Friday, December 21, 2012

Fireflies from The Jubilee Project

Every time I think that they have done as well as possible, the folks at The Jubilee Project publish a video that is even more compelling.  Watch it here and below.  Please share it widely over the next couple of weeks as I take a seasonal blogging break.

Thursday, December 20, 2012

Intuitively obvious?

I hold no grudge against Intuitive Surgical, even though I think its marketing campaign to promote the use of its DaVinci surgical robot was overly clever in securing sales for a device with unproven clinical effectiveness.  How successful?  Well, sales growth has been in the range of 45% per year.

But there is an immutable law of health care finance:  "No one wins big for long."

Starting a few months ago, I heard of people who were selling the stock short, expecting its value to fall because the market for its surgical robots had become saturated.

Then, in April, reports emerged of product liability lawsuits being filed against the company.  This story summarizes one such lawsuit:

The lawsuit, filed by Gilmore McCalla, alleges that the death of his daughter, Kimberly McCalla, was caused by the surgeon’s mistakes during her hysterectomy, as well as by flaws in the robot’s design, such as badly-insulated surgical arms and overly-strong electrical current that can connect with healthy tissue. The da Vinci allegedly burned one of the woman’s arteries and her intestines. She died two weeks after the surgery. The lawsuit also claims that Intuitive Surgical did not give hospital staff adequate training on the robot’s use.

Citron Research gave its point of view on December 19:

Imagine a medical company with a single product — one which lacks any clinical data proving medical efficacy superior to other conventional treatments … or in case of one of its major applications, little to no advantage over no treatment at all.

Now imagine that same company’s product under a host of lawsuits that range from patient death after “routine” surgery, to a man defecating out of his penis.

Worse, imagine this one company being sued in the past  four weeks by some of the biggest name tort attorneys in the United States. Now imagine this company has a $21 billion market cap and a lofty forward P/E.

Citron believes that Intuitive Surgical’s stock price will soon suffer. The da Vinci robot-assisted surgery device is a solution in search of a problem — but one hell of a marketing machine.

Now, look how the stock market has reacted:

In health care, no one wins big for long.

New for 2013: The Pain Index

A recent report by the New York Times contained an excellent graphic showing the current percentage of uninsured people in each state.  The range is from a high of 24.6% in Texas to a low of 4.4% in Massachusetts.

I have combined this rate with the most recently reported CDC rate of obesity in each state to create what I call The Pain Index.  It is a simple sum of the two numbers.

The theory behind the total is that obesity is a rough guide for the level of unhealthiness in the population.  My hypothesis is that, when insurance is made available to people, they will use it, roughly in proportion to the degree they are unhealthy.

Yes, I know this is a crude metric, but I think it will be a relatively good predictor of the rate of increase in health care costs in each state over the coming years.  This will show up in the insurance premium rates offered in the health care exchanges and will also affect the need for state appropriations to pay for newly eligible Medicaid subscribers.

States with a Pain Index in the top decile are: Texas, South Carolina, Lousiana, Mississippi, and Arkansas.  Others with scores over 45 are Nevada, Florida, New Mexico, Georgia, Alaska, Oklahoma, North Carolina, Kentucky, Alabama, and West Virginia.

My advice to policy-makers:  Get ready!  My advice to health care CEOs:  This would be a really good time to focus on quality, safety, and front-line driven process improvement as the most effective way to reduce your costs and improve efficiency.

     Percent     Obesity          Pain
State   Uninsured        Rate        Index
TX 24.6 30.4 55.0
NV 21.6 24.5 46.1
FL 20.7 26.6 47.3
NM 20.6 26.3 46.9
GA 19.7 28.0 47.7
CA 19.5 23.8 43.3
SC 18.8 30.8 49.6
LA 18.4 33.4 51.8
AZ 18.4 24.7 43.1
AR 18.3 30.9 49.2
MS 18.2 34.9 53.1
AK 18.0 27.4 45.4
OK 17.4 31.1 48.5
MT 17.2 24.6 41.8
ID 17.1 27.0 44.1
NC 17.1 29.1 46.2
WY 16.8 25.0 41.8
OR 15.8 26.7 42.5
NJ 15.1 23.7 38.8
KY 15.0 30.1 45.1
AL 15.0 32.0 47.0
IL 14.6 27.1 41.7
MO 14.5 30.3 44.8
CO 14.3 20.7 35.0
TN 14.3 29.2 43.5
UT 14.2 24.4 38.6
WV 13.9 32.4 46.3
NY 13.8 24.5 38.3
OH 13.6 29.6 43.2
WA 13.6 26.5 40.1
MD 13.3 28.3 41.6
VA 13.3 29.2 42.5
SD 13.2 28.1 41.3
KS 13.0 29.6 42.6
IN 13.0 30.8 43.8
MI 12.7 31.3 44.0
NE 12.3 28.4 40.7
RI 12.0 25.4 37.4
DE 11.5 28.8 40.3
DC 11.3 23.7 35.0
ND 11.1 27.8 38.9
IO 11.0 29.0 40.0
PA 10.9 28.6 39.5
NH 10.8 26.2 37.0
CT 10.3 24.5 34.8
ME 9.7 27.8 37.5
WI 9.6 27.7 37.3
VT 9.1 25.4 34.5
MN 9.0 25.7 34.7
HI 7.6 21.8 29.4
MA 4.4 22.7 27.1

Dear hospital CEOs: Commit.

An open letter to the 5754 hospital CEOs in America,

You have been granted a public trust.  It's time to commit, publicly.

President Obama has decided that a form of gun control will be on his agenda for the coming year: "The president signaled his support for new limits on high-capacity clips and assault weapons, as well as a desire to close regulatory loopholes affecting gun shows.... [The] opposition shows little signs of fading away."

All I am asking is that you publicly identify yourself with a position on this issue, for or against.

I know that many of you have a tendency to be quiet of matters of legislation when there appears not to be a connection with hospitals.  But this is a public health issue. The CDC reports 11,492 homicides from firearms (out of 16,799 total) in a year in its most recent figures (2009), a rate of 3.7 per thousand population. (The total rate of deaths by firearms is about three times this, with suicide being the largest category.)

We need your judgment and thoughtful consideration.  We need your convening authority to create opportunities for discussion and debate in your institutions and your communities, to help inform your position. We need you to make your views known to your senators and representatives in Congress.

As Hillel said:  "If I am not for myself, who is for me? If I am only for myself, what am I? If not now, when?"  Please reach deep and think about how you will feel if this issue is decided without your engagement.  You've spent years getting to your current position.  For what purpose if not to participate in one of the major issues facing our society?

Here are some excerpts of articles that might help you decide:

A doctor who lists his name as J. Stefan Walker recently posted this comment about limiting the availability of assault weapons on another website:

The Second Amendment settled the issue, but even before that it has been one of the fundamental rights and responsibilities of our free society to live with firearms. America would likely have been conquered by external invaders or internal fascists long ago had it not been for the reality that common citizens have ready access and skill in handling even advanced weaponry; similarly, the right to keep and bear arms insures that citizens will not be mere prey when criminals or others of malevolent or misguided intentions bear arms against the innocent. I do not question the motives of those who feel the answer to tragic gun violence is to restrict guns or types of guns; but I do question the logic, and the legality. The real issues involved in gun-related tragedies center around more responsible handling / ownership of firearms – and in better mental health resources for the public. Free people must accept the harsh realities of violence in the world – and accept the concomitant responsibility to bear arms of at least equal potency at the ready to protect those within our charge. This does not just mean the police and the formal military: simple math proves that approach will never guarantee adequate safety. There is just no way around these realities.

Here is a contrasting view by Leah Hagler Cohen on WBUR's Cognoscenti:

To feel is good.

It is a kind of intelligence. It’s a first response which may spur us — if we don’t hasten to deaden it — to further response: to action.

If the reason this latest event stands out from the rest has less to do with its uniqueness and more to do with the tender age of the majority of those killed, how shall we make use of our emotional response? How shall we let it — our grief — inform us? 

I am no policy maker. I have no expertise in violence or gun laws or mental illness or video games or the Second Amendment. I am only a mother. Even that is irrelevant. Would I feel any less if I had no children of my own? We are all in this together.

Here’s what we can do. We can tell our stories and listen to one another. We can educate ourselves about the issues and about who has the power to implement change. We can find creative ways to partake of that power and responsibility. We may even choose to reckon with ourselves — privately and collectively — about the role each of us played in the most recent tragedy, if only through silence and inaction. Others will have more practically useful ideas. I know only this: we start by being willing to feel.

Former hospital CEO Nick Jacobs adds:
Back in the eighties, much of the inpatient mental health system all but vanished in this country, and today behavioral health challenges continue to carry a stigma that is not only tenuous but also very detrimental to the well being of not only those challenged individuals but for all of us.  So, yes, behavioral health issues have clearly been a part of each of these attacks. And is that an easy fix?  I think not.  I believe the stigma associated with mental illness is a huge problem, and even if we seek help, it is many times not available.

Let’s discuss the third rail.  As a kid I grew up with guns and target shooting was one of my favorite family pastimes.   I can tell you that we never had a problem due to the fact that we owned those guns.  They were locked up; they were handled appropriately, and they were used for what they were intended.

However, when you see facts like:  There have been 62 gun-related mass murder attacks across this country since 1982, or that approximately 50 million people own about 250,000,000 guns in the U.S., you have to wonder about connectivity to this issue.

The chief medical examiner has said the ammunition was the type designed to  break up inside a victim’s body and inflict the maximum amount of damage,  tearing apart bone and tissue.  So what about gun control?   Do I believe that semiautomatic weapons, armor piercing bullets, extended clips, et al., contribute to the ease of access for these mass murderers? Yes, I do.  I would love to see controls regarding the above mentioned killing devices, but I do not believe this is the only solution.  Should people be permitted to own guns?  Yes.

There is no easy solution.  I would hate to see our schools and colleges become modified prisons.  I would hate to see our lives become self-imposed solitary confinement chambers, but clearly excessive access to kill-type weapons, inadequate access to behavioral health treatment, lack of understanding of drug interactions, and excessive exposure to violence seem to have created the perfect storm.

Wednesday, December 19, 2012

What, Me Worry (about a mere statute)?

Much was made of the recent health care cost control legislation in Massachusetts, Chapter 224 of the Acts of 2012.  And, after all, who can be against "An Act Improving the Quality of Health Care and Reducing Costs Through Increased Transparency, Efficiency and Innovation?"  Well, apparently the state's own Division of Insurance can be, having decided that the Legislature didn't really mean an important part of the act.

There is a provision of the law ("Chapter 176T, Risk-bearing Provider Organizations") that was written to provide some assurance that provider organizations--physician organizations, physician-hospital organizations, independent practice associations, provider networks, accountable care organizations and any other organization that contracts with carriers for payment for health care services--would be financially capable of bearing the risk of alternative payment contracts.  In particular, a provider organization that accepts downside risk in a payment contract is required to file an application for a risk certificate with the Division of Insurance.  It has to include:

(1) the filing materials submitted to be registered as a provider organization, pursuant to chapter 6D;
(2) a list of all carriers and public health payers with which the provider organization has entered into alternative payment contracts with downside risk;
(3) financial statements showing the risk-bearing provider organization’s assets, liabilities, reserves and sources of working capital and other sources of financial support and projections of the results of operations for the succeeding 3 years;
(4) a financial plan, including a statement indicating the anticipated timing for receipt of income from alternative payment contracts with downside risk versus the incurrence of expenses, a statement of the applicant’s plan to establish and maintain sufficient reserves or other resources that will protect the risk-bearing provider organization from the potential losses from downside risk, copies of insurance or other agreements which protect the risk-bearing provider organization from potential losses from downside risk, and a detailed description of mechanisms to monitor the financial solvency of any provider organization subcontracting with the applicant that assumes downside risk in its alternative payment arrangement with the risk-bearing provider organization;
(5) a utilization plan describing the methods by which the risk-bearing provider organization will monitor inpatient and outpatient utilization under the alternative payment contracts with downside risk;
(6) an actuarial certification that, after examining the terms of all the risk-bearing provider organization’s alternative payment contracts with downside risk that the alternate payment contracts are not expected to threaten the financial solvency of the risk-bearing provider organization; and
(7) such other information as the division may specify through regulation.

Sorry about all this detail, but you can see the purpose.  The Legislature wanted to protect provider organizations--and the patients served by them--from the untoward results that might emerge from a failure to meet the spending limits of alternative contracts.  In the language of the law, the insurance commissioner is supposed to:

ensure that a risk-bearing provider organization is not subject to adverse conditions which in the commissioner’s determination have at least a moderate potential to impact a risk-bearing entity’s ability to meet its risk-bearing responsibilities under any alternative payment contracts.

So how did the Division of Insurance interpret this mandate?  In a bulletin dated November 20, 2012, it said:

Although Chapter 176T became effective on November 4, 2012, the Division considers the period from November 4, 2012 through December 31, 2013 to be a transition period (“Transition Period”) with respect to the issuance of Risk Certificates or Risk Certificate Waivers.  During the Transition Period, provider organizations and Carriers may enter into and continue to participate in alternative payment contracts with Downside Risk if the provider organization applies for and receives a transition period waiver from the Division.

And what are the requirements for the "transition period waiver?" A highly watered down version of those included in the statute.  Indeed, the required documentation is a virtual nullity when it comes to providing an ability to determine if a provider organization is financially capable of handling downside risk.  Here's the list:
  1. The name of the provider organization;
  2. The name and contact information for the person within the provider organization designated to be the Division’s primary contact;
  3. The official names of all health care payers and employers, as defined in Chapter 176T (if any), with which the provider organization currently has alternative payment contracts with Downside Risk;
  4. Net patient service revenue earned by the provider organization in 2011;
  5. Whether the provider organization has any alternative payment contracts with Downside Risk directly with individuals;
  6. For provider organizations that do not yet have any alternative payment contracts with Downside Risk, the names of all health care payers and employers with which the provider organization is proposing to enter such contracts; and
  7. Any additional information deemed necessary by the Division.
Requirements for insurance carriers are also corresponding diluted.

Chapter 224 of the Acts of 2012 also amends Chapter 176O to prohibit Carriers from entering into or continuing an alternate payment contract with Downside Risk with a Risk-Bearing Provider Organization, unless the organization has obtained either a Risk Certificate or a Risk Certificate Waiver, as described in Chapter 176T.  During the Transition Period, any Carrier that is either entering into or continuing an alternate payment contract with Downside Risk with a provider organization that has obtained a Transitional Period Waiver shall be deemed to be in compliance with the relevant provision of Chapter 176O.
When I was a commissioner in the state government, I considered an enacted statute to be the law.  Oh wait, it is the law!  Here we have a regulatory agency that has unilaterally postponed the effective date of a law by over a year.  This action was not the result of a rule-making, during which the agency received comments from the public and interested parties.  It came out in the form of a bulletin.  No statutory support is offered for this determination, just the Division's "consideration."

The Legislature's determination on this issue was not an academic exercise.  The law envisions and encourages a dramatic increase in the use of risk-bearing contracts.  Those contracts are quite different from the fee-for-service arrangements that have existed in the past.  At least some provider groups may not have the sophistication to perform a proper analysis of these contracts.  Others may feel forced into them by heavy pressure from the major insurers.  Or by competitive pressures.

Insurance companies are created to bear risk and have corresponding capital reserves.  Provider organizations were not created to bear risk, have little experience with it, and are unlikely to have accumulated capital reserves for the purpose of covering such risk.

The Division of Insurance is supposed to safeguard the public interest in this matter.  Now, not after December 2013.

Tuesday, December 18, 2012

In memoriam: Werner Gans

Werner Gans passed away today, but a great story is left behind.  Werner was one of the Ritchie Boys, a top secret World War II US intelligence unit comprising German Jewish refugees who worked in counterintelligence and in the interrogation of captured Nazi soldiers.  Werner's story was told in this review.  Excerpts:

In 1943, US military officials classified Werner Gans as an enemy alien. Within 18 months they changed their mind and trained the German Jew to be a spy.  Gans learned the art of espionage and psychological warfare at the elite Camp Ritchie in Maryland. He became one of the Ritchie Boys, refugees from the Nazis offered a chance to turn the tables on their persecutors.

Although he was trained to go behind enemy lines and numerous times received orders to ship out, Gans wound up serving from this side of the Atlantic. His job was to interrogate German POWs.

"We tried to get as much information as we could in a benevolent manner," said Gans, adding that while the grilling was intense, it didn't turn physical. `"We had Army officer uniforms and medallions, so the prisoners thought we had real authority."

Gans served at Long Island in Boston Harbor. POWs were held there, including Germans captured in France. At the time, the Allies were preparing to invade Germany. `"Our job was to find out everything we could about the Nazi installations," said Gans, "where they had been and where the troops were headed." The prisoners ranged from ordinary soldiers forced to don the swastika to die hard Nazis who felt honor bound not to talk.  Gans said one tactic the Ritchie Boys used to motivate the POWs was to display a large poster of Stalin in the interrogation room, playing on the Germans' fear that they would be sent to a Soviet camp.

Gans grew up in Mannheim , an industrial city on the Rhine. After the Nazis took over, he said, life became very difficult. His classmates ruthlessly chastised him , and his father's passport was taken away as a penalty for his crossing the street, by foot, against a red light.  His ticket out was the cello. At 13, Gans was sent off alone to study music in Milan, where he lived with a family. He knew no one, nor did he speak Italian. Meanwhile, friends and family in Mannheim were desperately trying to get out of Germany.

After paying a hefty fine, Gans' father got his passport back, and the family secured a transit visa to Cuba. Gans returned from Italy and they left in October 1938. In Cuba, Gans played with the Philharmonic Orchestra of Havana. While his parents had to wait two years for permission to enter the United States, he got a student visa after only four months. A pianist in the orchestra recommended him for a scholarship to the Malkin Conservatory of Music in Boston, whose staff included Harry Ellis Dickson and Arthur Fiedler.

"I had no idea where Boston was," said Gans. `"For me it could have been Timbuktu."

Gans has returned to Germany twice since he fled as a teenager; in 1987 , when his son wanted to learn about his roots, and in 2000 , when his family was invited back by the mayor of Mannheim, a custom many German communities practice to show remorse.

But perhaps one of the most fulfilling jobs he's undertaken, Gans said, is at a Roxbury elementary school, where he tutors in English, reading, and geography once a week through Generations Incorporated, a nonprofit organization committed to intergenerational awareness.

I didn't know all this, although I have known Werner for decades.  All I knew was that he loved playing with the Boston Civic Symphony and adored his family.  But, as his son Steve reports, "He was also the best man I have ever known."  We will miss him greatly.

Recognizing George Tsokos

I'd like to take credit for recruiting George Tsokos to be head of rheumatology at BIDMC when I was CEO, but it was Dr. Mark Zeidel, chief of medicine, who secured the deal.  I'd like to take credit because George is an extraordinary clinician, teacher, and researcher--beloved by patients and staff alike--who has made major substantive contributions to the field of systemic lupus erythematosus.

Nonetheless, I want to share my happiness in the fact that George was just awarded the 2012 Lee C. Howley Sr. Prize for Research in Arthritis.  The award recognizes those researchers whose contributions during the previous five years have represented a significant advance in the understanding, treatment or prevention of arthritis and rheumatic diseases.

As noted by the Arthritis Foundation:

Over the past two decades at Walter Reed and Harvard University, Dr. Tsokos has systematically characterized biochemical and molecular abnormalities in immune cells from patients with systemic lupus erythematosus and furthered the understanding of the disease’s origin. His studies have identified novel treatment targets and disease biomarkers to improve the lives of patients.

Oh, did I mention that George is a very nice person, too?  Not a bad combination!


Would he help?

The Boston Globe reports that the private equity firm that owns the Steward Health Care System of for-profit hospitals also owns the company that makes the semiautomatic rifle used in the recent Newtown, CT, murders.  An excerpt:

Cerberus is one of the most powerful forces in the gun business. It owns Freedom Group Inc., a Madison, N.C., company that is the nation’s largest seller of firearms and the number two seller of ammunition. Freedom, according to its annual report, sold 1.1 million long guns and 2 billion rounds of ammunition that generated $775 million in sales last year.

Together with its gun brands, from Bushmaster to Remington, Freedom is a major contributor to the National Rifle Association and the fight against gun control, according to the Violence Policy Center, a Washington group that tracks corporate funding of gun advocacy.

Does this raise concerns of split purpose?  Dr. Robert D. Sege, director of ambulatory pediatrics at Boston Medical Center and coauthor of a policy statement on gun control by the American Academy of Pediatrics, seems to think so:

If Cerberus is not working for laws to make guns and the community safer, he said, “At the very least it calls into question the overall aims of Cerberus Capital.”

The story notes that the Cerberus officials and the Steward CEO were not available for comment.  It wasn't so long ago that the latter person hosted President Obama at his home during the campaign.  If they had a chance to meet now, would the topic be health care or guns?  Isn't it a good time for this hospital CEO to offer to use his bully-pulpit to help the President make the case to reduce the danger of assault weapons?

(While we are at it, how about other hospital CEOs, even the ones who don't have partners in the weapon business?)


Addendum:  I just learned that Cerberus plans to sell its interest in this gun company, as it was facing pressure from its investors. "The announcement comes one day after the California State Teachers Retirement System, a large pension fund, told The Wall Street Journal that it was reviewing its $500 million investment commitment to Cerberus because of the firm's stake in Freedom Group." Perhaps that will make the choice easier for the CEO.

Another reason to see The Waiting Room

@waitingstories Yesterday NPR's Monkey See blog posted the 10 films you should go out of your way to see from 2012, and The Waiting Room was on the list.  Look here.

BORIM delivers help

The Quality and Patient Safety Division at the Massachusetts Board of Registration in Medicine is putting out a lovely newsletter that contains quality and patient safety initiatives from hospitals in the state and from its own work.  It is simple and straightforward, a great example of how the government can be helpful.  The current edition is about hand-offs.  Check it out here.

Is event reporting good or bad?

A friend sent me the link to this great interview of Lucian Leape and Bob Wachter on PBS in 2005.  It is illustrative to re-read it seven years later.  One statement by caught Bob my eye:

I'm actually not a big fan of reporting. Reporting was one of the aviation analogies from around the time of the original IOM report. The Aviation Safety Reporting System is very robust and really very helpful. . . . [When] a near miss gets reported . . . useful action comes from those reports. They get 30 or 40 thousand reports a year, and it's been very, very helpful that way.

The health care analogy doesn't work very well in terms of reporting, and what we've seen with some of these state reporting systems is they get -- some of them have gotten 100,000 reports, and they're sitting mostly accumulating dust on shelves or in computer databases. In some ways this is part of the problem. There are so many errors, there are so many near misses in health care, that reporting them up to the state or to the federal government, nobody has really quite figured out how to take those reports and do something useful with them.

Where I think we have made some progress in reporting is that individual hospitals have something called incident reporting systems, and in good ones, my hospital has a good one where it's a computerized system when a nurse or a doctor sees something that went wrong, they report it through that system. And there is then a feedback loop. Action occurs.

This prompted my memory of a recent email from Steve Spear.  I think he makes some great points:

A colleague asked, "Is event reporting good or bad?"
The answer is, "It depends."
And both the question and the answer apply beyond clinical settings.

The answer first depends on:

1- what is reported (frequent, small disruptions such as
    momentary break in routine versus infrequent, but large
    and consequential realized hazards)
2- when it is reported (immediately or on lag)
3- how is is reported (information content, format)
4- by whom it is reported
5- to whom it is reported
6- for what purpose it is reported (to trigger problem
    containment, investigation, indictment.

IF we start with the basic premise that for large, complex, dynamic systems
THAT there will always be gaps between intent and actual experience
THEN we need mechanisms to see problems and swarm them at the time and place they occur
IN ORDER TO contain them from infectious spread (metastasis)
AND IN ORDER TO investigate their cause while the conditions that caused the problem are still "hot."

In short, we want to answer the questions above:

1- frequent and small
2- immediate
3- detailed about symptom and associated causal conditions
4- the person immediately affected
5- someone designated to respond immediately (organizational antibody)
6- contain, investigate, solve to prevent recurrence.

This dynamic of "see a problem" "solve a problem" is what biological systems do to maintain homeostatic self regulation.

Complex technical systems also have high speed, nested feedback and control loops to maintain a combination of reliability and responsiveness.

So too, complex work systems must also have a similar dynamic.

On the other hand, if we answer the questions, above, as:
1- infrequent and at the point of crisis
2- on delay
3- poor detail and accuracy
4- by third party
5- to someone who cannot or does not act
6- catalog, report, retribute

...we have a system with TERRIBLE control properties that is sure to 'crash,' literally and figuratively.

Sunday, December 16, 2012

The proton beam chain reaction

The Wall Street Journal had a good article the other day on the issue of proton beam treatment.  The thrust--familiar to my readers--is that these expensive machines have yet to demonstrate clinical efficacy commensurate with their cost:

[P]roton-beam therapy provided no long-term benefit over traditional radiation despite far higher costs, according to a study of 30,000 Medicare beneficiaries published Thursday in the Journal of the National Cancer Institute. 

Yet, as I have mentioned, federal pricing policy is supporting a proliferation of these behemoths, building a cost structure into our health care system that will be a mortgage for years to come.  The Mayo Clinic alone is building two.  The scale:

During the building phase of each project, a total of 500 construction jobs will be created. When fully operational, the two proton beam programs will employ more than 250 new staff members, including 19 physicians and 19 physicists.

Want to build one for your practice or your hospital? Just check out this full-service development company.  Maybe you, too, can get a time-lapse video of your groundbreaking!

If you are a policy geek, here's the scariest part of the WSJ story:

Meantime, researchers at Massachusetts General Hospital and the University of Pennsylvania are enrolling patients in a randomized trial to directly compare proton therapy [for prostate cancer] with IMRT for the first time. "Men need to know which is better, and cancer doctors need to be able to provide the evidence," said Justin Bekelman, a radiation oncology at Penn who is one of the principle investigators.

Think of it, over a billion dollars has now been spent on these machines in the United States; Medicare is paying more for the treatment than for conventional radiotherapy; and we are only now asking the question of whether they offer treatment that is better.  In a rational environment, the study would have taken place using the small number of the first generation machines that were funded with federal support.  Then, if the results were positive, we could have made a rational decision as to how many installations would make sense and where to place them geographically.  But now, the horse is out of the barn.  (Check the locations on this website if you have any doubts--and see this direct-to-consumer advertising as a hint of things that are in place.)

Meanwhile, north of the border, Canadians are debating whether and where to build a full-scale proton beam treatment center.  (My Google search reveals only a small one thus far, for melanoma of the eye, in British Columbia.)  Because of its cost, a large machine would have to be federally authorized; but the organization of health care in Canada is by province, raising the prospect of an interesting competition.  When you consider the size (and thus space needs), technical staffing requirements, and financial condition of the various provincial governments, there are only a few candidate cities.  Toronto would seem a logical spot, for example, but there is not enough space near the major medical center, and the Ontario finances are weak.  Oddly enough (given the small population of the province), Saskatoon might end up as a top candidate.  It has physical space, expert staff, and a surplus in current provincial accounts.

But does Canada need one at all?  The issue appears to have been decided.  As an expert said to me recently, "If we don't build one, there will be a huge outflow of patients to the US for treatment, and we will be forced to pay US prices for something that would be less expensive if we owned it.  Canada cannot afford to export millions of dollars to the States to treat our patients."

The medical arms race has now gone international.  In the words of nuclear arms policy, this is mutually assured destruction.

Friday, December 14, 2012

Commitment to your team: You can't force it, or fake it

My friend Jim Dougherty has written his first blog post (on a Harvard Business Review site), and we should all hope that it is one of many.  It is entitled, "To get a commitment, make a commitment," and it deals with a leadership attribute that is often notable for its absence.  As Jim summarizes the point, "I valued individuals more than any work accomplishment.  The highest motivation for team members is to get that kind of emotional connection to the team leader."

After giving some examples, he summarizes:

What's the lesson here? If you want to get an emotional commitment from the people who work for you — or with you, or with whom you have business relationships — you need to be willing to commit to them too, unsolicited and without direct hope of reward. 

You can think strategically about how to do this, so you're ready when opportunity presents itself to take the kinds of actions that produce such a result. But you can't force it, or fake it. If you do something purely for the hoped-for economic gain, it will show and you will likely fail.

A good lesson from a person who has been extremely successful in his business ventures. I hope Jim shares more with us.

Thursday, December 13, 2012

KHN offers exposure on proton beam waste

Thanks to Kaiser Health News for including me in this survey of things that CMS might do to reduce Medicare costs.  It was fun to offer my comments on Skype.  Regular readers will not be surprised to hear some thoughts about the proliferation of proton beam machines because of the perverse rate structure in effect at the federal level.

John Polanowicz joins the administration

Governor Deval Patrick has made an excellent choice in his new Secretary of Human Services, John Polanowicz, and the timing could not be more propitious.  I had the privilege to serve with John on the board of the state hospital association, where he also was a member of the Clinical Issues Advisory Council that I chaired.  At the time, he was CEO of Marlborough Hospital, where he had shepherded the institution through a financial turnaround.

More important than this accomplishment in my view was John's steadfast commitment to improving the quality and safety of patient care in his hospital and the state as a whole.  He was not content with the status quo and was a strong supporter of increased transparency of clinical outcomes--not to create competition among hospitals, but to assist all of them in raising the standard of care.

While many in the state fret about the cost of health care, John understands that a key component of that cost is the waste and inefficiency associated with the level of harm caused to patients in clinical settings.  It will be good to have a strong advocate for quality and safety improvement in the Executive Branch.

Wednesday, December 12, 2012

Phase difference

@CherClarHealth, aka Cheryl Clark, reports some important comments by Don Berwick in an interview published this week in HealthLeaders Media.  An excerpt:

[T]here is a gap between the improvement movement on the one hand, which has a lot of knowledge about using improvement to achieve cost reduction, and the responsible public policymakers and public servants who formulate regulations and laws.

And I have to say the same gap often exists between the improvement movement and the C-suite in medical organizations, hospitals and large systems. There is too much distance between the front office and the front line, and so executives can fail to appreciate quality as a business strategy, just as policy makers can fail to appreciate quality as a public policy strategy. 

I feel like Don and I are like a sine function and a cosine function, moving along with the same periodicity, but slightly out of phase.  He notes:

I came out of the improvement movement. That's my original knowledge base; but I and many others are learning how to bring our knowledge into the political arena. That bridge needs to be built. 

In contrast, most of my previous experience comes out of the political arena, running state agencies in Massachusetts and Arkansas.  My stint in health care came along later.  With help from Don and his colleagues and other really great people around the world, I learned a bit about patient care.  But the way I applied it in the hospital setting was based on principles of negotiation and constituency building that have their roots in political theory and community organizing.

The main thing that I learned in the political environment is that top-down thinking does not work when you are trying to create a coalition or build a movement for change.  I also learned that financial incentives and penalties are not motivational, and that they are crude tools often accompanied by unintended consequences.  A good leader trusts in people's good intentions--their desire to do well and to do good--and understands that their underlying values can provide the foundation for transformational change.

The article concludes with this statement by Don:

You didn't ask me the optimist or pessimist question. The answer is, I'm an optimist. I like what I'm seeing at the local community level. And the next couple of years, the story of healthcare in America may be told community by community rather than from inside the Washington beltway.

Again, he and I are out of phase, but I am hoping he is right.  I am not yet an optimist.  I, too, see some wonderful things going on in some communities.  But I don't see leadership, and I don't yet see a movement.  The major question I get as I travel is, "How can I get my CEO (or my department head) to reduce 'the distance between the front office and the front line?'  I still see many, many CEOs, chiefs of service, and boards of trustees who have yet 'to appreciate quality as a business strategy.'  Their minds are elsewhere.  In my view, hope lies in three possible vectors for change:

1)  Small groups of like-minded people in organizations who get together and experiment with small, incremental improvements and prove the case to themselves and, gradually, to those in the upper echelons;

2)  The coming generation of medical students and residents, who are fascinated and passionate about employing the scientific method in clinical process improvement and who believe in using transparency to hold themselves accountable to the standard of care they have chosen;

3)  A budding patient advocacy movement, people like e-Patient Dave, Patty Skolnik, Helen Haskell, Linda Kenney and others who have experienced fear, pain, and/or tragedy and who persistently demand to be let in and be partners in the design and delivery of care.

Don is correct to point out that there are more examples than ever of movement, success, and excitement in community settings.  He's been at this a lot longer than I and so likely has a wiser perspective.  The "sine-cosine" phase difference between his optimism and my reluctance to be optimistic just yet is that I have seen the power and speed with which other political movements have emerged.  In my view, this one is still a bit pokey.  I'd like to see more acceleration.

Tuesday, December 11, 2012

#IHI24Forum: Yell "bingo" if you see this...

at the social media lunch session.  If you are the first one, you will win a prize and be featured on this blog.

(For those not attending the IHI Annual Forum, this is a demonstration of the power of social media.  This blog post will be picked up by Twitter and then sent to those watching the conference hashtag.  I wrote it days ago and had it scheduled to appear in the midst of my presentation.)


And the winner was . . .

Stephanie Van Vreede, Systems Manager at ThedaCare Center for Healthcare Value, in Appleton, Wisconsin.  The prize, of course, was a copy of my book, Goal Play!  Congratulations!

La méthode Toyota pervertie

An article last month in Montreal's La Presse, entitled "Soins à domicile: tollé contre la méthode Toyota" ("Home Care: Outcry against the Toyota Way") set forth a terrible scenario in which the wrong application of the Lean approach in the home health care setting led to awful results.

Here's a rough translation of some excerpts (with thanks to Google translator and apologies for inaccuracies. Je ne parle pas français.):

The implementation of the famous Toyota Way in home care in Montreal by a private firm is currently causing nurses, social workers and occupational therapists to be on the verge of hysterics. And it is on track to cost a small fortune in the health care system in a context of budgetary restrictions. The new Minister of Health, Dr. Réjean Hébert, has also pledged to hold accountable those health centers that are in the process of implementing the method.

In Montreal, a dozen centers of health and social services centers (CSSS) recently approved contracts with a private firm for a sum of at least $12 million. Fees are up to $27,540 per week (excluding taxes) for a period up to 35 weeks, it was found.

The firm, named Proaction, was founded in 2004 and first imposed its approach in the manufacturing sector. Its founders had never set foot in a hospital or a health center before 2009.

"Currently, many employees are exhausted, emotional and in physical distress. And when we try to denounce the situation it is perceived as a sign of weakness and we are afraid of the consequences," said a social worker from CSSS Canvendish. The lady preferred anonymity for fear of reprisal, but a dozen nurses, social workers and occupational therapists with whom La Presse spoke were outraged by the situation.

According to what La Presse has seen, the Proaction method is largely based on the creation of a grid of "planning and implementation" on which all acts . . . are timed. This grid is developed by an internal committee consisting of a few handpicked employees. For example, washing one ear by a nurse should take 15 minutes. Two ears 20 minutes. A single wound care should not take more than 15 minutes. There is provided a time of 30 minutes for follow-up "post death". 

On the ground, it will even tell therapists not to intervene with patients in cases of psychological distress, and transfer the task of the social worker to save time. If an employee has not been able to perform his or her task in a timely manner, he or she shall explain the reasons.

In a follow-up article, "La méthode Toyota pervertie," ethics consultant Pierre Deschamps noted, "The correct approach would not have led home care nurses to the edge of a nervous breakdown."

In fact, what it is has nothing to do with the Toyota method, but instead is a practice of Lean, disembodied from the fundamental values of the Toyota approach.

At Toyota, the continuous improvement process is based on the respect that the company provides to its customers, suppliers and employees. Continuous improvement, yes, but never at the expense of respect for persons.

In recent years, several consulting firms who see the Toyota approach as a business opportunity have appropriated some of its processes and argued that organizations that adopt it would rapidly increase their performance and efficiency.

What these companies have forgotten is that the Toyota is successful when it is part of a corporate culture that is strong and in businesses where there is a healthy work environment. There is no success in organizations where there is a significant psychological distress and mental suffering high among employees, as appears to be the case with several employees of the health system.

In addition, the Toyota approach to be successful within an organization requires that those who want to use have an excellent knowledge of the culture and to develop a profile of the organization in terms of governance, leadership, ethics, practices, traditions, etc.

In a book called The Toyota Way to Lean Leadership, the authors make a serious warning in regard to the use of external consultants.

The traditional role of external consultants is to manage a project and produce a plan of action. Indeed, the consultants step into the customer's shoes. They claim to have expertise in Lean methods and guarantee that they will make the client organization more efficient by eliminating all unnecessary tasks and standardizing work.

However, in reality, learning new methods remains with consultants and what they leave at the end of their mandate is very fragile.

Several months ago, I declaimed:

If there were a form of medical malpractice lawsuit that I would like to encourage, it would be against those consulting firms that promise hospitals that they will teach them how to "do Lean."

[They] leave behind your "trained" cadre of managers to carry on -- which they cannot or will not do.  Charge the hospital several hundred thousand dollars for this "service."  But not before you have given Lean a bad name and, worse, have caused it to be associated with layoffs.

In their search to find financial savings, hospitals and health care administrators are often carried along by the latest fad.  Governments, too.  Here, the previous government health minister of Quebec opened the financial gates to support his "transformation" intentions several years ago.  But the concept was not well thought through.  The consultant community responded as you would expect.

As I have said:

You don't "do Lean."  Lean is not a program.  It is a long-term philosophy of corporate leadership and organization that is based, above all, on respect shown to front-line staff.  There are two essential aspects, training front-line workers to be empowered and encouraged to call out problems on the "factory floor," and training managers to understand that their job is to serve those front-line workers by knowing what is going on on the front lines and responding in real time (when problems are fresh) to the call-outs.

Please, if you are hospital or government leader and are not prepared to adopt the overall philosophy, don't start down this path.  You will just pervert the nature of Lean.  Soon enough, la merde va frapper le ventilateur.  (Again, a Google-assisted translation.  No doubt there is a better idiomatic version, but you get the point.)

Monday, December 10, 2012

Who needs a waiting room? (Part 3)

In a post below, I report on Dr. Sami Bahri's use of Lean principles to improve patient flow in his clinic.  In their comments, Sami and others explain more about how this is done.  Upon reflection, I need to issue a caveat:

You cannot just extract Sami's recipe for scheduling appointments and expect it to work  The cultural and thinking shift that he led for his staff is really central. Having now watched a lot of medical people in hospitals and outpatient settings, I have seen a tendency to try to take shortcuts, not knowing the depth of what is involved.   As I have said before, you don't "do" Lean:

Lean is not a program.  It is a long-term philosophy of corporate leadership and organization that is based, above all, on respect shown to front-line staff.  There are two essential aspects, training front-line workers to be empowered and encouraged to call out problems on the "factory floor," and training managers to understand that their job is to serve those front-line workers by knowing what is going on on the front lines and responding in real time (when problems are fresh) to the call-outs.   Yes, there are all kinds of methods and tools and terminology, and as Virginia Mason Medical Center's Sarah Patterson notes, "Lean provides a common language for process improvement." She also reminded us, though, that it is a focus on process, not on the outcomes.  The idea is to "build key features into processes that are waste free, continuous flow."  To do this we need to "grow leaders-- to respect, develop, and challenge your people."

This may scare some of you away, but it's important to know there is no silver bullet.  This is hard work and needs a strong and steady commitment from senior clinical and administrative leaders.

Sunday, December 09, 2012

Who needs a waiting room? (Part 2)

In a post below, I give a short summary of Dr. Sami Bahri's dental clinic in Jacksonville, FL, and how he has employed Lean principles to make things better for patients and staff.  That elicited some good questions.  Answers have now been provided by some real experts, including Sami himself. 

If you are at all interested in applying Lean to clinical settings, these comments are worth a look.  Click here.

Why Nobody Believes the Numbers

For your book list this holiday.  Here's the summary:

Why Nobody Believes the Numbers introduces a unique viewpoint to population health outcomes measurement:   Results/ROIs should be presented as they are, not as we wish they would be.  This viewpoint contrasts sharply with vendor/promoter/consultant claims along two very important dimensions:
(1)     Why Nobody Believes presents outcomes/ROIs achievable right here on this very planet…
(2)   …calculated using actual data rather than controlled substances.
Indeed, nowhere in healthcare is it possible to find such sharply contrasting worldviews, methodologies, and grips on reality.

Don't believe this?  Well, author Al Lewis reports:

My book Why Nobody Believes the Numbers was named Forbes' healthcare book-of-the-year.

Hmm...2012 must have been a very slow year for healthcare books

You have to scroll to Page 2, but, at least in my considered opinion, it is worth the wear-and-tear on your down-arrow key to do so.

And remember, Why Nobody Believes the Numbers is also a terrible gift idea for colleagues you can't stand. The last think you'd want to give them is a book that entertains them while also showing them how to do their job better.

Also, make sure to hide the Amazon link from them because if they see the reviews, they might order it on their own -- the reviewers unanimously agree that Why Nobody Believes the Numbers could possibly be the best book ever written.*


*By me

Saturday, December 08, 2012

There's something happening here

Now that the Supreme Court has affirmed the law and the people have spoken through the recent election, the US health reform plan (Obamacare) will proceed apace.  Attention may turn back to Massachusetts, whose implementation of similar policies is several years in advance of the rest of the country.  There is much good to report in the Bay State in terms of near-universal health care insurance coverage for the population.  But there is also something quietly happening that is greatly concerning.

Read this recent summary from the Massachusetts Hospital Association:

On Tuesday, Governor Deval Patrick announced 9C budget cuts as part of a plan to help close a $540 million FY2013 budget gap caused by slower-than-expected tax collections.  [Note: 9C cuts are those made by the Governor without requiring legislative approval.]

As opposed to an across-the-board budget cut, the governor's 9C budget reductions to the MassHealth program will have a direct $26 million effect on specific hospitals, namely, freestanding pediatric acute care hospitals and qualified pediatric specialty units; three critical access hospitals; plus those hospitals that will apply for MassHealth infrastructure and capacity building grants. Another $26 million was cut from Medicaid managed care plans. In total, the governor's actions shaved more than $128 million from three MassHealth line items

Of equally great concern to hospitals is the expected release of the 2013 RFA – which is the main contract between the MassHealth program and hospitals. The RFA has been delayed for four months and is expected to be released soon. The 9C cuts that the governor announced will be incorporated into the RFA in addition to the other planned reductions affecting all hospitals statewide, and will further exacerbate the Medicaid underpayment gap.

In simplest terms, we have now made it possible for more people (300,000 since 2006) to be covered by Medicaid, a good thing.  But providing insurance coverage means that people are more likely to use it.  If, at the same time, you impair the ability of hospitals to cover the costs of carrying for those people, you have simply pushed the problem upstream.

In prior times, the shortfalls in Medicaid would have been made up by private insurers, but those days are over.  Also, you could count on Medicare to be fully compensatory, but those days are over.

So, in total, the Massachusetts reimbursement system is systematically being pared back to a level that will not permit many hospitals to cover their costs.  The ones that will be most vulnerable will be the hospitals serving the most vulnerable, the safety net hospitals, who derive a large percentage of their income from Medicaid.  But other hospitals will be hurt as well (except for the lucky system whose market power provided above-market private insurance payment rates.)

Here's the big picture prediction for Massachusetts and other states watching the Massachusetts experience:  Continued concentration of the hospital industry to create a larger referral base and to gain market power over the insurers.  But the safety net hospitals will be left out of those deals, for fear they will be a drag on earnings since such a large portion of their revenues is subject to state appropriations.  The ironic end result: A growing disparity in the level and quality of hospital care offered to the poor, precisely at the the time the poor are given greater access to health care services.

Maybe it's time for a new movement.  For inspiration from another era, watch this video.

Friday, December 07, 2012

Who needs a waiting room?

Passing through Jacksonville, FL, I took the opportunity to catch up with "the Lean dentist," Sami Bahri, about whom I have written before.  Walking into his office, I was struck by this view of his waiting room.  This is a more or less typical situation.  Patients entering the clinic are immediately escorted into a treatment room.  Organizing a clinic's work flow to produce an efficient treatment of patient flows is a direct result of Lean process improvements.  I joked with Sami that he should find some other use for this space, like starting a book store or something!

One of the things I like about this clinic is the practice of treating a patient for all of his or her needs during one visit.  Most of us go to dentists who require us to come back for a second visit if we have a cavity that needs filling or some other procedure that emerges from the cleaning and examination.  Not here.  If they find a cavity, they fill it on the spot.  The result has been a 24% reduction in the number of appointments at the clinic (for the same number of patients.)  Besides making life more convenient for the patients, the office has eliminated the make-work associated with second or third visits: scheduling, confirmation, extra cleaning of each exam room, billing and collection.

Sami and his staff are very proud of customers' reviews on Angie's List--all "A" grades.  Comments reflect the perspectives of patients.  They don't know that this is a Lean clinic, but they do notice the aspects of customer service that result from the Lean philosophy:

This group is wonderful. Personnel are all low key.  I had a crown pop off.  No pain but they offered me a same day appointment if I wanted it.  Fixed tooth with the same crown.  None of this high-priced push for work you don't need.  I can really get intimidated at dental office and I didn't here.  My old dentist had retired and the new one was sell sell sell.

Thorough, professional and kind.  I was seen today and will be taking my children to this office also.

They are kind and compassionate.  They are all encompassing.  They will squeeze you in if you need them even if it is night.  You never seem to have to wait more than 10 minutes.  The staff is great and knows you by name.

There is not a single person there that I would not trust to provide 100% excellent service with skills, knowledge and compassion.

Thursday, December 06, 2012

Advancing Hernia Solutions

Hernia surgeries are often considered to be prosaic.  At academic medical centers, for example, they are rarely discussed, compared to the attention paid to higher level tertiary and quaternary cases like transplants and Whipples.  But they are important procedures for the patients who need them.  They are also rife with complications, both short-term and long-term.

Bruce Ramshaw, at Advanced Hernia Solutions in Daytona Beach, FL, believes there are two reasons for this.  First, these procedures often fail to receive the kind of rigorous analysis and review that others do.  For example, there are dozens of kinds of mesh that can be used, but there is no clear evidence as to which type of mesh works best for which kind of patient.  Some varieties of mesh have been in use for decades without ever having to demonstrate clinical efficacy, in that they were grandfathered from approval by the FDA.

Second, there has been little effort to apply the use of effective teams to deliver person-centered care in this arena.  He notes:

Person-centered care is embodied by care teams, with the person who is the patient and family at the center, and with the care team all working for the best interest of the patient, learning and improving to provide value for the patient and for the overall system.

It is this model that Bruce and his colleagues have constructed at their clinic.  In addition to surgeons, the team includes patient care managers--who get to know the patients and families intimately and are on call to assist them 24x7.  Here you see Brandie Forman, director of patient care management, who arrived to work with Bruce in the medical world years ago after being a flight attendant.  There she learned and developed keen skills of personal interaction and service delivery.

The team also includes an engineer, Joe Johnson (left), who evaluates the systems issues around the delivery of care as well as technical issues that arise from the equipment being employed.  Joe arrived with no medical background, but with a sound foundation in systems design and process analysis.  There is also a materials scientist on call.  That person concentrates on the issues surrounding the durability and effectiveness of different types of mesh.

Bruce and his colleagues take seriously the idea of patient and family input, and they have created an advisory panel with whom they review their plans, their educational materials, and other aspects of the clinical pathways.  As demonstrated in a meeting I attended today, the participants are out-spoken, thoughtful, and extremely experienced in other fields that they are keen to apply to the "boring" world of hernia surgeries.

These patients and spouses know, of course, that the issues surrounding hernia repairs are not boring at all.  They have experienced such surgeries--sometimes successfully and sometimes not--and they are prepared to offer advice and assistance to Bruce's group as it develops and expands its program.

As we come to the end of the year and look forward to the inevitable lists of "great medical advances of 2012"--the usual assortment of still-in-the-clouds technological innovations--it is good to remember that the real medical advances are those occurring on the ground.  It is by the kind of thoughtful hard work and planning demonstrated by Bruce and his colleagues--and by his patient and family partners--that the quality of life is being enhanced and that lives are being saved today.  Let's rank them and similar groups among the greatest medical advances of the year!