Immigrants left in the lurch again

Kay Lazar in the Boston Globe tells a sad story. Several weeks ago, Governor Patrick and his administration pushed through a plan to help assure that legal Massachusetts immigrants would continue to receive coverage under the state's landmark health care access bill. This was a gutsy move, staving off prejudice and xenophobia, and many of us joined in thanking him for his political courage.

Now, in ways the Governor and his folks could never have anticipated, the insurance company that is providing that coverage has decided to limit the network of physicians and other providers these patients can see. Kay's story outlines this problem. Here are more details that apply to BIDMC and the community health centers affiliated with us.

But the same points apply to Cambridge Health Alliance and Boston Medical Center, the major "safety net" networks in Eastern Massachusetts. CeltiCare’s refusal to negotiate in good faith with key providers that serve this population is jeopardizing and severing thousands of primary care physician/patient relationships and also separating patients from their specialty practitioners.

I summarize some information provided to me by Ediss Gandelman, our Director of Community Benefits:

Over the years, BIDMC has worked tirelessly over the years to ensure that the patients served in our affiliated community health centers have seamless, high quality and culturally competent access to primary care, and to tertiary and specialty services when needed. In downtown Boston, the Fenway, Brighton, Chinatown, Quincy, Roxbury, Dorchester and beyond, BIDMC built these affiliations to prevent poverty, fear and isolation from serving as barriers to responding to the persisting unmet medical needs of these communities.

Given the challenge of administrative burdens and delays in access to care for both primary and specialty care appointments, these community-based affiliations have resulted in timely, efficient and meaningful access to needed care in the appropriate setting for our community health center patients. This is the result of a decade’s worth of effort and investment to ensure that our health centers have electronic health records, and a seamless connection to BIDMC for the real-time sharing of needed laboratory and essential clinical information for their patients.

In short, we BIDMC have created an integrated care delivery system that – for our affiliated community health center patients – means timely, efficient, safe, and linguistically and culturally appropriate care and communication between the community health centers’ and BIDMC clinicians. (Paul's note: This integration is at the heart of recent policy standards set forth by the state. It is also what is visualized in pending federal legislation.) It crucial to minimizing opportunities for medical error and ensuring high quality care to these patients.

These patients deserve no less.

Immigrants, many of whom have never benefited from a relationship with a primary care physician or a specialty physician, are especially vulnerable to a disruption of this caring relationship—that hard-earned trust will not transfer easily (or at all) to a new provider in an unknown care delivery system. The medical literature is replete with data about how the
patient/physician relationship impacts health outcomes, including adherence to treatment protocols and keeping medical appointments. Being able to continue care with trusted providers and institutions is critical to the health of these patients.

Another element that affects continuity of care and quality and safety is the institutional support for culturally and linguistically diverse patients. BIDMC has invested deeply in its Interpreter Services department with 47 staff interpreters and more than 54 additional free-lancers. With our health center partners we have also invested significantly in other programs that facilitate access. (For example, Latina and Chinese Cancer Patient Navigators provide compassionate care for vulnerable patients finding their way through a complex medical system). Chinese labor coaches work hand in hand with obstetricians in delivering more than 300 Chinese babies annually, and our Latino mental health team provides invaluable care to the newly arrived who are most prone to depression.

These support systems are not easily replicated and are essential to providing culturally responsive care to CeltiCare members.

Prostate teams

I had dinner tonight with a grateful prostate cancer patient who was able to take advantage of our Cyberknife to receive targeted radiation therapy. But what especially impressed him was the fact that he was able to meet with a medical oncologist, a urologist, and a radiation oncologist all at the same time to help him decide on his treatment plan.

Our approach is to help each man understand the nature of his disease and clearly present the relative value of treatment options -- open surgery, laparoscopic surgery, traditional radiation, radioactive seeds, Cyberknife, and watchful waiting -- in a direct, unbiased fashion.

Until tonight, I thought that every place did this, but apparently not. One of our urologists at the dinner told me the story of a friend of his in New York who had been diagnosed and was wondering where to go and what to do. He advised his friend that there were lots of good hospitals and doctors there, and the key was to find a place that offered an interdisciplinary team. His friends searched and searched but was unable to find a place that offered this kind of team. Well, one place offered a team, but did not offer the full range of treatment options.

Now, maybe his friend did not do a full survey or missed some program, but he was clearly an informed consumer, and he could not get what he needed. I'm curious to see if this is typical of other people's experience. Please comment here.

Too risqué for a hospital?

Seen at our hospital. No further comment.

Hollywood stands up for health care victims

Although I disagree with the policy argument, you have to appreciate the cleverness of this video.

Whose woods these are

When you walk through New England woods, you often come across stone walls. They are a reminder that the region is more forested now than it was 100 years ago. The stone walls used to delimit pastures.

This one is in Rocky Narrows, a Trustees of Reservations property in Sherborn, MA. The video below is the view from King Philip's Overlook (with someone flying a toy plane).

Hub on Wheels 2009

The BIDMC team again joined in the Hub on Wheels, a bike ride through the neighborhoods that is a fundraiser for the Boston public schools. Our team raised about $7000, and we and Cataldo Ambulance Service also donated medical services for the ride. Mayor Menino's bicycling czarina Nicole Freedman visited the medical tent before the ride. BIDMC team captain Michael Keating braved the elements on a wet and windy day.

And here's a movie Michael made, the production of which actually sent him to one of those first aid stations.

SNMA @ BIDMC

We were so pleased that the Student National Medical Association decided to hold its Board of Directors meeting and National Leadership Institute at BIDMC this weekend. SNMA is the nation's oldest and largest independent, student-run organization focused on the needs and concerns of medical students of color. Membership includes more than 8,000 medical students, pre-medical students, residents and physicians.

The students were pretty busy, with seminars like:

Knowing vs. understanding: How do you learn, with Dr. Rich Schwartzstein;

Thoughts on selecting a residency program, with Dr. Carrie Tibbles; and

How scientists think, with Dr. Steve Freedman.

There were also demonstrations and practice in our skills and simulation center. See below. The fellow shown here learned how it feels to have splint put on!

And, also there was a poster presentation showing some recent research projects. I was joined by Beverly Edgehill, CEO of The Partnership, Inc., in addressing the students during their dinner session tonight.

More from SNMA

Some more photos from the SNMA session mentioned above. These were taken by Dr. Rafael Campo.

Signature collection grows

I have previously written about the email signatures used by some of the girls on the soccer team I coach. Here is another one, from a player with musical talent as well as excellent foot skills.

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Basic Eating

Jeremy Warner MD, a Hematology & Oncology Fellow at BIDMC, writes a neat blog called Basic Eating: Food Defined, Not Refined. The theme: Basic eating means increased awareness, increased health, and reduced impact on the environment. Check it out.

Twitter apps

Bill Ives posts 25 Creative Twitter Applications. He embeds this link.

Examples go from really useful -- but dangerous if you text while driving:

CommuterFeed aggregates tweets about traffic from people stuck in jams. By following your city’s feed, you can get updates about ongoing traffic tangles. New Jersey Transit riders have created a similar service.

To just plain goofy:

When Tyler Aaron Menscher (@kickbee) was born in January, he already had hundreds of followers. That’s because his dad, Corey Menscher, created a device that recorded and tweeted his son’s kicks from the womb as they happened.

A surgeon's view of Thoreau's neighborhood

Many of you were engaged by the story by Jim Hurst, our chief of surgery, in which he outlined his experience as a patient in our hospital. Well, Jim's doing fine and is out and about. He is an excellent photographer and was kind to send me these recent photos of Walden Pond, since he knows I often swim there. I hope you like them. (You can see more of Jim's work here.)

Fenway Fantasy

Several dozen BIDMC staffers took part in the annual Fenway Fantasy softball game yesterday. Here's one group of smiling players from our OB department holding up the Green Monster.

The rich and famous get sick, too

Here's a neat blog called Celebrity Diagnosis. Here's the statement of purpose: "One of our main goals at Celebrity Diagnosis is to increase health awareness and medical knowledge using examples of common diseases affecting uncommon people."

I think this is an engaging way to get people informed. See what you think. Does it make you feel like one of the paparazzi?

ACHI brunch on October 3

A colleague at the Harvard School of Public Health asks me to spread the word about an event sponsored by African Community Health Initiatives. ACHI connects African in Massachusetts to health and social service. It not only helps many people overcome barriers and receive care, but it also facilitates the delivery of services by providers to African immigrants.

The event is a brunch on October 3, from 11am to 2pm at the Hyatt Regency Hotel in Boston. Featured speakers are Amadou Diagne, Associate Director of Medical Sciences at Gilead Sciences, Inc., and Frederica Williams, President and CEO of Whittier Street Health Center. Admission to this fund-raising event is $75, which you can send to PO Box 120094, Boston, MA 02112. More information is available at achi_org (at) yahoo (dot) com.

Things are cooking at Codman Square!

Bill Walczak, CEO of Codman Square Health Center, sends the following note:

Dear Friends,

I'd appreciate if you would consider coming to our event -- Men of Boston Cook for Women's Health -- this Thursday, September 24 from 6-9. If you haven't had a chance to come to one, you're in for a treat. Food from 30 restaurants served by prominent men of Boston in a gala atmosphere under a big tent in Codman Square. It is our only fundraising event, and all funds raised support the many services we offer to women in Dorchester and surrounding communities, including OB/GYN, Family Planning, Mammography, public health, fitness and adult education programs. And it's tax deductible.

Hope to see you.

Bill

Moral high ground?

Oh, I forgot to mention below another example of the SEIU's moral high ground. Here's the latest comment:

In another controversial affront to consumers, BIDMC CEO Paul Levy has recently called for new taxes to be imposed on employer-provided healthcare. Such a tax has been unpopular in most corners of the health care debate, since it is widely believed any such charges would simply be passed on to consumers, and would particularly hurt seniors who pay more for health insurance if they are not yet on Medicare. The CEO of BIDMC has aggressively attacked national healthcare reform efforts . . . .

Regular readers here know what I actually said, looking for a progressive way to pay for health reform, while pointing out the importance of expanding health care access in the US.

But, as below, what on earth does this have to do with union organizing? Answer: Attempt to isolate someone politically based on a mischaracterization of his views, all part of trying to denigrate the reputation of the target you are attacking. Perhaps this worked in other cities, but it just doesn't sell in Boston.

How to be persuasive?

It is striking to me that the SEIU continues to think it is persuasive to hire a billboard truck that adds to the pollution and congestion of Boston streets to spread its message. It is also curious that it thinks that parking the vehicle in front of the hotel in which our volunteer community leaders are holding their annual meeting will be useful. And then, too, there is the trash barrel overflowing onto the street with its leaflets.

What's even more curious is the idea that the union apparently views criticism of ER doctors' billing practices as an effective way to gain support.* Especially since they were mighty silent about some controversial CEO compensation at a hospital in which they already have organized the workforce: "Representatives of SEIU 1199, the union that represents many of Boston Medical Center’s workers, declined to comment."

Oh, I forgot. This is not about organizing workers. It is about conducting a corporate campaign.

What's next? Demonstrating at the grand opening of the newly improved hospital in Needham, the one where it opposed the bond issue to pay for a project that has widespread community support? What a moving case that would make.

*Note: The physicians are not employees of the BIDMC or the other hospitals cited in the story.

The best care we can offer

Sometimes the best care we can offer consists in getting a patient home as quickly as possible, particularly in end-of-life situations. Here is a letter of appreciation, reprinted with permission, from the daughter and other relatives of an elderly patient. As noted by our chief palliative care nurse, "Everyone worked very hard to get this woman home in an extremely short time so she could die with her family around her in her own home."

We members of AB's Family want to thank you all for your amazing support and guidance. Because of your compassionate guidance, our Mom was able to die in peace at home by the fireplace with her dog and children and Grandchildren around her.

The Grandchildren picked wild flowers for her and brought her chocolate bars.

My youngest son, age 9, helped take care of her. He and his cousin gave my Mom the gift of their presence when she passed. She gave them the gift of seeing how peaceful and beautiful death can be.

We are so grateful for your help and have spoken with all our friends and family about the amazing support that you all gave us.

We held my Mom's wake in our small chapel that was built in memory of my brother, her oldest son, who died when he was 11 years old.

With the candles and fireplace going, we and hundreds of friends and extended family sat with her, reminiscing and celebrating an amazing woman.

The funeral service was simple elegant and deeply religious, just as she would have wished. No eulogy, just poems, written and read by the grandchildren.

How fortunate we all are, including my Mother, that we ended up in your care.

We will remain eternally grateful.

SafetyNurse names 25; Gratton aggregates them

I am humbled by patient safety nurse Barbara Olson's inclusion in her list of "top 25 tweeps for patient safety". She has assembled a list of 25 of us whose Twitter feeds he has "identified as valuable patient safety resources, visionaries, or exemplars; their approach is consistent with the science of patient safety and they're currently active in the Titterverse."

And then, faster than you can say "social media", Fabio Gratton, at Ignite Health, aggregated the tweet feeds of the 25 of us here.

I like Barbara's summary of the issue:

The systems used to deliver care and the culture of the organization where care is provided influence how often inadvertent harm occurs. Transparency, disclosure, error reporting, and an urge to prevent errors by learning from others are hallmarks of patient safety. People who champion the science of patient safety borrow from cognitive psychology, systems engineering, and human factors, recognizing the inherent fallibility of humans. They use proven strategies that mitigate the consequences of human error. Like other worthy endeavors, this one is realized with high-end metrics, and, like others, patient safety relies on IT solutions.

At the New Hampshire Hospital Association

Just heading back from Bretton Woods, where I was honored to be invited to address the annual meeting of the New Hampshire Hospital Association. Here are Peter Davis, chairman; Steve Ahnen, president; and the panel who responded to my talk -- Nancy Formella from Dartmouth-Hitchcock Medical Center; Mike Green from Concord Hospital; and Stephanie Wolf-Rosenblum from Southern New Hampshire Medical Center. The topic was transparency and its role in quality and safety improvement. There were lots of good questions during the program and continued interchanges afterward.

Policy unravels, regional strife begins

In a post below, I raised questions about the application of a new tax on relatively expensive insurance policies, pointing out the potential inequities depending how it was designed. Well, thanks to Senator Baucus, we now have confirmation that I was correct to be concerned.

As noted in this Boston Globe story by Lisa Wangsness, the tax has a broader reach than so-called "Cadillac" plans. It disproportionately affects states whose health care premiums are above the national average, or plans within states that are more expensive for actuarial reasons.

We are finding out, again, that President Obama's formulation of health care reform as offering more access, lower costs, and consumer choice is flawed and misleading. As long as Congress tries to pass a bill based on this fiction, it will be forced to make political -- not policy -- choices that try to hide the real costs.

But the derivative of doing so is that the battle between the states will begin in earnest: Now, it's just about money. There is a minuscule chance of holding together 51 votes for the Baucus plan when 17 states -- including many represented by Democrats -- are affected disproportionately. Especially because their labor partners oppose it. (By the way, on that front, keep an eye out for union-friendly amendments that would exempt collectively bargained insurance plans from the tax.)

But, here's the rub. If you diminish or roll back this tax, you have to come up with other money to keep the program deficit-neutral, a commitment made by President Obama. If you can't find new dollars, you have to cut back on subsidies for low-income people and undermine the goal of universal access. I think access is the most important goal, but it requires a broad-based, progressive tax plan. We should accept the fact that we have to pay for a national priority.

She didn't quite get the message

I have a rule for the 13-year old girls for whom I am a soccer coach: If they are going to have to miss a game, they are supposed to notify me personally in a timely fashion. This is not their parents' job. The girls are now old enough to take personal responsibility for their actions.

Here's the entire transcript of a voicemail I received late this morning, just before two matches scheduled for 1 and 4pm. The playing time for the games was sent to the entire team many days ago. Putting aside the tardiness of the call, do you think a couple of important items are missing from the message?

Hello, this is one of your soccer players, and I wanted to confirm what times the games were at, and if they are both in the afternoon, I can't make either of them, so can you call me back as soon as possible? Thank you.

Cuttlefish in action

Fall mushrooms in New England

Pictures taken on beautiful day at the MA Audubon Sanctuary in South Natick. Perhaps Doctor Halamka will identify them for us.

L'shana Tovah

Happy New Year to those of the Jewish faith.

Whether you are or not, you might appreciate this video.

And this one, too!

Prostate on the BostonChannel

Please check out Heather Kahn's video and the links leading from it to learn more about prostate health issues.

Recognizing talent

A story from a former BIDMC staffer:

I sent my niece, her husband and their 8 year old William (my great nephew and godson) to his first Sox game at Fenway today. A man a few rows in front of them got hit by a foul and the BIDMC medical team sprang into action. William (who I say is gifted) said, "Hey mama look, those guys have the same logo as Auntie Michelle has on stuff at her house...are they special, too?"

Yes, William, they are.

First week in school

This young lady has a backpack big enough for all of her books through high school!

Helping the vets

Here's an announcement of a wonderful program between the Red Sox Foundation and Massachusetts General Hospital. Program director John Parrish also leads the 11-member multi-institutional research program called CIMIT, which has a division focused on PTSD that will be integrated into this new joint venture.

ED and House meet Sherlock Holmes

Dr. Jonathan Edlow of our Emergency Department offers fifteen engaging tales in The Deadly Dinner Party and Other Medical Detective Stories (Yale University Press). Here are some other chapters from this new book to whet your appetite:

The Baby and the Bathwater
The Forbidden Fruit
Two Ticks from Jersey
The Case of the Wide-Eyed Boy
A Study in Scarlet
The Case of the Overly Hot Honeymoon

Abracadavers are sure to reach the beach

Bilal sent me this note on Facebook:

Hi Paul,

I thought you might like to know that a group of ten residents and fellows from various years within the Department of Pathology are taking part in a 36 hour 200 mile relay race in NH this weekend. Ideally, we will be using the collaborative skills we have developed over time within the workplace to coordinate the massive effort to reach Hampton Beach. This is a refreshing change of pace for us and we thought you would certainly appreciate the mini-adventure we're about to embark on.

Regards,
Team Abracadavers...get it? :)

Thanks to Lois

A large crowd gathered last night to express their gratitude to Lois Silverman upon the completion of her term as Chair of the BIDMC. Among the group gathered were many of the previous chairs of New England Deaconess Hospital, Beth Israel Hospital, and BIDMC. Here they are wearing their white coats, one of our traditions to honor past leaders. (Don't worry, they are not allowed to practice medicine. Actually, alone among the group, Lois, being an RN, could.)

This remarkable collection of community leaders includes: John Hamill, Robert Melzer, Eliot Snider, Carl Sloane, Alan Rottenberg, Ed Linde, Ed Rudman, Lois, Norman Leventhal, and Steve Kay.

Too many VPs, or too few?

In the comment section of a post below, two doctors bemoaned the proliferation of vice presidents and other administrators in many hospitals. I replied that this was often the case, but that it was my impression, too, that very often the medical staff have little or no idea of the personnel needs of complicated places like hospitals. It is often easy to blame clinical or budgetary woes on "the overhead", especially when you have had no experience in administration.

I said, "I'll give you an example in a future post, and you can be the judge." Here it is. First, a thoughtful note from one of our most loyal, engaged, and best doctors, whom we'll call Sam, to our Chief Operating Officer:

Dear Eric,
In your August letter to the Board you wrote: "The key to making this operating margin for the year is expense control…" and yet immediately following you note that you are creating "a new senior leadership position to oversee all employee safety related issues and activities." You mention that you "...gathered all the leaders in various aspects of employee safety - from Occupational Health, Radiation Safety, Infection Control, Environmental Health and Safety, etc…" to discuss employee safety (I'm curious how many additional leaders there were in the etc category). There would appear to be plenty of existing senior leadership and expertise to oversee employee safety. Is it necessary and politically wise at this time when everyone else is being made to make personnel cuts (I understand more are coming) and not to replace open positions, to add this position?

Why can't this long list of leaders attend to issues of employee safety which I agree are important? Furthermore, why is a search consultant being employed which will cost an additional 20-30% of the individuals salary? Again, it seems like this is a luxury in this time of belt tightening that is hard to justify. I'm sure there are injuries to be prevented, money to be saved, and public relation points to score, but wouldn't it be better to hold this long list of present leaders in employee safety accountable for improving employee safety? I hope you will reconsider this decision or more adequately justify it to those who are questioning its need.

Sincerely,
Sam

To which Eric replied:

Hi Sam,

Thanks for your thoughts, but I can’t agree with you on this one.

Even in times of constraint, we still have the run the institution, and that means setting priorities and spending and investing where necessary. This is one such area, in my opinion.

We have distributed responsibility for different aspects of this problem but no overall coordination and no clear responsibility. More importantly, we don’t have enough detailed subject-area expertise in this area. The issue has been turfed out to folks already burdened with other significant clinical and administrative responsibility. Our organizational structure and resources devoted to safety compares very poorly to any medium-sized manufacturing or construction company, and we have much higher rates of injuries. There’s a connection, I think. While most of them are not of the death-and-dismemberment type, many are serious or potentially serious, and I can’t justify 800 or 900 employee injuries a year. Despite ongoing efforts to improve, we’re not getting anywhere. We need a different approach.

I’m in the process of pulling together a more comprehensive analysis of the financial impact of the current situation, in medical treatment and medications, workers compensation costs, short-term and long-term disability costs, admin costs associated with comp and disability claims, return to work and wellness programs, and the staffing expense in the Occupational Health department associated with responding to injuries. I don’t know what that number is yet but it is many multiples of the cost of better leadership, and I fully expect that once we get an effective safety program in place, the result will be significantly lower overall cost. That’s been the case in most private sector industries, which probably explains in part why they are so far ahead of healthcare with respect to safety. A good record in protecting employee safety will more than pay for itself.

I don’t know what you are hearing about personnel cuts, but the budget that we will send to the Finance Committee later this week includes increases in positions over the staffing levels at which we are currently running. There will be a few areas where VPs have decided to lay off a current employee to make room for a critically needed hire. I expect there will be about a dozen or so such moves, in the context of a budget that includes funding more than 6100 FTEs.

Sam, I have never been someone who has added overhead for its own sake to any organization for which I’ve had substantial responsibility. By my count, I am net –1 in senior administrators reporting to me since coming to the Medical Center two years ago. The people I have brought in from the outside – Walter Armstrong for construction & capital facilities, and very recently Bob Cherry for food service, housekeeping and other support services – have both immediately generated very significant savings for the hospital. In FY ‘10, we will fund every single one of the highest priority projects for capital investment, in large part due to a very good process that Walter structured that significantly improved physician involvement in setting priorities. And last week Bob Cherry submitted a operating budget for his areas that was almost $2 million less than ‘09, without reducing service. In both cases: strong management, deep subject area expertise, strong partnership with physician leadership. I’m confident we can do the same in employee safety.

Best regards,
Eric

QCC posts its Roadmap

Some of the materials referenced below from the state's Quality and Cost Council have now been reposted to its website, here. Click on the "Roadmap to Cost Containment" under the September 8 meeting.

A significant detail, as yet unironed out

As President Obama said in his speech last week, "there remain some significant details to be ironed out." Let's focus on one:

And this reform will charge insurance companies a fee for their most expensive policies, which will encourage them to provide greater value for the money -- an idea which has the support of Democratic and Republican experts.

The manner in which this idea is implemented matters a lot. The first question is whether jurisdictional boundaries will be taken into account in this calculation. Let's say that Aetna or some other national insurer provides coverage in many states. We know that premiums vary significantly from state to state for lots of reasons, one of which is the degree to which each state requires certain types of medical services to be included. Beyond these underwriting rules, there are differences in health care costs, demographics, and consumer benefit preferences.

Given these differences, how do we decide what are "the most expensive policies?" There is a danger that the states that are the most progressive with regard to coverage requirements and other plan design features would find themselves in the "most expensive" category if the chosen jurisdictional boundary is a national one. By taxing insurance plans more in those states, we would create a regional imbalance in states' contributions to the national pool that will subsidize insurance access for the poor. Indeed, we might find that a high-premium state like Massachusetts, which already offers insurance to the vast majority of its population, would find itself subsidizing insurance access in low-premium states that have a high percentage of uninsured.

Along those same lines, will premiums be indexed by cost of living in the various states? Again, one reason Massachusetts premiums are high is because wage rates are higher here, and hospitals have to pay higher salaries to nurses and other health care professionals.

Or, will the tax be defined within each state, or within each insurance company? You can immediately see other types of problems of implementation if that happens.

Whatever method is used, the addition of a tax on higher premiums will make those premiums higher. The idea that businesses and others will then discontinue or redesign those plans ignores the significant friction in the employment market (not to mention the rules and regulations of state insurance commissioners). Will school teachers and other unionized public employees agree to a change in their collective bargaining agreements that lowers their health care benefits, or increases the monthly amount they must pay? Likewise, will auto, steel, petrochemical workers and other private sector unions be amenable to similar changes?

I'm sure there is more to be said on this topic, but thus far I have not seen a cogent explanation of how this portion of the plan would be implemented that does not create large flows of money from one region to another, or from one group of employees to another.

By the way, my proposal to remove the tax exemption for employer sponsored health insurance also has inter-regional impacts, essentially shifting money from those states with greater benefit packages and higher priced insurance to those with lower priced insurance. My only defense of this proposal is that it takes place within a progressive income tax system that at least deals with the issue of lower-income versus higher-income workers. But, it would clearly have a higher net cost to workers in states and industries with more generous health benefits.

Is SEIU writing itself into the health care bills?

I think the National Right to Work Committee can be a bit over the top sometimes, but this article by its president, Mark Mix, makes interesting assertions which, if correct, would be worth some public focus. He says, with regard to health care reform committee bills: "Tucked away in thousands of pages of complex new rules, regulations and mandates are special privileges and giveaways" for organized labor.

We know that Andy Stern, head of the SEIU, has had unprecedented access to the White House over the first several months of the Obama administration. "Stern estimates he visits the White House once a week. SEIU officials talk to senior Obama advisor Nancy-Ann DeParle about healthcare -- a top priority for Stern.... We get heard," Stern said." I wonder how this compares to the access that certain defense contractors and energy firms had during the Bush-Cheney administration, something that riled a lot of people and raised the hackles of good-government advocates.

Parenthetically, I note that the Obama administration has recently agreed to disclose the names of advocates visiting the White House, but we will not see those names until December 31, well after legislative action on health care is likely to be completed.

We know further than the President and many members of Congress feel indebted to the SEIU for its huge financial and logistical support during the last election. While SEIU has been unsuccessful in obtaining support for its proposal to eliminate elections as part of union organizing drives, it is quite conceivable that it would use that feeling of indebtedness to obtain provisions in the reform bills that would strengthen its ability to organize health care workers.

Perhaps Mr. Mix's article will stimulate reporters and editorial writers to do their own research on the matter.

Tom does it again

When cancer survivor Tom DesFosses puts his mind to something, it is a sight to behold. Today's second annual Reason to Ride attracted 185 bike riders devoted to raising money for cancer research at BIDMC. This was well over double the participation from last year.

Here are some pictures:

Tom and his doctor, neuro-oncologist Eric Wong; Dave deBronkart (aka e-Patient Dave) and his orthopaedic surgeon, Megan Anderson; a friendly server from event sponsor Fuddruckers with BIDMC staffer Allison.

Finally, here's a video of The MERJ, a wonderful musical ensemble who donated their time and kept the place hopping, even after the ride. Here they are singing the Hank Williams favorite, "Jambalaya (On the Bayou)."

More scenes from Jessica

Make sure you keep up with Jessica Lipnack's scenes as she observes things during a friend's extended stay in a hospital. Best to bookmark that site or get the RSS feed, as you are sure to enjoy each chapter.

Tennis anyone?

We have many loyal and grateful patients and families who want to help out. Here's the next event, on Thursday, September 17.

Boston Realty Advisors invites you to participate in their annual Tennis Tournament on the grass courts at the Longwood Cricket Club to benefit the Center for Violence Prevention and Recovery at BIDMC.

There are still some slots left. Check our Grateful Nation website for the details.

Can this be true?

A story by Liz Kowalcyzk in today's Boston Globe has to cause some raised eyebrows. It is about a plan by the state's Quality and Cost Council to reduce health care costs over the coming decade, a very significant public policy goal. Here's the quote in question:

The state removed the draft recommendations from its website after the Globe inquired about them.

I understand that this is a draft report that might change before it is formally issued. But what could it contain that is so sensitive that the Council would want to avoid public review and comment? When bills go through the legislature, we all get to see early drafts. When environmental impact statements are under preparation by state agencies, we get to see drafts.

Why, in a field in which transparency is becoming a watchword, would the Council not want to have the advantage of a final stage of public comments on its draft document? In contrast, see this earlier (12/10/08) press release by the same Council: "Members of the Massachusetts Health Care Quality and Cost Council (HCQCC) gathered with members of the Legislature, health care advocates and consumers today for the launch of an interactive website designed to promote transparency in the health care industry."

A Reason to Ride

There is nothing like spending a fall morning on the North Shore bike riding along a beautiful rural route. And there is nothing like doing so while helping to raise money for cancer research.

Please join cancer survivor Tom DesFosses, his family, and lots of us for A Reason To Ride, a 10-, 20-, or 50-mile ride starting in Danvers, MA, on Sunday, September 13.

Tom says, "For me, this ride will be very emotional, but in another way it will give me incredible joy. It will give me time to reflect on how blessed I am to be a cancer survivor, and to think of others who are not able to join me on this quest. I hope other cyclists will join me on this ride to help raise greatly needed funds for life-saving cancer research."

Tom wanted this to be a very inexpensive fund-raiser to encourage many people to join in. It is just $50 per adult and $25 for a child, or $100 for a whole family. Get the full story here.

Groupon, Livingsocial, and digital norms

Regular readers have noticed that I am a bit of a social media junkie -- this blog, Facebook, Twitter -- but I am also intrigued by social media sites that are set up only for commercial purposes. It is fun and instructive to watch the evolution of these sites.

Along those lines, a few weeks ago, I wrote about Groupon. The concept: The retailer offers a discount deal in the city of your choice, but only if enough people sign up for it. The viral power is amazing, because after you sign up for something you want, you contact all your friends asking them to do the same so you can get the deal. Meanwhile, the retailer gets noticed by people with an affinity for his/her product or service, and gets a bundle of cash in prepayments. The folks at Groupon get some kind of fee. Everyone is happy

Now arises a new site, soon to go into business, called Livingsocial. Like Groupon, you can sign up for the deal of the day, and if enough people sign up, the deal is on; but unlike Groupon, if you get three other people to sign up for the deal, you get your coupon for free.

I'm not sure, but I do not think this last feature is going to catch on. I think people will be reluctant to try to get their friends to sign up for a coupon so that they can profit from the experience. I think friends, too, will be put off to think they are being "used" that way by their digital buddies.

One of the things I have learned about social media users might seem a bit paradoxical. People value their privacy. Huh? People who expose all on their blogs, Facebook pages, and Twitter feeds value privacy? Well, yes, in certain respects. They don't like receiving commercial spam, even from their real friends. I wonder if the Livingsocial model will feel like it violates that cultural norm.

Time will tell, but in the meantime, please offer your thoughts on the matter.

Transforming at the Joint Commission

Here's an announcement from Mark Chassin at the Joint Commission. I recall that Mark set forth some of these themes several months ago, and it is great to see that he and his folks are implementing them:

Today, I am excited to announce the launch of the Joint Commission Center for Transforming Healthcare, which was created to address the most pressing safety and quality problems in health care. The Joint Commission is using a new approach to systematically measure the magnitude of serious quality and safety problems, pinpoint their underlying causes, and develop and test targeted, long-lasting solutions. And, we aim to provide these proven effective solutions to you as an additional benefit of accreditation. The Center is well on its way to completing its first initiative - developing solutions to improve hand hygiene and reduce preventable health care-associated infections.

I know you are searching for - and are eager to implement - highly effective, sustainable solutions that are relevant to your most difficult quality and safety problems. This new approach is required to achieve the level of consistent excellence that is sought by you, by patients and their families, by physicians and other clinicians, and by other public and private stakeholders. I strongly believe that the Center for Transforming Healthcare will live up to its name - transforming the delivery of health care so that all people always experience the safest, highest quality and best-value health care.

The Center is developing solutions by using the same Robust Process Improvement(TM) (RPI) methods - including Lean Six Sigma and change management - that other industries have long relied on to improve quality, safety and efficiency. You may recall that the Joint Commission deployed RPI internally in 2008, and we are aggressively using these proven methodologies to improve our systems and processes for the benefit of customers. Likewise, the Center's participants - volunteer hospitals and health systems throughout the country - have substantial, real-life expertise using RPI in the health care environment. They are using a proven systematic approach to analyze specific breakdowns in care, discover their underlying causes, and develop targeted solutions that solve these complex problems. In addition, the Center is engaging industry to create new products that will amplify and sustain the impact of its solutions.

The Joint Commission has led the way nationally and internationally to identify the highest priority health care quality and safety problems and to address them. Our National Patient Safety Goals, core measures, and state-of-the-art accreditation standards have helped health care organizations focus their efforts to gain the greatest improvements in safety and quality. And you and your colleagues have focused your efforts and made great progress - often with scarce resources and limited help. Now, the Joint Commission Center for Transforming Healthcare aims to provide you with specific guidance on exactly how to improve and sustain quality and safety using Center-developed, proven effective solutions that will be customized for differences among health care organizations. Importantly, the Center's solutions are designed so that your organization will not require any expertise in RPI methods in order to use them.

Ultimately, the Center will provide knowledge and practices that will help transform health care into a high-reliability industry, with rates of adverse events and breakdowns in routine safety processes comparable to air travel or nuclear energy. To accomplish this goal, the solutions that are developed and tested by the Center must make their way into health care organizations across the nation. The Joint Commission is uniquely positioned to facilitate this process. As the Center's solutions are proven effective, the Joint Commission will speed their distribution to our accredited health care organizations and, in the future, we may consider them for possible inclusion in our standards or National Patient Safety Goals.

The Joint Commission is successfully obtaining outside funding for the Center's vital work, so we can deliver these solutions to accredited health care organizations to the extent feasible at no additional cost. In addition to the hand hygiene project, the Center is also developing solutions for hand-off communications and safeguards to prevent wrong site surgery and will work on additional projects for the range of health care settings we serve. To learn more about these projects, visit the Center's Web site and make it a regular resource for your organization.

The Center for Transforming Healthcare is already creating excitement about its new approach to solving problems that we all face every day. I know you will find value in these and other solutions emanating from the Center. Together, we can make a difference and transform health care for patients everywhere.

Sincerely,

Mark R. Chassin, M.D., M.P.P., M.P.H.
President
The Joint Commission

Quick reactions to Obama at the NYTimes blog

Several of us were invited to submit comments to a New York Times health care blog about President Obama's speech tonight. Here they are.

MICUs go Lean: Result = Happiness

Continuing our spread of Lean process improvements, a team recently assembled to use the 5S process to redesign the supply rooms in two of our medical intensive care unit ("MICU") supply rooms. The objective was to standardize the arrangement and display of supplies in the two rooms, which are on two separate floors. Beyond making each room more efficient, we wanted them to be identical because the same staff people work in the two units. It is better for them to see supplies in the same configuration in the two venues. The plan was to organize items to make the supply collection process more intuitive and also to require less motion. After all, these are intensive care units, and people can often be in a hurry when supplies are needed. Time matters.

And beyond one quick fix, we were looking for sustainability, an organization and process that would keep the units well organized and neat well into the future.

As always, this Lean project was multidisciplinary, involving attending physicians, residents, nurses, respiratory therapists, patient care technicians, and our supply and distribution folks. Able assistance was provided by our Business Transformation unit (aka "Lean Team"), but also people from other units who had conducted similar improvement events on their floors.

The results:
-- 100 distinct, unnecessary items were removed from the supply rooms.
-- 86 frequently used items were converted to par items (i.e., restocked regularly, rather than being called for as needed.)
-- 100% identical supplies in the two supply rooms. See Venn diagram above for the before and after.

But, most impressive, the amount of time accumulating supplies for a given procedure was dramatically reduced. See these before and after videos of nurse Tim collecting arterial line supplies. And then view the third video for Tim's triumphal conclusion!

Why am I always in the slow line?

Here's an excerpt from a lovely little book by John D. Barrow called One Hundred Essential Things You Didn't Know You Didn't Know; Math Explains the World. This selection has a great lesson about statistical inference. The chapter is entitled, "Why does the other queue always move faster?"

You will have noticed that when you join a queue at the airport or the post office, the other queues always seem to move faster. When the traffic is heavy on the motorway, the other lanes always seem to move faster than the one you choose. Even if you change to one of the others, it still goes slower.... In fact, the reason you so often seem to be in the slow queue may not be an illusion. It is a consequence of the fact that on the average you are usually in the slow queue.

The reason is simple. On the average, the slow lines and lanes are the ones that have more people and vehicles in them. So, you are more likely to be in those, rather than in the faster moving ones where fewer people are.

The proviso "on the average" is important here.... You won't invariably be in the slowest line, but on the average, when you consider all the lines that you join, you will be more likely to be on the more crowded lines where most people are.

This type of self-selection is a type of bias that can have far-reaching consequences in science and for the analysis of data, especially if it is unnoticed. Suppose you want to determine if people who attend church regularly are healthier than those who do not. There is a pitfall that you have to avoid. The most unhealthy people will not be able to get to church and so just counting heads in the congregation and noting their state of health will give a spurious result.... [W]hen we do science or are confronted with data the most important question to ask about the results is always whether some bias is present that leads us preferentially to draw one conclusion rather than another from the evidence.

BIDMC-style behavior and gratitude

Kristin sends me a note this morning on Facebook:

"Wanted to post a hospital wide thank-you to whomever found my wallet next to my car in the garage and put it in my door handle untouched....it is refreshing to know that there are good people out there and makes me proud to call them my coworkers. Thank you!!!!"

More than "a matter of convenience"

Back in July, the Lewiston, Maine Sun Journal published an editorial entitled "A matter of convenience," supporting a move to furlough state employees for 20 days spread out over the year but disagreeing with a plan to require those furlough days to be taken in such a way as to lengthen regular holiday weekends. "What isn't so good is the inability of that public to access government services during these furlough days, most of which are conveniently scheduled to extend already long weekends for government workers.... The shutdown days were scheduled to save salaries, not the costs of heating, cooling, insuring or otherwise of operating offices, so there was no real need to tie these days to existing holidays."

Well, it looks like those editorial writers had the right concerns. A colleague wrote me last night:

I was in Mid-Coast Hospital in Brunswick, Maine, all weekend with my father, who was suffering from a viral infection that was giving him some kind of dementia. It may have been H1N1, possibly Lyme disease. But here's the kicker. The Maine state lab employees were on furlough. No test result, which resulted in us staying the whole weekend and my father leaving without a result. Hospital officials said that Medicare and Medicaid patients also had to stay longer because there was no one to process their papers. Amazing. It was frugality over functionality, and blind bureaucracy trying to find savings that ended up costing probably millions in unnecessary health claims.

Facebook leaks data

For those Facebook users out there, here's something you will want to know. Facebook quiz technology lets developers (who are not screened by Facebook) see not only your data, but your friends'.

This article links to the American Civil Liberties Union's Facebook quiz, which demonstrates what developers can see when you agree to let an application get access your data. As noted: This is mostly due to the fact that Facebook's default privacy settings allow access to all your profile information whether or not your profile is set to "private."

A tale of two cities

Comparable street scenes from Boston and Estes Park.

Freecycling

Swap shops are spreading around the hospital! An email went out this week in one of our office buildings:

Beginning today, Sept. 1, look for the new “Take It or Leave It” freecycle swap table in the second floor elevator lobby.

Items such as paper clips, pens, pencils, paper, envelopes, manila folders, tape dispensers, staplers, binders, toner cartridges, etc …, can all be dropped off at the table (please help keep things tidy). Anyone who needs the supplies can take whatever they want from the table — just use it!

Jane Matlaw is seen above, hawking.

Scenes from a hospital

Jessica Lipnack offers perceptive observations while visiting a patient in an out-of-town hospital.

Will this be in the President's speech to Congress?

In contrast to the you-can-have-it-all-without-sacrifice approach of the President, Jonathan Gruber states the case pretty clearly today in a Boston Globe op-ed:

"Fundamental cost control is simply incompatible with unrestricted consumer choice."

"The premiums that all employers and most employees pay are exempted from both income and payroll taxation, unlike wages. This shields firms and employees from reaping the financial benefits of lowering insurance costs."

"Health care reform can be financed by reforming the tax exclusion, and can also include stronger regulatory reforms on the supply side. Just capping the tax exclusion at the average cost of employer-sponsored insurance, so that individuals pay tax only if they have plans that cost above average, could raise as much as $500 billion over the next decade to finance reform."

Reprise: Compensation for directors of non-profits

Some time back, I raised the issue of compensation for members of non-profit boards, particularly those of insurance companies in Massachusetts, noting:

I do not write this to give any sense that I begrudge the insurance company board members their annual retainer and meeting fees, but I wonder how the custom evolved that they should be paid. Has it always been such, or is this a recent development? Is there is anything special expected of them in return for that payment that we do not expect of unpaid board members serving other non-profits?

Apparently, people with lots more statutory authority than I have had similar questions. Our Attorney General, Martha Coakley, has issued an announcement through her Division Chief David Spackman that she intends to have her Non-Profit Organizations/Public Charities Division investigate this practice, noting:

In the area of director compensation, we will address the unusual practice of compensating otherwise independent directors at four of our eight charitable health care insurers. The basis for compensation has not, to the Division's knowledge, ever been clearly articulated to the public and we are asking each of the current boards to take a fresh look at the practice. If the practice is to continue at any of them, it should do so only on the basis of a sound and well considered foundation, for which the benefits and risks have been fully explored and appropriately considered, and in a manner in which the independence of the board has been preserved.

The announcement also suggests a more thorough and contemporaneous review of insurance company and hospital executive compensation, also a welcome step. As I would expect, the Attorney General takes a measured and thoughtful approach to the issue, but she also reminds us of the overall context and the need to be especially diligent:

Today's announcement should not be construed as an attempt to substitute the judgment of the Division for that of committed, knowledgeable and diligent boards. The most expensive mistake an organization can make is to place the wrong person at the helm or the wrong people in the board room. The charitable sector needs to compete for executive talent with the for profit sector in an employment marketplace often insensitive to tax or charitable status. Our most effective managers will be and should be fairly compensated and we acknowledge that the results of the most perfect of compensation systems will be found offensive by some. Members of our charitable boards should be talented, qualified and experienced. Nevertheless, unless this Division and our charitable boards address these issues head on, particularly given recent economic trends and the serious crisis in health care costs, the discretion now vested in our boards is more and more likely to be subjected to far more dramatic externally imposed limits and controls.

McNeil shares the facts

A group of us hospital administrators heard an excellent talk this morning by Dwight McNeil, the new MA Assistant Commissioner for Health Data Analytics in the state's Division of Health Care Finance and Policy (shown in picture). As you might expect, he showed us some interesting data, including the three charts above.

We in Massachusetts tend to think we live in Lake Wobegon, always being above average, especially when it comes to health care delivery. Not so, as demonstrated quite clearly here. We look good versus the US as a whole, but not so against the other New England states, and worse so versus the best in class.

Not here, thankfully

A Boston friend visiting a relative sent these pictures to give a view of how hand hygiene (note empty soap dispenser) and tap water ("Do not drink") are dealt with in an out-of-state hospital.

Thank you, Governor Patrick

Governor Patrick and his folks deserve lots of credit for figuring out how to preserve health care benefits for legal immigrants in Massachusetts, as documented in today's Boston Globe story by Stephen Smith. See here for an earlier request to help out on this front.

The solution is not perfect, but it is a practical and thoughtful response to the matter.

It is a sad state of affairs that this issue arose at all. This is about legal immigrants, people who work hard, pay taxes and otherwise are like everybody else in the state. The only difference between them and "us" is that they don't yet have the right to vote. As such, they were all too easy for the body politic to ignore.

As we consider appropriate tributes to our late Senator Kennedy, omission of insurance for this group is the kind of thing he would have found anathema. Bravo to Governor Patrick for recognizing the Commonwealth's obligation to them as part of the health plan that is being viewed as a model while the country considers its own national plan.

Better water

Remember the bottled-water-versus-tap-water taste test I wrote about a few weeks ago? Here's a recent note sent to folks in the hospital from our catering department head. The response was very positive:

Dear catering customer .
I am emailing you to inform you that BIDMC catering will be removing bottled water from our menu. Instead, we will default to tap water with ice in pitchers with reusable glasses. We have made this decision for environmental reasons detailed below. However, as a large catering consumer, you will also save money by switching to water pitchers. The transition date is September 14th, 2009. From that date moving forward, if water is ordered, you will receive as stated above. If, for any reason, you feel you need bottled water for your event, please contact me directly.
Thank you,
Gail Spileos

Reasons for “Going Green”
In the past few years we have received many requests to recycle catering bottles, and we hope to have that program in place soon. However, eliminating the bottles is even more environmentally sustainable. Each year, 55,000 bottles, or almost 5% of the 1.2 million bottles cans consumed here at BIDMC, are catering water bottles even though an identical product is available directly from our tap. The decision to phase out these bottles eliminates both unnecessary plastic and the fuel needed to truck water from a bottling plant to a distribution site and then on to BIDMC.

I understand that part of the reason we have been serving bottled water instead of tap has to do with the misperception that our tap water is dirty and unsafe. Because this perception has more to do with the successful marketing campaigns of bottled water companies than reality we would like your help in supporting and promoting this shift to a more environmentally sustainable model. This shift will be successful if we work together to educate our meeting participants.

What folks should know is that tap water is at a minimum as clean and safe as bottled water but often it is cleaner and safer. The MWRA tests our drinking water for 227 contaminants every year and publishes its result on its website. Bottled water companies are held to a lower standard because they don't have to test their water in certified labs. They also don't have to publish the results of any of the tests they do perform. As a result, as an institution that is committed to the public health and safety, we can say unequivocally tap water is certainly no less safe than bottled water and may, in fact, be safer.

There is also a perception that tap water tastes lousy. However, in a recent blind taste test here at BIDMC, 60% of the participants preferred the taste of tap water to that of bottled water and another 15% had no preference. This means we are currently serving water that was only preferred by 25% of the participants. The switch to tap water will mean a shift to the water preferred by the majority of participants.