Success in Ipswich

Back in 2012, my colleague and I ran some workshops for senior management and clinical leaders introducing the Lean philosophy and some of its practices at Ipswich Hospital NHS Trust.  As noted at the time:

We started with an introduction based on the Toast Kaizen video produced by and featuring GBMP president Bruce Hamilton.  Then it was off to gemba, the "factory shop" floor, where the class members shadowed a member of the staff. The idea was to practice observation skills and try to identify the various types of waste found in all organizations. 

The class members gained a new appreciation for the degree of difficulty faced by their colleagues in doing their everyday jobs.  They noticed impediments, inefficiencies, and work-arounds.

Later, I gave everyone a homework assignment, which was to answer the following question: 

"Waste exists in Ipswich Hospital because the people who work here are uncaring and lazy. True or False? Provide evidence in support of your answer." 

I suspected (and hoped!) that the answer would be "false," and it always was.  People understood that the well-intentioned and hard working people in the hospital face the common problems of complex organizations.  

Phil Windsor offered the following answer:

To say waste exists at Ipswich Hospital because the people who work here are uncaring and lazy is a statement that couldn't be further from the truth. 

The people that work at Ipswich are uncaring and lazy is a generalisation as extreme as saying they are all angels. Let's be real, we all have our bad days, but an organisation whose primary function is the health and welfare of others can not attract a workforce who are naturally lazy and uncaring. If that was your disposition why would you work at all. 

Wasted resources are a result of our inability to re-use the by product of our activity. It may be argued that it's ok to accept a degree of this and it may also be argued that everyone is entitled to an off day. The question is how much are we willing to accept and how much better would the world be if we all accepted a bit less?

Well, it appears that Phil and his colleagues really went to work applying lessons from this experience and more.  In a note today from surgeon Isam Osam:

Since taking the role he has transformed the emergency department. Lean is about a culture and incremental improvements. This is a great example!

And he linked to this story from the Ipswich Star:

Ipswich Hospital’s emergency department one of the top 10 performing for hitting Government target for seeing patients in four hours 

Ipswich Hospital bosses praised the “amazing” work of emergency department staff last night, as it emerged the unit was among the top 10 in the country for seeing patients within four hours.  

New figures released by NHS England put the Heath Road trust as the eight best out of almost 140 departments for hitting the Government target of seeing, treating and admitting or discharging 95% of patients in that timeframe, between October and December. It averaged 95.7% in the three months, according to the data.

Bravo to Phil and others on the team!  As noted in the story:

“It is a fantastic tribute to not only our amazing emergency department team, but in fact the whole hospital."

The judge saw through the lie

In a Boston Globe story, here's how Priyanka Dayal McCluskey reports on how the outgoing CEO of Partners Healthcare System described the deal that was turned down today by Suffolk Superior Court Judge Janet L. Sanders:

“The judge has said ‘no’ to an agreement that we believe would have paved a pathway to delivering high-quality care closer to home for patients and their families in a lower cost community-based setting."

Well, no.  First of all, there was no need for PHS to acquire these hospitals to achieve proper care management for patients.  All it takes is an agreement to coordinate care and share access to medical records.

Second, hospitals that would be incorporated into the PHS system would gradually assume the pricing advantages of this near-monopoly supplier and would not be lower cost community hospitals (compared to other community hospitals.)

Third, the agreement would have permitted PHS to recruit doctors in the vicinity of these hospitals, moving them from lower cost systems to the higher physician rates of pay enjoyed by the PHS doctors.

Attorney General Healey had it just right when she said that the proposed agreement was a case of the cart leading the horse. As many of us had noted, the commitments to lower costs contained therein were unsupportable and unenforceable. Instead, implicitly building on the findings of the state Health Policy Commission, she suggested:

“One of the greatest challenges our state faces is rising health care costs,” Healey said. “I’d like to see how [Partners’] work in the market is helping to contain costs.”

(By the way, should this case ever reopen, it would be good to see how an unfettered US Department of Justice would behave. Their position in this case was strange, compared to their other activities in the country.  One must assume that it was based on the Administration's desire to help a fellow Democrat in her gubernatorial campaign.)

In case you are interested, here's the full ruling by the judge. It is worth reading, at a minimum, the first few pages.

Marching, but where? Moscow, I fear.

Melanie Evans and Bob Herman at Modern Healthcare report that "a new task force made up of providers, insurers and employers has committed to shift 75% of its members' business into contracts with incentives for health outcomes, quality and cost management by January 2020."

What's up? Well, the theory is that risk-based payment mechanisms like "accountable care, bundled payments and other contracts with the potential for rewards or penalties based on quality performance and better cost control" will bring about greater efficiency and higher quality in the health care system.  It is argued that the current system, mainly based on fee-for-service schemes, leads to overtreatment and waste.

In the midst of all the excitement, there are very few thoughtful observers who raise questions about the march.
 
I've devoted a lot of columns here to the unanswered questions and potential unintended consequences associated with risk contracts.  I've also been hard on the health care industry for a lack of analytical rigor when it comes to designing public policy prescriptions to deal with rising health care costs.  I don't want to go through all those arguments now, but let's just outline some as yet unanswered concerns:

1) As risk is shifted from insurers to providers, what adjustment will be made in the insurers' cost of business, and how will those adjustments be passed along to consumers.  A reduction in risk should be accompanied by a reduction in capital reserve requirements of insurers:  How and when will those huge investment accounts be reduced and redistributed to the public?  Likewise, if payments are made on the basis of annual population rather than individual claims, when will the insurers stop adjudicating claims data and reduce the size of their staff involved in these functions?  When and how will those savings be passed along to consumers?

2) The decisions by ACOs to take on more risk is already driving mergers and acquisitions as those entities try to expand their risk pools.  That market concentration acts to increase the leverage of the providers over local insurers, driving up rates (whether fee-for-service, capitated, or bundled).  How can we be sure that whatever savings might emerge from risk contracts are not offset by the greater market power of provider groups vis-a-vis insurers?

3) What will be the internal distribution of risk and reward for the various physician specialties within ACOs?  How will that negotiation take place? Is there any reason to believe that the current fee schedules which offer higher relative payments to proceduralists than cognitive specialists will not form the base for ACO internal transfer pricing?  If there is a surplus within an ACO, which doctors will get which share?  Likewise, if there is a deficit?

4) Similarly, what will be the internal distribution of risk and reward for the various entities within ACOs--the tertiary care centers, community hospitals, multispecialty clinics, and post-acute care facilities.  If there is a surplus within an ACO, which facilities will get which share?  Likewise, if there is a deficit?

5) What will be the governing structure of ACOs?  If, as is often the case, the large tertiary centers hold the cards, how can the other players within the ACO rest assured that they will be treated fairly in matters of risk and reward allocation?

6) And finally, if quality metrics are not properly drawn, don't risk-based contracts offer the potential for undertreatment of patients, swinging the pendulum too far in the other direction?

“If all you're going to do is you're going to put providers at risk for cost, but you don't have a robust system for measuring quality, then you're not leaving patients better off,” said Dr. Ashish Jha, a Harvard University health policy professor.

We are all pleased, of course, to see the following kind of optimism:

“As a doctor, I am very excited about the direction this is going,” said Dr. Stephen Ondra, chief medical officer of Health Care Service Corp. “For much of my career, payers and providers had an adversarial relationship that often created win-lose choices.”

But I fear that Dr. Ondra and his like-minded colleagues are naive.  The adversarial relationship he sees today may very well be replaced by a new set of adversarial relationships--between physician specialties; between tertiary and other health care facilities; and, sadly, between patients and ACOs. The main drivers of health care costs are not overuse related to fee-for-service care.  As I have noted here, they start with the changing demographics of society.  Fee-for-service is way down the list.  Quoting myself:

If we were being rational and rigorous about policy prescriptions, we would rank order these causes and determine the costs and benefits of policies that might offset them.  For example, we cannot change demographic patterns, but it could make sense to introduce public health programs to promote exercise and proper nourishment.  We could change the compensation system for primary care doctors so they could spend more time with patients.  We could subsidize physician education so they wouldn’t have to earn so much to pay off loans.  We could reform malpractice laws to reduce defensive medicine. And we could certainly engage in full-scale process improvement training of doctors and implementation of those techniques in hospitals to reduce the extra medical costs associated with harming patients.  (Those of us who have done the latter have demonstrated conclusively the cost savings, not to mention the mortality and morbidity benefits.)

But, our public policy leaders have not done this.  Instead, they assert that pricing-based over-treatment is the key problem, and they offer capitated rate plans and bundled payments as the solution.  If you look closely, you will find that most of those proposals come from payers, either insurance companies who have a corporate desire to shift risk to providers or government officials who are trying to reduce appropriations.  Or from economists, who have a tendency to simplify market behavior and blame everything on pricing regimes.  As I have said, when you have a hammer, everything looks like a nail.

We shouldn’t dismiss a change in the payment system just because it might benefit the insurers or the government, but we also shouldn’t adopt it just for that reason -- or because it fits into economists’ idealized models.  Instead, we should determine how big a portion of the over-treatment problem comes from the payment system versus other causes.  And then we should rigorously review the experience of such regimes and evaluate their costs and benefits.  We should also determine how practical it is to implement a new pricing regime. 

I have a deep seated feeling that the march that is seen as so optimistic today might start to feel more like Napoleon's attack on Moscow, nicely represented in the chart above from Edward Tufte.

Lynne: Initial CMS Evaluations of Readmissions Have Serious Flaws

Joanne Lynn M.D., Director of the Center for Elder Care and Advanced Illness at Altarum Institute, wields a scalpel and a battle axe in her recent criticism of initial CMS evaluations of readmissions. The lede:

The Centers for Medicare and Medicaid Services (CMS) has quietly put out two evaluations of the readmissions work– and both documents are remarkable for their failure to evaluate the programs fairly or to provide insights as to what works in what circumstances.

Excerpts:

The readmissions/discharges metric that CMS and its evaluators use for categorizing success or failure is seriously flawed.  There is no reason why a 20% reduction in the now thoroughly discredited readmissions/discharges ratio is the best target. A more informative target would clearly focus on providing a reliable, well-characterized set of services that work to the advantage of patients and families and that also reduces total costs.

Much of the problem with the measures probably has roots in national leadership still conceptualizing the transitions work as being dominantly the responsibility of hospitals and their staffs, while people living with serious chronic conditions need a more comprehensive, community-anchored, population-based approach. Even so, responsible evaluation would require, at the very least, a close examination of actual numerators and denominators in order to interpret the simplistic and routinely misleading ratio. 

The most important issue is whether the CCTP (Community-Based Care Transitions Program) program is helping to improve transitions and keeping people who are living with fragile health in a more stable condition while living in the community, thereby reducing hospitalization. It would be easy for the evaluation to show that the supplemental services are desirable. Evaluators could test whether enrolled patients had many fewer medication errors, many more patients and families confident in their self-care, many more social services in place, and much more medical support in the community. However, the current evaluation does not address these points.

These first forays into evaluation of the readmissions work are quite disappointing. There are contractors and participants who know much more, and there are evaluation methods that would be much more revealing. The work on care transitions has been a powerful catalyst toward more comprehensive care planning and service support for people living with fragile health. It is time to push CMS and PCORI and any other funding agency, contractor, or grantee to do the work that informs managers and policymakers about what to do next, given what we’ve learned in the work so far.

John Q. Sherman Award for Excellence in Patient Engagement

It's time again for the John Q. Sherman Award for Excellence in Patient Engagement.

This year’s award will be conferred by Standard Register Healthcare in partnership with the National Patient Safety Foundation’s (NPSF) Lucian Leape Institute at the 2015 NPSF Patient Safety Congress in Austin, Texas on April 30 and the award-winning program will be featured on EngagingPatients.org.

Last year the award was given to the Open Notes Collaborative and Dr. Nasia Safdar, hospital epidemiologist for the University of Wisconsin Hospital.

 

Who was Mr. Sherman?  Here's background:

Founder of Standard Register, John Q. Sherman was a leading philanthropist in Dayton, Ohio with a deep commitment to healthcare and his community. At the onset of the Great Depression in 1928, he led the campaign to raise over one million dollars in just 30 days to build Good Samaritan Hospital. He left a legacy that lives on today through the company’s support of Dayton’s Samaritan Homeless Clinic, in the launching of EngagingPatients.org and now through the John Q. Sherman Award program.

This year's deadline is February 28. Here are the details.

Sampson engages through Chop Chop

I love Sally Sampson's enthusiastic persistence with regard to teaching kids about tasty good food.  She has been publishing Chop Chop magazine for some time now, and each issue is a treasure of ideas and stories.  The magazine is widely endorsed by pediatricians and is distributed through children’s hospitals, health centers, public schools, afterschool programs, Indian reservations, and community organizations. ChopChop is also available at newsstands and by subscription.

Here's the latest set of blog posts. I like this one on knife skills, with this introduction:

Slicing, dicing, chopping, and cutting: it’s hard to cook without using a knife to prepare the ingredients! Hard, but not impossible. A pizza cutter makes a perfectly excellent cutting tool for soft things that aren’t too big: bananas, for example, or tofu. And scissors are great for snipping up herbs and greens. But if an adult in your family thinks you’re ready and is willing to supervise you, it might be time to learn to use a sharp knife in a safe and responsible way. We got some tips from knife maker Adam Simha of MKS Design in Cambridge, MA.

WIHI on identifying patients with complex needs

Madge Kaplan writes:

The next WIHI broadcast — When Everyone Knows Your Name: Identifying Patients with Complex Needs — will take place on Thursday, January 29, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:

• Catherine Craig, MPA, MSW, Independent Consultant; Faculty, Better Health and Lower Costs for Patients with Complex Needs, IHI
• Matt Stiefel, MPA, MS, Senior Director, Center for Population Health Care Management Institute, Kaiser Permanente
• Eleni Carr, MBA, MSW, Senior Director of Care Integration, Cambridge Health Alliance
• Kathy Weiner, MHSA, Regional Executive Director, Medicare, Kaiser Permanente

A relatively small percentage of the US population accounts for the largest share of health care costs. Everyone knows who we're talking about, right? Well, not exactly. Broad assumptions (e.g., high utilizers of the emergency department) and sweeping generalizations often substitute for more robust inquiries and analysis designed to better pinpoint a hospital or clinic's patients with unmanaged, complex health problems. And, without this specificity, it's hard to know who will benefit most from additional supports and interventions.

This is among the reasons why an IHI Collaborative involving some 45 health care organizations has been focusing like a laser this past year on developing reliable ways to identify patients with complex needs. It's hard but necessary work, and we're going to explore what it entails on the Jan. 29 WIHI: When Everyone Knows Your Name: Identifying Patients with Complex Needs.

We’ve pulled together a terrific panel for the program. Catherine Craig will set some context and background for adopting more sophisticated methods to identify patients with complex issues and needs. The Cambridge Health Alliance’s Eleni Carr will walk us through the tools and systems her safety net organization is now using to enroll patients in a complex care management program. Matt Stiefel and Kathy Weiner from Kaiser Permanente (KP) have been hard at work developing and refining tools to further segment populations with complex needs which, in turn, leads to better predictive models. This helps KP plan for the services and costs necessary to meet patient needs.

The January 29 WIHI will be followed by another in 2015 focused on new care designs and better outcomes for patients with complex needs. We look forward to your comments and participation!

You can enroll for the broadcast here. We'd also appreciate it if you would spread the word about the show via Twitter.

Would you have guessed this percentage?

A friend of mine with small children, on advice of his pediatrician, inquires of the parents of playmates whether they have a gun in their house.  (This is also the advice of the Brady Center.)  If so, he respectfully asks that the play date take place in his home instead of theirs. 

Here's the surprise (at least to me):  30% of families he has talked to have guns.  This, in my hometown, one of the highly educated, affluent, low-crime rate suburbs west of Boston.

Change Day in Oz

A lovely note from Oz, from my buddy Mary Freer.  I'm happy to share worldwide so people can join in directly or vicariously--and perhaps share it further:

I wanted to share with you the gorgeous little film that we have just made for Change Day Australia. Here's the link.

It's 4 minutes of wonderful inspiration. If you are encouraged by it you might like to share it with your colleagues.

Change Day in Australia is growing and providing this incredible platform for health and social care professionals to put forward the best version of themselves.

We are making Change Day work through sheer determination and passion. We crowd-funded to raise the money to make this little film, and we are very much in need of some funding to enable us to grow Change Day to the next level. More here.

Not ambulance chasers, bus chasers!

Remember this story about an out-of-town bus that crashed into a too-low bridge underpass in Boston?

Well, in the category of a story that takes on its own life, the Bucks County Courier Times reports:

Eleven Bucks County residents seriously injured when the charter bus they were riding on hit an overpass in Boston almost two years ago have filed a more than $15 million civil suit alleging the GPS improperly routed the bus driver onto the height-restricted road.

“Faulty directions by GPS systems have resulted in numerous bridge collisions throughout the U.S. The systems do not take into account the height of the vehicle being used or provide warnings concerning height restrictions on affected roadways,” the law firm said in a press release.

The law firm clearly doesn't want to leave anyone out:  

Also named as defendants in the lawsuit are Calvary Coach Bus Company and its owner Raymond Talmadge, Prevost Car Inc., Volvo Group North America, and the Commonwealth of Massachusetts Department of Conservation and Recreation.

Good step by AG Healey. Next steps?

Brava to the new Massachusetts Attorney General, Maura Healey, for indicating her displeasure with the Partners Healthcare System deal submitted by her predecessor.  I'm guessing that the Court is now very unlikely to appprove the proposed settlement.  That's good.

What next?  It would be tempting to view this question of system expansion as solely a Partners issue.  After all, they have extensive market power.  But the fact is that all of the major systems in the state are acting to expand their reach through mergers and acquisitions.

It's time to put a stop to all such anti-competitive activities.

There is simply no reason that major academic medical centers need to own community hospitals and physician groups to accomplish the purposes of creating accountable care organizations.  Clinical relationships that bring about appropriately managed care are not a matter of corporate structure.  They require, instead:

1) Complete interoperability of electronic medical records among the various segments of the health care spectrum of care; so that no one "owns" a patient and s/he is free to choose the best place to get care;
2) Transparency of financial charges and relationships between and among hospitals, doctors, and other health care facilities so that patients and referring doctors can see what the true costs of care will be in different settings;
3) Transparency of clinical outcomes so that referring doctors (and patients) can make decisions about the right venue for care based on evidence, rather than anecdote and conjecture.

Here's what the new AG should do.  She should establish a "safe harbor" for mergers and acquisitions only after the state as a whole has put these standards and practices in place.  Until then--whether it is PHS, BIDMC, Lahey, Steward, or Tufts--no more acquisitions or mergers should be permitted.

Against the grain

There was a session at the Jaipur Literature Festival that I found surprisingly close to home in the health care world.  It was titled “Against the Grain” and was summarized as follows:

Voices of individual courage and conviction examine strategies of steadfast truth telling in the face of social pressure and mass opinion.

The panelists comprised a Who’s Who of writers who have taken a stand and engaged in acts of conscience in their work.

Swapan Dasgupta, an Indian conservative columnist, says he is labeled as “contrary because I betray my class, “ a group that has “a self-image of being progressive” but are actually condescending towards those with other views.

“I have lost a lot of friends” by taking positions, he notes. He bemoans this result.  “I don’t think political positions should be viewed as so polarizing as to preclude normal social relationships.”  He proclaimed, “Can’t we let this closed mind attitude disappear?”

Salima Hashmi’s father was jailed in Pakistan for his political views decades ago. This episode and the isolation from her previous friends and neighbors provided lessons for her:  “You learn about value, friendships, and loyalty in these situations.”

These memories, along with her own work, prompted her to elaborate on the themes mentioned by Dasgupta.  “People accept self-censorship.  They accept dictatorial behavior.”  Such attitudes become socialized as the norm.

And then, Gideon Levy, an Israeli whose very life has been threatened because of his views about his country’s occupation of Palestinian territory, went further.  He described many of his countrymen as being in “a pathological denial.  No one wants to know.  No one wants to say.”  They are “ignorant, blind, apathetic, without any moral doubts.”

He went on to explain the role of the journalist: “We are there to give a message that is not convenient.”

I don’t put myself in the category of these great writers.  But I have to say that I have found similar patterns of behavior from many in the health care field when I have raised concerns about the actions of doctors and hospitals that tread on medical ethics, that fail to address ongoing problems of quality and safety in patient care, or that employ overly greedy approaches to corporate acquisitions, mergers, and management.  Several other writers I know have faced the same patterns.

In short, instead of arguing the merits of those issues we raise, those who disagree often adopt the kind of unsocial behavior noted by Dasgupta.  Some simply do not respond, favoring a passive aggressive approach.  Some respond by personal attacks.  Sadly, in the words of Levy, they often present symptoms of being “ignorant, blind, apathetic, without any moral doubts.”

Imagine another world.  Imagine one in which, when challenged about an issue, health care people would listen modestly and carefully, engage in civil discourse, and try their best to think of what approach would best serve their communities—as opposed to what would best serve their individual or corporate interests.

I believe that health care folks can get away with bad social behavior because many media outlets and journalists fear being put in the outcast role described by the JLF panelists.  It is a problem for the public good when journalists accept the unstated and do not probe behind the scenes and expose the inefficiencies, the harm, and the injustices that are endemic to our health care system.  The media simply become outlets for the press releases and pablum produced by vested interests in the field. Were it not for people like Charles Ornstein and his colleagues at Pro Publica, John Fauber at the Milwaukee Sentinel Journel, Elisabeth Rosenthal at the New York Times, many of the major issues facing US health care would receive no attention at all.

I wish my health care journalist colleagues could have been present for this session in Jaipur.  Maybe they would have been stimulated to take on Gideon Levy’s advice: “We are there to shake.”

Frankopan offers a view from the East

It is often said that you cannot understand the politics, acrimony, and wars of Asia Minor and the Middle East without understanding the place of the Crusades in the region's history.  In a marvelous pairing with that thought, Peter Frankopan has written a book that suggests that you cannot understand why the First Crusade occurred without an understanding of what was happening in the Byzantine Empire, and especially the region extending east from Constantinople.

I met Peter after he gave a marvelous talk at the recent Jaipur Literature Festival.  Now I've finished the book and am pleased to highly recommend it.

It is hard to imagine how a reconciliation between the two major factions of the Catholic Church could occur after this event:

On 16 July 1054, the papal legate, Cardinal Humbert of Silva Candida, along with other envoys from Rome, strode into the great church of Hagia Sophia in Constantinople as the Eucharist was being celebrated. In a moment of high drama, they walked directly up to the front of the chuch, not pausing to pray. Before the clergy and the congregation, they produced a document and brazenly placed it on the high altar.  The patriarch of Constantinople, it read, had abused his office and was guilty of many errors in his beliefs and teaching.  He was forthwith excommunicated, to suffer with all the worst heretics in hell, who were listed carefully.

And yet, within 40 years, Pope Urban II joined forces with the eastern church and, in a notable address at Clermont, "drew careful attention to the suffering of Christians in Asia Minor [at the hands of the Turks] and to the persecution of the churches in the east--that is to say the churches following the Greek rite."  His call for aid stimulated the First Crusade, an invasion by 80,000 European knights, soldiers, and others.  But why then?  The Holy Land had been in the hands of "the infidels" for centuries.  Why did it take until 1095 for this call to arms?

Frankopan, using established sources but also other primary sources previously ignored, tells the story of how the confluence of two geopolitical struggles led to an alliance between Urban and the Byzantine emperor, Alexios.  One part of the story is Urban's attempt to reestablish his authority within the Roman Church, where he was in danger of being made irrelevant by Clement III and his protector Henry IV.  "He was forced to build bridges wherever he could," notes Frankopan, including a conciliation with Constantinople.

Meanwhile, the Byzantine emperor was facing military attacks from all sides and was increasingly vulnerable to the Turks from his east.  He had insufficient forces to hold them off and needed an infusion of arms and men.  He saw the potential for an alliance and worked with the local religious leaders, including the patriarchs of Constantinople and Antioch.  "These steps reopened dialogue with Rome and paved the way for a major realignment of the Byzantine Empire on the eve of the First Crusade." When Alexios later appealed for military help:

The Pope immediately recognized the opening. He had already been intending to visit France. He reacted quickly and decisively to the appeals from the emperor's envoys. Rather than sending out letters that talked about the principles of an expedition without providing detail, structure, or purpose, Urban decided to devise and put in place personally an expedition to transform the eastern Mediteranean.

They worked closely on the narrative:

Urban's words were chosen to speak to his western audience but his appeal was shaped by an agenda that was to a large extent set by Alexios in Constantinople . . . rousing mass enthusiasm to raise an efficient, controllable military force that could meet very particular Byzantine military objectives.

But it was one thing to provoke a military invasion of "the faithful" to free Jerusalem, and it was another altogether for Alexios to maintain control of his own empire as the Europeans passed through it overtaking the Turkish towns and fortifications.  He needed some way to assure that the Crusaders would not immediately turn on him and grab his territory for themselves.  It was here that he exercised his own form of genius--based on his excellent understanding of the cultural mores of the West.  He went beyond offering the leaders of the Crusades the highest in diplomatic courtesies; gifts of jewels, gold, and other treasures; and logistical support in the form of food and other supplies for thousands of soldiers.  Meeting with each leader individually and "adopting them as his sons," Alexios also asked each to swear an oath of fealty to the emperor.

Fealty was a key element in the feudal structure and well established in Western Europe by the time of the First Crusade.  It created a relationship with specific legal implications between a vassal on the one hand and a master on the other.  Paying homage, the vassal committed to serve his lord and not harm him by swearing an oath over the Bible or another suitable religous object, such as a sacred relic, in front of a cleric.

I'll end the summary here, leaving the rest for interested readers.  You can already imagine the difficulty--for both the Pope and the emperor--in maintaining the holy alliance in the face of strong-willed political and military leaders from Europe.  Particularly after the Crusaders captured Antioch and Jersualem.  You can also imagine the ongoing internal struggles faced by Alexios from his local allies and enemies.  Can oaths of fealty survive in this environment?

A view from Rajasthan

I'll be reporting soon on some observations from the Jaipur Literature Festival held this past week in Rajasthan, India.  The festival was created by author William Dalrymple (seen here during the opening session) several years ago.  He jokes that 14 people attended the first year, many of whom were a group of Japanese tourists who had lost their way and walked into the venue in error!  Now, thousands attend and hear presentations from and mingle with many of the leading authors from Asia and around the world.  The event is a non-stop five day affair, with parallel sessions from 10am to 6pm every day.  The major problem you face as an attendee is choosing among them.

But for a humorous introduction to the local culture, though, here's a scene from nearby Jodhpur.  The old city is a rabbit warren of narrow curving streets, occupied by a cacophony of horn-beeping rickshaws and motorbikes.  Every now and then gridlock ensues.  Here's a short video to give you a taste.  Note, in particular, the arrival of a pedestrian who offers "helpful" advice to one of the rickshaw drivers.  And then, note, too, the humorous acceptance of the situation by a bevy of motorbikers.

If I had to apply two words to life in India, one would be "acceptance," as seen here.  The other would be "scrapping," as millions of people claw their way to survival and, with luck, success.

On holiday

I'll be taking a blogging break for several days.  See you in a while.

Where are the medical associations?

Over the last several years, many of us have raised issues concerning the propriety and appropriateness of doctors receiving funding from medical device companies.  For my part, I consider such payments as harmful, violating the trust between doctors and patients.  In some cases, they clearly influence the clinical behavior of doctors.  In other cases, they simply raise doubts about doctors' loyalty to patients' interests at a time when we should be enhancing that partnership, rather than eroding it.  When I make these points--in general or in specific--many US doctors respond by saying, in essence, "Well, everyone does it."

In contrast, people from other countries are appalled when they read of these kinds of payments.  They are viewed as unseemly, at a minimum, and often as corrupting of the relationship between doctors and patients.

But how likely are thing going to change in the US?

There are a plethora of US medical associations, each representing a specialty in the field, e.g., urology, obstetrics and gynecology.  They perform useful and helpful functions, from board certification to publication of professional journals to continuing medical education.

However, many of those associations themselves solicit and enjoy the sponsorship of those same companies that provide funds to individual doctors.  So how can we ever expect that they would adopt meaningful prohibitions on these matters for their members?

Until and unless the specialty associations start to take decisive action on these issues--for themselves and their members--the press and other observers of the health care system will write about examples that raise doubts about whether the public trust is being fulfilled.  Doctors may very well say, "That's not fair!"

Sorry, but it seems to me that "everyone does it" isn't a good enough answer any more. 

ACO: Let's start with organized

Dartmouth's Eliott Fischer once asked whether accountable care organizations would be accountable, caring, and organized.  For this concept to succeed, things are going to have to work a lot better than set forth in a friend's recent note about her elderly parent:

After Mom spent the night in the ER a week ago, I asked the hospital to send the assisted living place the discharge summary (which they had requested, to their credit.)  The hospital said they would when it was dictated.  I got the fax number for them and, of course, it never happened.

So now the assisted living place, which has its own physician, wants to draw her blood tomorrow to do lab work. I mentioned that, when we interviewed this facility, I had been told they had a computer connection to the hospital, and was this not so?

They hemmed and hawed and said, "Yes, maybe."

I said, "Then why don't you look in the computer and get her lab work from the ER visit and then you will have the information you want? "

"Um, well, I guess we could try to do that. "

So then they said, "Are you saying you don't want us to draw her blood tomorrow? "

I said, "Yes, that's what I'm saying. It would be better for everyone if you get the lab work that already exists." (Mom is a difficult stick anyway, by the way.)

It's like the 2 facilities, 3 miles apart, just function in parallel as if the other place doesn't even exist!! It absolutely boggles the mind. And of course they would charge Medicare AGAIN for the lab work-- which, if it had any sense, it wouldn't pay for.

I just sit here and say, it's really, really obvious why health care costs so much here. If you multiply this little stuff by the millions, and remember it includes repeat imaging studies, it really adds up, doesn't it?

End-of-Life Conversation Ready on WIHI

Madge Kaplan writes:

The next WIHI broadcast — End-of-Life Care and How Communities Can Become “Conversation Ready” — will take place on Thursday, January 15, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:

• Jean Abbott, MD, MH, The Conversation Project, Boulder County; Faculty, Center for Bioethics and Humanity & Professor Emerita, Emergency Medicine, University of Colorado
• Diana Silvey, MA, Program Director, Winter Park Health Foundation
• Kimberly Flowers, MSW, LICSW, Senior Outreach Social Worker, Elder Services of the Merrimack Valley (Northeastern Massachusetts)
• Kate DeBartolo, National Field Manager, The Conversation Project, Institute for Healthcare Improvement

It doesn't necessarily “take a village” to have a conversation with loved ones about wishes for end-of-life care. But it can help to have others in the community to turn to for ideas, resources, and support — especially if the “kitchen table” conversation with important people in one’s life isn’t happening so readily. Sometimes it’s easier to start this conversation with peers who get together once a week at the community center. Or with a rabbi or minister. Or, initially, with perfect strangers who’ve started to meet at the local library to talk about death and dying. 

With an aging population, and too many people not dying as they’d choose, community groups all across the US are creating more ways and places for people of all ages, and states of health, to articulate their end-of-life care preferences, and to make sure their preferences are known and respected by loved ones and local health care alike. We’re going to look at some efforts underway in Winter Park, Florida; Boulder County, Colorado; and in the Merrimack Valley of Massachusetts, on the January 15 WIHI: End-of-Life Care and How Communities Can Become “Conversation Ready.”

For many community programs, the resources offered by The Conversation Project, including the Starter Kit, are often foundational. And, as you’ll learn on this WIHI, for a community to become Conversation Ready, meeting people where they are in their lives (literally and figuratively) is key. This could be at a homeless shelter, the Elks club, or a class at a community college. There are no right or wrong answers when it comes to people’s end-of-life care wishes; and, as you’ll hear from our terrific panel on the January 15 WIHI, they’d like there to be no wrong doors, including those of health care providers, for having a discussion that couldn’t be more important to us all. Join in and tell us about efforts in your own communities on the January 15 WIHI.

You can enroll for the broadcast here. We'd also appreciate it if you would spread the word about the show via Twitter.

More on fast food in Melbourne children's hospitals

My post on fast food in children's hospitals received a lot of comments.  Here's the latest chapter from Melbourne, an opinion piece in The Age written by Alessandro Demaio.  He says, in part:

As a medical doctor and as a public health scientist working internationally, I can assure Victorians that there is good scientific evidence to support our concerns. This is not about banning or taking away choices in a nanny state. Excluding a US multinational from selling junk food inside our public hospitals is simply sound health policy. It is about sending a clear and consistent message to the community, and particularly young people, about what is healthy. 

Having a McDonald's embedded in a respected, taxpayer-funded institution like the Royal Children's Hospital does wonders for its brand power. McDonald's spent more than $1billion in 2013 alone on advertising junk food and any parent will tell you how powerful the golden arches are when children see them. There is good research showing that having a McDonald's next to hospital clinics makes people think its food is healthier than it is and that eating it will support the hospital. On a clinical level, it is counter-productive, too.

Boiling the public debate down to reductive rhetoric, Mr Andrews said "people who would like to tell parents every single thing they ought do and not do" is "nanny statism" that undermines legitimate government warnings for parents. 

Mr Andrews has missed the point. This was never about a ban, or creating a "nanny state", or about telling parents what to do. This was and is about a consistent message, defending our world-class public health-care system, and protecting the health of families across our state. It is about having a proper public debate and considering the health of the children in these hospitals, but also the health of the millions of young Victorians increasingly at risk from obesity-related disease. 

Time to think about Telluride

The deadline for applying to the Telluride Patient Safety camps has been extended to February 15.

Repeating my earlier post here:

Here's a lovely video summary of the Telluride Summer Patient Safety Camps that are conducted for residents and medical students.  The official name is now: Academy for Emerging Patient Safety Leaders: The Telluride Experience.  If you know anyone who might be interested, please have him or her apply, here.

True transparency in hospital PR campaigns

GOMER blog, which modestly refers to itself as the earth's finest medical satire news site, provides the ultimate in hospital transparency in this recent post, Hospitals Unleash New, Brutally Honest Slogans.

Here are excerpts:

Forget the days of the compassionate and uplifting slogans like “A Passion for Healing,” “Because Your Life Matters,” or “Every Day, a New Discovery.” With record numbers of nurses and doctors burning out and hospitals busting at the seams with sicker and sicker patients, hospitals are waving their white flags and this is being reflected in new, brutally-honest slogans to deter patients from seeking care.

The first hospital to make the change is New York Medical Center, who earlier this month changed their decades-old slogan of “Advanced Medicine, Trusted Care” to “Death is Inevitable”.

Intentionally or not, the site then reflected the faddism that characterizes hospital advertising compaigns:

Other New York hospitals were quick to follow suit, calling the move “brilliant” and “revolutionary.”

But geographic diversity is evident:

In the Southeast, new hospital slogans are financially motivated. 

In the Midwest, slogans show a little more frustration.  

In the Southwest, hospitals have taken a different angle by trying to remain modest at best while focusing on flaws as a major deterrent to patient care.

And the body politic jumps on the bandwagon, just like in real life:

“This is an important moment in our country’s history,” said President Obama at the White House, with both Democrats and Republicans united in support behind him. “This is outside-the-box thinking at its finest.  What better way to decrease healthcare costs than by decreasing healthcare access and decreasing patient care across the board.”

Lightning goes to ground

I respect and admire Lucien Engelen, the spirit behind the REshape Center for Innovation at Radboud University Medical Center in the Netherlands, so when he recently posted an article entitled, "10 TED talks that change(d) healthcare," I was intrigued.  Who doesn't love TED talks, after all?

But then I concluded that he was off base.

Not because the talks aren't great.  They are great.  They are stimulating, well presented, thoughtful, and challenging.

But they have not changed health care.  Look through the talks and see what's imagined in them. Now, compare them to what's happening on the ground in most places.

(By most places, I am talking about the economically developed countries.)

What we see in those countries is the presence of two inexorable forces.  One force comprises underlying demographic factors.  The old are living to an ever-older age and are putting unprecedented demands on the health care system as we take care of their chronic and acute illnesses.  Meanwhile, the next generation (the Baby Boomers) have entered the age of hospitalization, compounded by an extremely high level of entitlement.  ("I hurt my knee playing soccer.  I need to be able to play as soon as possible.  I demand an MRI and arthroscopic surgery to repair that rip.") And, finally, the next generation is characterized by a sedentary lifestyle, which has and will lead to obesity, diabetes, and the sequelae of those diseases.

Meanwhile, in the face of this demand, pharmaceutical and technology companies invent new diagnosis, treatments, equipment, and supplies.  They seek to grab their portion of the growing health care budget.  Very few of their inventions, whether efficacious or not, lower the cost of health care.  They tend to be additive.  (And, by the way, many are not efficacious.)

So what we find around the globe is a persistent growth in health care expenditures.  Because there is a limit to society's ability to absorb such expenses, the costs are being pushed down--step by step--to those least able to seek alternatives, the general public.

Daniel Palestrant, the highly thoughtful CEO of Par80, has recognized this phenomenon and has likened it to Benjamin Franklin's most important invention, the lightning rod:

In this country, when it comes to healthcare, lightning has indeed struck.  Like a bolt of lightning hitting a colonial building (which were largely made of wood), the energy must find a path to ground as quickly as possible, scorching everything on the way down.  The question isn’t whether it will find ground, it is only how much collateral damage it will do as it gets there.  The healthcare crisis is lightning hitting our society.  If it isn’t managed carefully, it will burn down the house.

As healthcare costs have exploded, the cost and responsibility has been shifted from private companies paying for employee benefits, to physicians, to insurance companies, the American taxpayer, and most recently, the Chinese (who we have been asking to lend us the money to pay for these costs).  In turn, each of these parties has now found a way to either defer the liability or signal they are no longer willing to finance the effort to sustain the status quo.

Lightning grounds when costs and responsibility are shifted back to the only remaining entity….the patient.  That’s where we are heading.

Daniel offers a hopeful prediction:

It’s not all bad, though.  Directly engaging consumers in their own healthcare will inevitably lead to two trends:

Disintermediation - As the lightning accelerates, it will look to cut out as many intermediaries as possible.

Price to Value - Once consumers are more responsible and accountable for the cost and manner of their own care, it will become more likely that healthcare goods and services will be priced on relative value, rather than an arbitrary value set by a third party.

Well, maybe. I think that some consumers will have those opportunities, but I think that most will not.  Taking just one recent item, the trend to high deductible health plans, we already see the growth of inequity based on income.  Lower wage people choose the high deductible plans to reduce their monthly premium, but then they systematically choose to avoid spending more of their disposal income by deferring or avoiding appropriate medical care.

As the Institutes of Medicine recognized years ago, a health care system that is not equitable is one that fails.

I bet if we surveyed the viewers and listeners of TED talks, we would find a bias towards higher educated and wealthier people.  Sure, they're really excited about the ideas Lucien proclaims as changing the system in the direction of higher quality, greater safety, and lower costs.  And sure, many firms in the marketplace will aim their products and services to those groups.  How much will trickle down to the rest of society?

My fear is that what trickles down will not be the innovations that bring about higher quality, greater safety, and lower costs.  What makes me pessimistic?

Frauds already abound, attacking the economically weakest in society.  As Al Lewis, Vik Khanna  and Shana Montrose have documented, the so-called wellness industry has started to impose its own form of tax on the health care system.  In cahoots with the HR departments of firms that have pushed deterioration of employer-sponsored plans, the wellness companies offer a "goody bag" of options that appear to help you save money on your premiums.  Well, that's the first step.  The next step is that you get penalized if you don't "comply" with the wellness plan your employer has chosen.  Who won't be able to comply with the exercise and diet programs?  I'm willing to predict it will be disproportionately the lower wage earners.

On this blog, I've documented aspects of how direct-to-consumer approaches have empowered medical device companies to charge consumers for unnecessary costs.  I've pointed out how the medical-industrial-government complex aids and abets such practices through opaque rate-setting and rule-making procedures highly influenced by those same companies.  When those higher costs get passed along directly to consumers, they act as a regressive tax on those with lower incomes.  When they get passed through indirectly through Medicare, they end up stretching the government's budget.  Searching for budget relief, CMS engages in arbitrary penalties for failure to meet arbitrary quality metrics.  Which organizations tend to do worse on those metrics and pay the penalties?  The hospitals serving the lower income portions of society.

Let's look at other industries that have moved in the directions predicted by Daniel for health care--disintermediation and price-to-value--like finance and banking and telecommunications..  While we can point to overall societal gains in each of these fields, the predominant part of the value obtained from these structural changes has tended towards the wealthier components of society.  Why should we expect health care--which is intensely more complex than any of those other sectors--to behave otherwise?

I don't offer these thoughts out of some socialist desire or expectation.  I offer them to remind Lucien and others that their job isn't done until or unless there is a greater democratization of the benefits of all those innovations.  That democratization will not arise from lovingly produced TED talks viewed by the elite in society.  It will require a movement from the patient advocacy world.

That world, however, remains inchoate.  Many patient advocates arrive to this field as a result of personal injury to themselves or a loved one.  They are not trained in the skills needed to build coalitions.  They are on their own, without sufficient resources to get their own word out, much less have the time and energy to meet with other and build a national movement.

There is no established organization in America or, from what I have seen, other countries that has devoted itself to the promotion of a vibrant, widespread patient advocacy movement.  Those that might have done so have shied away from this kind of engagement--perhaps because they know that any movement so constituted will be unpredictable and beyond their control.  Yes, some hospitals seriously try to engage patients in a clinical partnership, using advisory councils and the like, and these efforts are useful.  But they only go so far in that they are islands of activity with little or no crossover beyond the catchment areas of each hospital system.

Years ago, I came to know a wonderful man, V.B. Mishra, who was engaged in trying to stop the pollution of the Ganges River.  He decried the lack of political support for this effort, saying, "The river needs its Gandhi." Well, the truth of the matter is that Gandhi's and Mandela's and M.L. King's come along very seldom and usually only in times of great change and crisis.  During most times, it is not a single leader who brings about change: It is a coalition of many local leaders who figure out how to join hands and bring persistent pressure on the body politic.  Until the patient advocates figure out a way to create that coalition, the lightning will go to ground in a manner that many of us will consider inequitable and inconsistent with the objectives of political stability and economic prosperity for all.

Do they need to get over themselves?

One of the things I enjoy about Australians is the tendency for straight talk, but I wonder if the Premier of Victoria will come to have second thoughts about a recent comment concerning the availability of fast food in the state's children's hospitals.  Here's the issue:

A group of people feel strongly that allowing McDonald's to have a franchise in the lobby of children's hospitals is not appropriate.  As noted in a story by Julia Medew in the The Age:

Public health experts are calling for the new Monash Children's Hospital to exclude fast food outlets and say the Royal Children's Hospital should dump its contract with McDonald's because it is creating a "healthy halo effect" that sends the wrong message to families.

With one in four children overweight or obese, Melbourne University public health professor Rob Moodie said Australia's leading paediatric hospitals should not be supporting multinational fast food chains like McDonald's that targeted children.

"It's hard enough to encourage people to eat healthy foods at the moment. We don't need the branding of some of Australia's most prestigious hospitals lending their support to something that is fundamentally promoting a poor diet. There's a real clash of purpose there."

Premier Daniel Andrews' response to this was offered in Medew's next story:

"I'm also a parent and frankly the notion that it is somehow a bad thing to give a sick child a treat, to give a sibling of a sick child a visit to McDonald's, that is just nonsense and we'll have none of it, none of it at all," he said.  

The premier added that "people who would like to tell parents every single thing they ought do and not do" was "nanny statism" that undermined the power of other advice governments give parents.  

"The McDonald's is here to stay in this health service as part of a balanced offering and that's exactly the outcome we'll achieve at Monash Children's as well," he said.

"There will be no prohibition as some would like and frankly, they need to get over themselves." 

The response:

Professor Moodie and Obesity Policy Coalition head Jane Martin, who both spoke out about the issue last month, said Mr Andrews had missed the point.

"It's not really about whether children should be having these treats or not, it's about whether a children's hospital should be seen to be endorsing the kind of food that McDonald's basically sells. They basically sell nuggets and fries," Ms Martin said.

"Hospitals are dealing with a huge burden of diet-related disease ... This is our new smoking."

The whole issue has been brought into the public consciousness worldwide by a coalition called Value [the] Meal Campaign organized in great measure by Corporate Accountability International.  It seeks "to restrict predatory junk food marketing to children" and block such restaurants in children's hospitals and in schools.

What's your take on this issue?  Please offer comments below.

Young doctors suggest use of evidence and disclosure

A follow-up to an earlier post. Jonathan Giftos, a resident phsyician in primary care and social medicine at Montefiore Medical Center, and his colleague Dr. Sam Cohen attended this session:

Lenox Hill Hospital, part of the North Shore-LIJ Health System, is offering a free informative evening on Thursday, January 8^th from 6-7:30 p.m. with David Samadi, MD, chair of urology and chief of robotic surgery, about what women can do to help keep the men in their lives healthy and happy.  

I include excerpts of Jonathan's report on Facebook without further comment:

Drinking a beer with Dr Sam Cohen after going toe-to-toe with David Samadi at his shameless, chauvinistic, pandering and misleading talk promoting en masse PSA screening in an unselected patient population, described famously by Shannon Brownlee as "the loss-leader for robotic surgery." 

Unsurprisingly, there was no conflict of interest disclosure. Gross deception as he described "screening" as a uniformly good thing that the government is trying to take away in order to save money. Characterizing women as emotional, shop-a-holics and then exploiting their worries over their husbands' health to promote evidence-less medicine for profit was also a highlight. That an academic medical center like North Shore-LIJ Health System allowed this to happen is deeply problematic.

Sam and I got the mic for about 5 minutes. Challenged his blatant disregard for USPSTF recommendations. Challenged his conclusion that because there isn't a better test out there we might as well continue using one that is known to cause more harm than good. He dodged the conflict of interest question and essentially told us to go back to Brooklyn. 

There were no other dissenting views in the room. He ignored my question as to whether someone who earns close to $8 million dollars a year off this test should disclose their conflict of interest when promoting a test so indiscriminately. He responded to Sam's question re: the data that shows en masse the PSA to be more harmful than good by bringing up the wife of a former patient who was diagnosed with early prostate cancer to go on record and "teach us" why the PSA saved her husband's life. The audience clapped. The intellectual dishonesty was tough to watch. He concluded by saying that Elizabeth Hasselbeck is on board with his approach, as we should be. 

All in all, an enormously frustrating event to attend. But glad to stand up against the shameless exploitation of our patients and our healthcare system for financial gain.

Now, what to do with this lousy t-shirt.