Friday, July 18, 2014

Let's give them points for staying on message

I need to apologize to my readers, especially those from outside of Massachusetts, for what might appear to be excessive attention to the issues surrounding Partners Healthcare System.  I truly don't want to write so much on these topics, but I do so because what is happening here is a type of morality play that has relevance to many other parts of the United States (and even some other countries.)  At one level, this is a classic issue of economic and political power: At what point do the perils of market concentration offset the potential benefits from a corpoation's consolidation and growth?  Recent changes to federal health care law appear to encourage market concentration, but for a purpose--to garner economies of scale to reduce costs, to create a larger risk pool to reduce costs, and to enable more coherent management of patient care across the spectrum of services to reduce costs.  It is when those purposes are corrupted that there is a conflict between public policy and corporate arrogance and greed.

In the case of Partners Healthcare System, arrogance and greed predominate as corporate characteristics.  I want to make clear here that I distinguish between corporate characteristics and the purpose, hopes, desires, and commitment of the vast majority of those working in the organization.  I know hundreds of doctors, nurses, and administrators in PHS--and I am personal friends with dozens--and I would not hesitate in any way to say that they are among the most devoted people in the world, living their lives to alleviate human suffering caused by disease.

I believe that there were many good instincts when PHS was created, but in my view the company began to lose its way when founder Richard Nesson, one of the great humanitarians and visionaries in the Boston medical community, died in 1998.  Leadership really matters, and with Nesson's death, the business aspects of corporate strategy rose in prominance relative to the humantiarian purposes that could have been achieved.

Again, this was not a matter of bad people doing bad things.  It was a matter of good people neglecting to do good things.  I could relate many stories of troubling management choices made by PHS leaders over the years, but I fear that doing so would leave the impression that I am attacking them personally, so we'll leave those stories for some time far in the future.

Now, though, I am again forced to respond to a recent letter to the editor submitted to the New York Times by the corporation's CEO.  As a public relations item, it is masterfully written, consistently "on message," but it is deceptive and misleading.

Here it is in its entirety:

The Risks of Hospital Mergers” (editorial, July 7) notes the leadership of Partners HealthCare in supporting the Affordable Care Act by improving care and controlling costs.

Partners’ founding institutions, Massachusetts General and Brigham and Women’s Hospitals, have for centuries offered hope and lifesaving care; one in six of our patients is brought to us from another hospital. Our doctors, nurses, care teams, researchers and educators are among the very best, recognized nationally for their commitment to excellence year after year.

Partners has been a leader over the last 20 years in innovation and science, continually improving care for patients everywhere. Today we are building on our past, tapping into our vast expertise across our system to deliver the highest quality, coordinated and accessible care to bend the cost curve of medical expense.

We have made the commitment to cap our prices and restrict our physician and hospital growth. As a result, we will become the most regulated health care provider in Massachusetts, if not the country. 

Patients choose where they wish to receive their care. They, along with others, will hold us accountable for the quality and cost of the care we deliver. 

Have you been taken in?  Are you a believer?  Beyond the obvious exaggeration that "patients choose where they wish to receive their care" where there is a dominant, closed provider organization, does it matter to you that there is no evidence to support the assertion of highest quality and coordinated care?  Remember Gene Lindsey's words:

If the motivation of Partners over the last twenty years has been to use its market power to really integrate care and lower the cost of care, they have failed monumentally. The care within Partners is no more integrated, and certainly much more costly than in any other healthcare system in the state, the nation, on this planet, and therefore presumably anywhere in the universe. Partners offers spectacular care in specific areas at a high cost. Partners’ performance on some of the metrics of care that is routine in the community arguably falls short from being unequivocally “the best,” although its price never reflects that reality.

Does it matter to you that the price caps permit prices to rise, in contrast to the promises made that mergers would reduce prices?

When the current CEO took over Partners in 2009, I rather unabashedly suggested some agenda items for his term of office.  He was not pleased with this "help," of course, but let's look at them today and see if Massachusetts might have been better off if there had been real attention paid to those items:*

If there is any organization in the state that has the potential to demonstrate the potential for an integrated health care delivery system, it is PHS. But, it will come as no surprise to participants in that system that this has not yet happened. The long-standing rivalry between the two flagship hospitals has meant that rationalization of tertiary and quaternary clinical service between the Brigham and the MGH has often been deferred. Previous Partners CEOs have focused their efforts on integration of back-office and other business aspects of the system, leaving clinical integration essentially untouched. Gary will face an interesting and important choice as to how and if he will address this unachieved potential benefit to the region. If the Partners system first sets an internal example, it might then be possible to achieve a broader rationalization of care in cooperation with the other academic medical centers (BIDMC, Boston Medical Center, and Tufts). We all need to garner these economies to control costs in the over-served Boston marketplace.

The Partners hospitals are full of well intentioned, dedicated people. But there has not been a corporate public commitment to reduction of harm and to transparency of clinical outcomes that could help build broad public confidence in the quality and safety of patient care -- and with this a confidence that we are also attempting to control costs. I would love it if Gary were in the position of challenging me and the other hospital leaders in this arena, rather than vice versa. Ironically, some of the world experts in these matters are faculty members in his hospitals. The Partners system should be a world leader in the science of health care delivery, along with the fields in which it already holds prominence.

The promise remains unmet.

* I also made some suggestions with regard to dealing effectively with the threat presented by the Service Employees International Union.  That has a particular irony today, in that the previous Vice President and Political Director of SEIU 1199 is now Martha Coakley's campaign manager!


Barry Carol said...

No apology is necessary Paul. Indeed, I hope you keep pounding away on this subject. You’re a former hospital CEO. You have expertise. You have important things to say that need to be said. Your blog is presumably read by people in Massachusetts health policy circles and at The Boston Globe newspaper.

Yesterday’s post inspired me to mail in a comment on the Attorney General – Partners proposed deal that I would otherwise not have sent because I didn’t know where to send it. Keep up the good work.

Matthew Holt said...

I thought you were a little gentle. And one piece of PR genius got by you! (It got by me too until I reread it)

When Gottleib says "one in six of our patients is brought to us from another hospital" he's saying "our patients are sicker" and implying, as the medical establishment has said for decades, you outsiders dont' understand how hard it is to care for sick people so shut up and pay up!

Anonymous said...

By "mass. health geek"

See some facts on Case Mix Index for Massachusetts....are Partners Patients the sickest?

all data from CHIA for 2012, CHIA is the mass agency who collects and publishes this information:

CMI - Case Mix Index

MGH CMI: 1.50
B&W CMI: 1.39

Tufts Med CMI: 1.51
Lahey CMI: 1.47
BID CMI: 1.27
Umass CMI: 1.24
Baystate CMI: 1.19

CMAD - Cost of case mix adjusted discharge

MGH CMAD: 12.3
B&W CMAD: 13.6

Tufts Med CMAD: 9.0
Lahey CMAD: 8.5
Umass CMAD: 9.8
Baystate CMAD: 8.2

Facts don't support the view that MGH & Brigham are more expensive as the data above shows and as has been validated over and over by Health Studies in Mass.

Partners is more expensive because its market power allows it to charge more.

Anonymous said...

Dont apologize. What you talk about can happen any where. We need to know and ask questions. I've certainly found out a lot by asking questions and the answers, the lack of answers, or the way they answered.

Anonymous said...

Thank you for staying on top of this. I fully agree that we need to separate mgmt from "regular employees"... unfortunately, the body follows the head. While good work is done there, they are not the god they have convinced many they are and the arrogant attitude flies in the face of first do no harm.

Anonymous said...

Don't apologize, Paul. I love your take and the way you bring in other thought leaders. If there was a time to shine a light it is now! Facilitating the on-going rate gap with the proposed agreement will have downstream, long term consequences harmful to the economy and community hospitals that don't enjoy the rate protection and support the PHS receives. How about holding rates flat for at least 5 years?