.

The center and award are named after Ken Schwartz, a Boston healthcare attorney who died of lung cancer in 1995 and came to believe that medicine is about more than performing tests and surgeries, or administering drugs. As he wrote in an article published in the Boston Globe Magazine, “These functions, as important as they are, are just the beginning. For as skilled and knowledgeable as my caregivers are, what matters most is that they have empathized with me in a way that gives me hope and makes me feel like a human being, not just an illness.”

Nominees must work in a health-related organization or practice, such as a hospital, physician office, outpatient clinic, community health center, visiting nurse or home health agency, nursing home, or hospice organization. Any paid caregiver or team of caregivers with direct patient contact in Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island or Vermont is eligible. Nominees may include physicians, nurses, physical and occupational therapists, social workers, psychologists, nurse practitioners, physician assistants, certified nursing assistants, home health aides, and chaplains – as well as interdisciplinary teams. Nominations may be made by patients or healthcare professionals.

In 2010, the Schwartz Center Compassionate Caregiver Award® was given to the Haitian Mental Health Team at Cambridge Health Alliance in Massachusetts. In 2009, the award went to Dr. Amy Ship, an internist in the Division of General Medicine and Primary Care at Beth Israel Deaconess Medical Center in Boston. [My note: Listen to her speech here.]

The winner and finalists will be selected by a regional review committee based on how well the individual or team embodies the characteristics of compassionate healthcare, which are defined by the Schwartz Center as follows:

  • Showing respect for the patient, the patient’s family, and those important to the patient
  • Conveying information in a way that is understandable
  • Treating the patient as a person, not just a disease
  • Listening attentively to the patient
  • Striving to gain the patient’s trust
  • Always involving the patient in treatment decisions
  • Apologizing to a patient if a caregiver makes a mistake
  • Communicating test results in a timely and sensitive manner
  • Comfortably discussing sensitive, emotional or psychological issues
  • Considering the effect of an illness on the patient, the patient’s family, and those important to the patient
  • Expressing sensitivity, caring and compassion for the patient’s situation
  • Spending enough time with the patient
  • Striving to understand the patient’s emotional needs
  • Giving the patient hope, even when the news is bad
  • Showing understanding of the patient’s cultural and religious beliefs

The Schwartz Center for Compassionate Healthcare was founded in 1995 by Ken Schwartz, a prominent Boston healthcare attorney who died of lung cancer at the age of 40. Based at Massachusetts General Hospital in Boston, the center sponsors programs to educate, train and support caregivers to provide compassionate, patient-centered care. Its signature program, Schwartz Center Rounds, has been adopted by 215 hospitals, outpatient centers and nursing homes in 32 states and reaches more than 60,000 clinicians a year.

The Schwartz Center Compassionate Caregiver Award is made possible in part by the generosity of AstraZeneca, a leading pharmaceutical company.

Cheaper than newspaper ads, I guess

You can tell it is spring in New England when your yard gets pelted with these. They are advertisements for landscaping companies. The proprietors drive through the neighborhoods tossing out plastic bags weighted down by pieces of pea gravel.

These seem to be about as effective as hospital advertising -- which is to say, not very -- if we are to judge from the fact that most of them lie untouched for weeks.

Thursday, March 24, 2011

Two Degrees delivers

You may remember my post about Two Degrees, a company that donates a packet of food supplement for each nutrition bar they sell. Well, they recently went to Africa and made their first delivery -- 10,800 nutrition packs to malnourished children in Malawi. Here is a picture of co-founder Will Hauser and a local community health worker preparing to disburse the Two Degrees/Valid Nutrition RUTF packs. You can read more about it on Will's blog post. You can also follow this activities of this innovative company on their Facebook page.

Remember, the food supplement is produced locally, so jobs are created, also.

The company is seeking companies, colleges, schools, and other institutions who might want to distribute and sell the bars in company cafeterias and snack bars and other corporate settings. I will vouch for the taste and nutrition (as they helped me and some friends get through a bike trip in the Atlas Mountains), the integrity of the founders, and the good cause. (I have no financial interest in the company.)

Wednesday, March 23, 2011

Choosing to stop dialysis

I know there has been a lot written about assisted suicide, but this is in the category of a patient choosing to forgo treatment when he or she knows it will lead to death. It comes from a friend who writes about a relative, noting, "I think this is an interesting situation, with a lot of moral threads hanging from it." There are no children involved or living parents.

M (age in mid-60s) is stopping dialysis because his quality of life is too sucky for him to want to continue. He is legally blind and can't read or watch movies for more than a short time per day. As far as I know there is no physical pain. He did have a long time dealing with infection from a botched surgery, about a year, which might be influencing his thinking, but I don't know.

I have mixed feelings. He is relatively young, but I know you join me in wishing him the least painful way out.

Neither I, nor you, dear readers, have a right to judge the actions of the patient. (Remember that Art Buchwald did the same thing?) Perhaps, though, we can offer advice to my friend as to how to handle the situation now and afterward, for he feels he will have to explain to other friends and relatives that he knew what was coming but could not reveal it.

Tuesday, March 22, 2011

That will be a marvelous kiss!

Although I have talked before about the tendency for medical priorities to be based on the "rule of rescue" rather than more cost-effective reasoning, who cannot be moved by this recent surgical success at Brigham and Women's Hospital? Excerpts from the Boston Globe story by Kay Lazar:

[A] 25-year-old Texas man suffered horrific burns in a 2008 electrical accident that obliterated his lips and most of his other features, but last week he received the nation’s first full face transplant.

“Dallas is looking forward to giving his daughter a kiss again,’’ Dr. Bohdan Pomahac, director of the Brigham’s burn unit and the plastic surgeon who led the transplant team, said in an interview after yesterday’s announcement. “It’s such a simple human function that we take for granted.’’

To modify a quote from The Princess Bride:

“Since the invention of the kiss, there have only been five kisses that were rated . . . the most pure. This one will leave them all behind.”

Indeed. Congratulations to the team!

Monday, March 21, 2011

Maryly proceeding off course

Maryland, the only state with a hospital rate-setting process, also has an interesting financial incentive program related to quality indicators. It is described here. Some excerpts:

This initiative, which commenced July 1, 2009, links payments to hospital performance on a set of 49 Maryland Hospital Acquired Conditions (MHAC) across all-payers and patients in the State.

During fiscal year 2008, these hospital-based preventable complications were present in approximately 53,000 of the State’s total 800,000 inpatient cases and represented approximately $500 million in potentially preventable hospital payments.

The MHAC methodology provides a system of payment incentives based on a hospital’s actual number of complications versus a statewide target rate for each of the 49 MHAC categories. Under this approach, hospitals face strong financial incentives to reduce complication rates. They will also be armed with a sophisticated data analysis tool that will enable them to systematically help achieve this collective goal of reducing complications.

The Washington Post recently (March 19) published a letter to the editor from Robert Murray, the Executive Director of the state's Health Services Cost Review Commission, which offered more detail:

The [MHAC] method of applying hospital rewards and penalties is based on measuring each hospital's performance and determining whether the complication rates are lower or higher than, or on par with, expected rates. The expected rates of complications for each hospital are calculated using statewide average rates for the type and severity of illnesses of the patients treated by a given hospital. Therefore, hospitals with more complex patients are not disadvantaged because their expected complication rates would be higher than those hospitals with less complex patients.

The MHAC approach to funding the rewards and imposing penaities is revenue-neutral and does not raise money for the state through fines; for poorer-performing hospitals, a portion of their approved increase in prices for the current year has been withheld and redistributed to the better-performing hospitals based on performance in the previous year.

In this article, you can see some of the objections to this scheme:

The head of the Maryland Hospital Association says the complication list is too broad and that part of a reported drop last year in the overall rate of complications may simply have been hospitals doing better record-keeping. One leading patient safety expert says the Maryland program – and other national efforts – are moving forward despite insufficient evidence to truly measure and verify the types of preventable complications that should be targeted.

"There is so much pressure to drive down cost and improve quality that politics have gotten ahead of the science," says Dr. Peter Pronovost, a professor at Johns Hopkins University School of Medicine and winner of a MacArthur Foundation "genius grant” for his work on improving hospital safety, often through the use of simple checklists. "There’s a gap between regulators, who say the measures are good enough and clinicians, who say they’re not."

From this vantage point, I am hard-pressed to see how a "focus" on 49 metrics makes much sense. That is unlikely to stimulate a sensible approach to process improvement. Also, the dollars at stake are de minimis -- 0.5% of total inpatient hospital revenue in the state or about $60M -- unlikely to act as much of a financial incentive. Dr. Pronovost has it right. Government regulation of this sort is invariably crude and off-point. It would be much better if the medical profession demonstrated that it is capable of self-regulating in a way that persuasively exhibited a commitment to quality and safety and to patient involvement in the design and delivery of care.

Medical innovation grows in Boston

Now that I am free of the day-to-day responsibilities of running a hospital, I have had more chance to meet people working on new medical diagnoses, therapies, and services in the Boston area. There are a slew of them, as this is a hotbed of innovation and invention because of the concentration of hospitals and research universities. From time to time, I will tell you about some of these.* In particular, I will try to focus on innovations that, in my opinion, have the potential to decrease the cost of health care or provide more patient-centric care.

Here's one I learned about recently, a new company called Novocure. (I have no financial interest in this company.) They have developed a potential non-invasive treatment for solid tumors. Mild electrical currents are applied from an external source through the skin into the body, with the idea of interfering with the growth mechanism of cancer cells. The most promising arena is currently brain tumors, glioblastoma multiforme.

Of course, there is an extensive FDA-guided clinical trial regime to go through, as there is with all such inventions. Last week, the FDA's Neurological Devices Panel Advisory Committee met to review the company's application for recurrent GBM and provide guidance to the agency on approval. The panel voted in favor of the treatment, bringing the company one step closer to being able to offer this treatment option to GBM patients. You can read more here and here.

* I will only report publicly available information. I will, of course, disclose if I have a personal financial interest. I will no longer comment on any financial interest of my previous employer or staff there, as I in no way represent them; nor do I keep track of such matters and therefore neither can I speak knowledgeably about them.

Insurance companies dancing without touching

A story in the Washington Post talks about health insurance companies seeking new lines of unregulated business as the profitability of health insurance falls and as more and more requirements are placed on that line of business as a result of the federal health reform law. Here's an excerpt: "Insurers have moved into technology, health-care delivery, physician management, workplace wellness, financial services and overseas ventures in wide-ranging efforts to mitigate the new rules imposed by the law."

I raised some of these issues several months ago, where I also suggested that a merger of the Number 2 and Number 3 Massachusetts health plans might be forthcoming. Well, they tried, but decided not to, as they announced a few weeks ago.

Meanwhile, Blue Cross Blue Shield of Massachusetts is clearly laying the groundwork to shed its non-profit status. And, really, why not? It is in no way a charitable organization of the sort envisioned in earlier years, and the constraints of being a nonprofit bind in a number of ways.

When the HPHC and Tufts merger fell through, the operative statement was: "We have now determined that we are stronger as individual competitors than one company."

I predict that will turn out to be a strategic error. In the new world order, scale matters. This statement is, to me, revealing in its own way: "Our operations are very different and, in many important aspects, not fully compatible without significant changes to existing processes and applications." In other words, they chose not to merge because it felt like it was not currently cost-effective to change. This suggests that the operations of the two plans as presently configured are not scalable. But if they don't merge, they will be left behind by those with stronger market power. For now, that is BCBS of MA. In the future, as the business becomes less about taking on insurance risk and more about other services, it could well include some major national players as well. Now, rather than later, would be a better time to consolidate assets and use the cash on hand to make the investments that will be needed to grab market opportunities in the future.

Saturday, March 19, 2011

Probably right, or wrong

In the post below, I ask you to make a diagnosis of a medical condition. Most people get it wrong, probably because the actual diagnosis is far removed from the setting presented. People apply their inductive forces to a new problem, based on probabilistic inferences from other situations with which they are more familiar.

I attended a seminar on Friday at which MIT's Joshua Tenenbaum presented a theoretical basis for this learning process. If you subscribe to Science Magazine, you can read his recent article on the topic: "How to Grow a Mind: Statistics, Structure, and Abstraction."

It turns out that people are reasonably good at inference, from a very young age, as Joshua notes:

Generalization from sparse data is central in learning many aspects of language, such as syntactic constructions or morphological rules. It presents most starkly in causal learning: every statistics class teaches that correlation does not imply causation, yet children routinely infer causal links from just a handful of events, far too small a sample to compute even a reliable correlation!

In a more theoretical section, the author describes a probabilistic, or Baysian, model to explain this learning process:

How does abstract knowledge guide inference from incomplete data? Abstract knowledge is encoded in a probabilistic generative model, a kind of mental model that describes the causal processes in the world giving rise to the learner's observations as well as unobserved or latent variables that support effective prediction and action if the learner can infer their hidden state. . . . A generative model . . . describes not only the specific situation at hand, but also a broader class of situations over which learning should generalize, and it captures in parsimonious form the essential world structure that causes learners' observations and makes generalizations possible.

Except when it doesn't work! As several of you demonstrated below, that same probabilistic model can lead to cognitive errors.

I summarized Pat Croskerry's explanation below:

Croskerry's exposition compares intuitive versus rational (or analytic) decision-making. Intuitive decision-making is used more often. It is fast, compelling, requires minimal cognitive effort, addictive, and mainly serves us well. It can also be catastrophic in that it leads to diagnostic anchoring that is not based on true underlying factors.

Why the dichotomy? How can a learning process that works so well in some cases led us awry in others? I asked Joshua, and he suggested that it might have to do with the complexity of the issue. For those functions that were important in an evolutionary sense as humans evolved -- e.g., recognizing existential threats, sensing the difference between poisonous and healthy plants -- a quick probabilistic inference was all that mattered.

Now, though, in a complex society, perhaps we get trapped by our inferences. The sense of tribalism that led us to flee from -- or fight -- people who looked different and who might have been seeking to steal our territory or food becomes evident now as unsupported and destructive racial or ethnic prejudice.

Likewise, the diagnostic approach to illness or injury that might have sufficed with simple health threats 10,000 years ago no longer produces the right result in a more complex clinical setting. Think about it. If you were a shaman or healer in a tribe, most conditions or illnesses healed themselves. You recognized the common ailments, and you knew you didn't need to do much, and whatever herbs or amulets or incense you used did no harm. If you couldn't cure the disease, you blamed the evil spirits.

In contrast, as a doctor today, you are expected to apply an encyclopedic knowledge to a variety of complex medical conditions -- cancer, cardiovascular disease, liver and kidney failure -- that were relatively unknown back then. (You were more likely to die from something more simple at a much younger age!) Many cases you see today have a variety of symptoms and multivariate causes and different possible diagnoses. It is no surprise that your mind tries to apply -- in parsimonious form -- a solution. The likelihood of diagnostic anchoring is actually quite high, unless you take care. As I note below:

Croskerry thinks we need to spend more time teaching clinicians to be more aware of the importance of decision-making as a discipline. He feels we should train people about the various forms of cognitive bias, and also affective bias. Given the extent to which intuitive decision-making will continue to be used, let's recognize that and improve our ability to carry out that approach by improving feedback, imposing circuit breakers, acknowledging the role of emotions, and the like.

Eye couldn't guess!

Quiz for doctors and lay people out there: What is your diagnosis for this eye condition?

Be honest and put your answer as a comment below before looking at this article.

Friday, March 18, 2011

In their boats . . .

There is an old joke about a university with a certain ethnic background (mine) that decides to set up a rowing team. After months of practice, the crew arrives at the Head of the Charles Regatta to compete. They are demolished -- recording by far the worst time of any 8-person boat.

Discouraged, the coach sends out the captain of the team to visit with other college teams to figure out how to get better at the sport. Hours later, Sam comes back and says, "Coach, I figured out the secret of their success!"

"What is it?" asks the coach.

"In their boats, eight people row and only one person talks!"

Apropos of that, please see the photo below of a sculpture from Jaffa, Israel, which seems to exemplify the lesson:

Those who have worked in hospitals already see the relevance of this story, but I present it more to provide a warning of what I see happening in the Massachusetts state government.

You may recall a post from a few months ago in which I set forth great hope about the usefulness of an all-payer claims database. Here's an excerpt:

Over the coming months, in accordance with an act passed last summer, the Division [of Health Care Finance and Policy] will be constructing an all-payer claims database (APCD). It will comprise medical claims, dental claims, pharmacy claims, and information from member eligibility files, provider files, and product files. It will include fully-insured, self-insured, Medicare, and Medicaid data. It will also include clear definitions of insurance coverage (covered services, group size, premiums, co-pays, deductibles) and carrier-supplied provider directories.

The Commissioner noted that the result will be "a dataset that allows a broad understanding of health care spending and utilization across organizations, population demographics, and geography." In my view, it will be a moving force in rationalizing payments to providers across the state....

One of the things then-Commissioner David Morales promised was that the database would be widely accessible, so that independent researchers, policy analysts, advocates, market participants, and others would be able to manipulate it to test hypotheses and assumptions. Well, the Commissioner has since announced he is leaving his post, and it already has become evident that there is no one in the government who is steering the boat along the lines he so clearly presented. Instead, there appears to be the classic bureaucratic situation: Too many people involved, none with authority, and certainly no one exercising the leadership needed to make this incredibly useful tool available to the public.

It is time for one person in the Executive branch to talk, and for the others to row, to make sure the Legislature's intent with regard to the transparent presentation of these claims data occurs in a timely and useful fashion.

Thursday, March 17, 2011

The Inspector General observes

A recent report by the Massachusetts Inspector General raises a thoughtful concern about the implementation of global payments in the state.

In the effort to contain health care costs, much discourse has centered on moving from a predominantly fee-for-service system to one based mainly on global payments to providers organized as Accountable Care Organizations (“ACO”). There is little doubt that fee-for-service reimbursements create incentives for providers to increase utilization of health care services, with obvious inflationary consequences. But moving to an ACO global payment system, if not done properly, also has the potential to inflate health care costs dramatically.

There is nothing inherent in the current marketplace that would cause an ACO-based global payment system to contain health care costs. The evidence, in fact, suggests the opposite conclusion. For the past two years, the primary experiment with global payments in the private insurance market in Massachusetts has been the Alternative Quality Contract (“AQC”) popularized by Blue Cross Blue Shield of Massachusetts (“Blue Cross”). The payments to providers under this contract are made on a global capitated basis. The capitated amounts are determined by starting with the previous year’s experience of the population of lives covered by the specific AQC. That entire amount becomes the base year from which all future payments are derived. Therefore, the AQC embraces and adopts any excessive or wasteful payments in that base year, including all overutilization resulting from over a decade’s worth of fee-for-service provider contracts. Implicitly, the premium increases of that decade, which overall were well in excess of 100%, are made a permanent part of our health care system’s cost structure.

Once the base year is determined, any excessive provider costs from that year are trended into the future. And the rate of the trend is alarmingly high. While specific details of individual AQCs are kept confidential by Blue Cross and the contracting providers, the OIG estimates that increases in reimbursements to providers over the five-year term of an AQC could be in the 50% range.

The IG's remarks are especially apt in that the first global contracts contained very good deals for those providers who signed on, as rewards for being early adopters. The big problem he identifies, as I have mentioned before, is the lack of transparency surrounding this issue. Absent an open presentation of rates and practice patterns, we will never know how effective this payment regime really is. Meanwhile, the Governor and other policymakers have chosen to proceed, blindly trusting a path that has huge ramifications for patients.

I know of no other arena in public policy in which so many decisions are being made with so little substantive support and so little data-driven debate. Reporters, too, seem willing to accept relatively unsupported and undocumented assertions that global payments are working -- parroting statements made by stakeholders who have tremendous financial interests -- while demanding no independent verification.

Wednesday, March 16, 2011

Radio gets it right on end-of-life issues

Here is an excellent interview with WBUR's Sacha Pfeiffer and Dr. Lachlan Forrow about the Massachusetts Expert Panel on End of Life Care report I cited below.

It is deeply disappointing that the newspapers in Boston did not cover this important report, one of the most thoughtful pieces of work in the health care field.

Tuesday, March 15, 2011

No MRI in the Emergency Department

At a major hospital in Israel, one with a very extensive emergency department, they do not have an MRI for the ED. Why? The payment for an emergency room visit is a flat rate, and a low one at that, regardless of diagnosis. While they have X-Rays and CT scanners, they cannot justify the cost of an MRI. Besides, noted my host, "How often do you really need an MRI for an emergency room visit?"

What a contrast with the US, where an MRI in each hospital's ED is de rigueur. But the same question could be asked, "How often do you really need an MRI for an emergency room visit?" Not, how often is one used? This article, for example, shows a tripling of MRI and CT usage in the ten years after 1998. The JAMA abstract is here. (It doesn't separate the two modalities.) During this same time period, there was a small increase in the prevalence of life-threatening conditions; but there was no change in prevalence of visits during which patients were either admitted to the hospital or to an intensive care unit. Visits during which CT or MRI was obtained lasted 126 minutes longer than those for which CT or MRI was not obtained.

So, how often is an MRI really needed? At what cost to society?

Jubilee Project benefit concert

You have seen me post productions here from the Jubilee Project. This is a a non-profit that that harnesses the power of Internet videos and the spirit of philanthropy. As noted by the founders:

- Our mission is to make videos for a good cause.

- Our core value is to partner with those in our communities to help make these videos possible.

- And our hope is that we can create entertaining videos that will empower, enable, and inspire others to do good as well.

Eric Lu, one of the founders, now informs me of a fundraising event in Harvard Square on March 26. Here's the invitation. Bands include: Rooftop Pursuits, Sophia Moon, Courtney Ateyeh & Hilary Reynolds, The Extra Fingers. It looks like fun, and you should order tickets soon, as they are likely to sell out. Details are also available on Facebook.

Addendum: The Jubilee Project added a new video for relief for Japan following the big earthquake there. Here's a message from Eric on that topic, followed by the actual video.

Click here if you cannot see the videos.

Monday, March 14, 2011

Tough Talk helps people be gentle

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

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;
- 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

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."

Thursday, March 10, 2011

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

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

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

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.

Wednesday, March 09, 2011

Observations about the Israeli health care system

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.

Tuesday, March 08, 2011

Mideast drama

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

Hospital Governance Issues in Israel

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.