Ohio steps backward on transparency

After expressing enthusiastic support for many quality initiatives by hospitals in Ohio, I must report with disappointment an action by their trade association to dismantle the state's hospital transparency website.  This article summarizes:

The Ohio Hospital Association (OHA) is backing a piece of recently introduced legislation that would free hospitals from the requirement to report performance data such as measures of heart and surgical care, infection rates and patient satisfaction.

The reason?  Alleged duplication of effort with the CMS Hospital Compare website.  According to an OHA spokesperson:

The time and effort spent on reporting the data to the state as well as the federal government reduces the resources Ohio hospitals can devote to patient care.

To which I reply, "Bull twaddle!" (This is a family blog, or I would use stronger terms.)

First, let's acknowledge that the data presented in the the CMS site is old, very old.  It accomplishes little or nothing with regard to transparency.  As I have noted:

While you cannot manage what you do not measure, trying to manage with data that are a year or two or more older is like trying to drive viewing the road through a rearview mirror. The principles of Lean process improvement and other such systems suggest that real time "visual cues" of how the organization is doing are essential. Why? Because that kind of data is indicative of the state of the organization right now, not what existed months or years ago.

Second, let's be real about the amount of time this state-run site "takes away" from delivering patient care.  This data would be collected regularly by hospitals, as part of delivering patient care, even if there were no federal or state reporting requirements.  It is not an incremental responsibility.

Next, the Ohio Department of Health says:  “It was an unfunded mandate for ODH to collect the information and make it public."

To which, I can only repeat the above, "Bull twaddle!"

Since when does a state agency get to complain about unfunded mandates from the legislature that supervises it?  (You only get to complain about unfunded mandates if a higher level of government imposes a cost on a lower level of government.)  The staff of the agency get funded every day they work there.  This is a matter of priorities.  In any event, this is a gross overstatement of the amount of effort needed for this task.

I am willing to bet that a graduate student or health care club at OSU, Case Western, or one of the other fine schools in Ohio would gladly set up and maintain a voluntary website for the Ohio hospitals.  Each hospital could enter through a password-protected portal to enter real-time data about the metrics that are of value in pursuing important quality and safety goals.  At virtually no cost.  It would take seconds, not even minutes or hours, to enter it once a month or once a quarter.  As I have noted:

Such data are collected in hospitals on a current basis. If their main purpose is to support process improvement, they do not need external validation or auditing to be made transparent in real time.

Come on, Ohio.  Don't step backward.

AMCs: Off target and lacking a sense of urgency

As noted in a previous post, I was impressed negatively by a Mt. Sinai hospital paid op-ed that extolled the virtues of academic medical centers while making no reference to the role that such centers could play in improving the quality of care delivered in America.  While acknowledging the attributes of AMCs, I said:

But these statements fail to tell the story of how academic medicine, in many institutions, is failing the American public.

It does not, for example, explain why many AMCs have been slow to adopt proven tools of process improvement to reduce harm to patients and improve efficiency. 

It does not explain the  persistent lack of transparency in many such institutions with regard to clinical outcomes, notwithstanding the documented value of such transparency in improving quality and safety. 

It does not explain why the medical schools that own or are affiliated with many AMCs have failed to train their students in how to use the scientific method to improve the delivery of care.

It does not explain the huge variation in practice among residents and attending physicians, giving lie to the concept of evidence-based medicine.  

It does not explain the reluctance of many AMCs to engage patients and families in the design and delivery of care.

A friend referred me to a summary of TEDMED talk by Daniel Kraft, which reinforced these points:   

Notably Daniel spoke about how when he finished his training at Massachusetts General Hospital 15 years ago the hospital still functioned, from an delivery standpoint, in about the same way as it does today, with specialty silos, defined training hierarchy, etc.

I am guessing that Daniel's talk was mainly on how to leverage new technologies in the health delivery system, but his observation applies more generally, too.

Ironically, one of those Mt. Sinai op-eds (John Morrison and David Muller, "Science and Medicine in the Service of Society," September 10, 2010) made related points:

Historically, medical schools emerged within universities primarily to educate physicians, yet Master’s and Ph.D. programs centered at medical schools now produce the vast majority of the scientists trained in biological arenas relevant to medicine.

All too often, these programs simply co-exist, isolated by different curricula and cultures. If we are to maximize our capacity to impact clinical practice through scientific discovery, we need to produce leaders in biomedicine and health care who see themselves as members of large, interactive teams committed to clinically relevant breakthrough science.

Meanwhile, Michael Nielson in the Wall Street Journal notes that networked science uses "online tools as cognitive tools to amplify our collective intelligence. The tools are a way of connecting the right people to the right problems at the right time, activating what would otherwise be latent expertise."

He notes, though, that this is not rewarded in the field:

Even if you personally think it would be far better for science as a whole if you carefully curated and shared your data online, that is time away from your "real" work of writing papers. Except in a few fields, sharing data is not something your peers will give you credit for doing.

How interesting that people in academic medicine are able to see the need for a more integrated, cooperative, and collaborative approach to medical training, research, and work flows when it applies to the advance of basic science and technology, but they have yet to modify the structure of their academic centers to allow such behavior to thrive.  And, beyond that, they remain blind to the idea of applying those same concepts to the actual delivery of care.  Were they to do so, we could be saving thousands of lives right now, well before the next great cures to disease are developed.

Example:  At a recent meeting of medical academic leaders, the president of one center proudly reported over the growth in faculty, in enrollment, in buildings, and so on at his institution.  Someone asked him about systematic quality improvement.  He cited improvements on Press-Ganey results, acting as though this was the surrogate for quality improvement.

Off track and too slow, folks.  Too slow.  As we have seen, if you don't start to define the important clinical improvement issues and make progress, the government will do it for you and do it wrong.

Recall what Captain Sullenberger said, ""I wish we were less patient. We are choosing every day we go to work how many lives should be lost in this country."

"We have islands of excellence in a sea of systemic failures. We need to teach all practitioners the science of safety."

A green car!

Heavy wet snow combines with leaf-laden trees to offer an opportunity for a new paint job -- and more -- for my little Honda civic hybrid!

Danielle will find your lost pet

I have written about a number of new businesses on this blog, in health care and beyond, but none has caught my attention as much as Compassionate Pet Services.  Owned and operated by Danielle Robertson, the company helps pet owners recover their lost animals.

Danielle notes:

Losing a pet is a very stressful and even traumatic experience.  A well organized search plan provides the best chance to bring your pet home safely.  Unfortunately, most people do not know how to effectively search for a lost pet, and the advice that you receive from well-meaning people and the information that you find on the internet may be inaccurate or just overwhelming. 

Compassionate Pet Services is here to provide the services, information, and resources that you need to help find your lost pet.  I am a certified Missing Animal Response Technician and have been helping people find their lost pets since 2009. 

I never knew there was such a thing as a Missing Animal Response Technician, but Danielle actually has extensive training in wildlife management and then special training in this field of finding lost pets.  To learn more, you can check out her blog, Lost Pet Research and Recovery, and for dramatic and moving stories of recoveries, Lost Cats Found.

Here's a sample: 

Many of you may have heard about the tornado that tore through Springfield, MA, and  surrounding towns on June 1, 2011.   One man, Michael Roescher, was home with his step-daughter and their seven cats when the tornado leveled their house.  Initially he was convinced that none of the cats had survived, but then he miraculously found their goldfish still alive in the rubble.  With renewed hope and the help of many friends and strangers, Roescher persisted in his search, and he was able to find all seven cats over the course of five days and none were seriously injured.

Best of luck to Danielle in her venture, and good luck to all of you searching for your lost pets.

Addressing health care at Jewish Family & Children's Service

Charlie Baker and I shared a podium today at the annual meeting of the Board of Advocates of the Jewish Family & Children's Service.  JFCS provides a multitude of services to the community, and does so very well, and we both felt honored to be invited.  We were led in a panel discussion by Sy Friedland, former CEO of JFCS, on the topic of "What's going to happen in health care, no matter what happens in Washington?"  (You see Sy and Charlie in this photo.)

Before attempting a run for Governor in 2010, Charlie was CEO of Harvard Pilgrim Health Care, a highly respected health insurance company in the state.  In previous lives, he served both as Secretary for Administration and Finance and as Secretary of Health and Human Service for the Commonwealth.  As you might expect, he has lots of thoughtful things to say about the health care system.

I remember, during the campaign, that Charlie explained the major items of his health care platform to be increasing payments to primary care doctors and other cognitive specialists, with the purpose of giving them the chance to spend more time with patients and thereby avoiding as many referrals to higher paid specialists; pursuing broad-based transparency of cost and quality to offset unsupported reputations of certain hospital and physician groups that were thereby able to exercise undue market power; and to create coordinated medical management programs for the 120,000 dual eligible people in the state.  These are folks who are "old enough for Medicare, but sick and poor enough for Medicaid."

As Charlie noted today, dual eligible people constitute 20% of Medicare subscribers, but account for 40% of Medicare spending.  Likewise, they account for 15% of Medicaid enrollees, by 30% of Medicaid costs.  Based on relatively small pilot programs in the state, covering about 15,000 to 20,000 people, coordinated management of these patients results in service delivery at 30% lower cost than the two uncoordinated programs.  (My keen readers will quickly note that these contracts are annual fixed fee payments based on patient risk characteristics -- the one clear example that capitation can work in selected environments.)

Charlie's remarks were timely during the gubernatorial campaign, and they were more so today, in the Governor Deval Patrick has announced that he wants to create just such a program.  Charlie graciously complimented the Governor on his intentions in this regard.

That still leaves his other two items to be implemented.  Both remain excellent ideas.

Dump your old drugs safely this Saturday

This Saturday is "National Prescription Drug Take-Back Day."  This is a program originated by the U.S. Drug Enforcement Administration to fight drug abuse by adults and teenagers in the United States.  Studies show that people who abuse these types of drugs get them by raiding the medicine cabinets of their friends and family members.  To keep unused or unwanted prescription drugs out of the hands of drug abusers, on Saturday, between 10 a.m. and 2 p.m., people can safely throw away their unused prescription drugs at designated collection sites around the country.

I see a further value in that this offers a safe disposal regime for return of unused antibiotics.  If you throw unused antibiotics down the toilet, they can end up entering the ecosystem, where they can help create disease resistant bacteria or, even thought less likely, harm fish and wildlife.  In this program, they will be properly destroyed.

Also, of course, expired drugs may be ineffective or even harmful.  For example, taking expired tetracycline (an antibiotic) can cause serious kidney problems.

You can find a local collection site on this webpage.

Hospital Pumpkins

As we approach Halloween, there's been a lot of pumpkin traffic on my blog this week, linking back to this site about a pumpkin carving contest at my former hospital.  Here it is.  Some great images (one at left)!

Rational economic creatures?

I heard a wonderful talk by Abhijit Banerjee, economics professor at MIT, about his and Esther Duflo's new book entitled, Poor Economics.  Here is a short summary, accompanying this video interview of the authors.

Why do the poor remain poor despite a million different strategies to counter poverty? Well, perhaps because policies that deal with poverty alleviation are often based on cultural and literary stereotypes of how the poor are "lazy or enterprising, noble or thievish, angry or passive, helpless or self-sufficient." And therefore we often rely on over simplistic policies with readymade formulae - "Free markets for the poor," "Make human rights substantial," "Give more money to the poorest." A new book, Poor Economics, tries to make one key point - let’s stop staring at data and theories, and understand instead the coherent story of how really poor people live their lives.

The authors present several examples of policy and programmatic interventions that have failed because policy-makers do not take the time to understand how things work on the ground in these poor communities.

I am struck by the similarity to many proposed interventions in health care.  In the last several days, I have discussed this with regard to penalties for failure to meet certain metrics regarding patient readmissions to hospitals.  But it is a broader issue.  For example, a move to capitated rates of pay is viewed by some as the sine qua non of health care policy.  I have noted that there is little empirical support for this approach, even if it might have a sound economic rationale.

But does it have a sound economic rationale?

Still feeling the after-effects of a morning at MIT, where I first learned the term over four decades ago, I propose we conduct a gedanken experiment.  That is, let's consider a hypothesis for the purpose of thinking through its consequences.

I put forth the following thought experiment.  Advocates of capitated, or global, payments argue that the current system of fee-for-service medicine leads to overuse, in that doctors and hospitals have a financial incentive to conducts tests and procedures to generate revenue.  The economic underpinning of a global payment system is that hospitals and doctors are rational economic creatures.  Setting a per-patient budget, it is argued, will cause the hospitals and doctors to work within that revenue envelope to deliver care more efficiently.  They are at risk for any over-spending and they get to keep the surplus if they beat the budget.

But, answer me this.  Let's say, we have a system where, say, 25% of the patients are on a global budget and the remainder are on a fee-for-service payment plan.  

If the economic theory is correct, that the hospital and doctors are rational economic creatures, shouldn't we notice a difference within the same provider network in how the global patients are treated from how the FFS patients are treated?

Let's turn away from the thought experiment briefly to review real data.  I pose a question for my readers:  Has such a difference been documented in those systems that have this mixed payment regime?  I think not.  But if you have counter examples, please provide cites to support your answer.

But now, pretend you are running that hospital and physicians network.  As suggested above, you believe that professional ethics should not allow your system to treat people differently based on the kind of insurance plan that covers them.  So, you instruct everyone to think about all patients as though they are covered by the global fee.  You do this even though you suffer revenue losses from the FFS patients, who, by the way, remain the majority of your patients.

If we do this, haven't we just disproven the hypothesis that doctors and hospitals are rational economic creatures?

So, which is it?  Are they rational economic creatures, willing to treat identical patients differently based on pricing?  Or, are they not rational economic creatures -- treating all patients alike -- in which case the theoretical basis for global payments appears to be problematic?

Trash talk: More on unintended consequences

As we consider the issue of unintended consequences in health care from certain policy formulations, we can bring in an example from another field.  Let's review it and guess if the kind of policy questions I referenced below were applied to this case.

Residents in our city recently received this mailer:

 

It used to be that you would put your used computers and monitors out on the curb on trash collection day, and they would be carted off to be properly disposed of.  There was no extra charge, and you didn't need to call anyone in advance.  Now, you have to call a number or go to a website three days in advance and pay $12 for the pick-up.

It is easy to imagine why the new policy was adopted.  Perhaps the old approach was costing the city a lot of money, and officials thought this would work better.

But let's think through the likely result.  (Please note that I am not advocating this approach, but it seems to me to be a rational response.)  Our city employs these rather large trash bins that are mechanically lifted and emptied into a garbage truck each week.  The truck driver does not leave his perch as he rides along the street, and so no one sees what is in these barrels as they are lifted over the truck and emptied of their contents.

So, let's say I have an old personal computer and screen.  I quietly -- after dark, so my liberal neighbors don't see me -- put them in my regular trash bin, which I then wheel out to the curb in its regular location.  Next morning, the garbage truck comes by, scoops it up, and empties it into the back of the truck.  No need for a scheduled pickup.  No extra charge.  No muss, no fuss.

But maybe I am wrong.  Maybe the residents in this city are so motivated by environmental concerns that they would do no such thing.  Wait, aren't those the residents who regularly litter our streets with recyclable bottles and cans or who don't pick up the ones they see there?

I am not being critical.  I am just saying that people do what is easy for them.  When you invent a policy regime that attempts to impose higher cost or inconvenience on the citizenry, there are often unintended consequences.  I'd love to be proven wrong, but how will we know?

Here's how.  Let's see if our city's commitment to transparency extends to the effectiveness of this new approach to disposal.  It should be easy to have a section of the municipal website on which is posted the weekly summary of computer and monitor collections and payments under the new scheme, compared with the numbers collected previously.

Transparency in Retractions

Nature News has a very interesting article by Richard Van Noorden about retractions of scientific papers.  I hadn't thought about some of the points raised, and I think many of you will likewise find them and the associated graphic compelling.  Some excerpts:

[R]etraction notices are increasing rapidly. In the early 2000s, only about 30 retraction notices appeared annually. This year, the Web of Science is on track to index more than 400 . . . even though the total number of papers published has risen by only 44% over the past decade.

When the UK-based Committee on Publication Ethics (COPE) surveyed editors' attitudes to retraction two years ago, it found huge inconsistencies in policies and practices between journals. . . . That survey led to retraction guidelines that COPE published in 2009. But it's still the case, says Wager, that "editors often have to be pushed to retract".

Other frustrations include opaque retraction notices that don't explain why a paper has been withdrawn, a tendency for authors to keep citing retracted papers long after they've been red-flagged . . .and the fact that many scientists hear 'retraction' and immediately think 'misconduct' — a stigma that may keep researchers from coming forward to admit honest errors.

[A]s more retractions hit the headlines, some researchers are calling for ways to improve their handling. Suggested reforms include better systems for linking papers to their retraction notices or revisions, more responsibility on the part of journal editors and, most of all, greater transparency and clarity about mistakes in research.

RWJ seeks ideas in behavioral economics

The Robert Wood Johnson Foundation seeks innovative ideas that apply the principles and theories of behavioral economics to perplexing health problems. They are particularly interested in supporting either experiments or secondary data analyses to test innovative solutions to the challenges of obesity and consumer engagement.  Check out the details here.  The deadline for the first stage of proposals, a 1500-character brief proposal that describes your idea, is due on November 2.

Harold Miller offers advice on readmissions

If you had asked me to predict which topic on this blog would generate acrimony and criticism, I would have been hard-pressed to guess that it would have been hospital readmissions.  Recall that I expressed objections to the use of financial penalties to persuade hospitals and doctors to reduce this phenomenon.  Also, I cited a paper that showed that the data do not exist to fairly and accurately implement such a penalty scheme.  I followed this with a post citing an article suggesting that such penalties might especially adversely affect lower income hospitals.  Then, I suggested the kinds of questions that should be answered as we consider any type of public policy change.

To me, this is the kind of straightforward discussion and debate that occurs on a variety of health care issues.  Who would have thought that this might bring an accusation of "willful stupidity" and a complaint that "you have shown yourself even more opposed to universal healthcare than this relatively easy, low cost way to improve outcomes"?

The more serious commentators, though, asked, "What would you do?"  My general answer, as many of you know, is that a focus on quality and safety and clinical improvement is well within the power of each and every hospital; that such programs are consistent with sound financial planning, whether under a fee-for-service, bundled, or capitated payment arrangement; but that progress on this front demands leadership from the administrative and clinical leadership; and that such leadership must include a commitment to redesign the hospital's workflows using Lean principles or other approaches that engage front-line staff and also engage patients and family members in a respectful and meaningful way.

A more conversant observer than I, Harold D. Miller, Executive Director of the Center for Healthcare Quality and Payment Reform, offered some useful thoughts on these matters in a talk he recently gave in Oregon, entitled "Reducing Readmissions:  How Oregon can become a national leader in reducing costs and improving quality." I will present just a few slides from what is a very thorough presentation.

First he summarized  the multi-factorial nature of the problem.

Next he gave a summary of the kind of work that is currently being carried out.   He included lots of examples that I do not have space for here.

Then he pointed out that a big percentage of the readmissions are not caused by hospitals.

Nonetheless, he explained that hospitals could have a role in reducing the number of readmissions.

In the final slide in his presentation, he gave a work plan for those hospitals wishing to make a difference in this arena.  I particularly like the last bullet.

Yes, they blinked

I ran into an insurance company executive the other day who questioned whether I really thought that Blue Cross Blue Shield of MA could have done better in its recently signed contract with Partners Healthcare System here in Massachusetts.  Recall that the state's largest insurer gave away a huge rate increase to the state's dominant health care system  --  a 2-3% increase on a base that is, what, 15 to 20% higher than the rest of the market.   I said, "Whether it is fear of government regulation or a desire to go along to get along, a tremendous opportunity to truly control costs has been squandered."

This person said, "Remember, this was a private negotiation between two parties."  I allowed how I wasn't in the room, and it is easy to criticize, but, as I thought about it later, this statement alone might be indicative of why the insurance company blinked in this case.

A negotiation of this sort is never a private negotiation between two parties.  When two economic behemoths talk, there are a huge number of interested parties in the community.  And, those constituencies had already made their views known, views that could have been leveraged in this discussion.  Here are examples:

The Attorney General had pounded away two years running that a major issue facing the health care system, one that was driving up costs for the entire state, was the large disparity in rates paid to this provider group compared to others in the state.

The Governor had filed a bill to expand the authority of the Insurance Commissioner to review the rates paid by insurers to providers.  (By the way, many current and former state officials feel that the Commissioner already has that power.)

The Inspector General had expressed concerns that PHS would try to rush through a new contract before legislation passed that could limit payment increases.

Members of the legislature were publicly expressing concern about the rate disparity issue.

The insurance company had had noticeable success in marketing a tiered product, requiring higher co-pays from patients visiting the high-priced providers.

Lower cost competing hospital groups were creating ever more integrated alternative clinical networks.

Business groups in the state were clamoring for real cost controls in premium increases.  Given the unemployment situation, with people less likely to leave jobs for new ones, they felt that tiered insurance products could gain greater acceptance than in the past.

This provider group had not paid a promised $40 million to reduce insurance rates and was being derided for that delay.  It had every reason, given the pending legislation, to try to strike a deal before the law changed.  The insurance company, in contrast, had no reason to hurry.  Further, it had the moral upper hand, having forced other, more poorly paid, providers in the state to take dramatically lower rate increases.

In a public hearing about two years ago, this insurance company had said that it did not have the heft to fight the market power of PHS.  It seemed to fail to understand that the world had shifted.  If there was ever a time to go head-to-head, publicly if necessary, this was it.  An opportunity was lost.

Twenty questions for public policy proposals

As I re-read the comments I have received regarding my critique of plans to impose financial penalties for variations in readmission rates, I realized that my correspondents and I were talking past one another.  I was presenting views based on how to design public policy, while they were stressing (understandable) concerns about the quality and cost of medical care.  They were viewing high readmission rates as something that deserved the hammer of a financial penalty, while I was viewing the issue as one of many public policy issues surrounding the health care environment, where unintended consequences of policy intervention are something to be considered.

To help explain how I view these kind of issues, I am going to share a list of twenty questions modified slightly from those Larry Bacow used to share with his students while a professor at MIT (before heading off to be President of Tufts University.)  Even though the list is over twenty years old, and Larry might modify them even more at this point, it is still a remarkably useful framework within which to view a wide range of issues.  Some are not germane to health care, but many are. 

These kinds of questions underlie a lot of the commentary you see from me here on this blog.  Please understand that these questions, although demanding some degree of analytical rigor, are not designed to stymie public policy advances, but to focus public policy interventions in the hope of more effectively solving problems.

1.  In identifying the problem, or proposing the program, what does one hope to change?  Examples:  The overall distribution of income; the income of particular groups; incentives; resources; bargaining power; political power; competitive advantage or opportunities; a condition that afflicts some particular target population; a source of social conflict or friction; some legal, customary, or social arrangement or the legitimacy of certain actions or arrangements; values, tastes and interest; the range of choice available to some group; other.

2.  In identifying that problem, exactly what specific characteristics of the state of the world concern you, and what changes in these specific characteristics is your proposed program intended to achieve?  (Specify characteristics in terms of "final," not intermediate, objectives, e.g., the quality of life of individuals affected by the program.)

"Characteristics" should consist not only of concepts but estimates of the values of these variables.  Identify the data you use in determining these values.

Express the magnitude of the problem in terms of numbers, severity, costs, etc., and indicate the urgency or priority it should have on the agenda of those whose concern it is.

3.  What is there, if anything, about the problem or issue that makes it a matter of public concern rather than something better left to private action or allowed to take care of itself?

4.  What is it that makes the problem hard to analyze or the solution hard to apply?  Examples:  Objectives not clear; instrumental relations not clear; data not available; technological uncertainty; incentives conflict with compensatory objectives; strongly conflicting interest among parties; legal or moral or traditional obstacles; sheer magnitude or cost; jurisdictional confusion; novelty or unfamiliarity of the problem; administrative costs; incentives within administration, including possibly corruption; bad side effects; wasteful side effects; "horizontal" inefficiency; "vertical" inefficiency; political weakness of beneficiaries and advocates; others.

5.  Can you distinguish elements of the problem in terms of:  Market efficiency; administrative efficiency; equity; ethics; justice; information; technology; individual rationality, responsibility or self-control; other.

For example, would the problem disappear if you were satisfied with: The distribution of income (by income size or by particular groups); the working of the market; the equal and effective enforcement of the law; the adequacy of private insurance; the responsiveness of the political system; the elimination of specific handicaps; the goodwill of the parties involved; the state of public information and knowledge; the way existing programs are administered; the conformity of individuals to law or ethical principles; etc.

6.  What are the main changes in behavior that will be induced by the incentives, resources, information, etc., that the proposed program creates?

a.  The intended changes, without which the program serves no purpose;

b.  The undesired changes that nullify the program or elevate its cost;

c.  Changes that are neutral with respect to your purpose but that have to be allowed for or taken care of.

Distinguish the changes in behavior of the intended and unintended beneficiaries from changes in the behavior of administrators and others whose actions matter but who are intermediaries, not beneficiaries.

7.  What is it that defines, bounds or delineates the problem area of the program?  How much leeway is there in defining the problem or in the coverage of the program?  For example:  The "package" of activities involved, e.g., "medicine"; the nature of production, e.g., nuclear energy; the nature of consumption, e.g., alcoholism; the marketing arrangements, e.g., cable television; governmental jurisdiction, e.g., zoning; some connection between revenues and expenditures, e.g., social security or highway programs; the nature of the target population, e.g., the elderly; law, tradition, custom, some moral principles, e.g., adoption; other.

Is there some minimum scope or scale on which the problem has to be tackled to do any good?

8.  a.  Is the problem peculiar to the social and institutional structure of the United States or of the particular area in which it occurs, or is it a universal problem that any society must solve?

b.  How was the problem defined and handled 25 and 50 years ago?

c.  How is the problem defined in other countries or other jurisdictions, and how do they handle it there?

d.  What is new and novel about the problem or its solution?  How do the newness and novelty affect the definition of the problem, the choice of technique for solving it, flexibility or inflexibility in choice of solution, and the precedents that bear on this program or that this program will establish?

9.  Generalization of the problem:  similarities and analogies.

a.  What other problems are like this one, and what are the similarities and differences?

b.  What are the "solutions" of those other problems, and what do they suggest about solutions for this one?

c.  What is the larger problem of which this is only a part?

d.  What are the smaller problems into which this one can be subdivided?

e.  Does your problem fall into some general analytical class of problems, e.g., discrimination, public goods, externalities?

10.  What are the interdependencies between this problem and other problems, this program and other programs?

a.  The solution of which other problems will make this one disappear?

b. What other problems will disappear if this one is solved?

c.  What problems will become solvable by identifiable programs if this one is solved?

d.  What programs should be enlarged or tapered off if this one succeeds?

e.  What small problems does this one subsume?

f.  What big problem is partially ameliorated if this solution works?

g.  What problems get harder if we try this solution here?

h.  What problems are discovered if we solve this one -- i.e., what is it that we ignored that we'd stop ignoring, or begin to treat as a "problem," if this program proves workable?

11.  Is the desired change incremental or systemic?  Is the object: A Constitutional change; a major change in institutions; a shift to a new"equilibrium" that once achieved, will last; a consolidation or standardization of existing programs; an intensification or modification of existing programs; bringing old programs up to date; once-for-all change or change continuous through time; reversible or irreversible change; establishment or disestablishment of precedents?

12.  How do the dimensions of the problem and the effectiveness of the solution vary with the passage of time?  Is the problem getting better or worse over time?  Is the solution getting more effective or more obsolete over time?

13.  What checklist of techniques do you use to determine the optional ways of approaching the problem?  Examples:  Transfer payment in cash; transfer payment in kind; tax or subsidy on the transaction; licenses and prohibitions; contract enforcement; control of prices, rents or wages; insurance; information; publicity; property rights; public provisions; nationalization; provision of legal services; restructuring or a market or profession; provision of some public good or service.

What is, or ought to be, the relation of the technique or instrument to the nature of the problem or the purpose of the program?  (What techniques can be ruled out?)

14.  What assumptions, if any, about the following underlie your analysis:  Cost functions; supply elasticities; consumer preferences; market structure and market response; income elasticities of demand; price elasticities of demand; productivity trends; distribution of income, wealth, and opportunity by income size, by age, by occupation, by residence, by ethnic group; time preference and discount rates; substitutability of inputs and resources; substitution possibilities in consumption; incidence of taxes, benefits, or price changes.

15.  What determines the level of government at which the problem is perceived or the solution is initiated?

a.  Does the problem area coincide with an effective area or jurisdiction?

b.  Is multi-level collaboration or strategy involved?

c.  Is uniformity among states or regions important?

d.  Is it the nature of the problem, the nature of the preferred solution, or what, that determines the level of government or the agency of government?

e.  How much is the current definition of the problem and the current governmental action a product of historical evolution rather than of defensible choice?

16.  Identify the various interested groups that affect and/or are affected by current governmental action on the problem or program.  In what ways does your proposed program (or even your definition of the problem) reflect the need to reconcile conflicts, balance the conflicting interests, combine diverse interests in a "package," avoid drastic shifts of power, observe tradition, and appeal to diverse ends and goals?  Is the problem one that could conceivably be solved with a mix of measures that would leave nobody worse off?  Or does it necessarily detract from the wealth, welfare, power or status of some group?

17.  If you could set research in motion to help you understand this problem and its solution, what research would you initiate?  How long would it take?  Would you wait for it?  Whom would you want to do it?  What would it cost?  Would it involve assembling existing data, generating new data, experiments, regression analysis, case studies, or what?  Could you build the research into the program?  Would it be basic research or applied?  Could you count on getting the results you need?  Exactly how would your proposal be affected by the results?  What process could produce decisive evidence to establish or to falsify the more controversial hypotheses that underlie your analysis or your proposal; and can you identify what results you would take as conclusive?

18.  What mid-course corrections would you envision if your program does not work as planned?  How will you know when and if it is time to make those mid-course corrections?  How will you convince others that the time is ripe and the corrections are the right ones?

19.  a.  Assume that you held the position of one of the actors currently dealing with your problem.  How would you attempt to get your proposed program adopted and implemented?

b.  Identify a specific bet about governmental action in your policy area and the odds at which you would take  a bet that satisfies two further conditions:  (1) you believe that you can win money from your examiners; and (2) you believe your advantage stems essentially from your understanding of causal factors that your examiners might neglect (rather than any specific information you might have.)

20.  If your definition of the problem is correct and if your proposed solution is any good, why hasn't the problem been so defined and a solution applied already?

Electric soccer

Here is a remarkable company called sOccket, started by young women from Harvard, that is trying to light up the world -- literally -- using specially equipped soccer balls.  They generate and store electricity while moving, which can then be tapped for low-voltage LED lamps, water sterilization devices and mini refrigerators.

Did I say unintended consequences?

I raised lots of hackles in my post below about penalizing hospitals for readmissions, generally and in the face of poor data to support such penalties.  Some commentors have said, in essence, "What can be the harm?  We'll move the needle the right way, even if the methodology is not so precise."

Well, here's one example of the kind of harm that can occur when policies are not clearly thought out.  In December, Karen E. Joynt and Ashish K. Jha from Brigham and Women's Hospital published an article in Circulation: Cardiovascular Quality and Outcomes, entitled, "Who Has Higher Readmission Rates for Heart Failure, and Why? Implications for Efforts to Improve Care Using Financial Incentives."  I quote the abstract:

Background—Reducing readmissions for heart failure is an important goal for policymakers. Current national policies financially penalize hospitals with high readmission rates, which may have unintended consequences if these institutions are resource-poor, either financially or clinically.

Methods and Results—We analyzed national claims data for Medicare patients with heart failure discharged from US hospitals in 2006 to 2007.  We used multivariable models to examine hospital characteristics, 30-day all-cause readmission rates, and likelihood of performing in the worst quartile of readmission rates nationally.  Among 905 764 discharges in our sample, patients discharged from public hospitals (27.9%) had higher readmission rates than nonprofit hospitals (25.7%, P<0.001), as did patients discharged from hospitals in counties with low median income (29.4%) compared with counties with high median income (25.7%, P<0.001).  Patients discharged from hospitals without cardiac services (27.2%) had higher readmission rates than those from hospitals with full cardiac services (25.1%, P<0.001); patients discharged from hospitals in the lowest quartile of nurse staffing (28.5%) had higher readmission rates than those from hospitals in the highest quartile (25.4%, P<0.001).  Patients discharged from small hospitals (28.4%) had higher readmission rates than those discharged from large hospitals (25.2%, P<0.001).  These same characteristics identified hospitals that were likely to perform in the worst quartile nationally.

Conclusions—Given that many poor-performing hospitals also have fewer resources, they may suffer disproportionately from financial penalties for high readmission rates.  As we seek to improve care for patients with heart failure, we should ensure that penalties for poor performance do not worsen disparities in quality of care.  (Circ Cardiovasc Qual Outcomes. 2011;4:53-59.)

Clean up your act, Mt. Ida students

Mt. Ida College is a wonderful school that thoughtfully provides hourly shuttle bus service from the local MBTA stop to the college, enabling commuting students to easily get to and from classes.  Unfortunately, after each group of students patiently waits for their bus, sipping coffee, eating pastries and ice cream, they leave behind their detritus on the sidewalk and in the parking lot.  They do so even though there is trash bin right where they wait.

The parking lot is on my route to and from the train station, and so I often get to witness this.  Here a bag from the doughnut store has been dropped within three feet of the trash bin, a typical pattern visible after the bus leaves.

The college offers a large variety of courses of study.  Maybe there should be a required class in environmental studies, or maybe the administration can just send word to the students to be better neighbors.

How regulation adds layers

Secretary of HHS Kathleen Sebelius recently proudly announced that three burdensome regulations in the health care world had been changed.  In an article entitled "Reducing Red Tape to Help Hospitals Improve Care and Reduce Costs," she explained the first change:

[T]oday hospitals must have a single Director of Outpatient Services who manages all of the various outpatient services throughout the hospital. This requirement was created years ago when most of the care given in a hospital was inpatient. Back then, it made sense to have 1 person in charge. But these days, everything from arthroscopic knee surgery to tonsil removal can be done on an outpatient basis. And each of these departments oversees its own services. This has made having 1 director oversee all of these specialty directors an unnecessary administrative burden on hospitals. So as part of the proposed rules, we would do away with this requirement and allow hospitals to decide the best way to oversee and manage these patients.

Directionally, of course, this is very sensible, as are the two other changes discussed in the article. One would also allow Critical Access Hospitals in rural areas to have lab work, radiology services, and other items be done outside of the hospital.  (Who knew that they couldn't?)  The other would free up hospitals to use advanced practice registered nurses and other non-physician providers to their fullest potential.

When I ran a hospital, I became aware of the Conditions of Participation under which hospitals were eligible for federal reimbursement.  These and hundreds of other regulatory standards are immensely detailed and complicated.  It is easy to imagine how they got that way.  There were likely two main categories.  One category consisted of rules that were written because in some hospital, somewhere, something harmful happened to a patient.  This would provoke a rule.

I am guessing, for example, that the 18-inch rule came from such an incident.  What's that rule?  The purpose is to prevent storage or any other obstruction from interfering with the spray of water from a sprinkler head during a fire.  So, when your hospital is surveyed by the Joint Commission or CMS, inspectors go around measuring the top of storage containers to make sure nothing is within 18 inches of the ceiling.

This one has some logic, although it is often applied more stringently that necessary.  For example, some hospitals and inspectors apply it even where there is no chance of obstruction, e.g., when the storage area is against a wall and not in the way of a sprinkler or the spray pattern.  But that is just a minor burden.  Other rules that are not necessary can be quite expensive, or perhaps harmful.

For example, there was the one imposed by the Joint Commission in 2004 that required giving patients an antibiotic within four hours of presentation if they went to an emergency department and were discharged with a diagnosis of pneumonia.  The standard was developed after publication of 2 large retrospective studies showing an association between antibiotic timing and outcomes in patients with pneumonia.   But doctors have explained to me that this approach could also result in overuse of these medicines, in that it was not dependent on growing and identifying cultures within that amount of time, or even sufficient certainty that pneumonia was, in fact, present.  This latter point was documented in a study from the University of Connecticut School of Medicine:

What the researchers found, as reported in the July 2006 issue of the journal Chest, was that there was too much “diagnostic uncertainty” to deliver antibiotics to 22 percent of patients.

Perhaps in response to this kind of analysis, the standard was modified in 2006 to require the finding of a positive chest x-ray or CT scan during the hospitalization to confirm the diagnosis of pneumonia.  It was later modified to extend the 4 hour period to 6 hours.  But in the interim, thousands of patients received antibiotics without sufficient reason -- at a time when we are told that overuse of antibiotics is an important cause of drug resistance in bacteria.

Let's now go to the next category.

I suspect, but cannot prove, that some portion of existing rules were put in place to protect the jobs or economic interests of various constituencies.  It feels like the two mentioned above -- requiring in-house radiology and labs, and limiting the roles of advanced practice nurses -- might have originated in that way.  I imagine, too, that there are howls of complaint from affected special interests when these types of changes are proposed.

So, congratulations to the Secretary for moving in the right direction on these three items.  The fact that there were only three is indicative of how hard it is to change rules once they are put in place.

WIHI on Safety Net Hospital Transformations

Safety Net Hospitals: Untold Stories of Quality Transformation​​
October 20, 2011, 2:00 PM – 3:00 PM Eastern Time

Guests:
Bruce Siegel, MD, MPH, President and Chief Executive Officer, National Association of Public Hospitals and Health Systems (NAPH)

Linda Cumming, PhD, Vice President for Research at the National Association of Public Hospitals and Health Systems (NAPH) and Director of the National Public Health and Hospital Institute (NPHHI), NAPH’s research affiliate

Steven R. Counsell, MD, Chief of Geriatrics and Medical Director for Senior Care, Wishard Health Services, Indianapolis; Professor, Indiana University School of Medicine; Director, Indiana University Geriatrics
 
Caroline M. Jacobs, MPH, MSEd, Chief Patient Safety Officer/Senior Vice President, Patient Safety, Accreditation and Regulatory Services, New York City Health and Hospitals Corporation
 

The usual way safety net hospitals wind up in the news in the US is when – faced with insufficient reimbursements and other reductions in funding – survival is questionable. The story angle becomes one of fiscal woes exacerbating and undermining the efforts of dedicated providers to deliver good care to mostly uninsured and underserved communities.

This situation and the necessity to address it remain quite real. But it often obscures another picture that's emerging in this critical sector of US health care: the ways in which safety net and public hospitals are innovating their way to greater stability. Even with financial constraints, they are improving care for patients, becoming leaders in quality and safety, and acting as mentors to other health care organizations interested in population health. Denver Health, Contra Costa Health Services, Cambridge Health Alliance, and Stony Brook University Medical Center are just some of the names of places with visionary leaders and bold initiatives underway – so much so that they're gaining the attention of national policy leaders in search of new models of care to achieve health reform.

This exciting trend will be further unpacked on the October 20th WIHI. Host and producer Madge Kaplan will welcome Bruce Siegel and Linda Cummings of the National Association of Public Hospitals and Health Systems to the show to describe a comprehensive agenda for change that’s underway to support the ambitions of their members. They'll be joined by Caroline Jacobs of the New York City Health and Hospitals Corporation and Steve Counsell of the Indiana University School of Medicine and Wishard Health Services, each of whom will provide some rich examples of what’s being achieved at their hospitals on the front lines of care

The focus of the October 20^th WIHI is especially timely as all of health care gears up to engage with greater numbers of low-income patients gaining insurance under health care reform. Who better to turn to for decades of experience but public and safety net hospitals? Please join us!

To enroll, please click here.

Modeling readmissions

The current intent to judge hospital performance and modify hospital payments based on relative rates of readmissions is not wise.  Contrary to President Obama's characterization that readmitting a patient to the hospital is equivalent to bringing a car back to the mechanic after a repair, rates of readmissions are based on a number of factors, of which a significant portion are services not provided by the hospitals and environmental conditions not controlled by the hospitals.

But let's put my objections aside and determine how we would model an "appropriate" rate of readmissions.  Well, a new article in JAMA* explores existing models, noting that robust models are needed "to identify which patients would benefit most from care transition interventions, as well as to risk-adjust readmission rates for the purposes of hospital comparison."  The article concludes that the capability for doing these things does not yet exist.

In "Risk Prediction Models for Hospital Readmission," the authors state as their objective:  "To summarize validated readmission risk prediction models, describe their performance, and assess suitability for clinical or administrative use."  Their conclusion, after reviewing two dozen such models, was that "Most current readmission risk prediction models that were designed for either comparative or clinical purposes perform poorly."

For the technically inclined among you, here's more of the abstract:

Fourteen models that relied on retrospective administrative data could be potentially used to risk-adjust readmission rates for hospital comparison; of these, 9 were tested in large US populations and had poor discriminative ability (c statistic range: 0.55-0.65). 

Although most models incorporated variables for medical comorbidity and use of prior medical services, few examined variables associated with overall health and function, illness severity, or social determinants of health. 

So, even if the readmission rate is the right metric to use for comparison purposes, we don't have a model that would accurately compare one hospital to the others.  This suggests that the time is not ripe to use this measure for financial incentives or penalties.  It might give the impression of precision, but it is not, in fact, analytically rigorous enough for regulatory purposes.

---

*2011;306(15):1688-1698. doi: 10.1001/jama.2011.1515

The big lie

There is a wonderful expression in politics, "If you say something often enough, it becomes the truth."  Of course, it doesn't really become the truth.  A lie retold is still a lie.  But, you can succeed in diverting political attention, especially in today's news environment, when reporters are not given enough time and bandwidth to really explore issues.

Take today's New York Times story about Massachusetts health care costs by Abby Goodnough and Kevin Sack.  The thesis is that the introduction of capititated, or global payments, will offset cost increases resulting from universal health care access.  The reporters give credence to the premise, even though there is not empirical support for the conclusion.  Indeed, such support as exists in Massachusetts suggests that the manner in which global payments were introduced resulted in higher, rather than lower, costs.  The story also fails to discuss consumer concerns about such plans, which would limit choice.

But then, the reporters retell the big lie, the one that suggests that concerns about the cost trends of the dominant provider group have been alleviated by a recently signed contract.  Ready?  Here you go:

Under market and political pressure, Partners also agreed to renegotiate its contract with Blue Cross Blue Shield and accept lower reimbursements, which is expected to save $240 million over three years. ... Blue Cross Blue Shield of Massachusetts said payments to Partners would increase at about 2 percent a year rather than the previously anticipated 5 percent to 6 percent.

Let's deconstruct this.  First of all, the PHS contract had one year to run, not three years.  Whatever rate renegotiation they accepted for the last year of the contract, they would have been smoking something to think that they would have received 5 to 6 percent going forward.  Also, as previously mentioned here, the base on which they get their "about 2 percent" increase is substantially above the market.  Other hospitals that were at or below market rates also received rate increases in the "about 2 percent range" -- starting one or two years ago.  Indeed, with other, non-dominant hospitals, BCBS started those negotiations by offering negative or zero change in rates.  Partners, then, didn't give up anything going forward.  It was permitted to keep its huge bolus of embedded, above-market rates.

Oh, and what's this "about 2 percent," anyway?  Remember that it was reported as "between 2 and 3" percent?  This week, it's been rounded down to 2 percent.  At this rate, in a month, they will describe it as "practically zero."

One thing the reporters get right is this:  "The politically powerful hospitals clearly hope to persuade lawmakers that price controls are not needed."

Likewise, the insurance company, it appears.  Whether it is fear of government regulation or a desire to go along to get along, a tremendous opportunity to truly control costs has been squandered.

But you will never see that story.  The big lie persists.  Welcome to the spin cycle.