Off-base optimism: Part 1

I like to view myself as an optimist, but two recent reports demonstrate the danger of misplaced or premature optimism.  I fear that they are influenced by what the authors hope will be the case rather than what has proven to be the case.  I find this generally to be the situation in the health care arena, where public policy is often based on shallow interpretations of data and on people's political wishes rather than rigorous analysis.

The first comes from Karen Davis at the Commonwealth Fund, in a blog post entitled, "Health Spending Continues to Moderate, Cost of Reform Overestimated."  We should know from the title alone that the conclusions cannot be accurate:  It is just too soon to reach them.  It would be like drawing a picture of climate change from one year of data about temperatures.

Here's an excerpt:

A recent report from the Centers for Medicare and Medicaid Services (CMS) shows that national health spending grew at a historically low rate of 3.9 percent in 2010, almost paralleling the 3.8 percent increase in our gross domestic product (GDP) last year. This is . . . good news for the federal government as the slowdown indicates that the cost of health reform has been overestimated.

Now, let's look at the possible reasons: 

First . . . continuing declines in employment and private health insurance coverage have contributed to fewer people receiving both essential and nonessential treatment. [F]ewer people have received needed preventive and acute care. And people have increasingly gone without prescriptions, tests, and elective procedures.

Let's see, is this good news or bad news?  Health spending is down because insurance coverage has become more limited.  But, what proposition does it actually support?  Answer, as universal coverage is restored under the new federal law, costs will rise again.  As we found in Massachusetts, when you give people insurance, they use it.  Indeed, that is the purpose.  Thus, this statement offers no support to the proposition that the cost of health reform has been overestimated. 

Some of the slowdown in 2009 and 2010 may be related to the uncertainty surrounding the enactment and implementation of the Affordable Care Act. During earlier reform efforts . . . health care cost growth abated as cautious hospital and other health care leaders held back on hiring decisions until the implications of proposed changes were clearer. In 2009 the health care industry—including hospitals and pharmaceutical companies—also pledged to achieve voluntary savings. 

Let's start with the last line first.  Those "voluntary savings" are vacuous estimates related to the trends that might have occurred.  They are not absolute savings.  They are not measured.  They are not enforced.

But, it may be the case that hiring has slowed down.  In hospitals, though, it would be due to reduced earnings as states and the federal government have cut Medicaid and Medicare payments because of their budget woes.  This goes back to President Obama's misrepresentation as to the nature of cost savings that would result from the Act.  These were not cost savings derived from increased efficiency in the health care system, as most economists would define that:  There were reductions in governmental appropriations that have led to reduced earnings, slowly decapitalizing hospitals and forcing reductions in staff.

There is a parallel in the private insurance market, as rate increases from those companies have also leveled off because of pressure from employers and individual subscribers.  Again, this is not an efficiency gain in the health care system.  It is simply a price reduction forced by payers who have more market leverage than the providers.

Health spending trends may also reflect almost a decade of voluntary efforts to improve patient safety and quality, and eliminate waste—cutting costs while improving health outcomes. The Institute for Healthcare Improvement has completed several successful campaigns to improve patient safety and continues to support widespread initiatives that encourage efficiency. The Commonwealth Fund’s own Commission on a High Performance Health System has been publicizing approaches to reduce hospital readmissions, implement medical homes, and improve the quality of nursing home care. Some hospitals are now using “Lean” techniques used by other industries to improve care and cut out waste. 

Now, here we might have something, if it were true and could be proven.  As my regular readers know, I certainly hope it would be the case, but there is a paucity of data to show that this has occurred on a wide scale.  There are industry leaders and early adopters.  Among the large systems, Ascension Health, Gundersen Lutheran, Thedacare, and several others show the way.  In Boston, the fact that hospitals like BIDMC and Mt. Auburn Hospital can achieve earnings comparable to their counterparts in the much more highly paid Partners Healthcare System is a demonstration of the virtuous feedback loop between improving patient quality and safety and reducing waste.

I would dearly love to engage in the kind of wishful thinking that would suggest that these efforts have made a noticeable blip in the health care cost trajectory.  But, as I speak to front-line staff people in hospitals around the country, it is clear that there are miles to go on this front.  The most common reaction I get from enthusiastic doctors and nurses and managers to my presentations at national conferences is this:  "We believe in what you say.  How can I get my -- fill in the blank -- CEO, CFO, CMO, Chief of Service -- to provide leadership on this, to focus on it, to provide training and resources to make it happen."

Notwithstanding her optimistic lede, though, we finally get to Dr. Davis' real conclusion:

Despite the slowdown, U.S. health care spending per person is still more than twice that in other major industrialized countries, and costs are projected to rise though 2020. The retirement of “boomers” born after World War II will continue to cause health care expenditures and federal budget outlays to increase as a percentage of the economy.

Yes, that is certainly true. But it is not an issue facing the US alone.  Other developed economies in Europe and elsewhere are seeing a similar trend.  Their overall expenditures as a percentage of GDP will be growing even more rapidly than ours as public pressures emerge that push them in the direction of trying to replicate aspects of the tertiary care system that exists in the US.  (See Denmark as one example.)

But then Dr. Davis returns to unsupported hoping:

It is important to implement key cost-saving provisions of the Affordable Care Act, including value-based purchasing, shared-savings incentives for accountable care organizations, innovative payment pilots such as patient-centered medical homes, and creation of the Independent Payment Advisory Board. 

I have previously addressed the underlying structural problem of ACOs under the Medicare rules, which is that the PPO character of Medicare would not change:

"The provider may not require a beneficiary to obtain services from another provider or supplier in the same ACO."

How can you be held accountable, as a provider group, if you cannot control the management of care of your patients? I'm not blaming CMS for this contradiction. The agency is simply implementing what Congress and the President ordered it to do. There is no way Congress will limit choices among the Medicare population.

Meanwhile, too, the IPAB is under political assault, as Congresspeople figure out that it, too, could limit constituents' choices and have other unintended consequences:

Quite simply, IPAB has so many opponents because it embodies centralized planning from Washington, D.C., and enables unelected bureaucrats to make decisions about people's health care. The contrast couldn't be more clear: a new government body (IPAB) charged with taking resources away from the beloved Medicare program.

Further, IPAB is a threat to critical medical treatments and services for all Medicare beneficiaries. Proponents of the board have argued that IPAB will improve the quality of care as a result of the cost-cutting measures it enacts in order to save. However, it is doubtful this will happen because the board will have to make cuts that reach annual targets. Thus, standard line item cuts will result, which will only reinforce systemic problems, not fix them, and create unsustainable savings.

What about new pricing regimes?   This leads me to my next example of overly hopeful analyses, in the post below.

Off-base optimism: Part 2

In the post above, I present a review of a recent blog post from the head of the Commonwealth Fund that, to me, represents an all-too-common analysis of health care issues, one driven by desire rather than clear-headed thinking.  I promised a second example, and here it is, using a recent article in the New England Journal of Medicine.  It was again brought to my attention by this teaser from the Commonwealth Fund:

New Study: Innovative System for Paying Health Care Providers Slows Spending, Improves Patient Care

Findings from a Harvard University study conducted with Commonwealth Fund support reveal that a recently implemented global payment system for physicians and hospitals in the Blue Cross Blue Shield of Massachusetts network is lowering medical spending and improving the quality of patient care.

This is delicate as I offer comments, in that I know several of the authors and have the greatest respect and fondness for them.  But the fault lies not in their analysis.  I quibble more with the Commonwealth Fund's interpretation of the results than with the study itself.  The Fund seems to be looking for a "quick win" on the issue of capitated, or global, payment contracts.  As noted above, drawing any conclusions from one year of data is problematic.

The title of the article is "Health Care Spending and Quality in Year 1 of the Alternative Quality Contract," and the authors clearly lay out the limitations of their analysis.  Here is a section of the discussion, upon which the Commonwealth Fund seems to base its teaser:

The AQC was associated with modestly lower medical spending and improved quality in the first year after implementation. The savings derived largely from shifting outpatient care to providers who charged lower fees and were seen primarily among high-risk enrollees. Savings were larger among providers who were previously paid by BCBS in a fee-for-service system.

The improvements in quality are probably due to a combination of substantial financial incentives and BCBS data support. AQC quality bonuses are much higher than those in most pay-for-performance programs in the United States, since they apply to the entire global budget rather than to physician services alone or PCP services alone.

But, the Commonwealth Fund failed to mention this most significant finding:

The savings associated with the intervention do not imply that total payments made by BCBS declined. Total BCBS payments must take into account quality bonuses and end-of-year budget surpluses paid to the AQC groups. In 2009, quality bonuses were generally between 3% and 6% of the budgets. Additional BCBS support for information technology, staffing, and other needs was between 0% and 2% of the budgets. Moreover, all AQC groups spent less than their 2009 budget targets, earning, on average, 3% in budget surpluses (consistent with our estimates). Taken together, these first-year investments and payouts exceeded our average estimated savings of 1.9%, suggesting that total payments by BCBS to AQC groups rose for AQC groups in the first year.

I have discussed aspects of this before, citing an article in Commonwealth Magazine:

Blue Cross padded first-year global payment budgets to entice hospitals and doctors to sign on.... [T]he current goal is not to actually reduce costs, but to cut in half the rate of growth in medical costs after five years.

An insurance company has a major incentive to shift actuarial risk to providers and away from itself.  It also has an interest in price stability, for competitive and earnings reasons.  We cannot fault BCBS or otherwise for behaving in a manner consistent with its corporate goals.  But we can fault policy advocates who take incomplete results and use them in an unrigorous manner to support a policy agenda.

In memoriam: Rita McCafferty McQueeney

In these days of unfortunate denigration of people who choose a career in state government, it is important to recognize those who devote their lives to public service -- not in a flashy or ostentatious way -- but in just doing their job thoughtfully and well every day of the week.  Rita (McCafferty) McQueeney was one such person, and she passed away peacefully and quietly this week.

Rita was a secretary in the state's Department of Public Utilities, working for a succession of Commissioners in that regulatory agency.  She lived in Mansfield, south of Boston, and would take the train to work every day.  I don't ever recall her missing a day of work.  Even during the worst snow storms, she would show up bundled up with boots on.  But beyond that, her attitude and approach to work and life was always positive.  She had a marvelous sense of humor and excellent judgment about people, which never got in the way of her being inevitably polite, respectful, and helpful to all.

I was fortunate to work with her during my two terms in the agency, from 1977-78, and then again from 1983-1987.  During the second term, my young daughters would often come to visit the office, and they adored Rita.  I have wonderful memories of their laughing together about some secret that they were keeping from their father and boss!

Rita and I stayed in touch after I left the DPU, but irregularly.  She always knew about my latest job and would have astute observations about the political environment within which I was working.  But she mainly wanted to know how "her girls" were doing and would have the pride of an honorary aunt when I would tell her of their accomplishments.

She will be missed by all who knew her.

Finding Joy and Creativity in Infrastructure

I apologize to my regular health care constituency for the recent spate of postings about infrastructure and other urban planning topics, but it just seems to be one of those times that many of those stories have ripened. To get this out of my system before returning to hospitals and health care next week, I offer this compendium of stories.

I write these in tribute to those public servants who, over the years, joyfully and creatively built or improved the infrastructure that serves the public every day. You might be surprised to think of those activities as either joyful or creative, especially during periods of tight budgets. But, there have been several people who have thrived in the environment, pursuing investments for the public good.Their stories might provide inspiration to current and future generations of public officials.

The Librarian

Notable among this group was Theodore Mann, the longest-serving Mayor of Newton, a suburb west of Boston.  While he did a lot for the City, his pet project was the construction of a new library.  I met with him in the early 1990s, just before the ground-breaking.  He was bubbling with enthusiasm and with the glee of a Depression-era child who had just gotten something for nothing.

“I was able to get a third floor,” he said.  “I only had approval for two floors, but I put an alternate into the bid document.”  Ted knew the public construction laws well enough to understand that you did not have to re-bid a building project if you put a provision asking bidders to scope out an optional extra additional item.  As the City prepared the bid documents, he was alert to the fact that the construction market was a bit soft, and so the bids for the two-story building would likely come in under the architect’s estimate.  What if he could get a third floor added, and still have the whole thing come in under budget?

It worked.  The bids, including the third-floor alternate, were low enough to expand the scope of the library substantially.  “We’ll need that space eventually,” he told me.  “But if we don’t get it built now, it will never happen.”

The Dairy Farmer

When Bill Geary took over as Commissioner of the Metropolitan District Commission in 1983, he noticed an odd traffic phenomenon.  About once a week, a truck would enter Storrow Drive or Memorial Drive and attempt to go under the Mass. Avenue underpasses.  It would get stuck, and the roof of the truck would roll up like the top of a sardine can.  Traffic would back up to Watertown.  The MDC police and road crews would go to work, rescue the truck driver, deflate the tires, and tow the truck away.  Meanwhile, thousands of commuters would be late to work.

On the Cambridge side, the freshmen women living in MIT’s McCormick Hall would jump with a start when they heard a crash and would watch the rescue operation.  By second semester, they had become so accustomed to this pattern that they didn’t even look up from their homework.

Bill brought his team together and suggested that having a truck crash into a bridge every week was not acceptable.  Couldn’t something be done?  “No, Commissioner,” he was told.  “Besides, we have a routine all worked out.  The police handle the traffic.  We bring in the tow truck, the Jaws of Life, whatever we need.  We clean out the whole problem within an hour.”

“What if,” he said, “we put signs up at every entrance to the river roads, at the height of the underpasses, with a pictogram warning taller trucks to stay out?”

“Commissioner,” they replied. “Can you imagine the liability if our sign breaks a windshield and sends glass flying into the face of a truck driver?’

“Well, what if we make the signs out of rubber so they don’t break the windows?”

“Rubber signs, Commissioner?  There is no such thing.”

Shortly after this conversation, Bill was driving his car along the Mass Turnpike and was approaching the toll booth that displayed an elevated sign saying, “Cars only.”  He looked closely.  The sign appeared to be made of rubber.   He stopped in the toll plaza, climbed up onto the hood of his car, and grabbed the sign.  It was made of rubber!

He got on the phone and called Jack Driscoll, then head of the Turnpike Authority, and found out where he had purchased the signs.

At the next meeting with his staff, Bill reported that he had found rubber signs and suggested that they be ordered.

“But Commissioner,” someone said, “What good is a rubber sign?  Truck cabs are noisy places.  A trucker will just hit the sign and drive right through without even hearing that he has hit it.”

“Well, then, let’s hang cow bells on each sign, so drivers will hear a noise as they approach our roadway if their vehicle is too high to go through the underpass.”

“Where will we get cow bells?” he was asked.

“I don’t know.  Call a dairy farmer and ask where they get their cowbells.”

The signs were installed, cow bells and all.  The frequency of crashes in the underpasses went from one per week to less than one per year.

The water guy

Boston was growing rapidly in the late 1800s, with the population surging to staff local industries and commerce.  But public officials were worried.  Where would the city get sufficient drinking water?  Local supplies were in danger of contamination from sewage in the city streets.  As reported at the time, “Under certain conditions . . . especially on summer evenings, a well defined sewage odor would extend over the whole south and west ends of the city.”  The danger of typhoid and cholera epidemics was persistent and real.

Frederic Stearns, a civil engineer working for the City’s Engineering Department, designed a system capable of disposing of sewage for the metropolitan area.  The system was later cited by Scientific American as “important advance in sanitary engineering." Later, as chief engineer for the Metropoltan Water and Sewerage Board and later, the state’s Board of Public Health, he devised a plan for providing adequate supplies of clean drinking water.  He envisioned a series of reservoirs to the West, capturing pristine rainwater from central Massachusetts rivers and streams.  The led to the construction of the 65-billion gallon Wachusett Reservoir in 1906 and the 412-billion gallon Quabbin reservoir in the 1920s and 1930s.

Remarkably, all of that water flows by gravity to Boston and its suburbs, avoiding energy costs associated with pumping.  Also, the reservoirs have unheard of levels of reserves – over five years’ worth of supply, even if it totally stops raining for that length of time.  Finally, thousands of acres comprise the catchment area around Quabbin.  These forests, now called “the accidental wilderness”, ensure that this supply is protected from contamination.

Stearns’ attentiveness to detail was legendary.  His 1901 “Report of the Chief Engineer,” to the MWSB stretched to 91 pages, ranging from the “force employed on works” to “removal of soil” to “culverts and crossings” to “consumption of water” to the “quality of the water.”  His management skills with regard to construction were prodigious.  In 1906, he was able to report, “The design of the Wachusett Dam and the contract for its constructions . . . was made . . . on October 1, 1900. . . . There has been no material change in the plant or in the methods.”

Just an engineer

Fred Salvucci’s prowess as a transportation planner is well known, but as Secretary of Transportation, he also played a lead role in shepherding public works projects through the political labyrinth of Beacon Hill.  His tenacity is legendary, but it is based on a substantive knowledge that can only be described at encyclopaedic. An example:

One day, I boarded a flight at Logan Airport, headed to Washington, DC.  I found myself in a row with Fred, with another fellow in the center seat.  This was around the time that people were trying to decide how to design and build the Charles River Crossing of the new Central Artery Project.  It was a tricky engineering problem, with lots of environmental and political ramifications, as well.  The design had been through many revisions, and they were up to number 26, or “Scheme Z.”  As we sat on the tarmac in Boston, I casually asked Fred, “Can you tell me about Scheme Z?”

He started talking, and I started listening.  He stopped talking as we taxied up to the gate at National Airport.  I learned more in that hour-and-a-half about the history of the highway project than I had learned before or have learned since.  I still wonder, though, about the poor guy sitting between us!  I sure hope he was interested in the topic.

I recall a radio interview with Fred during that time, as he engaged in a long discourse with the reporter about the many aspects of the Central Artery project – financial, engineering, work force, and politics.  The interviewer was clearly impressed and started to end the interview by complimenting Fred on his political acumen in creating and maintaining support for this major public works project.   Fred modestly replied, “I’m just an engineer.”  The reporter, tongue fully in cheek, ended the segment, “Thank you, Fred Salvucci, engineer.”

Training the IG to be practical

The office of the Inspector General was created in 1980 by the legislature after the publication of the Ward Commission report.  Officially entitled, the Special Commission Concerning State and County Buildings, this body of experts determined that there had been a pervasive pattern of corruption in the design and construction of state buildings.   The idea was that there should be an office distinct from the Attorney General and the State Auditor:

A "vast middle ground". . . between the ability to review all state transactions to a limited degree without the power to investigate [i.e., the Auditor], and the power to investigate allegations of fraud on a case-by-case basis [i.e., the Attorney General]. . . .

The value of such an office is incontrovertible, but some of us engaged in building major infrastructure projects sometimes found the IG and his staff to be meddling and troublesome interlopers in our plans to be creative with public funds.  I say creative advisedly.  We had no intention or interest in doing anything that would come even close to being illegal.  But sometimes you just have to think outside of the box if you want to actually get infrastructure built.

While at the MWRA running the Boston Harbor Cleanup Project, I needed to build a pier in the Squantum section of Quincy to serve as a ferry terminal for thousands of construction workers who would head to Deer Island every day to build a $3 billion sewage treatment plant.  The ideal site was owned by the local electric company, Boston Edison, which did not want to sell it.  While we had sufficient money to purchase the land and build the pier, my agency did not have eminent domain powers.  But Bill Geary’s MDC did have eminent domain powers.

I called Bill and laid out the issue.  Would he have a way to receive and spend money from the MWRA, without legislative appropriation, take the land from Boston Edison, and permit us to build a pier?  I was operating under a strict Court-ordered schedule and therefore could not await a lengthy and uncertain legislative process.  Without a moment’s hesitation, Bill informed me that he had a parkland renovation trust fund that could be used for such a purpose, on the condition that the acquired land and pier would be available for public use.  “It’s a deal,” I said, and the next day our lawyers codified the transaction.

The Inspector General blew a gasket.  We had no authority do such a thing, he argued.  He threatened that would hold a press conference and otherwise raise a ruckus about our action.  Bill and I quietly suggested that instead, he should make his case before the Federal Judge in the Boston Harbor case, and we would abide by the result.  Silence quickly reigned.

Thanks for riding the T: Have a drink on us.

While we are on the topic of signs, I thought a previous Secretary of Transportation had made a commitment that the MBTA (Boston's transit system) would turn down advertisements that sold alcoholic beverages.  Instead, the T seems to be targeting those ads to the poorer sections of town and near colleges and universities.

At least one state representative recognizes the public health implications of this practice and has filed a bill to ban it.  But, shouldn't the Governor take this issue on without legislation?  It would be a good time to just say no.

Naming rights and wrongs

The thing I liked best about Mitt Romney as governor was that he refused to put his name on signs throughout the state.  You know, like the ones that say "Welcome to Massachusetts" as you cross the border. Why? Well, he felt that those signs were public property, not private bulletin boards for elected politicians trying to get more name recognition.  He also, I think, was offended by the idea of spending public money every time a new person was elected governor.

This is very unusual.  I recently drove through a number of states, and at virtually every border crossing, I saw the governor's name attached to the welcome sign.  Like this one:

In times of tight budgets, why are we spending taxpayer money on this kind of self-aggrandizement?  But even in more prosperous times, why should any elected person's name be placed in a public way like this?

Shouldn't there be a general rule that the names of elected officials should not be included in signs on public ways?

Mayor Menino and Nicole deliver Hubway

BIDMC team at opening day of New Balance Hubway

I just returned from an opening ceremony for Boston's bike share program, entitled New Balance Hubway.  This is a citywide installation or bikes for hire.  You pick up a bicycle at one set of racks, ride to your location, and leave it any another.  The bike locations are also closely coordinated with the local transit system, to provide a mutual feeder system.

The program is the brainchild of Nicole Freedman, Mayor Thomas Menino's biking tsarina.  With the Mayor's encouragement and support, Nicole had already succeeded in expanding the number of bicycle lanes on city street and installing dozens of bike racks in public spaces.

But they had bigger plans.

A couple of years ago, Nicole came to me in my capacity as CEO of BIDMC and asked if we would sponsor a couple of the stands for Hubway, at a cost of $100,000 each.  Our hospital and staff already had volunteered to help other biking programs that Nicole had organized, like being medical providers for Hub on Wheels, and so I had great confidence in her vision and ability.  I immediately committed to the effort and promised to solicit other hospital CEOs to do the same.  Today, many of those hospitals were announced as partners, along with the Boston Red Sox, housing developer Steve Samuels, and others. Later, my successor at BIDMC, Eric Buehrens, committed to a third station as well.

New Balance, the Boston-grown and run athletic shoe company, tossed in funds to become the naming sponsor of the program, and now it is up and running.  Here's Matthew Lebretton, director of Public Affairs, at the opening ceremony on behalf of the company.

The Boston way versus the Bay Area way

While Boston is a hot-bed for innovation in the technology arena, it takes second place to the Bay Area of California.  I recently had a chance to see symbolic demonstrations of this while riding the BART.  Whether a public service announcement or a sales pitch from a store, many of the subway ads had QR codes that allow someone with a smart phone to view more detailed information about the services or products being offered.  Even billboard ads that you view from the platform across the train track have the codes.  (I hadn't realized that you could extract the data message from that far away.)  My unofficial survey indicates that this level of penetration has not yet reached Boston.

But, the evidence goes beyond that.  At the recent Health Foo conference of health care "techie" types, a preponderance of participants were from the West Coast.  Strikingly, many of them had started out at MIT or other Boston universities but had chosen to move west as their careers developed.  A story by Katie Johnson in today's Boston Globe documents this:

“The reality is that somebody graduating school in Massachusetts can basically double their salary by getting on a plane and going to San Francisco,’’ said Jones, chief executive of the Boston social media analytics firm Buzzient.

Maybe it is the weather, and maybe it is the salaries, but I think it is something else. I was recently talking to an angel investor/venture capitalist and he said that when a business concept is brought to his peers in Boston, the focus is on what could go wrong if one part of the business plan fails to come through.  In Silicon Valley, potential investors focus on what could go right if all the stars align.  It is basically the difference between prudence and risk-taking, between pessimism and optimism.

Now, this can raise unreasonable expectations for twenty-something year olds in California who are convinced that their idea is the next Google and spin away hours of time in that pursuit.  But Thomas Edison did the same thing a few years ago.  It is that indomitable spirit of innovation, of trials and errors and repeated failures, that eventually leads to approaches that change the world.  While he did not mean it in this context, Victo Hugo was correct when he said, "There is nothing more powerful than an idea whose time has come."  Who can blame a young person for thinking that s/he has that idea?

In the overall picture, there is probably a place for both approaches, but I just have a feeling that the Bostonians are missing the boat here.

Another summertime thought

And, another message for summertime to supplement those below.  Could be used by soccer referees, too!  (Source:  Creators.com.)

Serious and adorable summertime messages

In the heart of swimming season in this hemisphere, I repost a reminder from Jim Weadick, CEO of Newton Medical Center, in Covington, Ga, that I put up last summer:  Drowning doesn't look like drowning.

And, then, on a much lighter note, check out this inspirational video on how to learn to ride a bicycle.

If you cannot see the video, click here.

The clinic as newsstand, salesman, and data miner

When it comes to offering freebies to the medical staff, hospitals have gotten very good at keeping drug company representatives off their premises, but what about for patients?  A friend recently went to a hospital-based clinic in another state and found this magazine being given away in the information racks.

"Nice," he thought, "a useful and informative magazine about health issues."  But then he opened it up.  Sure, there were interesting articles about COPD, diabetes, cholesterol, hip replacements, and overactive bladders.  But every single one was tied to an ad from a drug or device company related to that syndrome or procedure.  Indeed, the format of the magazine made it difficult to know where the article ended and the ad began.

The magazine also had a business reply card included, allowing you to get direct mail from those advertisers, but also savings coupons from the drug companies.  You are asked to "check the health conditions you have."  But then, notice the small print at the bottom:  "Our sponsors represent many types of companies, including pharmaceutical and medical device manufacturers that may use the information you share on this card for marketing and research purposes."

Wow, even the hospital itself cannot use that kind of personalized information -- for scientific research -- without getting approval from an IRB, providing appropriate disclosure to patients, and blinding the data to protect people's privacy.

I don't begrudge the fact that pharmaceutical companies choose to advertise, even in this way.  But do you think it is appropriate that hospitals offer these kinds of magazines and their associated data-gathering tools to their captive patients?  Beyond the obvious issue of promoting specific drugs and collecting personal information, the organizational issue arises.  Who decides to allow these magazines to be placed there?  How are those decisions made?  Are any standards applied?  Is there any supervision of this process?

Kaiser and Liverpool set examples on sepsis

I had the pleasure of meeting Dr. Alan Whippy and some of her colleagues from Kaiser Permanente this past weekend.  We got to talking about the recent work they had done on sepsis detection and treatment.  I had missed her presentation last December at the IHI National Forum.  You can see the summary here.  An excerpt:

[W]e developed an algorithm and standardized approach for early screening in the ED, and testing of patients for sepsis. This has led to an increase in sepsis detection by 102%, and an ability to treat our patients earlier with a reduction in our sepsis mortality from 25% to 15%.

This looks really good to me, and it is great that they are sharing their experiences.  As I have quoted OSU's Dr. Jim O'Brien before on this blog, in terms of general public understanding, sepsis is a seriously underrated hazard in hospital settings.

Meanwhile, look at this story from Royal Liverpool Hospital. Excerpts:

Hospital chiefs admitted there was a delay in giving the right treatment to a young woman who died after developing [sepsis].

[A]fter the family questioned the actions of staff prior to her death they admitted there were failings in her care.

Hospital chief executive Tony Bell has written to them apologising “unreservedly”.

And in further correspondence the hospital trust admitted there had been a 20-hour delay from when she was admitted to when antibiotics were given.

The hospital said it is now planning to learn from Miss Gore’s death and has put an action plan in place, which includes training staff and increasing awareness of sepsis.

How many other hospitals, in the US or elsewhere, would do the same?

Children are smarter

This a beautiful short video about a Hitler youth who befriends a young Jewish girl in hiding during the Holocaust.

If you can't see the video, click here.

A note on governing

A short rant.  I have been doing a slow burn over the last several months whenever I hear Congresspeople talk about "how hard we are working" and "how tough our decisions are" as they consider budgetary issues in their legislative sessions.  If they want to think how hard work really is, consider the jobs of nurses, housekeepers, transporters, respiratory therapists, lab technicians, and others in clinical settings.  If they want to think how tough decisions are, consider the ones that have to be made in real time by intensivists, surgeons, oncologists and other doctors.

Not to mention how hard it is for normal people, in all walks of life, to get by day to day.  Or how tough their decisions are.  Check out the the two stories below for a view of that, one, an immigrant intent on serving his country, and the other, a person who inadvertently discovered that he had stage four kidney cancer.

No, dear legislators, you do not have it hard or tough.  You often seem to be making it harder on yourself by maintaining unreasonable and extreme positions, and by forgetting that a key component of governing is learning to compromise for the greater good.  Our system of government was designed by John Adams and all those really smart people to have checks and balances.  That is the best way to insure that minority rights are protected.  What is going on in Washington right now is a serious and dangerous perversion of those principles.

Rambo Ravi serves his country

This is a wonderful story from the Snap Judgment radio show about the American melting pot, and also about personal commitment and drive.

A summary: Ravi, an immigrant from India, who is not a US citizen, wants to join the U.S. Army.  But he arrives malnourished and too underweight to pass the physical exam.  Plus, he's Hindu, a therefore a pacifist and a vegetarian. Also, they can't seem to pronounce his last name.  Somehow, he and the Army manage to make it happen.

Listen here, as his niece Dhaya Lakshminarayanan helps tell the story.

Dave is four years old(er)

A heart-warming thank-you post from e-Patient Dave deBronkart.  An excerpt:

Today, July 23, 2011, is the fourth anniversary of my last dose of HDIL-2 (high dosage interleukin-2), the treatment that rapidly reversed the course of the cancer that was killing me. I haven’t had a drop of treatment – and thus not a single side effect – since then. Nobody can predict the future, but this I know: I am well.

Dave is now an international leader in promoting patient involvement in the delivery of health care, both at the individual and institutional level.  Many of us are very glad he's around.

Country-style wedding limo

Seen in Wytheville, Virgina (population 8,225).

The Infrastructure Chronicles -- Volume 10

Missing directional street signs is a pervasive and long-lasting problem in Eastern Massachusetts. This article in the Boston Globe, "Looking for direction to Storrow Drive," reported the action of a citizen in pointing this out.

Reader Charles Barr of Waltham said he has been itching to ask city transportation officials why there are no signs to assist drivers trying to find the entrance to Storrow Drive at the corner of Berkeley and Beacon streets in Back Bay.

“I can’t remember the number of times in decades that I drove past this spot, missing the huge sign which has always been obscured by foliage, until I finally memorized that Berkeley is the street where I must turn right in order to access Storrow westbound,” Barr writes in an e-mail, making it a point to note that he is a longtime native.

This is a jurisdictionally tricky one, as the streets are owned by the City of Boston, but Storrow Drive is owned by the state.

[A]fter hearing from GlobeWatch, the [state] department sent engineers to check on the signs last week, and they discovered they are no longer there. Port said it is unclear how long they have been missing. New signs are now “in the queue” to be replaced, she said, although she could not provide an estimate of how long it will take to install them.

A friend offers this comment:

Who are they kidding? Half the street signs in the city are obscured by trees. Cambridge, too.

Kinda like hospitals - just fix the one problem somebody complains about and don't look any further.

When will UPMC explain the whole story?

The UPMC kidney transplant story continues to develop.  This was the one where a doctor and nurse were disciplined in a matter that clearly reflected some systemic problems, more than personnel problems regarding those two people.

Now UPI reports: 

A report by a federal agency on a kidney transplant at the University of Pittsburgh Medical Center suggests more problems than the hospital has acknowledged.

The Centers for Medicare and Medicaid Services said its investigation found the nephrologist should have been aware the kidney donor was infected with hepatitis C, the Pittsburgh Post-Gazette reported Tuesday. The hospital has suspended the lead surgeon and the transplant coordinator.

The CMS report said the test results were available for two months in the donor's medical record. But none of the doctors and nurses apparently reviewed the record, and the kidney was transplanted into a man who was not infected with the virus.

The story concludes in a manner that feels like an oxymoron with regard to confidence: 

Dr. Abhinav Humar, the head of the UPMC transplant coordinator, said he is confident the hospital has developed appropriate corrections for its failures.

Wouldn't it be great if UPMC would tell the whole story and help all the transplant centers in the world understand the nature of the problems that occurred, so all could benefit from this experience and improve programs worldwide?

They will now

A lovely story from a friend:

A teacher was in school with young children, and they had just begun a drawing session.

"What do you plan to draw?" she asked a little girl, who was about to start in with her crayons.

"God," was the reply.

"Oh, that's hard because nobody knows what God looks like," offered the teacher.

"They will in a couple of minutes," said the girl.

Payment Reform on WIHI

Payment Reform As We Speak
July 21, 2011, 2:00 PM – 3:00 PM Eastern Time

Guests:
Stuart H. Altman, PhD, Sol C. Chaikin Professor of National Health Policy and former Dean of The Heller School for Social Policy and Management, Brandeis University

Jeffrey Selberg, MHA, Executive Vice President and Chief Operating Office, Institute for Healthcare Improvement

What's the value of value-based purchasing? This is the term used for a new initiative of the Centers for Medicare and Medicaid Services (CMS) that is perhaps the government’s boldest move yet to tie hospital reimbursement to quality, focused initially on 13 measures, including patient satisfaction. The intent is pretty clear, but how likely is it that the new “carrot,” in the form of bonus payments starting in October 2012, will accelerate better patient care and usher in a new day of financial expectations?

IHI’s Jeff Selberg says the answer isn’t clear BUT, as a former hospital executive, he can’t imagine sitting on his hands waiting to see how things will play out. In other words, to Jeff, the handwriting is on the wall, and depending on how hospital leaders react, the money is either on the table or eventually being taken off the table and...most importantly, it’s not going to be put back. There is just no viable future, he says, for a health care system that’s hospital-centric, episode-centric, and procedure-centric. And it’s not just CMS that’s throwing down the gauntlet. So are employers and private insurers. The good news is that some health care providers are getting the message; Selberg hopes we can all learn from their example.

Stuart Altman doesn’t disagree. But the seasoned health care economist has been around too long, and in and out of government often enough, to know how hard it is to forge policy and payment reforms of the CMS value-based sort. Decades of doing things differently is a hard habit to break. On the other hand, like Jeff, Stuart wouldn’t advise hospitals to sit this one out, and he worries about serious unintended consequences for patients if the hospital system doesn’t develop new business models built upon delivering high quality most of all.

Does this sound like an interesting discussion? WIHI host Madge Kaplan certainly hopes so and that you’ll join her, Stuart Altman, and Jeff Selberg to learn more on the July 21 program. All three welcome and value your insights as well, so start thinking about the questions you’d like to ask and the comments you’d like to offer.

To enroll, please click here.

Peter is seeing you, really well

One more interesting person I met at #healthfoo:

Peter Tu works in GE's research facility on how computerized monitoring systems can take visual images of people's actions and motions and draw information from them. There was a good story about this by Steve Lohr in the New York Times in January, 2011, entitled, "Computers that see you and keep watch over you." Excerpts:

Hundreds of correctional officers from prisons across America descended last spring on a shuttered penitentiary in West Virginia for annual training exercises. Some officers played the role of prisoners, acting like gang members and stirring up trouble, including a mock riot.

Perched above the prison yard, five cameras tracked the play-acting prisoners, and artificial-intelligence software analyzed the images to recognize faces, gestures and patterns of group behavior. When two groups of inmates moved toward each other, the experimental computer system sent an alert — a text message — to a corrections officer that warned of a potential incident and gave the location.

The computers cannot do anything more than officers who constantly watch surveillance monitors under ideal conditions. But in practice, officers are often distracted. But machines . . . are tireless assistants.

And here's the health care connection: "A computer-vision system can watch a hospital room and remind doctors and nurses to wash their hands, or warn of restless patients who are in danger of falling out of bed."

The trick is how to take this innovative technology and integrate it into the work flow and process improvement in a hospital, while avoiding the claims of violation of privacy and "gotcha"-type discipline and enforcement. This will be one worth watching.

Kendra does Emotional Automation

Another interesting person I met at #healthfoo:

Kendra Markle hangs out at Stanford and does work on emotional automation, asking the question,"How can technology represent and convey compassion to augment the doctor-patient relationship?" It turns out that having a compassionate listener, even a computerized one, can help people improve adherence with medical treatment regimes.

An example is Carmen, an computerized person developed by Tim Bickmore at Northeastern University, which has dialogues with elderly patients and others that "build and maintain long-term, social-emotional relationships."

Kendra notes:

As an entrepreneur and founder/CEO of AlterActions, I build persuasive technology tools for healthy behavior change. My tools use the latest research findings in psychology and neuroscience combined with persuasive, mobile and social technology to coach people through a series of achievable behavior changes. My techniques produce lasting changes in lifestyle in people struggling with obesity, anxiety, chronic conditions and emotional health issues.

Jane creates SuperBetter

One of the neat people I met at #healthfoo:

In the summer of 2009, Social Chocolate's Creative Director, Jane McGonigal, found herself struggling to recover from a severe concussion. Overwhelmed with the process of recovery, she decided to tackle the challenge of healing with the method she knew best – creating and playing games. To help her brain heal, she invented SuperBetter -- and became its first player. Within a few weeks, she was feeling better and recovering faster than she'd ever thought possible.

Read more of the story here. This game is still in testing and development. Keep an eye out for it in future months or, as the site suggests:

We're looking for a handful of great partners help us test SuperBetter in both medical environments (clinics and hospitals) and organizational environments (organizations, schools and communities). Let's join forces! Have another idea for collaborating? Let us know!

Here's how to Contact Us.

Is MD equity walking out the door in Iceland?

After all that Iceland has been through because of the financial crisis, who needs this? An assertion emerges from Reykjavik that the health care system is on the verge of "imminent collapse." Here are excerpts:

The medical director for the Primary Healthcare of the Capital Area is deeply concerned with a growing problem in Icelandic clinics; the number of postgraduates expected to return from specialist training abroad has declined after recent cutbacks in the healthcare system.

“We might lose a generation of physicians,” Lúdvík Gunnarsson.

Gunnarsson told Morgunbladid the situation in healthcare clinics around the country is poor and specialist positions are understaffed. He continued to say that “an imminent collapse of the healthcare system is impending and it cannot survive further cuts.”

This follows an earlier report about a 40 percent cut in health care funding in the 2011 budget.

Back in 2007, I was giving a talk at Iceland's Landspítali University Hospital in Reykjavík, and I asked my host how the annual budget for health care was established by that country's parliament. I reported the answer in this blog post:

[T]he parliament uses, as a rough guide, a desire to maintain overall health care costs at a certain percentage -- 10 or 11% -- of GNP.

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

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

The current cuts emerge because of the financial collapse of internet bank Icesave and its owner, Landsbanki, in 2008, leading to a huge impact on the country and the government.

It is hard to know from here if the current public statements are an exaggeration or a proper warning, but they are indicative of the description I provided above. They reflect the fact, though, that Iceland's approach to medical education subjects the country to a particular risk. While MDs receive their basic training in-country, they go abroad for advanced training. If they think that the market for their newly acquired skills is not sufficiently remunerative back home, they have the option of staying abroad. As we say in other professional fields, your "equity" can always choose to walk out the door.

Personal liberties versus public harm

David Ropeik, about whose excellent work on risk perception I have written before, recently offered some additional perspectives on the issue of vaccinations -- making us think about the cost of personal liberties to public harm. He wrote this Op-Ed, entitled, "Public health: Not vaccinated? Not acceptable," in the Los Angeles Times. The subheading is: "What should we do about people who decline vaccination for themselves or their children and put the public at risk by fueling the resurgence of nearly eradicated diseases?"

Here are some excerpts:

What does society do when one person's behavior puts the greater community at risk? We make them stop. We pass laws, or impose economic rules or find some other way to discourage individual behaviors that threaten the greater common good. You don't get to drive drunk. You don't get to smoke in public places. You don't even get to leave your house if you catch some particularly infectious disease.

Then what should we do about people who decline vaccination for themselves or their children and put the public at risk by fueling the resurgence of nearly eradicated diseases? Isn't this the same thing: one person's perception of risk producing behaviors that put others at risk? Of course it is. Isn't it time for society to say we need to regulate the risk created by the fear of vaccines? Yes, it is.

David keys in on examples of the growing threat to public health caused by people worried that vaccines will cause autism and other harms, despite overwhelming evidence to the contrary.

In many places, particularly in affluent, liberal, educated communities . . . unvaccinated people are catching diseases that vaccines can prevent, like measles, whooping cough and meningitis. In 2010, as California suffered its worst whooping cough outbreak in more than 60 years (more than 9,000 cases, 10 infant deaths), Marin County had one of the lowest rates of vaccination statewide and the second-highest rate of whopping cough. A 2008 study in Michigan found that areas with "exemption clusters" of parents who didn't vaccinate their kids were three times more likely to have outbreaks of whooping cough than areas where vaccination rates matched the state average.

He offers the follow ideas for our consideration, "each fraught with pros and cons and details that require careful thought and open democratic discussion:"

• Perhaps it should be harder to opt out of vaccination. (Twenty-one states allow parents to decline vaccination of their children simply for "philosophical" reasons; 48 allow a religious exemption, but few demand documentation from parents to support claims that their faith precludes vaccination.)

• Perhaps there should be higher healthcare and insurance costs for unvaccinated people, or "healthy behavior" discounts for people who do get vaccinated, paid for from what society saves by avoiding the spread of disease.

• There could be restrictions on the community and social activities in which unvaccinated people can participate, like lengthy school trips for kids, etc.

David expands on these thoughts on his blog and in Psychology Today and provides a full context in his most recent book: How Risky Is It, Really?: Why Our Fears Don't Always Match the Facts.

Women's World Cup thoughts

Whether or not you like the final result, I hope you will agree with me that Julie Foudy and Ian Darke were superb commentators during the Women's World Cup games on ESPN. Their knowledge of the game and the players came through. Their pacing was excellent. Although playing to a US audience, they were not overly chauvinistic. They truly enhanced the play on the field, an unusual result.

As Americans deal with their disappointment in the final score, it is heartwarming to think of people in Japan who have something good to think about after this year's devastation from earthquakes and tsunamis.

And, finally, in what might be a politically incorrect note, I repeat a joke I heard this week that was making the rounds amongst a group from the Subcontinent. It might explain why India did not have a team in the tournament:

India never wins soccer games. Whenever they get a corner they open a shop.