Thursday, August 28, 2014

Point, counterpoint, rebuttal

Laura Beil at Men's Health published a story in July about the risks of robotic surgery for men.  The summary:

American medicine has a history of embracing new technology first and asking questions later, Dr. Lotan says. "Our health care system is in financial distress, and it's important to understand why. Doctors are removing gallbladders robotically, and it makes no financial sense. At some point as a society, we have to say, We're spending this money, and what are we getting?'"

With robotic surgery, the answer may come too late to matter, he says. No one is going back. "Maybe with the next technology we will evaluate the cost-effectiveness prior to adoption."

The folks at Intuitive Surgery didn't like it, and the senior vice president for scientific affairs wrote a letter complaining. The lede:

Laura Beil makes a mistake common to journalists eager to write an eye-catching story: She chooses the facts that fit her narrative and ignores those that don't.

MH editor Peter Moore replied here.  The summary:

We pride ourselves on the accuracy of our reporting at Men's Health, so we took Intuitive's request for corrections very seriously. After an internal investigation—with the cooperation of Laura Beil and our research team, led by Jaclyn Colletti—we stand behind the article in it's entirety, as published.

Read for yourself and see who's most persuasive.

Wednesday, August 27, 2014

So, ask her to withdraw the deal!

The two Democratic candidates for Attorney General agree on one thing, that the current Attorney General's proposed deal with Partners Healthcare System will not achieve controls over rising healthcare costs from the dominant market player.

Here is the Youtube of a recent debate.  Start at 34:04 and listen through 36:09. Or read the transcript here at Commonhealth.

They should have tried a blog instead!


As we approach Labor Day, an important story.  Beth Kutscher reports in Modern Healthcare that "Prime Healthcare Services is suing a union it says is waging an ongoing smear campaign to pressure the chain into unionizing its workforce."  Here's more:

In the 69-page lawsuit filed Monday in U.S. District Court in San Francisco, Prime accuses the SEIU chapter of violating the federal Racketeer Influenced and Corrupt Organizations Act, which Congress enacted to help the government prosecute organized crime.

“While Defendants' methods are wide-ranging and elaborate, their purpose is straightforward: Defendants have met with and told Prime that if it does not turn over the nonunion healthcare workers at its hospitals on terms dictated by Defendants, they will destroy Prime and ruin the lives of its executives,” the suit states. “To make good on their threats, Defendants have embarked on a campaign of extortionate assaults on virtually every aspect of Prime's business.”


SEIU asserts that the lawsuit is without merit:

"The allegations in Prime Healthcare’s lawsuit against SEIU and related groups and individuals simply do not hold up to scrutiny," said Steve Trossman, director of public affairs at SEIU-UHW, in a statement. "Many of them were contained in a previous lawsuit against SEIU that was dismissed multiple times by a federal judge. SEIU will seek a fast dismissal of this complaint as well."

When will health care systems come to realize that by the time you choose to fight a corporate campaign in the courts, much of the damage is done?  Plus your chance of winning in court is based on a roll of the dice.

A more proactive, real-time approach is what's needed when a union seeks to denigrate a health system's reputation among key constituencies, with the goal of persuading management to agree to undemocratic concessions in the organizing process.  I've documented such an approach in my book, How a Blog Held Off the Most Powerful Union in America.

In the foreword to the book, Professor David P. Boyd, D'Amore-McKim School of Business, Northeastern University notes, "This is a powerful lesson in winning a battle of perception with the modern tools of transparency and internet speed."

And Dr. Harris Berman noted how "persistent and effective use of social media evened the playing field . . . keeping diverse audiences informed and engaged."

You can read more about this on one of my other blogs, Exposing the Playbook.

In-flew-enza

Wow, here's the story of how the great flu epidemic of 1918 started in Boston:

One this day in 1918, two sailors housed at Boston's Commonwealth Pier reported to sickbay. The men were the first Americans stricken with a strain of influenza that would prove far more dangerous than the German army. By the end of the week, 100 new cases a day were being reported among the sailors at the pier. The disease spread with terrifying speed through both the military and civilian populations. In the next 24 weeks, the epidemic would affect more than 25,000,000 Americans. More than 675,000 would not survive the illness. The flu would take far more lives than the war then raging in Europe. Worldwide, between 50,000,000and 100,000,000 people would die before the epidemic abated in December. 

No disease in human history — including the Black Death (1347-1350) — caused so many fatalities.

In Boston, children jumped rope and sang:

"I had a little bird
And its name was Enza
I opened the window and
In-flew-enza."

Tuesday, August 26, 2014

Is it all right to inform patients about unclear evidence?

What happens when patients are informed about the evidence, especially when the evidence is not totally conclusive?

Golly, perhaps it seems silly to ask, but let's give credit to Matthew Maurice and Robert Abouassaly for doing so in a rigorous way.  A current article in Urology 84 (2), 2014, is entitled "Patient Opinions on Prostate Screening are Swayed by the United States Preventative Task Force Recommendations."

The answer, simply, is that patients think about the evidence and draw their own conclusions.  Perhaps just like doctors do.  My take:  Working in partnership and sharing information, they'll both make better decisions.

The abstract:

Objective

To survey patient opinions on prostate cancer (PCa) screening in light of the United States Preventive Services Task Force recommendation against its use.

Methods

We conducted a survey of all-comers to urology and primary care clinics. Participants provided demographic information and responded to a 5-item questionnaire regarding their opinions on screening before and after reading opposing position statements.

Results

The overall response rate was 48%. After excluding incomplete questionnaires, 54 surveys were available for analysis. Patients were predominantly white, middle-aged and older, college-educated men with middle-to-upper-middle-class incomes who were seen at urology clinics. Patients rated their “pre” level of understanding of screening recommendations as good or very good (52%), okay (30%), and poor (19%). After reading the information sheets, good or very good understanding of screening recommendations improved (65%; P = .05), and agreement with the importance of screening remained high (80%). However, nearly 20% of patients expressed a more neutral or less favorable attitude toward the risk-benefit ratio of screening (P = .09). Agreement that men should undergo screening, that screening helps detect cancer, and that screening saves lives remained high, regardless of the exposure.

Conclusion

Overall, patients favor PCa screening, but heightened awareness of the current controversy raises concerns about its potential harms. PCa screening is a complex issue, and insight into changing public opinion will be crucial to our future discussions with patients who are wrestling with the decision whether to undergo screening.

Hey, there's an election coming!

With two weeks to go to the primaries, how could it be that all major media outlets in Massachusetts have failed to asked the Attorney General candidates their opinions on the efficacy and enforceability of the proposed AG-Partners Healthcare System deal? After all, one of them will have to live with it if it is approved by the Court. This is the major antitrust and health care issue facing the Commonwealth. Let's get them on record before we vote. Should AG Martha Coakley withdraw the agreement and let her successor decide on the right path to take? What do you think?

----

Addendum at 10:40pm.  A twitter post from Paul McMorrow at Commonwealth Magazine notes: 

Was a question at today's Globe . Both candidates said they're skeptical deal controls costs.

Monday, August 25, 2014

Fueled by patient demand? No way.

I frankly expected better from HealthLeaders Media, which usually has well researched and thoughtful stories.  This one, though, reads like a press release from the investment bankers and law firms that make a bundle from proton beam projects.

Here's the most troubling statement:

As more American patients have become aware of the less invasive technology, they are emerging as a key driver of proton beam center growth in the United States, Caron says.

Who's Mr. Caron?

A partner at Chicago-based law firm McDermott, Will and Emery, who has worked on proton beam therapy center projects for more than eight years.

Aided and abetted by Leonard Arzt, executive director of the National Association for Proton Therapy, who says:

[C]onsumer demand for the treatment has created a marketing opportunity for the top cancer centers in the country. "If you're in the radiation oncology business, you want the latest and greatest tool."

Only at the bottom of the story do we get a truly thoughtful comment:

But Cigna, which also works with Bluffton, SC-based CareCore National LLC to manage proton beam therapy coverage, reimburses the therapy for only three conditions, citing a lack of clinical evidence showing the treatment is superior to more conventional radiation therapy for most cancers. "While PBT has been used in patients in the United States since the mid-1950s, and although it has been shown to be effective in some malignancies, there is no published data clearly demonstrating superiority over conventional forms of radiation therapy," state the Bloomfield, CT-based carrier's guidelines for radiation therapy.

If you want to know what's really driving consumer demand, it is the growing supply of these machines, supported by ill-conceived Medicare funding--a true product of the medical-industrial complex.  Gary Schwitzer and I have been writing about this debacle for several years.  In one, Gary quotes a Bloomberg report:

“Proton-beam therapy is like the death star of American medical technology; nothing so big and complicated has ever been confronted by the system,” said Amitabh Chandra, a health economist at Harvard University’s John F. Kennedy School of Government. “It’s a metaphor for all the problems we have in American medicine.”

A very productive hospitalist

Brad Flansbaum writes the story of a very productive hospitalist.

The physician profiled has 3000 discharges.  Just counting Medicare patients.

Most hospitalists I know run a daily census of 8 to 15 patients.  If this fellow is working at a very high level of 25 (and recall, that would imply no commercial or Medicaid patients) with an average length of stay of five days, that would imply 5 discharges per day.

At that rate, if you worked 365 days per year, you still would not reach even 2000 discharges.  So the 3000 number doesn't add up.

Brad tried his best to get an answer:

In preparing the post, I reached out to him by email and spoke to his practice administrator.  Regrettably, he did not want to comment on the data.  I aspired to learn if he leveraged NP and PAs or other unique resources to assist his group.  

By the way, does CMS do any analysis of this kind of outlier performance?

I'm reminded of the joke about the lawyer who arrives in heaven and is greeted with a spectacular welcoming party.  "What's up?" he asks. "Do you do this for everybody?"

"No," he's told, "but it isn't often we get someone who's lived to be 150."

"But I died at age 85," he says.

"Oh, there must be some mistake," they replied.  "We calculated your age by looking at your hourly billing records."

Depressing thoughts

The US and Canada differ on many aspects of health care delivery, but one area in which they have a common approach is inadequate care for mental health.  I was reminded of this when I met with a colleague who works at the British Columbia Division of the Canadian Mental Health Association.  She related several stories about slow and inappropriate treatment of patients--both in crisis and in chronic states--in the provincial health system.

Meanwhile, Modern Healthcare reported that south of the border a court ruled that, "hospitals in Washington state will be prohibited from boarding psychiatric patients in emergency departments while they wait for inpatient beds to open up."

This creates a terrible Catch-22:

“While we respect the state court's decision, federal law still prevents hospital emergency departments from discharging unstable patients, for example, suicidal or homicidal patients, back into environments where they could cause harm to themselves or to others,” Dr. Alex Rosenau, president of the American College of Emergency Physicians, said in a statement. “This ruling does not provide guidance for hospitals and physicians regarding resolution of the conflicts among federal law, this state ruling, and the medical liability risk of discharging patients based on a time limit rather than based on reaching a stable condition.”

These debates often focus on funding, but the human costs are high.  Marijke takes the recent death of Robin Williams to note on her blog:

Williams's death hit too close to home to many and it opened up a conversation that many people are afraid to have. Williams graced us with his humour and his talent, and seemed to have it all. Yet he didn't. He missed something incredibly important - good mental health. It reminds us that we are all vulnerable.

Virtually every family in these two countries has had or will have a member with mental illness.  I'd love to see some politicians who bravely break through the stereotypes and force political action that raises diseases of the brain to the level of diseases of the kidney, lungs, and liver.

Sunday, August 24, 2014

The femtosecond laser: Paying for the attendant in the washroom?

If there is a clear winner in the health care field--in terms of increased efficacy and lower cost over the decades--it has to be cataract surgery.  I remember my grandmother's cataract removal in the 1960s. An expensive, laborious procedure requiring days of unmoving bed rest afterwards while the eye healed, and a lifetime of thick glasses.  Now, the procedure takes minutes, the costs have plummeted, and the patient leaves the outpatient procedure ready to drive herself home. As noted here, "The surgery has become fairly common: millions of people have cataracts removed every year, and 98% of the surgeries are successful and free of complications."  The societal benefit has been huge, according to the American Academy of Ophthalmology:

Cataract surgeries performed over one year eventually save $123.4 billion over 13 years and delivers a 4,567 percent financial return on investment to society according to the results of a cost-utility study.

The majority of the $123.4 billion savings are in patient cost savings and Medicare savings, which accounted for 39.4 percent 29.5 percent, respectively. Other gains included employment/productivity (20.6 percent), Medicaid (2.7 percent) and other insurers (7.8 percent).  For each cataract surgery on a single eye, which costs an average of $2,653, the savings will amount to $121,198.


The overall cataract surgery cost in 2012 was 34.4 percent less expensive than in 2000 and 85 percent less expensive than in 1985 after adjusting for inflation. Furthermore, the inflation-adjusted physician fee in 2012 was only 10.1 percent of what it had been in 1985.

Now, the trend may change. Recent developments indicate a possible shift towards a high-cost procedure that is being marketed by ophthalmologists as a way to improve their income. The impetus is a new medical device that, on its face, would be too expensive given the relative improvement in efficacy that it offers.  A loophole in the Medicare billing system makes it possible. Cooperation by the manufacturers and doctors in direct-to-consumer marketing is the key, persuading unsophisticated patients that the extra money they pay is worth it.

The femtosecond laser

There is a new medical device that has been introduced to make the initial incision for cataract surgery, called the femtosecond laser.  No one disputes that it adds a level of precision to the procedure. Here's one remark:

Eric Donnenfeld, MD, immediate past president of ASCRS, says the clinical benefits of femtosecond laser cataract surgery are fourfold:

1. The primary incision allows the surgeon to create a uniform and consistent three-plane incision with a self-sealing reverse side cut, which has the potential to reduce the incidence of endophthalmitis.

2. Incisions are more accurate, safer and reproducible.

3. Capsulotomies are more precise.

4. The procedure is safer.

 
But there are strong feelings in the profession:

Can the laser do anything that a well-qualified surgeon can't already do? Steven G. Safran, M.D., Lawrenceville, N.J., and Brad Oren, M.D., Lake Worth, Fla., don't seem to think so. "There is nothing that this technology can do for me that I need help with," said Dr. Safran. "I can make a perfect capsulorhexis 100% of the time with a bent needle and capsulorhexis forceps and in my opinion, it takes less time than it would if a femto laser was added to the mix." "In my hands, this machine doesn't benefit the patient at all," said Dr. Oren. "I haven't had a wayward capsulorhexis since I was a resident. Any good surgeon hasn't." Dr. Safran likens the assistance the femtosecond laser gives cataract surgeons to bathroom attendants in high-dollar nightclubs and restaurants: Thanks, but I can grab the towel and soap myself.

Another states:

It seems like one of the best reasons now to get a laser is to ‘keep up with the Joneses’ rather than for any outcome or safety issue,” said Thomas A. Oetting, MD, associate professor of clinical ophthalmology at the University of Iowa. 

All of this back-and-forth is anecdotal.  Is it clinically relevant? Where's the hard evidence? An article notes:

“The literature on vastly improved safety and visual outcomes is limited, with traditional cataract surgery being so successful and laser-assisted surgery still being relatively new in terms of mainstream use,” says J. Christopher Freeman, OD, clinical director at nJoy Vision in Oklahoma City and president of the Optometric Council on Refractive Technology.

Clinical results, peer-reviewed evidence and cost-effectiveness will ultimately determine the level at which femtosecond laser technology is clinically embraced in the years to come. Further prospective clinical trials are needed to evaluate femto’s impact on the quality of cataract surgery and outcomes.(Roberts T, Lawless M, Colin CK, et al. Femtosecond laser cataract surgery: technology and clinical practice. Clin Experiment Ophthalmol. 2013 Mar;41(2):180-6.)
 
Some articles supportive of the technology are written by doctors with a financial connection to the equipment manufacturer.

Increased costs

So, in scientific terms, the jury is still out.  And the machine is expensive:

The machine alone costs about a half-million dollars. Then there’s a usage fee that comes in between $150 and $400 per eye, and maintenance costs of between $25,000 and $50,000 per year after the initial warranty has expired. 

There are other kinds of payment plans.

You can lease the laser, lease to buy, or buy it, and some [femtosecond] companies give away the laser for a nominal sum and then charge a higher click fee. If you’re leasing the equipment and just paying per click, the fee could be $650 to $750 per treatment.

And it has ancillary costs:

The space the laser takes up; the cost of OR time; staffing costs not just in the OR, but also for the receptionists, preop nurses, recovery room nurses, and ancillary staff, all of whom will be at the surgery center longer because of increased surgical time; the cost of doctor’s time; and the opportunity costs.

Increased MD Revenues

Even if there is an improvement in clinical outcomes, is the improvement worth these extra costs?  From the doctor's point of view, only if there is more revenue to make the investment financially viable.  How could this be this possible?  An MD friend explains:

It is important to understand how cataract surgery is billed. We typically use two different codes. Medicare reimburses the same amount regardless of the way you remove the lens and implant it. If you use the laser, they still reimburse the same, no matter what. See reimbursement rates below:

Regular cataract extraction CPT 66984- $687.71 
Complex cataract extraction CPT 66982  $855.58

The ethical dilemma arises because we now have new technology that can assist with intra-operative imaging in ideal lens placement for "premium" or "presbyoptic" lenses or lenses that correct astigmatism, "toric lenses." Medicare, again, will not reimburse for these items. They are an out-of-pocket cost to the patient. 

The laser also happens to assist in removal of the cataract by
1. Making incisions
2. Performing the anterior capsuolotmy or "capuslorhexis"
3. Performing the initial portion of breaking up the nuclear part of the cataract.

Surgeons would like to bill for this separately I'm sure; however Medicare does not allow it. Again, no matter how you remove the lens, it is the same reimbursement. So, how they have gotten away with it is that CMS has already ruled that physicians can charge the patient an out-of-pocket fee to implant the premium IOL and toric IOL.With the advent of the femtosecond laser,  recently CMS has also ruled that physicians may bundle in an extra fee for using the femtosecond laser for "imaging" purposes to implant these premium and toric lenses. Most physicians will then still use the laser for the above parts of the surgery described (#1-3) but technically they are billing for the imaging part of the procedure used to implant the lens. 

Why consumers choose to pay

Why would consumers choose to pay extra out-of-pocket costs if Medicare already covers the normal costs of cataract surgery?  Because the industry convinces them that it's worth it.  Here's how it is advertised by the Cleveland Eye Clinic:

The Cleveland Eye Clinic is the third practice in the nation to offer their patients the Catalys laser refractive cataract surgery system. Laser refractive cataract surgery offers the patient a greater level of precision and a greater level of customization. Patients can benefit from a truly innovative solution that allows for customization in cataract surgery that was never attainable before. When you choose to have your surgery performed with this Catalys, OptiMedica laser, you’ll enjoy a truly innovative solution that allows for customization in cataract surgery. A bladeless, computer-controlled laser allows the surgeon to plan and perform your surgery to exact individualized specifications, not attainable with past cataract surgery methods.

 With the Catalys, OptiMedica laser, you can move forward with confidence knowing that you’ve chosen the most advanced technology available for this life-changing procedure, one that enables a customized cataract surgery experience. If you are seeking a Cleveland cataract surgeon consider choosing the most advanced cataract surgery technology available right here.

Here's a Boston-based ad. Here's an outtake from the ad's video testimonial:

The marketing people have been clever: Note the use of the term "bladeless." This preys on our inherent fear of being cut in the eye. A laser is just as "sharp" as a blade, but it sounds so much more benign.

My MD friend summarizes the situation:

Seems a bit shady to me. I have heard adds on the radio that say, "If you aren't getting laser cataract surgery you aren't getting the best!" So what does this mean for the medicare patient convinced by their unethical ophthalmologist to have a premium IOL or toric lens implanted? 

Well, they not only will be charged for that premium lens (many times around $800-1000 extra depending on the surgeon) but also they will be charged an "imaging fee" for use of the femotosecond laser. This imaging fee can essentially be whatever the surgeon wants it to be. The various device companies charge you for the laser and a "per-click" use as well. Some places around here charge an additional $1000 for use of the laser. So now the patient is paying $2000 per eye extra for their "premium" cataract surgery.

Your government makes it possible 

We've seen this kind of direct-to-consumer marketing before, e.g., with robotic surgery.  Here, as with proton beam machines, the commercial viability of the equipment is made possible by an explicit Medicare pricing policy.

CMS offered its pricing guidance on these matters in 2012.  As my friend noted, the convoluted language chosen permits the femtosecond laser out-of-pocket charges to be imposed on patients:

If the bladeless, computer controlled laser cataract surgery includes implantation of a PC-IOL or AC-IOL, only charges for those non-covered services specified above may be charged to the beneficiary. These charges could possibly include charges for additional services, such as imaging, necessary to implant a PC-IOL or an AC-IOL, but that are not performed when a conventional IOL is implanted. Performance of such additional services by a physician on a limited and non-routine basis in conventional IOL cataract surgery would not disqualify such services as non-covered services.

In the second and third sentences, CMS created a loophole a truck could drive through. I don't have the resources to investigate how this occurred.  Perhaps reporters with interest and wherewithal will do so.  I find it extremely odd that CMS put out this advisory in response to a single press release issued by someone's ophthalmology practice (perhaps this one?), one that honestly attempts to portray the costs consumers might pay. Since when does the biggest agency in the federal government respond to a press release in that way? If I had to guess, I would surmise that medical industry representatives and the trade association of ophthalmologists noticed the ad, didn't like its implications, and made sure the agency did something about it.

What's the end result of all this? The decades-long trend of lower cost cataract surgery is about to reverse. Consumers will pay the difference.  For some, it is worth it.  Others are paying for the attendant in the washroom.

Saturday, August 23, 2014

Slow learning, poor context, and disloyalty

As I ease back in after a lovely vacation horseback riding in the isolation of the British Columbia mountains, I'd like to take one moment to comment on items that have piqued my curiosity as I've caught up on recent newspaper articles.  (Don't worry: Health care topics return soon, but this post also relates to my other favorite topics--leadership, cognitive errors, and negotiation.)

First, there's Thomas Friedman's August 8 interview with President Obama, with these final paragraphs:

Whether it is getting back into Iraq or newly into Syria, the question that Obama keeps coming back to is: Do I have the partners — local and/or international — to make any improvements we engineer self-sustaining?

“I’ll give you an example of a lesson I had to learn that still has ramifications to this day,” said Obama. “And that is our participation in the coalition that overthrew Qaddafi in Libya. I absolutely believed that it was the right thing to do. ... Had we not intervened, it’s likely that Libya would be Syria. ... And so there would be more death, more disruption, more destruction. But what is also true is that I think we [and] our European partners underestimated the need to come in full force if you’re going to do this. Then it’s the day after Qaddafi is gone, when everybody is feeling good and everybody is holding up posters saying, ‘Thank you, America.’ At that moment, there has to be a much more aggressive effort to rebuild societies that didn’t have any civic traditions. ... So that’s a lesson that I now apply every time I ask the question, ‘Should we intervene, militarily? Do we have an answer [for] the day after?’ ”

My reaction? I am pleased that the President learned this lesson but am shocked that he needed to learn it and that it took him so long.  I guess this just proves that ignorance about international cultural and political issues was handed down from the previous Republican Administration to the current Democratic one.

Then, today's story:

While President Obama has long resisted being drawn into Syria’s bloody civil war, officials said recent advances by the Islamic State in Iraq and Syria had made clear that it represents a threat to the interests of the United States and its allies. The beheading of James Foley, the American journalist, has contributed to what officials called a “new context” for a challenge that has long divided the president’s team.

“If you come after Americans, we’re going to come after you, wherever you are,” Benjamin J. Rhodes, the president’s deputy national security adviser, told reporters in Martha’s Vineyard, where Mr. Obama is on a much-interrupted vacation.

Huh, the death on one American is enough to change the context?  What theory of geopolitical action supports that kind of approach?  Is one American free-lance photographer who entered a war zone and has been missing for two years valued more than this result:

The number of dead in Syria’s civil war more than doubled in the past year to at least 191,000, the United Nations human rights office said Friday. The agency’s chief, Navi Pillay, bluntly criticized Western nations, saying their inaction in the face of the slaughter had “empowered and emboldened” the killers.

I don't claim to know the right answers to all these very difficult issues, and I don't expect our leader to be correct in the face of complex, changing circumstances.  But I'd feel a lot better if the narrative we received from our government indicated that they had a rigorous approach to decision making and a coherent strategy and purpose. 

----

As a side note, how low class is this?

The president has long expressed skepticism that more assertive action by the United States, including arming Syrian rebels as urged in 2011 by Hillary Rodham Clinton, then the secretary of state, would change the course of the civil war there.

What kind of former Secretary of State would let it be known that she disagreed with her sitting President while he is still in office?  When you have served in that kind of confidential advisory position, it is totally inappropriate to let the world know that you were second-guessing the president's decisions or advising against his course of action.

Of course, Hillary's folks have done this before, about Libya in 2011, when this self-serving story was offered to the New York Times:

Within hours, Mrs. Clinton and the aides had convinced Mr. Obama that the United States had to act, and the president ordered up military plans, which Adm. Mike Mullen, chairman of the Joint Chiefs of Staff, hand-delivered to the White House the next day.

Again, when you are Secretary of State, your duty of loyalty is to the President.  It is just not right to give the world a sense of your influential powers in the White House. These kinds of inside stories should be saved for memoirs long after the President's term is over.

Unfortunately, the Clinton's do not understand this kind of loyalty.

Friday, August 22, 2014

Combatants for Peace

If you are feeling frustrated and powerless with regard to the current state of relations between Israeli and Palestinians, here's a way to help.

The “Combatants for Peace” movement was started jointly by Palestinians and Israelis who have taken an active part in the cycle of violence; Israelis as soldiers in the Israeli army (IDF) and Palestinians as part of the violent struggle for Palestinian freedom. After brandishing weapons for so many years, and having seen one another only through weapon sights, we have decided to lay down our arms, and to fight for peace.  Our mission is to actively spread the message that a non-violent solution to the conflict is possible, and our hundreds of members and participants are living proof that it is.

They are conducting an Indiegogo campaign to raise funds to spread the message and build political support on both sides of the conflict.  The money will be used to:

· Hire and set up Bi-National media teams, which will work to get our story out and to act in order to influence public opinion in Israel, Palestine and the rest of the world.
· Bring consciousness to both publics regarding the hopes and suffering of the other side, and to create partners in dialogue.
· Educate towards reconciliation and non-violent struggle in both the Israeli and Palestinian societies.
· Create political pressure on both Governments to stop the cycle of violence, end the occupation and resume a constructive dialog.
· Reach beyond the region and connect with people around the world who believe in non-violence and the importance of allowing a new story to emerge - one of peace, coexistence and interconnectedness.

Please give if you are so moved.

Thursday, August 21, 2014

It's too crowded here!


Hi, I'm back from a trail-riding trip in the Chilcotin Mountains of British Columbia.


Long quiet days on the horses, through woods and flower-filled meadows.


Expansive views.

 
Not many people.  It's a bit hard to come back . . .

But lots of blog topics have piled up.  Watch this space next week.

Monday, August 11, 2014

Off duty

I'm taking a blogging break for several days.  Comments on old posts are still welcome, but they will not be moderated (i.e, published) until I get back on duty.

Friday, August 08, 2014

Finally, we hear from the AG candidates


We are fortunate in Massachusetts to have two excellent Democratic candidates for Attorney General.  With just 30 days to go until the primary election, you'd have thought the local press would have asked them for their opinions of the proposed deal inked by the current AG and Partners Healthcare System.  After all, it is the biggest antitrust and health care matter currently pending in the state, and the one with the biggest financial impact on businesses and consumers.  Wouldn't it be good to know if the candidates support the deal as written and also feel comfortable in their potential role of enforcer of the agreement over the coming years?

Well, finally the questions were asked, at a forum held by the Newton-Needham Chamber of Commerce.  The answers were captured on tape, which can be viewed here.

Warren Tolman spoke first (at minute 45:14 or so).  Here are some outtakes:

I have some misgivings about the agreement.

I have some concerns about it, frankly.

First, when I look at price controls and you have a disparity in prices in year one and you lock into [that] ... the disparity in prices will grow over time.  And that increases the power of the have's over the have-not's.  So that's one area that is of concern to me.

Secondly, I believe we need to promote transparency in health care, above all other things.  Consumers ought to know [about pricing differentials] as they make their health care decisions.  The disparity in prices is not reflected in a disparity of quality.

Third, [and here he diverges in the problem of substance abuse.]


Fourth, [on enforcement] a real challenge and commitment of resources. Some of the provisions are going to be very difficult and awkward at best.

Maura Healey was next (at 47:42):

This is a really important issue.  The agreement is now before the Court and the public has been invited to submit comments, which I think is really good because I think it's really important that this decision be made thoughtfully and carefully.

The next Attorney General is going to have a critical role to play in terms of monitoring and taking action in the health care space.

I have some concerns about this agreement.  There's a lot of frustration out there given what we all are frustrated about, which is the high cost of care in this state; but I know that what this agreement tries to do is to put some time limits on it and some caps, put some price limits on things; and it's going to require really vigilant, aggressive monitoring by the next Attorney General, and I would make sure that happens.

I agree with Warren's point that we need transparency.  I am committed to making sure that we are there to provide facts and transparency.  This is going to require vigilance and aggressive monitoring by the next Attorney General.

So, there you have it . . . so far.  This was not a very extensive discussion, but it was a start.  Tolman seems to understand the structural flaws in the agreement.  Healey didn't elaborate on her concerns.  Both understand the complexity of enforcing the agreement.

We have yet to hear from the Republican candidate, John Miller, but perhaps these initial comments from the Democrats will provoke some interest by area reporters to ask more questions of all the candidates.

I wonder if any of the candidates will publicly ask the current Attorney General to pull the proposed settlement from consideration by the Court and defer the entire matter to her successor.  After all, it would be only fair to let the next Attorney General help frame the enforcement requirements of the agreement, rather than inheriting terms set by his or her predecessor.

That's "informed" consent

My friend and colleague, Doug Hanto (a world class transplant surgeon) reports on Facebook about the birth of his grandson at St. Vincent Carmel Hospital in Indiana:

Interesting. Lindsay is about to have a C-section this morning, and we will welcome John Douglas into the world. The nurse handed Lindsay informed consent for C-section, anesthesia, blood transfusion, circumcision, and HBV vaccine with no explanation. Like signing the agreement you have to sign when updating your OSX or windows software. They all say "Your physician has explained ..." No one has explained anything. Trust is alive and well in the real world. This is "informed consent?" Hmmmmm!

Gee, I thought the purpose of informed consent was to be informed.  I also thought it was illegal for nurses to administer them, or, if not illegal, certainly inappropriate. 

Indiana hospital licensure rules say:

Sec. 13.4. "Informed consent" means a patient's authorization or agreement to undergo surgery or other invasive procedure that is based upon communication between a patient and his or her physician regarding the surgery or other invasive procedure. (Indiana State Department of Health)

Thursday, August 07, 2014

Maybe the AG could help

Bruce Mohl at Commonwealth Magazine reports:

Steward Health Care is refusing to turn over to state officials its audited financial statements, setting off a behind-the-scenes tug of war that could lead to fines being assessed on the for-profit company.

Steward, which is owned by the New York private equity firm Cerberus Capital Management, is notoriously tight-lipped about its finances. The only reliable source of information on the company's overall performance and its financial relationship with Cerberus has been its audited statements. For the past two years, Steward filed the statements with state regulators, who turned them over to CommonWealth in response to public records requests.

But this year, Steward is refusing to turn over the financial records. Mark Rich, Steward's chief financial officer, said in a June letter to state officials that the company provided detailed financial information on all of the hospitals it owns. Rich said Steward was not going to turn over the 2013 consolidated financial statement of the company as a whole because it "combines the results of hospital operations with our non-hospital businesses that are not covered by the regulations." 


Nancy Maroney, associate general counsel of the state's Center for Health Information Analysis, has insisted that state regulations require Steward to turn over the consolidated financial statements. She said in a June 9 letter that Steward could be subject to reductions in its Medicaid payments and other financial penalties if it refuses to comply.


I really hate to see such disputes escalate, and I have a suggestion as to how this one could be quickly resolved. Back in October 2010, when the Attorney General recommended approval of Steward's takeover of the Caritas Christi hospital system, she was able to get the following agreement:

Steward, and any successor-in-interest to Steward, will, notwithstanding its for-profit status, fully cooperate with any investigation, inquiry, study, report, or evaluation conducted by the Attorney General under her oversight authority of the non-profit charitable hospital industry to the same extent and subject to the same protections and privileges as if Steward were a public charity.

So all it takes is for the Attorney General to announce to Steward that she wants this information as part of a joint study with CHIA.  Perhaps she will make that offer to CHIA.

What residents teach us about residency programs

Medscape has issued its 2014 Residents Salary and Debt Report.  Here are some interesting charts, along with their associated description and my commentary:


 
Although 25% of residents have no debt, over a third (36%) still owe more than $200,000 after five years in residency. The Association of American Medical Colleges (AAMC) reports that the median four-year cost to attend medical school for the class of 2013 is $278,455 at private schools and $207,868 at public ones. Given these high tuitions, resident indebtedness has risen much more rapidly than inflation or resident compensation. According to the AAMC, medical school debt has increased by 6.3% since 1992 compared with the Consumer Price Index increase of 2.5%.

Perhaps, as we consider the high cost of health care in America, we should factor in the need for doctors to recover their education costs, something not necessary in many countries of the world, where there is little or no tuition charged to medical students.


When asked about relationships with nurses and physician assistants, there was very little difference in the opinions of male and female residents, with 62% of women and 66% of men saying that their relationships were very good to excellent. The most common complaint among write-in comments from residents with poorer relationships was the lack of respect paid to them by nurses. A small study of pairs of residents and nurses found a lack of shared perception and expectations.

Here's where many residents live in a dreamworld.  Their perception of the positive relationship with nurses is, in my experience, off-base.  There is extremely little communication at all--measured in minutes per day, and then often in machine gun format: "Do this."  When I've talked to nurses, they often say that the residents don't respect their abilities and greater knowledge of the patient's status.  Many residents display a lack of trust in nurses, and this does not go unnoticed by the nurses.


A number of studies have found a decline in idealism among medical students beginning as early as the second year of school. The Medscape survey suggests that idealism declines further during residency. In comparing responses by residents in post-med school years 1-4 with years 5-8, a shift occurred, with fewer residents finding patient gratitude rewarding in the later years (61%) compared with in their early years (67%), and more residents in later years looking to make "good money" (43% versus 36%). Authors of a 2014 study commented that as "students make choices in their medical careers, such as specialty choice or consideration of primary care, the influences of job security, student debt and social status increasingly outweigh idealistic motivations."

So we start with highly motivated and idealistic young people and beat it out of them!


Female residents tend to cite more idealistic rewards of their job than male residents do, with 72% of women selecting patient relationships compared with 62% of men. And only 28% viewed money as rewarding compared with 43% of men.

Remind me to request a female resident next time I am in the hospital!


When residents were asked to give their opinions on the quality of their training, 43% thought their own was superior and 29% felt that it was equal to others'. This was an informal opinion, based on perceptions only.

This is similar to the Lake Wobegon effect. Once you've matched, you really want to believe that you've made the right choice. 

We know, from hundreds of residents who attend the Telluride summer patient safety camps, that most trainees get virtually no training in quality and safety, in obtaining truly informed consents, in disclosure and apology for medical error, and in reporting adverse events and near misses.  In that regard, virtually all training programs are substandard and don't meet the requirements the ACGME says are expected.

Wednesday, August 06, 2014

Safety is joy


Brian Daily is a medical student (class of 2017) at Georgetown University School of Medicine. After attending our Telluride-East summer patient safety camp, he saw this construction truck on campus at Georgetown the other day and sent it to several of us faculty members because he thought we’d appreciate the bumper sticker.

And indeed we do.  Safety in the clinical setting, too, is joy.  At heart, it is result of a collegial work environment with excellent communication among the clinical staff and a true partnership with the patient and family. When all that occurs, it feels really good!

Tuesday, August 05, 2014

Post #4038, eight years later

The eighth anniversary of this blog slipped by on August 2.  That's 4038 posts, including this one, drawing several million page views.  From time to time, I've thought about stopping, but then a whole new set of topics emerge, and I say, "Not just yet!" Thank you all, especially the regulars, for reading.

My purpose is to serve as an advocate for patient-driven care, eliminating preventable harm, fostering transparency of clinical outcomes, and encouraging front-line driven process improvement.  When I take on people who act in ways counter to those goals, I do so in the hope of stimulating discussion and, yes, putting some pressure on those people, but not with ad hominem attacks.  In contrast, when I praise people who are acting in accordance with those goals, I mean it to be very, very personal--thanking them for their leadership and, sometimes, courage.

The following compendium might or might not surprise you.  Key words in posts have included:

Quality -- 902 posts
Doctors -- 708
Patient safety -- 642
BIDMC -- 601
Harm -- 407
Nurses -- 356
Lean -- 348
Leadership -- 3222
Transparency -- 310
Residents -- 230
Institute for Healthcare Improvement -- 188
Partners Healthcare -- 158; Brigham and Women's -- 95; MGH --53;
Medical students -- 156
Soccer -- 135
Careers -- 113
Blue Cross Blue Shield -- 109
Preventable -- 108
Incentives -- 73
Infrastructure -- 70
SEIU -- 68; Corporate campaign -- 36
NHS -- 61
Global payments -- 60
Don Berwick -- 55
Robotic surgery -- 43
Ohio (especially children's hospitals) -- 41
Jim Conway -- 34
Brent James --34
University of Illinois -- 32
Telluride Patient Safety Camp -- 30
Peter Pronovost -- 27
Bob Wachter -- 25
Saskatchewan -- 21
Jeroen Bosch Hospital -- 19
Gene Lindsey -- 19
e-Patient Dave deBronkart -- 18
Proton beam -- 18
Gundersen Lutheran Medical Center -- 18
Contra Costa Regional Medical Center -- 10

Monday, August 04, 2014

What Mona learned

Mona Beier attended last week's patient safety camp in Maryland (aka, Telluride East) and posted some deep thoughts after the experience.  Here's an excerpt:

I have had some really negative realizations of myself during these past few days. I hate to admit this, but during a lot of the talks and the videos, I saw things that I had done, and I have seen my colleagues do time and time again. It is almost a daily occurrence that I hear people labeling patients as “high maintenance” if they ask questions about their healthcare or if they “challenge” our decisions and our actions. 

I have replayed imagery in my mind about how many times I have rushed through explaining informed consents, or felt hurried to get histories and physicals because I have 48392 other things to do (seemingly). Or, how many times I have interrupted and not listened. 

I have thought about times when I have anchored, or had premature closure of patients I was taking care of—and it wasn’t until they were not getting better or something was going wrong that I ever stopped and thought that, hmm I could be wrong or that I was missing something. The talks at the conference have made me realize that I should be doing this every day–stopping, taking time to think–and say, is this what’s going on? what would be the worst thing that I could miss? should I go back and get more history? does this make sense?

Moreover, I thought about times when something actually did go wrong–when patients on my team have gone to the ICU or have died. I tried to replay in my mind,  and again, I saw myself saying “oh, they were very sick”–almost trying to justify it to make myself feel better. Being here these past few days is going to make me view this completely differently. I am going to take the time to think about what happened when things went wrong. Was it preventable? Was there something else we could have done? Why did this happen in the first place? What were the series of events that led up to this? Did I call the family? And more importantly, was my conversation meaningful with the family? Did I address their needs and reassure them? Was I there for them like I would want someone to be there for my family member?

There are a lot of other lessons I have learned. All I really know is that I am walking out of here a better person than when I came in. This conference has inspired me to take a deeper look into who I am—what kind of physician I want to be—and what kind of person and role model I want to be to my peers, my patients, and really everyone in my life.  I am inspired to try and break the mold of the culture we have grown so accustomed to—the culture where everything seems to be about me–and remind both myself and others that is not why we are here.

How to make RI a healthier state. Any takers?

Richard Asinof at Convergence RI challenges people in the state to map a future of sustainable health care.  Will anyone step up to the challenge?

Sunday, August 03, 2014

Hooper's Store

A now for a totally different subject, a little bit of Americana:

Many of us with children--and our children--recall Hooper's Store on Sesame Street. Wikipedia summarizes:

The fictional store was said to be founded by Mr. Harold Hooper in 1951 as a general store. The food menu was extensive and suited to the different characters that lived on Sesame Street, a fictional Manhattan street. Along with traditional American diner-type food, the store sold a wide range of goods from dry goods to soap dishes and stranger goods such as empty cigar boxes (in Christmas Eve on Sesame Street) and birdseed milkshakes for Big Bird.

I recently learned the origin of this concept.  The set designer for the program was from Massachusetts where he had lived near Manchester-by-the-Sea and the Trask House on Union Street across from the Public Library.  As noted here:

The house was built in 1823 by local businesswoman Abigail Hooper, who ran a thriving general store and millinery shop on the premises.  That same year, Abigail married Captain Richard Trask, one of Manchester’s most prominent merchant ship captains, who had lucrative trade relationships with England and Russia.

The set designer decided Sesame Street should also have an old-fashioned general store like Hooper's, and the rest is history.


A friend of mine who purchased the store several years ago and owned it for a while reports that it carried all kinds of items, like this axle grease.  Also, when prominent families (like the Bundy's) would plan to come back to summer in Manchester, they would contact the store to have their houses set up with supplies.  These would be delivered in wooden crates that had been used to send inventory to the store.  Like these:



So the idea of stocking empty cigar boxes in Sesame Street's Hooper's Store is not so improbable after all!