Monday, September 30, 2013

Small favors

In this blog post, Boston Business Journal reporter Julie Donnelly passes along a comment by Partners Healthcare System made for the pending Health Policy Commission Cost Trend Hearings that "it does not expect its prices to rise faster than the rate of general inflation in the next several years."

Excuse me if I am unimpressed.  PHS rates have been above the market for at least fifteen years.  Its most recent rate increase from Blue Cross, the largest insurer in Massachusetts (twice as big as #2 and equal to all the others combined), exceeded the BC statewide average, even though the base on which that increase was applied was already substantially above the other tertiary hospitals, secondary hospitals, and physicians in the state.

It would only be newsworthy if PHS is not able to beat the overall rate of inflation with that kind of head start.

As another party to the hearings notes:

We are concerned . . . that the direction of the Commonwealth’s cost containment efforts could have the unintended effect of institutionalizing significant market disparities and dysfunction in place if we fail to focus on the need for correction of these disparities, and on the cost containment goal as an aggregate goal.

Returning, though, to the point of Julie's article: "But if the government keeps cutting reimbursements to . . . hospitals, it is hard to see how they can survive without shifting more of the burden onto commercial insurers and the employers who buy their health plans."

Almost. If government payers do not do their share, there are two possible results:  Private payers will have to make up the difference, or many of the other providers will suffer decapitalization and losses.  I'm guessing it will be more of the latter than the former.  In which case, PHS market dominance will grow.

The fragmented system of government oversight and regulation created by the Governor and legislature in their most recent legislation, Chapter 224 of the Acts of 2012, continues to serve the powerful.

Cost Trends Hearings 2013

From the website of the MA Health Policy Commission:

The annual health care cost trends hearing is a public examination into the drivers of health care costs as well as the engagement of experts and witnesses to identify particular challenges and opportunities within the Commonwealth's health care system. Chapter 224 transferred the responsibility to conduct the hearing to the Commission, in coordination with the Office of the Attorney General and Center for Health Information and Analysis. The hearing is scheduled for Tuesday, October 1 and Wednesday, October 2 at 9:00 AM at the University of Massachusetts Boston Campus Center. The hearing will provide a unique opportunity to evaluate evidence and assess the health care market’s response to the cost growth benchmark and quality, transparency and care delivery innovations required by Chapter 224.

Check out some of the pre-filed testimony to get a sense of what is happening in Massachusetts and how it's being spun by the various participants in the marketplace. 

Sunday, September 29, 2013

Animal, vegetable, or fungus?

One of the joys of living in Massachusetts is being able to attend field schools offered by the Massachusetts Audubon Society at their Welflleet Bay Wildlife Sanctuary.  I've reported on some of these before and am pleased to do so again, after a two-day session led by Wesley Price, who, among other things, has organized the Cape Cod Mushroom Club.  Our diverse group of participants was introduced to the many aspects of this field, ranging from the ecological powerhouse represented by this part of the fungus kingdom (distinct from plants, animals, protista, and bacteria) to the details of structure and design of the most common genera.

Wesley is assiduous about documenting the location and setting of his finds.  After just a short time together in the forest, our eyes became trained, and we noticed mushrooms that we would have easily passed by previously.  Below is a pretty Amanita that I found growing among the bearberries.  Some varieties of edible and some are deadly poisonous, including one version that will kill your liver and require you to get a transplant to survive.  Wesley's practice and advise with regard to this genus:  Don't eat any of them.  There are very subtle differences between the good and bad ones, and his view is that it is just not worth the risk.

But then there are the Matsutaki mushrooms, a highly sought after variety, especially in Japan.  They are a bit harder to find, usually hidden under a clump of pine needles or other plant detritus.

At this time of year on Cape Cod, you will often find people of Russian or Eastern European descent searching for Boletes.  Unlike the amanitas, these do not have gills, but rather spongelike tubes and pores.

This sample was taken up with a chunk of the mycelium attached.  This is the major part of the fungus, a network of thin connectors spread throughout the soil.  Indeed, the mushroom that we see is the fruit of the mycelium, which erupts with the sole purpose of spreading spores into the environment to spread the fungus.  The mycelium is often found as a mycorrhizal, a symbiotic relationship with tree roots and other roots under ground, intertwined and helping the plant get moisture and nutrients form the soil.

We were also joined on this class by entomologist Hannah Nadel, Supervisory Entomologist at the US Department of Agriculture Otis Laboratory, who was able to present us with lots of information about the relationships between insects and fungi.

And, in anticipation of your final question, yes, we ate some.  Here was this morning's breakfast, some Cortinarius caperatus, commonly known as gypsy mushrooms, being readied to be sauteed and then served with polenta and avocado.


Friday, September 27, 2013

Breaking news: Health care may be becoming a political issue

A very funny article appeared in The Onion about US health care issues: "Area Man Worried Health Care Debate Might Be Getting Political." Read it if you need solace during the Congressional debates!  Opening:

COLUMBUS, OH—Local man Henry Allen, 56, expressed concern Tuesday that the debate over how United States citizens receive health care may in fact be becoming a political issue, sources confirmed.


Allen stated that, in the end, he believes elected officials know how great their responsibility is to the American people, and that they would ultimately of course never let something as petty as party politics get in the way of that.

Thursday, September 26, 2013

Career advice

A young friend writes this letter and asks me to forward it to potential firms in the field.

Subject: Recent [name of undergrad school]/[name of grad school] grad interested in health jobs

Having recently completed a Master of Science in Public Health degree from [name of school], I am now looking for job opportunities in innovation in health sciences. I have experience in both qualitative and quantitative analysis, using software such as STATA and atlas.ti. I also hold a bachelor's degree from [name of school].

As we discussed, I am attaching my CV for your review.
A friend who heads up a company responds after I do so:

Thank you Paul. It makes me nervous when people are so proud of their universities. My father used to say the people who are the most worthy of their credentials rarely mention them. 

A word to the wise: Spend time in your cover letter explaining what you care about and what you'd like to learn more about, not relying on credentials.

Wednesday, September 25, 2013

Negotiating on Purpose

I am honored to post guest blog articles on Athenahealth's Leadership Forum, and the latest one just went live.  I'd be very pleased if you clicked over there to read it.  The title of the article is "Negotiating on Purpose."  Here's the lede:

After her fifteen year-old son Lewis Blackman died from a series of preventable medical errors, Helen Haskell diagnosed the problems in the hospital by saying, “This was a system that was operating for its own benefit.”

What she meant was that each person in the hospital was unthinkingly engaged in a series of tasks that had become disconnected from the underlying purpose of the hospital. They were driven by their inclinations and imperatives rather than by the patient’s needs. Indeed, they were so trapped in that form of work that they could not notice the entreaties of a seriously concerned mother as her son deteriorated.

From there I go into a discussion of the role of a leader in conducting what can be viewed as a negotiation with the doctors and other staff of a hospital to help the institution's constituencies understand that their interests are coincident with the purpose of the organization and to help them jointly decide on the actions needed to carry out that purpose.

Some might read the article with a view of negotiation as a kind of transaction or a form of haggling.  That is a narrow view of the term.  A more expansive view, and the one I attempt to portray, is a respectful process that provides a means of satisfying parties’ underlying interests by jointly decided action.

I'd welcome your comments, either at the Athenahealth site or here.

I have quit texting while driving

A friend writes:

Your blog post on texting while driving was VERY powerful.

I have quit and shared the video with friends and family I care about. Thanks!

Another said,

I watched that video and, since them, I zip up my cell phone in my purse whenever I get into the car.  I asked the principal of my child's high school to show it to the kids to help them understand.

Please tell me your stories.  Let's keep it going.

Not everyone has gotten the word.  Zoom in on this picture.

Two sides of a coin, or TANSTAAFL

Economists like to say that there is no such thing as a free lunch, or TANSTAAFL, and this phenomenon is showing up in the rates to be charged for new health insurance products that will be offered by exchanges across the US.  Harris Meyer at Modern Healthcare reports:

An eagerly awaited report by HHS released Wednesday on health plan premiums and participation in the 36 states where the federal government is fully or partly running the new insurance exchanges shows that consumers in most of those states will have many plans to choose from and that premiums will be significantly lower than expected in 2014.

The new HHS report, combined with previous reports from states running their own exchanges that showed similar results, bolsters the Obama administration's case that the Patient Protection and Affordable Care Act is achieving its goal of fostering competition in the health insurance marketplace and producing affordable premiums for consumers. 

But now look at a report by Robert Pear in the New York Times:

Federal officials often say that health insurance will cost consumers less than expected under President Obama’s health care law. But they rarely mention one big reason: many insurers are significantly limiting the choices of doctors and hospitals available to consumers. 

From California to Illinois to New Hampshire, and in many states in between, insurers are driving down premiums by restricting the number of providers who will treat patients in their new health plans.  

To hold down costs, insurers say, they have created smaller networks of doctors and hospitals than are typically found in commercial insurance. And those health care providers will, in many cases, be paid less than what they have been receiving from commercial insurers. 

Consumers should be prepared for “much tighter, narrower networks” of doctors and hospitals, said Adam M. Linker, a health policy analyst at the North Carolina Justice Center, a statewide advocacy group. 

“That can be positive for consumers if it holds down premiums and drives people to higher-quality providers,” Mr. Linker said. “But there is also a risk because, under some health plans, consumers can end up with astronomical costs if they go to providers outside the network.”

None of this should be surprising.  As I have mentioned many times:

The logic and need for universal coverage of the population is incontrovertible, and it needs to proceed. But as I said many, many months ago, when the President promised the nation access, choice, and lower costs, he was misleading us.  You get two out of three, not all three.

But the President's decision to hedge this issue during the legislative battle on the act is nothing compared to the cruelty and stupidity of those governors who have decided to deprive their Medicaid-eligible residents of the opportunity to participate in the federally funded health care insurance subsidies under the new law.  And those in Congress who are holding up the national budget and debt ceiling by trying to defund the act are likewise cruelly rolling the dice on the national and world economy by their sore-loser approach to what is supposed to be the approach to compromise in a republican form of government.

Tuesday, September 24, 2013

A solution to clutter

#GBMP1 Sometimes unexpected proposed countermeasures to problems called out during Lean process improvement efforts come up.  Look at the one proposed here on a suggestion form!  While Lean envisions countermeasures as temporary or iterative or interim solutions to problems, I don't think even the most creative of Lean experts would have come up with this one--even for the short term.

Thanks to Gary Peterson at O. C. Tanner for this humorous example.

Notes from a Lean conference

#GBMP1 I'm currently attending the 9th Annual Northeast Shingo Prize Conference presented by GBMP, a non-profit that is engaged in Lean educational programs.  Entitled, "True North: Set the Course, Make Waves," the conference began with a short introduction by GBMP's president, Bruce Hamilton.  Regular readers will recognize Bruce as the star of Toast Kaizen, a wonderful video illustrating Lean principles in the "production" of toast in a kitchen.  He began with the concept of "True North," which he defined as "the way things should be," but importantly the way things should be for both customers and those providing service to customer.

The keynote speaker was Gary Peterson, EVP for supply chain and production at The O.C. Tanner Company.  "We've made a ton of mistakes" with our Lean journey, he began:

Most of the mistakes we've made centered on our people.  We implemented tools and imposed them on our people.  They worked, but people hated it. We hired "a cop" to enforce use of the tools.  "That should have made it obvious that we were doing something wrong!"

The fundamental principle has to be respect for people, he noted.  He suggested that there are four things that are critical for getting people involved:

(1) Setting a clear vision:  Establishing an understanding of True North (an aspirational vision of what might be achieved--but paradoxically might be unlikely ever to be achieved), provide free flowing information, engage in true transparency.  "By the way," he noted, "Things somehow move from aspirational to the way things are!"

(2) Providing a powerful reason for engagement.  Don't use, "If we don't do this we may go out of business."  Focus on the purpose of the organization, the intrinsic reasons that make daily work meaningful and create a sense of pride.  (By the way, check out his company's blog to get a sense of this.)

(3) Engaging in a thoughtful and good improvement methodology.  Develop people for contribution, particularly helping people evolve into leadership roles that are supportive of the philosophy.  "We want eveyone to become leaders." Minimize rules that control: Avoid systems that get in the way. "Don't act like you are cutting them loose and then have them drag a chain behind themselves." Hire well: Ensure that they believe in the elements of a living culture--safety, continuous improvement, trust, respect for others, we are all in this together, Arbinger principles (avoiding self-deception.)

(4) Inspiring a desire to continue to do it and stay engaged.  Make it fun to learn and safe to venture into unknown territory.  Above all, "Show me you value my efforts."  Help people believe: "There is no secret ingredient."

One is too many

An excellent story here about Jordan Hospital's success in avoiding catheter-associated urinary tract infections (CAUTIs).  Note the important elements of process improvement, starting right with the governing body.  Note, too, the lack of acceptance of industry benchmarks: The aim is zero. Zero is achieved!


An intensive education program involving the hospital's Board of Trustees and personnel in the Emergency Department, Critical Care Center (CCC) and other units throughout the hospital, has been followed by daily and even hourly assessments of patients with catheters.  The surveillance, discussion, and effort to curb infections are unending and are now ingrained within the hospital's culture.

"We began with the premise that anytime you insert anything into a person's body that they didn't come into the hospital with, it increases their susceptibility to infection," says Kathleen M. Mercurio, R.N., infection preventionist at Jordan.  

The challenge at Jordan was threefold - to reduce catheter associated urinary tract infections in the Critical Care Center (which is what Jordan calls its ICU); to decrease the number of days a Foley catheter stays in a patient (hence decreasing the chance for infection); and to promote alternatives to Foleys that are non-invasive. 

Nurses on each shift have to enter computerized documentation, answering, among other items: When was the catheter inserted? Where was it put in? (In the ED, CCC or on a med/surg floor) and why was it inserted.  To answer the "why," a nurse has to check off on the computer screen one of the CDC-approved guidelines.  Those same questions are answered for each patient when a new shift begins, demonstrating that for a quality-improvement strategy to work, repetition of many tasks is imperative.

"We had to create new strategies and processes easy for everyone involved. Using and incorporating a new process into their daily workflow requires a systematic, sensible approach," Mercurio says.

"Anytime you want to change a person's habits, you have to give that person a reason for the change - a reason that hits something inside of them that makes them value the change," Mercurio says.  For the different cultures throughout the hospital, the reasons she gave varied.

In July and November of 2012 and January and February of 2013, Jordan Hospital had one patient in each of those months who developed a CAUTI.  That's not a terrible track record, but as Mercurio says, "One is too many. One is someone's dad getting an infection."

But from March through August 2013 (the latest full month recorded), Jordan Hospital has had zero CAUTIs. 

And, the number of Foley catheter days - that is, the number of days that patients had catheters - steadily dropped, evidence of the strategy of removing them as soon as possible. The decrease in Foley catheter days occurred even as patient days in the CCC increased. That is, more patients, less days with them having catheters, and less chance of them getting an infection.

Gettting older? What can we count on?

"Advanced Old Age in America: What Can We Count On?"

Join Senator Mark Warner (D-VA) and Senator Johnny Isakson (R-GA) as we focus on health care reform and elderly Americans living with frailty in their last years, addressing questions such as:
  • How serious are the shortcomings in services and the expected growth in costs as the population ages? How much time do we have to make arrangements for the coming increase in numbers?
  • What should we promise to individuals living with frailty in old age and their families? How does this differ from the current trajectory?
  • Half of those who live past 85 years old will have cognitive failure. What health care, social supports, and financial arrangements would serve people touched by this challenging situation?
  • Which of the current reforms and trials offer prospects of moving us toward a workable set of solutions—that is, more appropriate and desirable services, at lower cost? Are there additional strategies that should be tested and developed?
  • What role might local coalitions, commissions, and communities have?
Speakers at the Roundtable:
  • Joseph Antos, Wilson H. Taylor Scholar in Health Care and Retirement Policy, American  Enterprise Institute
  • Shannon Brownlee, Senior Vice President, Lown Institute; Senior Fellow, New America Foundation; Instructor, The Dartmouth Institute for Health Policy and Clinical Practice
  • Suzanne Burke, Chief Executive Officer, Council on Aging of Southwestern Ohio
  • Susan Dentzer, Senior Health Policy Adviser, Robert Wood Johnson Foundation (Moderator)
  • John Feather, Chief Executive Officer, Grantmakers In Aging
  • Jennie Chin Hansen, Chief Executive Officer, American Geriatrics Society
  • Sen. Johnny Isakson (R-GA)
  • Joanne Lynn, Director, Altarum Institute Center for Elder Care and Advanced Illness
  • Anne Montgomery, Senior Policy Analyst, Altarum Institute
  • John Rother, President and Chief Executive Officer, National Coalition on Health Care
  • Mimi Toomey, Director, Office of Policy Analysis & Development, Administration for Community Living
  • Sen. Mark Warner (D-VA)
Final opportunity to register!
Click here to register to attend the September 26 Roundtable in person or to join via Webcast.
(For individuals registering to join via webcast, an email confirmation will be sent with further instructions.)
    Advanced Old Age in America: What Can We Count On?
    September 26, 2013 from 8:30 a.m. - 12:30 p.m. ET

     Webcast: from 9:00 a.m.-11:30 a.m. ET
    The Pew Charitable Trusts Conference Center, Washington, DC

Monday, September 23, 2013

Melody from Jubilee

The team from the Jubilee Project have done it again, producing a touching and warm video, entitled Melody.  I will not spoil it by describing it in any way. Just watch.

When persistence doesn't pay

A high ranking friend at a hospital sent me this thread of emails:

First the unsolicited invitation to a sales conference:

Space is limited and last year's events were packed so register to save your seat now.

My friend responds with an email with "pls delete me from your e-mail list" in the subject line.

He replies:

We work with a number of healthcare and assisted living companies today. We've been able to demonstrate huge returns for them in the millions by improving on internal processes, greater efficiencies, and driving overall OPEX down.

Given the blueprint of [hospital name], your vertical, employee headcount (3,000) and revenues ($280m+) I would predict you have approximately $70m in addressable spend per year that you and your team is trying to manage. Because of our model, user adoption rates and the ability to control all of this spend by 90% I would anticipate being able to save [hospital name] $150k per month.

I will be more than happy to take you off our email list. With your permission and based on your thoughts given the information I've shared with you today I would welcome a call to discuss how I cam (sic) up with this 15 minute analysis. I believe with your candid feedback and more accurate numbers the number I shared with you would be greater. 

She responds:

Do others find this an effective sales approach?  I asked you to take me off your list and you then write me back trying to still sell me services.  If I wanted to talk to you, I would not have asked you to take me off your e-mail list.

He replies:

I've taken you off any future email campaigns from Marketing, apologies. I sent you a personal email as I'm simply doing my job here.

Most employees I speak with that are tasked with improving operations with tools that drive down costs, improve efficiencies, and provide greater visibility into the organization typically welcome a discussion to learn more.

ConvergenceRI is born

@ConvergenceRI Welcome to the birth of ConvergenceRI, a new online subscription newsletter offering news and analysis at the convergence of health, science, technology and innovation in Rhode Island. It is the brainchild of Richard Asinof @RichardAsinof, who says,

“ConvergenceRI will fill a critical information need, covering Rhode Island’s innovation ecosystem in a cohesive, cogent and comprehensive fashion.”

“Rhode Island’s knowledge economy is on the cusp of a major growth spurt,” Asinof continued. “Its size, its connective sense of neighborhood, its embrace of health care reform and patient-centered changes in health care delivery, its maturing life sciences, biosciences and med-tech sectors, its emergence as a new hub for brain research, and its investment in transforming Providence’s former Jewelry District into a Knowledge District are all critical factors.”

The online newsletter will be published weekly every Monday, 48 times a year, with two-week breaks at the end of December and at the beginning of July.

A palindrome for patient safety

Thanks to David Mayer at MedStar Health for sharing this video by Victoria Nahum.  Well worth two minutes of your time:

No more visitors at Contra Costa

Check out this note from Anna Roth, Chief Executive Officer, Contra Costa Regional Medical Center.

I’m excited to tell our staff and Contra Costa County residents that Contra Costa Regional Medical Center (CCRMC) is eliminating the concept of visitors in our medical center and health delivery system. On September 17th, 2013, CCRMC will remain accessible 24 hours a day to family and loved-ones of those receiving care in the medical center.

Recognizing that family and loved-one presence supports safe and high quality care, we have worked over the last year to replace our “visitor policy” with this Welcoming Policy. Though we have carefully planned the introduction of this change, we remain open to ideas to enhance and improve our Welcoming Policy and will place it and all supporting documents on the CCRMC web page for your review, comments and suggestions for improvement.

And, then an update a few days later.  A learning organization at work!

We started on September 17, 2013 at 8:30pm. Our first night we welcomed 13 family members/care partners (and a pizza delivery person who brought pizza to a hungry family member). The second night we welcomed 18 family members/care partners and the third night we welcomed 15. That totals of 46 family members/care partners that had the opportunity to participate in the care of their loved one. It also means that we at CCRMC had 46 opportunities to learn from family members and loved ones about how improve the care we deliver and how to improve our Welcoming Policy.

Each night the team learned, modified and improved the steps of the process to better support the family members/care partners. Most of the challenges faced by the testing team on the first night were related to logistics of the process - small details really matter! For example, we had some challenges with language barriers. We have modified our signs and are testing use of the health care interpreter video machines (HCIN) at check in. Timely updates are given to the Nurse Program Managers who have been present at night to support the staff and address any concerns they may have. The manager for Admission and Registration also worked on the night shift to support the staff. The security staff have been fully engaged and critical in the implementation as well. We have conducted huddles daily to support rapid improvements of our process and support the staff and our community in this exciting change. 

Bravo to all!

Sunday, September 22, 2013

"This is not about me. It’s about the coat."

Photo by Webb Chappell, Boston Globe
A wonderful, marvelous, lovely (enough said?) story by my friend Cynthia Thomas in today's Boston Globe Magazine.  It's about a coat.

Read it.  That's all I have to say.

Problems of psychology and engineering, not of medicine

There is a superb (and open access!!) article in BMJ Quality and Safety about how human factors engineering can help reduce medical errors.  Well worth reading.  I like, in particular, its summary of fact and fiction.  Here are excerpts:

Human error in medicine, and the adverse events that may follow, are problems of psychology and engineering, not of medicine.

Medicine is devoted to human health and healing, but the science behind why errors occur, and how to reduce the likelihood of preventable harm to individuals, are well described in human factors literature. Human factors—a science at the intersection of psychology and engineering—is dedicated to designing all aspects of a work system to support human performance and safety. The goals of human factors in healthcare are twofold: (1) support the cognitive and physical work of healthcare professionals and (2) promote high quality, safe care for patients.

Fact #1: Human factors is about designing systems that are resilient to unanticipated events.
Fiction: Human factors is about eliminating human error

Fact #2: Human factors addresses problems by modifying the design of the system to better aid people.
Fiction: Human factors addresses problems by teaching people to modify their behaviour

Fact #3: Human factors work ranges from the individual to the organisational level.
Fiction: Human factors is focused only on individuals

Fact #4: Human factors is a scientific discipline that requires years of training; most human factors professionals hold relevant graduate degrees.
Fiction: Human factors consists of a limited set of principles that can be learnt during brief training

Fact #5: Human factors professionals are bound together by the common goal of improving design for human use, but represent different specialty areas and methodological skills sets.
Fiction: Human factors scientists and engineers all have the same expertise


Human factors is an established body of science that is positioned to assist with the challenge of improving healthcare delivery and safety for patients. Human factors and healthcare professionals can work together to identify problems and solutions that may not be apparent by traditional means. While human factors does not promise instant solutions for healthcare improvement, it can provide a wealth of scientific resources for sustainable progress.

Deadline approaching for IHI early-bird special

Oct 1 is the early-bird deadline for the 25th National IHI Forum. Registering by then saves $100.  My blue-shirted buddy Amanda Swiatocha notes:
Here are some exciting highlights about this year’s National Forum:

·         We have over 350 presenters representing over 80 organizations teaching over 100 sessions (!!) on lots of great new—and tried-and-true—topics.

·         We just announced our fourth keynote – it will be Nancy Snyderman, interviewing her patient (and two-time cancer survivor) Lindsay Beck. We also have some pretty exceptional special interest keynotes listed on here, too.

·         This year, we’re offering attendees the chance to virtually visit over 8 best-practice organizations including Kaiser Permanente and North Mississippi Health Services (2012 Baldrige Winner).

·         We have a nifty new session picker on our website, which allows people to browse topics by title, keyword, presenter, track, and more.

·         We’re offering a new Forum Excursion to LEGOLAND as well as a new Leadership Excursion to Darden Restaurants.  (Paul's note:  I am helping to run that one.  Join me!)

·         It is our 25th National Forum, and yes, we’ll be celebrating with all the attendees during a special event on Tuesday evening.

Saturday, September 21, 2013

The right way to handle a quality issue

Kudos to Trillium Health Partners in Ontario for this above-board, open, and honest public communication after they found problems in the work done by one of their radiologists.  The press release:

The web site notice:

Friday, September 20, 2013

88 feet per second

"I only text on the highway," was the comment overheard the other day.  Huh?  I guess the thought was that there is more traffic on local streets, along with pedestrians.

But really?

At 60 miles per hour, your car is going 88 feet per second.  In the time it takes for you to read a text message, say, 5 seconds, you have traveled 440 feet when you look up and see you need to stop.  That's over 100 yards.  And then you put on the brakes.  At 60 mph, "a driver could stop the described vehicle in a total of 6.87 seconds (including a 1 second delay for driver reaction) and your total stopping distance would be 302.28 feet, slightly more than a football field in length!"

In total, two football fields. And that's if you are just reading.  If you are writing, the result is worse.

Please don't.  You are going to feel very stupid if you say, "I killed that person in order to read (or write) a text message."

Watch the video.


Thursday, September 19, 2013

How to keep Lean while eating

One of the dangers of becoming a Lean aficionado is that you see opportunities for process improvement everywhere.  Also, you feel an affinity for people who are able to go to gemba (the place where work is done) and, either by training or by intuition, look at work flows and find ways to improve them.  You have sympathy for them when their supervisors are unable to recognize their helpful suggestions or respond approrpriately.

I was giving a talk at a conference in Connecticut today and walked up to the lunch buffet table when I heard one of the servers say to her supervisor, "Shouldn't we move the chocolate cake closer to the coffee? Then, the potato chips can be closer to the sandwiches, too."

Of course, she was right.  Look above.  The flow of customers gathering their main course is from right to left, using a large plate (not seen here) for their sandwiches, using the condiments, and adding a bag of chips to their plate.  The flow of customers getting desert would be from the far end of the table, moving left to right, getting their coffee or tea and picking up some cake using the small plates. As the table is organized, when the two flows get busy, they would interfere with each other.

Her supervisor said, "No, the cake has to be near the B&Bs [the bread and butter plates], so we can't move it."

Well, as you can see, it would be possible to switch the chips and the cake and reconfigure things slightly to still allow the B&Bs to be near the cake.

Sure enough, as lunch proceeded, traffic jams ensued between the people who were picking up their main courses and the ones who had already progressed to coffee and dessert.

I offer this not as a treatise in the proper placement of luncheon foods on a buffet line.  I offer it more as an example of a manager who quickly dismissed a suggestion from a staff member without engaging in a reasoned discussion of the alternatives.  We see this all the time in hospitals and other organizations, where a manager becomes blindly wedded to "the way we've always done it," and in so doing discourages front-line staff from offering suggestions for process improvement.

Different facts. Same issue.

Julie Donnelly at the Boston Business Journal graciously offers a mea culpa for a factual error in her recent column.  Recall that the thrust of the column was that Partners Healthcare System was only making its primary care doctors available to subsidized insurance products at its affiliated Neighborhood Health Plan.  She now corrects this:

It is the insurers, and not Partners HealthCare, that are limiting access to doctors at Massachusetts General Hospital and Brigham and Women’s Hospital. The reason is simple: the doctors are too expensive for most of the plans that are set to offer ObamaCare plans on the Health Connector.

Brava to Julie for admitting the error, but also brava for pointing out that an underlying problem exists: The excessive rates charged by PHS for its physicians.

In my commentary on the situation as Julie first described it, I wondered how the kind of self-dealing indicated by her story could take place.  I also wondered what state agency would have jurisdiction over such matters.

The same issue remains.  Let's think it through.  How is it possible that NHP can afford to include the PHS doctors in its Obamacare subsidized health plan, but other insurers cannot?  There are two possibilities.  One is that PHS has offered those doctors to NHP at a discount, a discount that is not being offered to other insurers.

The other possibility is that NHP is taking a loss on these plans, covered by the huge resources available to PHS generally.  This would permit NHP to gain market share relative to other insurers, in essence subsidized by the excessive rates paid by all insurers to PHS.

In either case, we again have the self-dealing issue, just in another form.

So, Julie, your mea culpa is thoughtful, and I predict that you will not let up on the importance of the underlying issue of this system's market power and ability to transfer costs and revenues to suit its overall corporate purpose.

Wednesday, September 18, 2013

Exceptional? Please.

I never, ever thought I would be quoting Vladimir Putin.  He said it in another context, and he probably said it to be politically manipulative, but the quote is a good one: "It is extremely dangerous to encourage people to see themselves as exceptional, whatever the motivation."

Thus, John McDonough's recent blog post, "Massachusetts Exceptionalism--A Forum on Costs," is interesting.  After describing a forum held by the Greater Boston Interfaith Organization, he notes:

That's what makes Massachusetts different.  Our intelligent and compelling health care cost conversation continues.  And because groups like GBIO are staying involved and attentive, the issue is far less likely to wither away.  But it's not just a conversation -- it's a conversation with consequences.  And no other state right now is close to having this kind of conversation. 

That's worth noting and celebrating.

The existence of the conversation is, indeed, worth noting, but people in other parts of the country would be smiling and indeed laughing at Massachusetts' self-congratulatory view of its public debate.  Why?  Because the Massachusetts health care environment remains provincial, arrogant, and hidebound.  The "conversation" to date has permitted a dominant provider system and a dominant insurance company to extract billions of dollars of business and consumer money for no added value to the public.  It stubbornly refuses to demand from hospitals what is the norm in many other regions in terms of process improvement and the quality and safety and transparency of health outcomes.  It allows a private equity firm to purchase a major component of the health care system with no regard to the downstream impacts of the financial model used by that sector of the economy.  Finally, it stands by and watches the slow and perhaps irrevocable deterioration of the safety net system.

For sure, Massachusetts can be proud of leading the country on providing insurance to most citizens.  It can be proud of the research, teaching, and much of the clinical care that takes place here.  It can be especially proud of the men and women who work in the hospitals, community health centers, and other health care facilities.  But it has--and will--incur a heavy burden for being politically unable or unwilling to take on major drivers of health care costs in the state.

Tuesday, September 17, 2013

Now, that's blog traffic!

Some very strange thing has happened to my blog traffic today.  The number of hits is over twice the normal traffic.  As much as I'd like to think that it's the result of something interesting I wrote, I doubt it.  Instead it looks like some kind of spam attack, using phantoms servers from around the world.  Look at this distribution of originating countries!  (Each image has a different scale.)

Facilitating second opinions

Simon Schurr at Collaborative Medical Technology Corporation suggests in this blog post that current levels of overtreatment and inappropriate care could be reduced by more widespread and judicious use of second opinions.  He points to unnecessary surgeries, overtreatment of back pain, mistreating ovarian cancer, and outdated procedures. 

His diagnosis: "The causes of inappropriate care are complex, but often the root is simply lack of knowledge, an honest mistake, or a healthcare provider who simply wants to help a patient when treatment isn’t working. Sometimes, profit-driven decision-making or fear of malpractice claims lead to over-testing and overtreatment."

His solution:  "The best approach may be a combination of well-informed patients asking the right questions and seeking top doctors who stay abreast of the latest research, and rigor in using second opinions."

It is likely that some of Simon's interest in this matter reflects his company's desire to be a facilitator for such increased collaboration and consultations. CMTC provides "a cloud-based platform with secure 'one-click access' for cross-enterprise connectivity among healthcare professionals, hospitals & payers."

But putting aside that pecuniary interest, there is broader merit in enhancing the ability for a patient and doctor to seek the second opinion they need in real time, with an assurance of the second doctor's availability, affability, and ability.

Monday, September 16, 2013

Finding value at Professor Restuccia's class

It's always a pleasure to be invited to address BU Professor Joe Restuccia's graduate course, "Health Services Delivery: Strategies, Solutions, and Execution."  The syllabus is well constructed and the MBA students bring lots of perspectives because they are working in a variety of health care-related organizations.

In the section before my talk, the student teams were reporting on their conceptions of the value equation by identifying domains and examples of specific measures that represented quality, along with defining how to create reportable metrics on that dimension.

I have copied below a humorous depiction of the concept offered by student Steve LeBlanc.  The hoped-to-be-maximized numerator represents happy and healthy workers in a company.  The hope-to-be-minimized denominator represents people with long-term or chronic disease requiring large expenditures of funds and lost work time.

Steve works at InterSystems Corporation in Cambridge, MA, a company that seeks to enhance interoperability among the various electronic health record companies.  Hmm, seems like a good idea, particularly for those health systems that have bought systems that are designed with other views in mind.

It was unclear if Steve's beatific smile derived from his pleasure in drawing the value equation or was in anticipation of a post-class birthday celebration.  I suspect the latter.

Sunday, September 15, 2013

Who has jursidiction to prevent self-dealing?

Lots of people expressed dismay at my Friday report concerning the self-dealing between Neighborhood Health Plan and its owner, Partners Healthcare System.

The unanswered question, though, is which of the alphabet soup of state agencies has responsibility for this matter.  Who approved this?  Who can investigate it?  Who can change it?

It is definitely not the Center for Health Information and Analysis (CHIA).  Is it the Health Connector?  It is the Health Policy Commission? Is it the Executive Office of Health and Human Services? Is this a matter for the Attorney General's jurisdiction because of anti-trust issues?

I fear that Chapter 224 of the Acts of 2012, titled “An Act Improving the Quality of Health Care and Reducing Costs through Increased Transparency, Efficiency and Innovation,” has created a hodgepodge of jurisdiction that leaves no one in charge when this kind of thing happens.

Here's the pertinent background. As I quoted Julie Donnelly at the Boston Business Journal:

Partners HealthCare aims to drive new members to its newly acquired health insurer, Neighborhood Health Plan, by cutting off access to some doctors within new health plans offered under ObamaCare.

Neighborhood Health Plan is one of 10 insurers that has been certified to offer subsidized and un-subsidized ObamaCare plans through the state’s Health Connector.

But what Neighborhood Health Plan has is exclusive access to primary-care doctors at Brigham and Women’s Hospital and Massachusetts General Hospital.

This is a departure from Partners’ strategy in the past. Before its purchase of Neighborhood Health Plan, Partners’ offered access to its doctors to all of the health plans within the state-subsidized health plans that were launched under Massachusetts' own statewide health reform. 

Why does this matter?  Because the PHS doctors dominate the state.  With newly acquired South Shore Hospital, PHS has about 1258 primary care physicians in 16 groups, roughly 27 percent of the 4684 statewide total associated with groups.*  In a 2009 study prepared by its COO, PHS was shown to have about 850 of the 3700 primary care physicians in Eastern Massachusetts, or about 23 percent.**

* Data on provider networks and medical groups is derived from Massachusetts Health Quality Partners’ Massachusetts Provider Database. Approximately three quarters of all primary care physicians in Massachusetts are associated with a major medical group. The remaining physicians are either in very small practices or are licensed but not practicing.
** "Influence of Market Forces on Healthcare: A Case Study," April 9, 2009.

Friday, September 13, 2013

Self-dealing between a health system and its insurance company

Just when you think you've seen the limits of market power, creativity emerges.  Julie Donnelly at the Boston Business Journal reports:

Partners HealthCare aims to drive new members to its newly acquired health insurer, Neighborhood Health Plan, by cutting off access to some doctors within new health plans offered under ObamaCare.

Neighborhood Health Plan is one of 10 insurers that has been certified to offer subsidized and un-subsidized ObamaCare plans through the state’s Health Connector.

But what Neighborhood Health Plan has is exclusive access to primary-care doctors at Brigham and Women’s Hospital and Massachusetts General Hospital.

Now that Partners, the parent organization of the Brigham and Mass General, owns a piece of the insurance pie, they have decided to offer access to their primary care doctors only to those members who choose Neighborhood Health Plan.

This is likely to drive new business to Neighborhood Health Plan from Boston-area patients who want to keep or begin a relationship with a primary-care doctor at one of the two most prestigious hospitals in the state.
This is a departure from Partners’ strategy in the past. Before its purchase of Neighborhood Health Plan, Partners’ offered access to its doctors to all of the health plans within the state-subsidized health plans that were launched under Massachusetts' own statewide health reform.

Thursday, September 12, 2013

Dear GBIO, No need for your meeting

Sometimes, the concatenation of news stories on the same day is too compelling to pass by.

On Wednesday, the Boston Globe reported:

The next big movement in Massachusetts health care may come not from the state’s world-famous hospitals or its cutting-edge research labs, but from houses of worship. Stepping up pressure on the health care industry to control spiraling costs, which are crimping family and government budgets, the Greater Boston Interfaith Organization will host a forum next Tuesday at Temple Israel in Boston’s Longwood Medical Area to grill hospital and insurance leaders about the affordability of medical care.

On the same day, with no hint of irony, the same newspaper reported:

Public health officials on Wednesday approved Brigham and Women’s Hospital’s proposed $450 million research and outpatient center, deciding that the project will allow the hospital to better care for patients.

(See more about this in a post I published in December 2011.)

Meanwhile, over at the Boston Business Journal, we read:

Boston Children’s Hospital . . .  said net patient revenue totaled $236.9 million in the three months that ended June 30, a 5 percent year-over-year increase driven by greater demand for outpatient services as well as several initiatives to boost revenue through “enhancement initiatives.”

The Patriot Ledger brings this to the personal level by explaining how individuals can be hurt by the current Medicare rules, which allow hospitals very little discretion about defining admission versus observation status:

Ann Gillis of Milton, who is 83, is fighting the denial her appeal of a $7,000 bill she faced for follow-up rehab services after being hospitalized at Beth Israel Deaconess-Milton last winter. The problem: she was placed on observation status rather than admitted to the hospital, even though she was in the hospital four days. Not being admitted meant Medicare wouldn't cover her rehab at follow-up skilled nursing care in Westwood.

And when research might help produce savings, WBUR tells us:

The Framingham Heart Study is considered one of the most important research projects in medical history. Over the last 65 years, data from the study has been used to develop and test technologies and treatments that have saved millions of lives and hundreds of billions of dollars in health care costs. But now, the mandated across-the-board budget cuts, known as the sequester, are dramatically reducing federal funding for the research.

So, GBIO, what is it you hope to learn at your meeting that isn't being splayed out in the daily media?

Coach gets failing grade in concussion training

Our state youth soccer association now requires all coaches to take an on-line training session (like this one from the CDC) about concussions.  This is a good thing because concussions of boys and girls can be serious, especially if the child is prematurely permitted to play and experiences a second one.  Here's the policy:

The Massachusetts Youth Soccer policy on concussions is intended to be clear and unambiguous so as to accurately reflect the seriousness of concussion-related injuries and our unwavering commitment to keeping our children safe.

A player removed from participation as a result of a head injury or symptoms similar to those of a concussion shall not be permitted to return to play to any extent until they have provided their team coach with a written unconditional “Medical Clearance to Return to Play” from a licensed Medical Doctor.

It is our expectation that this policy will clarify protective measures for all involved in youth soccer in Massachusetts and simplify communication between coaches and parents when concussion related issues arise. 

The training and policy are supposed to make it easy for a coach.  If the child is disoriented or dizzy following a head injury, or experiences several other symptoms (see below), we pull them off the field for the duration of the game.  Referees are likewise instructed to enforce this policy.

Today, when refereeing an under-14 boys game, after a collision in front of the goal, the goalkeeper started to walk off the field complaining of a head injury and dizziness.  Imagine my surprise when the coach came out onto the field and started to try to convince the boy that it was "not a very hard hit."  I intervened and said that he would have to leave the field.

The replacement goalie was excellent and made some terrific saves.  Nonetheless, the coach tried to replace him 15 or 20 minutes later.  I was some distance away and didn't recognize it as the same boy who had been injured, but my assistant referee, a high school boy, did.  He came running out to inform me and to make the point that the boy was not permitted back on the field absent medical approval.  Of course, we sent him back to the sidelines.  Who knows what kind of persuasion the coach had used on the sidelines to encourage the boy to re-enter the field?

After the game, in front of the other AR, I praised my AR for his good judgment.  He said, "I've had a concussion, and I don't want anyone to go through what I did."

Indeed.  It's time for the coach to retake the course.

Having their cake and eating it: Perverse incentives

A friend made an excellent point the other day, upon reading my post about Consumers Union's advocacy for warranties on orthopaedic devices.

"The thing about CU and the warranty struck me hard as a revelation. We in the health care field are brainwashed into thinking these normal business practices shouldn't apply to medicine, while embracing the idea that the money-making business ideas (like ROI) should apply. But basically it adds up to doctors, administrators, and equipment suppliers having their cake and eating it, too: Getting to apply the positives from business, while avoiding the negatives which apply in all other industries, like guarantees of your work."

The big costly examples are obvious:  An alliance among the three groups (doctors, administrators, and equipment suppliers) to install a surgical robot or a proton beam machine to gain market share, but take no responsibility for determining clinical efficacy or adverse impacts or overall inflation of medical costs.

But as my friend points out, the small, ongoing ones are equally obvious.  Orthopaedic devices that regularly fail after installation in human bodies, with no recourse to the suppliers, and no adverse consequences for the hospitals or doctors that have used them without insisting on warranties.  Ditto for minimally invasive surgical equipment, which is notorious for failing after normal cleaning and sterilization processes.

You would think that the payers--Medicare, Medicaid, and private insurers--would step in, but they are complicit or oblivious.  You would think that the group purchasing organizations would step in, but they, too, are complicit or oblivious.  Maybe they are motivated by the implicit or explicit kick-backs they get by favoring certain suppliers.

Wednesday, September 11, 2013

On the road with WIHI

The next WIHI broadcast — On the (Virtual) Road with Mobile Clinics and Population Health — will take place on Thursday, September 12, from 2 to 3 PM ET.
Our guests will include:
  • Nancy Oriol, MD, Dean of Students, Harvard Medical School; Co-Principal Investigator, Mobile Health Map; Co-Founder, Family Van, Boston, MA
  • Leonel Lacayo, MD, Gastroenterologist, Glenwood Hospital; Co-Founder, Health Hut, Ruston, LA
  • Anthony Vavasis, MD, Director of Medicine, Callen-Lorde Community Health Center, New York City, NY; Co-Principal Investigator, Mobile Health Map
  • Jennifer Bennet, BA, Executive Director, Family Van and Mobile Health Map
  • Niñon Lewis, MS, Director, Triple Aim Initiatives, Institute for Healthcare Improvement, Cambridge, MA
Enroll Now

What’s the first thing that comes to mind when you spot a mobile health clinic? Good people, probably volunteering their time, traveling to underserved neighborhoods to offer screenings, health education, and some helpful, friendly guidance on where to go for anything more serious or chronic that should be checked out? If this is your impression, it’s fairly accurate. Except for one thing. Nowadays, more and more mobile health vans are an integral part of the health care system… especially in cities and communities where traditional bricks-and-mortar health care services are linking up with innovative community outreach programs that, together, can better manage population health. 
With that as a backdrop, we’re going to hit the (virtual) road on the September 12 WIHI with some of the leading innovators and researchers who are injecting new fuel and purpose into more than 2,000 mobile health clinics across the US. They’re doing this by mapping what’s taking place at a range of health clinics mounted on wheels, and also by carefully investigating health issues that can be impacted and maybe even better addressed by a mobile health van.

If we’re serious about improving population health, it’s critical to look hard at what’s already “out there” that’s working or helping, and then determine how to strengthen its role. Mobile health clinics are increasingly one such trusted and effective resource in many communities. WIHI host Madge Kaplan and IHI’s Niñon Lewis invite you to find out the latest on mobile clinics from an expert panel of clinicians and researchers on the forefront of the issue.