Ribbons

I'm all for it when it comes to cancer support groups and advocacy.  Indeed, such support groups have helped many people and have advanced the progress of research.  But I admit to being highly influenced when it comes to ribbons by my late friend Monique Doyle Spencer, who was greatly bothered by the pink ribbon campaign surrounding her disease (breast cancer).  She felt that it had been commercialized to an extreme, especially by the Komen Foundation, allowing companies to profit by their association with it and their use of the logo.

Beyond that, she just had an interesting and thoughtful approach to the disease. As I noted shortly after she died:

Monique signed her comments on this blog with the moniker "NASOV."  When I asked her what it meant, she said, "Neither a survivor nor victim."  She continued, "I have this disease, and I am going to fight it, but I am not a survivor or victim.  I just have a disease.  There are lots of people who are going through worse."

While I can see how differentiated logos can act as a kind of touchstone for people with a specific type of cancer, I also worry that the spread of these multi-colored ribbons might actually undermine the effectiveness of individual groups in garnering support from the public as a whole.  Can we really expect the public to differentiate the type of cancer by whether the ribbon is burgundy or teal? (And by the way, the ribbons go well beyond cancer.)

On the other hand, maybe that's not the purpose.  Maybe it's designed to just send a quiet signal to someone else touched by your disease that they have someone else they can talk to.

I'd be very interested in your thoughts about this topic.

About privilege

An excellent reminder from Toby Morris about how some people--more and more, it seems--end up where they are.  I'm sorry to say, but I see an awful lot of the left-hand plate attitudes from people in leadership positions in hospitals--a belief that they deserve to be where they are, relative to those who've led less privileged lives.

An excerpt, one of a sequence....

(With thanks to Vijay Sadasivan, in Salem, India.)

A notable passing

The New York Times reports on the closing of the F. A. O. Schwarz toy store at the corner of Fifth Avenue and 57th Street.  Many people will remember a scene from the store in the Tom Hanks movie Big.

My memory is related to that scene.  My best friend growing up, Michael Sack, was the son of Harold Sack, one of the brothers who owned and operated Israel Sack, Inc., the most prominent antiques dealer in America.  They sold furniture to Jackie Kennedy at the White House, among other places.  Their showroom was on 57th Street, just a few yards from Schwarz.  As young boys, Mike and I would sometimes accompany Harold to work, and we'd play ball with our pink "Spauldeens" (yes!) among the "old furniture" in the showroom (including some very beautiful and valuable Goddard secretaries and the like.)*

Harold would gently suggest that we go downstairs to the toy store. We did, and we'd spend hours playing air hockey and the like, saving generations of antiques from irreparable harm!

Here's the scene from Big:

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* Another historical note.  Spauldeens were in fact made by the Spaulding Company in western Massachusetts.  The original pink balls were actually the inside core of tennis balls.  The defective ones were sold as playing balls on their own! A nice way of making a profit from cast-offs.

Where you stand . . .

In one of the more interesting demonstrations of "where you stand depends on where you sit," please note the co-author of this well done Perspective article in the NEJM, "The Good Merger." The key quote:

A “good” merger or affiliation is one that increases the value of health care by reducing costs, improving outcomes, or both, thereby enabling providers to generate and respond to competition. The all-too-common alternative is a merger intended to reduce competition — to ensure referral streams (which would otherwise be earned through superior offerings) or to help providers negotiate higher prices and thereby avoid the difficult work of improving outcomes and efficiency.
 
The co-author, Thomas H. Lee, now the chief medical officer of Press Ganey, was previously CEO of Partners Community Healthcare, Inc., and Network President for Partners Healthcare System.

The article advocates for everything Partners is not.

How to fake science

Journalist Johannes Bohannon tells the story of how he crafted an "experiment" that "proved" that eating chocolate helps weight loss--and sold it to millions of readers in the media world. How timely, especially the part about journalistic laziness.  Think of how often the techniques employed here been applied by medical equipment manufacturers and others.  Excerpts, with my emphasis:

Could we get something published? Probably. But beyond that? I thought it was sure to fizzle. We science journalists like to think of ourselves as more clever than the average hack. After all, we have to understand arcane scientific research well enough to explain it. And for reporters who don’t have science chops, as soon as they tapped outside sources for their stories—really anyone with a science degree, let alone an actual nutrition scientist—they would discover that the study was laughably flimsy. Not to mention that a Google search yielded no trace of Johannes Bohannon or his alleged institute. Reporters on the health science beat were going to smell this a mile away. But I didn’t want to sound pessimistic. “Let’s see how far we can take this,” I said.

I know what you’re thinking. The study did show accelerated weight loss in the chocolate group—shouldn’t we trust it? Isn’t that how science works?

Here’s a dirty little science secret: If you measure a large number of things about a small number of people, you are almost guaranteed to get a “statistically significant” result. Our study included 18 different measurements—weight, cholesterol, sodium, blood protein levels, sleep quality, well-being, etc.—from 15 people. (One subject was dropped.) That study design is a recipe for false positives.

It was time to share our scientific breakthrough with the world. We needed to get our study published pronto, but since it was such bad science, we needed to skip peer review altogether. Conveniently, there are lists of fake journal publishers. Since time was tight, I simultaneously submitted our paper—“Chocolate with high cocoa content as a weight-loss accelerator”—to 20 journals. Then we crossed our fingers and waited.

Our paper was accepted for publication by multiple journals within 24 hours. Needless to say, we faced no peer review at all. The eager suitor we ultimately chose . . . emailed Johannes to let him know that we had produced an “outstanding manuscript,” and that for just 600 Euros it “could be accepted directly in our premier journal.”

With the paper out, it was time to make some noise. I called a friend of a friend who works in scientific PR. She walked me through some of the dirty tricks for grabbing headlines. It was eerie to hear the other side of something I experience every day.

The key is to exploit journalists’ incredible laziness. If you lay out the information just right, you can shape the story that emerges in the media almost like you were writing those stories yourself. In fact, that’s literally what you’re doing, since many reporters just copied and pasted our text.

Take a look at the press release I cooked up. It has everything. In reporter lingo: a sexy lede, a clear nut graf, some punchy quotes, and a kicker. And there’s no need to even read the scientific paper because the key details are already boiled down. I took special care to keep it accurate. Rather than tricking journalists, the goal was to lure them with a completely typical press release about a research paper.

I felt a queazy mixture of pride and disgust as our lure zinged out into the world.

When reporters contacted me at all, they asked perfunctory questions. “Why do you think chocolate accelerates weight loss? Do you have any advice for our readers?” Almost no one asked how many subjects we tested, and no one reported that number. Not a single reporter seems to have contacted an outside researcher. None are quoted.

There was one glint of hope in this tragicomedy. While the reporters just regurgitated our “findings,” many readers were thoughtful and skeptical. In the online comments, they posed questions that the reporters should have asked.

Scripting Scripps

Gary Schwitzer and his buddies at Health News Review are the experts in critiquing medical stories, noting:

The mission of HealthNewsReview.org is to improve the public dialogue about health care by helping consumers critically analyze claims about health care interventions and by promoting the principles of shared decision-making reinforced by accurate, balanced and complete information about the tradeoffs involved in health care decisions. HealthNewsReview.org evaluates health care journalism, advertising, marketing, public relations and other messages that may influence consumers and provides criteria that consumers can use to evaluate these messages themselves. Improving the quality and flow of health care news and information to consumers can be a significant step towards meaningful health care reform.

In this respect, they are performing an excellent public service.  As a sole writer in my home office, I can't keep up with their expertise and output, but every now and then, a story comes along that deserves some commentary.

I really don't want to keep writing about proton beam therapy, but here's the latest from HealthLeaders Media.  Read it and weep:

The facility that houses the pencil-beam PBT devices at Scripps is owned by Advanced Particle Therapy, which spent about $220 million to develop the site. Even with that jaw-dropping price tag, Scripps has managed to achieve cost-competitiveness with photon-based treatments for some tumors, including early-stage breast cancer, Rossi told me.

"We can treat patients in two weeks compared to as many as seven weeks with other forms of radiation therapy. … We're able to treat them in a faster manner, with the same toxicology and the same side effects. It also cuts the costs of treatment dramatically."

Although Rossi declined to name names, he says two commercial payers have concluded that pencil-beam PBT at Scripps is delivering more cost-effective treatment for early-stage breast cancer than comparable photon-based radiation treatment. "Insurers have looked at this and said we are cheaper and contracted on that basis."

In the PR business, we call this "earned media." It's essentially an advertisement that hasn't been paid for.  There is no critical analysis of the points made by the protagonist.  There's no alternative view presented on the contentions offered.  Let's deconstruct:

The facility in question represents $220 million in capital costs that has to be amortized over some period of time.  In addition, there are operating expenses.  The method of how those costs are amortized over each early-stage breast cancer case is not stated.  Specifically how much is the fully loaded cost of two weeks of proton beam therapy compared to the fully loaded cost of seven weeks of photon therapy at Scripps or other institutions? Since we are not presented with those basic assumptions, there is no way to independently evaluate the basic contention, that Scripps has managed to achieve cost-competitiveness with photon-based treatments.

We also are told that two commercial payers have concluded that the therapy is more cost-effective, but Rossi declined to name names. Why on earth would you print such an assertion--made by a clinician--on behalf of insurance companies without verifying it with the primary sources. (I can understand when reporters allow sources to remain anonymous for reasons of national security or personal risk or commercial privacy, but here, the sources haven't even been interviewed.)

There are many other thoughtful and interesting parts of the story, but those are "after the turn." Most people will not get to page two or three of the article, and thus the main impression is that Scripps has done something that no one else in the industry has found to be possible.

I'm thinking that Schwitzer et al should start to conduct training programs for their colleagues in journalism.

Dear CMS, price matters

Your government at work.  Here's the pertinent quote from Melinda Beck's Wall Street Journal article on proton beam therapy:

But some insurers are balking at paying premium rates for proton therapy for such common cancers without more evidence that it does improve patient outcomes—ideally from randomized controlled trials. Several are now under way, but it will be years before results are clear.   

Most Medicare regions cover proton therapy for prostate—at about $1,100 per treatment session, compared with $600 for IMRT. But several major insurers stopped after a 2012 study found it has no added long-term benefit. Men with prostate cancer had made up 70% of patients at some proton centers; now they are less than half the facilities’ customers nationwide. 

It's time for the government to have the spine and judgment to change its pricing for this therapy.

As I have noted earlier, where are the Triple Aim advocates on this point?

Lean double header all-star session

Each summer, I particpate as a faculty member in an executive education short program at MIT called "Technology, Organizations, and Innovation: Putting Ideas to Work." We spend several engaging days with students from around the world.  They represent a wide range of industries.

From the course summary:

Innovation typically begins with a new technical concept or other bright idea. But the idea is just the first step on the long path to successful innovation. Technical change usually requires organizational changes as well. These changes include providing resources for technical development and acquiring the support of others in the organization or in outside organizations. Gaining this support requires negotiation, bargaining, and coalition building. Organizational change, then, is a very complex process. Change of this sort can be very difficult. Significant innovations can be resisted, fall victim to competing ideas, or fail to be sustained.

Thus innovators need their original idea and a vision of how the world will change if the innovation succeeds. The real bottleneck in achieving success is the organizational change needed for implementing that idea. This course focuses on strategies to overcome the bottlenecks: how to build the needed coalition of supporters who will enable the necessary organizational change. This change process is not captured by simple cookbook procedures, so we will investigate a variety of detailed, original case studies, rich in lessons for innovation success and failure. The cases are drawn from many sectors, public and private, from the U.S. and other countries. We will also explore the diversity of innovation experiences of the class participants.

Lean is always part of our agenda, and this year there is a Lean double header all-star session, with Jim Womack and John Shook presenting together.  It isn't often that you get to hear from and interact with the two most famous and influential Lean adherents in the world, and this should be a treat!

There will also be a visit to the Cambridge Innovation Center, a hotbed of start-ups in Kendall Square.

There are still some openings for the course, which runs from June 22 to 26.

Captivated by captives

One of the educational benefits of being CEO of one of the Harvard-affiliated teaching hospitals was that I also served on the board of our captive insurance company, CRICO, and its subsidiary, the Risk Management Foundation.  Like many people, I had not previously understood the ins and outs of risk retention groups, medical malpractice insurance, and risk management, and so this was a great experience.

As noted on its website:

In 1976, the crisis of insurance availability led the Harvard Medical Institutions to form a “captive” medical professional liability insurer, CRICO, an offshore insurance company operating and domiciled in the Cayman Islands. Harvard's model of creating an offshore captive—an insurer owned by the facility or health care system it exclusively insures—was later replicated by other health systems across the U.S. 

Risk Management Foundation of the Harvard Medical Institutions, Inc. (RMF) was established in 1979 to apply a data-driven approach to claims management and patient safety on behalf of our insured organizations. 

This has been a very successful organization on many fronts, not only in defending unwarranted malpractice asserts, but, more importantly, looking at the risk profile of the affiliated institutions and designing training programs for clinicians to help provide safer care.  Those programs are worth a look and might be informative to other health systems.

But my topic today is not CRICO.  It's about the panoply of captive insurance companies that have been set up across the country, and it's about probing what we might learn about safety and quality improvement from their results.

This paper by ProMutual Group contains some basics about the business model that must be followed by captives.  To a great extent, they must mimic other insurers:  Without a proper actuarial base, good financial management, and good claims management, they will fail.

Fundamentally, from an economic and operational perspective, captives are similar to traditional insurance companies, to the extent that a captive collects premiums from selected individuals and entities, invests its assets, provides services, and, eventually, pays claims. Any surplus or deficiency is either paid to or paid by the owners of the captive insurer, which are, for the most part, the insureds. 

Where the captive differs from a commercial insurer is that the owners--because they are also the insured--should have a strategic interest in reducing the likelihood of claims over time.  Indeed, as noted above, the RMF function of CRICO was focused on that purpose.

This got me wondering.  Could we measure the success of hospitals and physician groups in improving the safety of care by the degree to which malpractice asserts for those organizations declined over time? After all, everything else being equal, if safety has improved, the chance of doing harm and being sued should drop.

Further, to the extent a captive is successful at helping its members carry out risk management programs, shouldn't actuarial assumptions be modified, and shouldn't premiums go down?  Also, since previous premiums were based on old actuarial assumptions, shouldn't an effective captive generate a surplus in earnings that should be returned to its members?

(By the way, if there is a surplus to be returned, the question of who should get it--the hospitals, the doctors in general, or certain specialists in particular--should prompt a very interesting negotiation!  We'll leave that topic for another day.)

So, here's my challenge to those of you in hospitals and physician groups served by a captive medical malpactice insurance company:  What do the financial characteristics of your captive tell you about the change in safety performance of your hospital or your physician group?  Or turning the question around, if you know that the safety of your hospital or your physician group has improved, how has your captive dealt with that improvement?  Have premiums gone down? Have surpluses been returned?

Since your captive is owned solely for the benefit of, and is governed by, people from your organizations, you have a right to know the answers to these questions.  Maybe it's time to ask.

The Triple Aimers have missed the mark

This is one of those columns that will risk the respect and friendship of some of my closest colleagues in the health care world.  In addition to disagreeing with me, they may argue that I am giving aid and ammunition to "the enemy," where the enemy might be viewed as those forces in the health care world who really don't want things to change. But as you shall see, I will assert that it is those very colleagues who--by focusing on an overly simplistic ideological approach to health care policy--are inadvertently giving succor to that same group by providing political cover for nefarious behavior.

I refer to many of the most prominent advocates of the Triple Aim.

As set forth in this article and elsewhere, the Triple Aim is described as follows:

Work to improve site-specific care for individuals should expand and thrive. In our view, however, the United States will not achieve high-value health care unless improvement initiatives pursue a broader system of linked goals. In the aggregate, we call those goals the “Triple Aim”: improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations.

At first blush, who can argue with this set of desiderata?  The three components seem ineluctable.

But policy-making is not so simple as setting forth seemingly self-evident or self-fulfilling goals.  Policy-making must take place in the cauldron of competing private and public interests. The transmogrification of goals into policies, statutes, regulation, and corporate and individual action can be ugly and can result in unintended consequences.  It is on this point that I argue that the Triple Aim has been hijacked.

It has been hijacked by powerful political and economic forces--often represented by the nation's hospitals in general and by academic medical centers in particular--but also aided and abetted by federal action.

The clearest representation of the Triple Aim, baked into federal legislation and supported by many health care advocates, is the creation of Accountable Care Organizations (ACOs.)  The idea is that a group of health care institutions and practices in a given geographic area will join forces as an ACO to provide management of care across the continuum of care. The argument goes further, that by shifting from a fee for service rate-making formula to one based more on an annual per capita (risk-adjusted) budget, the ACO should have an interest in the health of the population--resulting in an increase in wellness programs, preventative care, early intervention, and a decline in more expensive hospitalization and procedures.

An interesting policy hypothesis, but what happens when policy turns to practice?  First, we see that the dominant player in many an ACO is the community's academic medical center (AMC) or tertiary hospital. It is not the local multi-specialty practice that has the long-term relationship with a person or family, and which might shop among the region's hospitals for the best care patterns and cost efficiency. No, the area's largest hospital is the one that sets up the ACO in most places and controls its governance and cash flow.

As a matter of corporate structure, a general hospital is often an exemplar of an over-capitalized, inflexible organization with an excessive amount of overhead.  As Clayton Christensen has noted:

The traditional general hospital is not a viable business model. . . . [T]he agglomeration of many  business lines and a desire to serve all kinds of patients results in a very high overhead burden rate -- roughly $9 for every $1 spend on direct patient care.

In light of this corporate structure, many hospitals have best been defined as "cost centers in search of revenue streams." As I have noted:

It's not that the doctors and nurses are any less caring or dedicated, but rather that the leaders of these centers have become calcified with regard to their social mission.  They focus instead on expanding market share, growing margins, and attracting philanthropists to contribute to unnecessary and flamboyant edifices.  They have no real interest in reducing costs, but rather in obtaining and securing revenue streams to cover ever-increasing costs.  Most importantly, they neglect the harm they cause to patients in their facilities, preferring to assert that they deliver high quality care without being willing to be transparent with regard to actual clinical outcomes.

I hesitate to give examples, for fear that they will be considered simply as anecdotes.  But the trends they demonstrate are more pervasive than anecdotal.  Plus, it is important that we look at the some of the organizations often cited as among the best in the country.  Places like Mayo Clinic, investing $180 million in a proton beam facility when there are similar facilities within easy traveling distance for those very few families who can benefit clinically from them. Places like North Shore-Long Island Jewish, belying its stated strategic objectives ("to realize cost efficiencies and ensure patient safety through adherence to best practices") by providing space, support, and publicity for a prominent doctor who affirmatively advocates overuse of diagnostic tools.  Places like the University of Illinois-Chicago, the University of California, and dozens of others who gladly accept "walking around money" for themselves and their surgeons from a medical equipment supplier to invest in market-share-growing robotic surgery.

It would be one thing if the tertiary hospitals and AMCs just engaged in revenue-generating activities.  But using the "population health" rubric of the ACO, they seek to consolidate market power by acquiring other facilities and practices in their geographic area.  And those same hospitals often attempt to foreclose consumer choice by purchasing electronic medical records systems that are not interoperable outside of their network and forcing that choice on their newly acquired clinical partners. Regular readers know that my favorite local example is Partners Healthcare System, but others have documented the same pattern in New York and elsewhere.  The goal is simple, to have leverage over local insurers to drive rates up.

In addition, the hospitals, the equipment manufacturers, and the investment counselors use their political clout to obtain favorable ratemaking treatment from the federal government for expensive new technologies, either to get paid directly from CMS or to allow excess payments from consumers.

Here's my point in going through all this background: We hear little or nothing from the prominent Triple Aim advocates about this tremendous use of political and economic power, power that is limiting customer choice and raising costs.  Instead they focus on Triple Aim "fixes," mainly in terms of insurance plan design and reimbursement penalties that are supposed to support their population health objectives.

But do those fixes work?  What about the adverse impacts on low income families when insurers and employers push high deductible health plans (ostensibly to get consumers more engaged in health care spending) because overall costs are rising?  What about poorly constructed penalties, like the one on readmissions, that have an adverse impact on safety net hospitals?  The comment I most often get on the latter matter is, "Well, it's not a perfect measure, in the grand scheme of things, but it has moved hospitals to focus on the discharge process in a far more meaningful way, and that's making a difference."

Is that really the best the Triple Aim advocates can do?  While billions are being extracted from insurers by growing monopolies, while billions more are being extracted from all of us by complicity between hospitals and equipment manufacturers, while low income families are forgoing care because they can't afford the deductible, we relish a single digit percent improvement in readmissions that has the consequence of hurting facilities carrying for the poor?

And where is the outrage when an entire industry arises around unsupported wellness programs, leading employers to engage in expensive and coercive practices with employees?

Look, there's nothing wrong with the Triple Aim objectives.  What's wrong is that its most prominent advocates--some of the most influential health care experts in the country--have focused so heavily on that ideological approach to health care policy that they have absented themselves from the real battles over power, money, customer choice, and cost.  They are losing ground every day.  While they glance elsewhere, the Triple Aim is being turned on its head: The individual experience of care will degrade; the health of populations will decline; and the per capita costs of care for populations will rise.

A strong sense of purpose from "the bottom"

Melanie Evans at Modern Healthcare reports: "One of the nation's largest health systems, Ascension Health, will for the first time set a system-wide minimum wage of $11 an hour."

This is good and as it should be, but these folks are slow to have made these changes.

A decade ago, when I was CEO of Beth Israel Deaconess Medical Center, I made a decision that no one in our hospital should be paid less than $10 an hour.  There was no market-based reason to change their wages.  Other Boston academic medical centers were also paying their lowest paid workers--housekeepers, transporters, and food service workers--below $10 an hour.  I just thought it was wrong for a health care organization, particularly one with a faith-based heritage, to pay people so little.

Later in 2009, when the majority of people in the hospital made sacrifices and took pay and benefit freezes to help avoid layoffs during the  recession, we exempted those same low-wage earners from having to make any such sacrifices.

It's been my experience that hospital managers often forget about this group of vulnerable workers even though, as you think about it, they have more interactions with patients than anybody else in the hospital.  I always found them to represent the heart and soul of organization. As Gloria Martinez, one of our transporters, once said to me and our Board:

We view our job as providing the kind of care we would want for members of our own family.

Let's never forget that the "bottom of the organization" has just as strong a sense of purpose as those highly trained and better paid doctors and nurses! Our job, as hospital leaders, is to remember that and treat them with the caring and respect they deserve.

A different kind of help for migraines

With the growing concern about the use of opioids, I recalled a Chronicle program from a few years ago in which Dr. Carolyn Bernstein explains other types of therapies that can help mitigate the pain and distress of migraine headaches.  Here's the link to this short segment.

In their own words

As the country moves toward ever greater concentration of market power in hospital systems, it is worthwhile to look back to the "mother" of all mergers, the creation of Partners Healthcare System in the 1990s.  This event should provide a warning to other parts of the country, as it resulted in substantially higher rates for this health care system compared to others in the state.  For those who think that creation of ACOs, as encouraged by federal legislation, is likely to reduce costs to insurance companies and consumers, think again.

This kind of market dominance often comes with a plausible sounding--but deeply flawed--rationalization by those who achieve it. As an example, here is a video of the president of Massachusetts General Hospital describing why their high rates were necessary and how they used the creation of Partners to achieve this result.

Start at minute 42:00 when the question is asked and follow through for just five minutes.  Listen carefully to the response.  As you face similar issues in your region of the country, it's important to deconstruct what's being said and what isn't being said.

I'll paraphrase portions of the answer, add emphasis, and reorder things to create some adjacencies for purposes of this discussion:

One of the reasons that Partners was created was that the insurance companies were playing MGH and the Brigham off against each other.  We came together and now insurers have to take both of us or neither of us and that has helped level the playing field with the insurers.

We built an organization that could level the playing field with the insurers.  Unfortunately, not many other provider organizations in this state did that, and now we're viewed as the problem when we negotiated rates that we thought were reasonable and others didn't become more indispensable and didn't increase their leverage vis-a-vis the payers and weren't able to get rates as high as ours.

This is what market dominance looks like, a chart showing the size of PHS relative to other healthcare systems in the state:

The creation of Partners was not just about joining the two tertiary hospitals into one group. The merger also brought in a number of community doctors and thousands of physicians. Those tertiary discharges shown above are the result of this immense referral network.  While it might have been theoretically possible to create another system of comparable size, it was not practical to do so.

Indeed, once PHS had higher rates, it could pay more to unaffiliated community-based doctors and grow its referral base even further, building still more market power.

What were those rate "requests?"

We were very judicious in what we asked for.  We compared our rates with other teaching hospitals around the country that we compete with--Johns Hopkins, Mayo, Cleveland Clinic, etc.--and we set out to get reimbursement that covered [our] costs

Similarly on physician contracts.  We did some studying to see what academic physicians in other parts of the country were getting.  We were losing physicians because we couldn't match salaries in Cleveland etc.  So we set out to get physician salaries that were comparable to other parts of the country.

Putting aside whether there is really much competition for patients across the country, seeking rates based on other regions in which other dominant systems exist was merely using other monopoly pricing power to justify the results that Partners sought here.  In addition, PHS was not just setting rates for its academic functions.  Those high paying insurance contracts also covered the PHS community hospitals and community-based doctors.  The leverage gained was system wide, not just for the two tertiary centers.

When Blue Cross Blue Shield balked during the first PHS negotiation at the level of rates, PHS CEO Sam Thier's words to the CEO of BCBS were, "This is what good health care costs."  The insurance company acceded.  When Tufts Health Plan balked, PHS simply threatened to leave them out of the network. Tufts folded with 72 hours.

Recall this comment from 2010 to understand the persistence of the degree of market power exercised:

"Andrew Dreyfus, executive vice president of health care service for Blue Cross Blue Shield of Massachusetts – the state's largest insurer – said he doesn't believe his company has the market power to eliminate disparities in the way doctors and hospitals are paid for their services."

If you look at markets around the country, in every market there is variability in payments.  For example, in New Hampshire, Dartmouth has very high rates.  Premiums in MA are fourth highest in NE, not highest.

Yes, there is variability. But it is in the range of five, or maybe 10 percent. In Massachusetts, PHS' rates can be 30% or more above those paid to other hospitals and doctors.

And note how he then he switches from rates to premiums.  Premiums are based on the total mix of payments made by insurers, across all providers.  A focus on premiums masks the fact that because PHS rates are higher, those to other hospitals and doctors are forced down.

And then the ultimate canard:

What we've done with those rates.  Our psychiatry program is one example. If our rates get cut dramatically, that's in jeopardy.  Ditto for five neighborhood health centers caring for the poor.  We have to invest in infrastructure to support our research program, the largest in the country.  We use our rates to help support our research program.  We invest in a lot of public goods as result of those rates.

Teaching hospitals have special mission: research, education, specialized units, taking care of more poor people. That's what's in jeopardy if our rates are equalized with community hospitals.

Notice how the conversation is switched to one of apples and oranges--what MGH should  be paid relative to other system's community hospitals.  The reports produced by the Attorney General did not suggest that the rates for PHS academic centers were too high relative to community hospitals: The showed that they were too high relative to the other academic centers--all of whom offer the public goods as well.  The analyses also showed that the rates paid to the PHS community hospitals were too high relative to other community hospitals. They also showed that rates paid to PHS community doctors were too high relative to those paid to other community doctors.

The evidence from Massachusetts is that once you let the market power horse out, it will be too late to close the barn door. Notwithstanding consistent evidence of the adverse impact on healthcare costs from PHS' dominance, there is no state action that has reversed it.  Indeed, recent "cost control" legislation in the state is a nullity when it comes to reducing the disparity in provider rates in the state.  By its language, the law bakes in the PHS advantage.  By its interpretation thus far, it has done even worse, permitting PHS to have a larger increase on a larger base than other systems.

Here's hoping it is not too late in your state.

Hep C irony renews questions of public confidence

In a nice touch of media irony, on the very day that Gilead Sciences, Inc. purchased a full page ad in the New York Times (web version here) talking about "new resources" available to fight Hepatitis C, a story by Andrew Pollack started with this lede:

Activists in several countries are seeking to void patents on the blockbuster hepatitis C drug Sovaldi, saying that the price being sought by the manufacturer, Gilead Sciences, was prohibitive.

The Initiative for Medicines, Access and Knowledge, a legal group in New York, is expected to announce Wednesday that it has filed challenges in Argentina, Brazil, China, Russia and Ukraine. In all those countries except China, the organization is being joined by local patient advocacy groups.

The actions are a sign that the controversy over Sovaldi is spreading beyond the United States, where the $84,000 charge for a course of treatment has strained Medicaid budgets, to middle-income countries.

My purpose today is not to offer an analysis of the pro's and con's of this issue. There's plenty of that discussion elsewhere.

My purpose instead is to again bring up the slippery slope that exists between academia and pharma.  As I discussed a year ago, when this controversy first arose, one of the board members of Gilead is Richard Whitley, a distinguished infectious disease doctor and researcher at the University of Alabama at Birmingham, who receives over $400,000 per year as compensation in his board role.  As I said then:

We can only imagine the extent of Dr. Whitley's personal commitment to eradicating disease.  This is truly an outstanding record.  I'd bet, too, that he would strongly support expanded access to Sovaldi for humanitarian reasons.  But in all the searches I have done, I can find no public statements from him concerning the financial issue raised in Andrew Pollack's [earlier] story.  Indeed, it would be very difficult for someone on the Gilead board to make a statement about such matters, as it would be viewed as inconsistent with the duty of loyalty and care required of corporate directors.

An extremely respected scientist with Dr. Whitley's credentials could be among the most qualified in society to "referee" this kind of issue--to help us understand and balance the legitimate financial needs of the pharmaceutical industry with the equally important humanitarian concerns about a drug's availability and cost in America.  He cannot do so while on the board of the company producing the drug. The loss to society is that someone of Dr. Whitley's expertise and compassion is taken out of the public debate on these matters.

Beyond that, what does his silence on this issue say to the country about his duty to two masters, a federally subsidized drug research effort and a pharmaceutical company? What message does that send to the public about how they should view the relationships between academic medical centers and industry? I think it doesn't help either sector retain the public's confidence.

Norman learns to show respect . . . again

I had the pleasure of meeting Norman Faull late last year in Johannesburg when we presented together some thoughts on process improvement to South African hospital folks. He is as kind, thoughtful, and respectful a person as you could imagine.  So when he reports that he is not necessarily respectful, I take notice.  His message is important, so please stick with me--especially if you are a Lean advocate or practitioner.

Here's a recent column he wrote.  Excerpts:

Some of us are not very good at showing respect.

‘Show respect’ is one of the core calls we make to lean leaders. That simple phrase was presented to me at a Lean Summit in the USA around 2007. The speaker was John Shook and he was quoting from a conversation that he had recently had with his former Toyota boss and then Global Chairman of Toyota, Fujio Cho. It was the third of ‘Three keys to Lean Leadership’; John presented them thus (in these exact words):

1. Go See – “Senior management must spend time on the shop floor.”
2. Ask Why – “Use the ‘Why?’ technique daily.”
3. Show Respect – Respect your people.

The cherry on the top for me was when John gave us Cho’s expansion on the last point: you respect a person when you work with them with an attitude that shows you believe in them.

And here is the important bit of self-awareness:

I’m not good at this ‘show respect’ thing. Not that I want to be disrespectful, but I like my thinking and feeling to flourish. And all too often I do this by telling and advising, rather than asking others for their thoughts and reflections, because I think I have the answers so why waste time in asking.

And the particular example:

I had a good lesson a few weeks ago. I was sitting in on a meeting between members of the Gauteng Department of Health first cohort of lean learners and an embattled departmental team at a busy public hospital.

The learners presented their analysis. The departmental staff listened patiently. Without pushing the point, the learners were suggesting a reallocation of staff, from areas of low intensity to the bottleneck process. At a certain point they asked the departmental staff, “What do you think would help to reduce waiting time for the patients?”

“We need more staff,” came the reply. And I sighed in silent exasperation, as I have too often heard this kind of reply, a reply that shows that the analysis set out has not been understood. It is also the reply you get before you even start the analysis. So my knee-jerk is to explain all over again, running the risk of sending a message of impatience and exasperation, rather than respect, to my colleagues.

Fortunately it was not my meeting. So the response was far better. “If you had more staff, where would you allocate them?” was the response from the lean learners. With that question the discussion could continue ‘with respect’ and with thinking and feeling fully engaged.

The message:  Even those versed in Lean--and especially those overconfident about the power of Lean thinking--need occasional reminders about how to show respect.

Seeing things clearly at the children's hospitals

It's hard to overstate the importance of the work being done by the multi-state Children’s Hospitals’ Solutions for Patient Safety (SPS) Network.  What started as a cooperative effort among the Ohio hospitals--"We compete on everything, but we don't compete on safety"--has spread beyond, representing over 70 pediatric hospitals across the country.

The network sets forth an urgent mission: To eliminate serious harm across all children’s hospitals.

They note:

The Network has compelling evidence that shows that if the SPS Prevention Bundles are implemented reliably, the Network will reduce harm.

Employing high-reliability concepts and quality improvement science methods, SPS is focused on reducing harm by preventing readmissions, serious safety events, and the ten hospital-acquired conditions (HACs) below:

• Adverse drug events (ADE)
• Catheter-associated urinary tract infections (CAUTI)
• Central line-associated blood stream infections (CLABSI)
• Injuries from falls and immobility
• Obstetrical adverse events (OBAE)
• Peripheral intravenous infiltration and extravasations (PIVIEs)
• Pressure ulcers (PU)
• Surgical site infections (SSI)
• Ventilator-associated pneumonia (VAP)
• Venous thromboembolism (VTE)

And, significantly, they are measuring the results and are posting the outcomes for the world to see.  Check that out here.  I post just one example for illustration.

And for those who argue that the key to quality and safety improvement is government regulation and changes in hospital and physician pricing, look at this summary:

Through implementation of the Network’s best practices, children are being protected from harm. Since 2012, this national effort has led to an estimated savings of more than $79 million and saved 3,699 children from serious harm, with a consistent upward trend in harm prevented every month.

These doctors and nurses and their associated hospitals are doing what they are doing not because the government is telling them to and not because rate structures may or may not have changed--but because it is consistent with their sense of purpose and motivational to them as professionals.

Now, if we could just get the adult hospitals to grow up and follow the lead of the children's hospitals!

In Washington State: It's not NICE, but it's good.

Back in 2006, the state of Washington enacted a law creating the Washington State Health Technology Assessment Program. Since 2007, the state's Health Care Authority has administered a Health Technology Clinical Committee (HTCC)--composed of eleven independent health care professionals who review information and render decisions at open public meetings. They determine whether and how selected health technologies (medical and surgical devices and procedures, medical equipment, and diagnostic tests) are covered by several state agencies. Participating state agencies include the Health Care Authority; Department of Social and Health Services (Medicaid); Labor and Industries; Department of Corrections; and Department of Veterans Affairs. In some respects, the program is analogous to the United Kingdom's National Institute for Health and Care Excellence (NICE), which performs similar functions for the National Health Service.

The agency sets forth the following problem statement:

New innovations in medicine, even in the last ten years, have improved the health and lives of patients, yet they have come at a high cost in terms of health, safety, and affordability. Health care spending and costs are rising dramatically, but patients in the U.S. are not getting healthier nor using health care that is available, recommended, and proven to work. Medical products and treatments are introduced without independent, scientific evidence about whether they are safe, effective, and provide benefits that are better than existing alternatives. The information age has compounded the problem – there is a flood of information, but doctors and patients don’t have the tools or the time to sort through it all.

It engages in this process:

[Chosen] technology topics will be posted for thirty (30) days to gather public comment. An impartial research firm, called a Technology Assessment Center, will then conduct a review of the evidence about safety, effectiveness, and cost comparisons and write a report that summarizes the evidence and the methods used to analyze it. These assessment reports typically take between two and six months to complete. Once the report has been completed, it is given to the Health Technology Clinical Committee. The clinicians on the committee will use the evidence report to decide whether the technology is shown to be safe and effective; whether Washington state agencies will pay for the technology; and under what circumstances. The initial review and decision process will take between six and twelve months, and technologies will be considered for re-review at least every eighteen months.

So what did the HTCC conclude about proton beam therapy?  They unanimously decided that its use should be restricted to clinically appropriate cases, based on the best available scientific evidence.

Proton Beam Therapy is a covered benefit with conditions for: Ocular cancers; Pediatric cancers (e.g., medulloblastoma, retinoblastoma, Ewing’s sarcoma); Central nervous system tumors; Other non-metastatic cancers with the following conditions: Patient has had prior radiation in the expected treatment field with contraindication to all other forms of therapy; and at agency discretion.

Proton Beam Therapy is not covered for all other conditions.

Well, here we go.  One state, at least, has the sense to mandate that clinical effectiveness analyses take place and the spine to take on the medical-industrial-hospital complex in disapproving clinically unsupported uses of a high-cost technology.

At the national level, it's another story, as noted in this 2014 Modern Healthcare article by Jaimy Lee:

The CMS hasn't issued a national coverage decision for proton-beam therapy. All local Medicare contractors have approved paying for the treatment.

In a 2013 Brookings Institution paper, [Amitabh] Chandra wrote that the willingness of Medicare to cover the average total cost of proton-beam therapy is incentivizing hospitals to build centers that cost hundreds of millions of dollars and also to “run through as many prostate cancer patients as possible to pay off the bonds.” Other policy experts, writing in the New York Times' opinion page, called proton-beam therapy “crazy medicine and unsustainable public policy.” 

(Note:  Thanks to @pash22 on Twitter for the lead on this story.)

Wachter and Jha trudge through the CMS readmissions Slough of Despond

When two of my favorite observers of health care policy talk, I pay attention.  So I was captured by Bob Wachter's comment on Twitter:

.@ashishkjha blog on readmissns is mastrpiece: rigorous anlysis, wise interpretatn, willing 2 change mind w/ new data

Recall that Ashish was pretty hard on the readmissions penalty in the past, citing the disproportionate impact on safety net hospitals.  In March 2014, I summarized an earlier piece prepared by him and Karen Joynt here:

Over two years ago, I summarized a research paper from Karen E. Joynt and Ashish K. Jha at Brigham and Women's Hospital that suggested that a one-size-fits-all readmission rate penalty policy would have the unintended consequence of harming safety net hospitals.  They said: 

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

So, I was intrigued by Bob's summary, limited by Twitter to 140 characters. The click-through got me to Ashish's article, here. Here's the lede:

I was initially quite unenthusiastic about the HRRP (primarily feeling like we had bigger fish to fry), but over time, have come to appreciate that as a utilization measure, it has value. Anecdotally, HRRP has gotten some hospitals to think more creatively, focusing greater attention on the discharge process and ensuring that as patients transition out of the hospital, key elements of their care are managed effectively. These institutions are thinking more carefully about what happens to their patients after they leave the hospital. That is undoubtedly a good thing. Of course, there are countervailing anecdotes as well – about pressure to avoid admitting a patient who comes to the ER within 30 days of being discharged, or admitting them to “observation” status, which does not count as a readmission. All in all, a few years into the program, the evidence seems to be that the program is working – readmissions in the Medicare fee-for-service program are down about 1.1 percentage points nationally. To the extent that the drop comes from better care, we should be pleased.

OK.  But on a key point, Ashish has not changed his tune at all:

HRRP penalties began 3 years ago by focusing on three medical conditions: acute myocardial infarction, congestive heart failure, and pneumonia. ... [W]e know that when it comes to readmissions after medical discharges such as these, major contributors are the severity of the underlying illness and the socioeconomic status of the patient. The readmissions measure tries to adjust for severity, but the risk-adjustment for this measure is not very good. And let’s not even talk about SES.

The evidence that SES [socieoeconiomic status] matters for readmissions is overwhelming – and CMS has somehow become convinced that if a wayward hospital discriminates by providing lousy care to poor people, SES adjustment would somehow give them a pass. It wouldn’t. As I’ve written before, SES adjustment, if done right, won’t give hospitals credit for providing particularly bad care to poor folks. Instead, it’ll just ensure that we don’t penalize a hospital simply because they care for more poor patients.

On surgery, he reaches a different conclusion:

Surgical readmissions appear to be different. A few papers now have shown, quite convincingly, that the primary driver of surgical readmissions is complications. Hospitals that do a better job with the surgery and the post-operative care have fewer complications and therefore, fewer readmissions. Clinically, this makes sense. Therefore, surgical readmissions are a pretty reasonable proxy for surgical quality.

He looks at the data, and summarizes the program's experience over three years:

Your interpretation of these results may differ from mine, but here’s my take. Most hospitals got penalties in 2015 and a majority have been penalized all three years. Who is getting penalized seems to be shifting – away from a program that primarily targets teaching and safety-net hospitals towards one where the penalties are more broadly distributed, although the gap between safety-net and other hospitals remains sizeable.  It is possible that this reflects teaching hospitals and safety-net hospitals improving more rapidly than others, but I suspect that the surgical readmissions, which benefit high quality (i.e. low mortality) hospitals are balancing out the medical readmissions, which, at least for some conditions such as heart failure, tends to favor lower quality (higher mortality) hospitals. Safety-net hospitals are still getting bigger penalties, presumably because they care for more poor patients (who are more likely to come back to the hospital) but the gap has narrowed. This is good news. If we can move forward on actually adjusting the readmissions penalty for SES (I like the way MedPAC has suggested) and continue to make headway on improving risk-adjustment for medical readmissions, we can then evaluate and penalize hospitals on how well they care for their patients. And that would be a very good thing indeed.

As Bob suggests, and as comes as no surprise to those of us who know Ashish, he looks at the data and gives his best view of what it all means.  The message for me, though, is a bit less pleasing.  It is clear that this whole program had an insufficient analytical and clinical basis at the start, might be improving a bit, but is a lot of time and effort spent on the wrong things. As things at CMS wend through a statistical Slough of Despond on this issue, the agency knowingly contributes to billions in waste in the system by employing rate structures and regulatory rulings that enable high cost technologies to propagate throughout the land, often in ways that harm the very constituency they are charged with protecting.

A Cerberus exit strategy for Carney Hospital: The SEIU

Jessica Bartlett at the Boston Business Journal reports that Steward Healthcare System, owned by private equity firm Cerberus Capital Management, has named Walter Ramos, CEO of DotHouse Health, a health center in Dorchester, to be the new CEO of Carney Hospital.  By all accounts, Mr. Ramos is an excellent choice, with a good administrative background and understanding of the needs of the neighborhood.

No, what's more interesting about Jessica's story is her placement of two sets of assertions.  Here's one from Steward's president:

“Carney Hospital is in the midst of an exciting resurgence. In recent years, Carney has consistently earned national awards for quality patient care, grown the number of primary care and specialist physicians, and significantly expanded available services and improved the facilities. We believe Walter Ramos will provide the leadership needed at this important time at the Carney.”

Here's the adjacent paragraph:

The change is the latest update at Carney, which saw its former president, Andy Davis, announce in January that he would be stepping down after only three years in the position. In a statement at the time, Davis announced he had been looking to leave the hospital for awhile. Under his leadership, the institution has continued to struggle financially, seeing a $1.3 million operating loss in fiscal 2011, a $10 million operating loss in fiscal 2012, a $9 million operating loss in fiscal 2013, and a $6.2 million operating loss for the first two quarters of 2014.

That trajectory of losses doesn't sound like "an exciting resurgence." Indeed, those are pretty big losses for a 159-bed facility.  Add to that the past problems retaining effective leadership for this hospital. As reported in the Dorchester Reporter in April 2012:

After 14 months at the helm, Savin Hill’s Bill Walczak is out as president of Carney Hospital. The sudden shake-up raises questions about the future of the Dorchester Avenue facility, which was sold to a private equity firm in 2010 and is now facing the appointment of its fourth president in two years.

So, best wishes for success to Mr. Ramos. It looks like he has a vote of confidence from the main union representing workers at Carney:

“1199SEIU members are looking forward to working closely with Walter Ramos in his new leadership position to help Carney Hospital continue to grow and improve,” said Veronica Turner, Executive Vice President of 1199SEIU, in a release.

Back in 2007, noting the ongoing financial problems at Carney, I made a suggestion that the SEIU could do even better than working closely with hospital leadership:

Why not . . . have the union purchase, own and operate Carney Hospital? Let the union show how it can handle the full panoply of issues of running a hospital and demonstrate how it can profitably operate a neighborhood facility without the kind of state aid that has been pouring into Carney for all these years. Let the union negotiate contracts with the insurance companies, encourage access for low-income patients, maintain high regulatory standards for patient care, and do all the other things required of hospital management, while, of course, providing excellent working conditions for staff members and physicians.

What better way for the SEIU to demonstrate its potential value to the community than to take on this worthy assignment and to do a good job at it?

It's not too late.  I bet Cerberus would be happy to sell the place at a hefty discount from its original purchase price.

Is it in Rochester, Mayo? Or Boston?

In the post below, I report on a technical study that reviews the clinical efficacy of proton beam machines.  In short, for the most common forms of cancer, there is no appreciable difference in results, but the cost of the proton beam technology greatly exceeds that of technologies generally in use around the world.

The exceptions are some of the more difficult forms of cancer, and who can argue with making this modality available to the few people who can benefit from it?  Such was clearly the case with 12 year old David Gerfast, who received several weeks of treatment for chordoma, a rare type of cancer that occurs in the bones of the skull and spine.  As noted here: "Chordomas are generally slow growing, but are relentless and tend to recur after treatment. Because of their proximity to critical structures such as the spinal cord, brainstem, nerves and arteries, they are difficult to treat and require highly specialized care."

What more moving presentation could be offered by Mayo Clinic than to present David's case as an example of what will be possible in its new $180 million proton beam facility, particularly in association with the grand opening event this past week?

There's only one problem with Mayo's use of David's story.  He was treated at the proton beam facility at Massachusetts General Hospital.  This is not mentioned by Mayo--here's the script from the video--although at one point in the story, there is an onscreen credit associated with some of his images.

And, if you search old stories about the case, you can learn the same thing. Here's one from the local ABC affiliate back in January: "David is preparing to undergo Proton Beam Radiation Therapy in Boston, his father said."

Why does this matter?  The good news is that David was effectively treated, something for which we should all be grateful. And, as I note above, the issue is not the efficacy of proton beams in these types of cases.

The issue is how many $200 million machines do we need in the country.  Yes, it was inconvenient for David and his family to travel to Boston. But look again at this map and note how many proton beam facilities there are and will be within just a few hundred miles of one another in the Midwest--and Texas--and Florida--and the East Coast--and California--and the Southeast:

For the remarkably small number of appropriate cancer cases that would benefit from proton beam therapy, we could spend a tiny portion of the billions being invested in facilities and offer deluxe travel arrangements for all affected families, including support for those left back home.  Instead, we spend the billions, and then hospitals justify the use of the machine on cancers that are not appropriate clinical targets for this form of radiation.  It is hard to imagine a less rational form of health care planning for the country.

Beyond this issue of national policy, I would be remiss if I didn't say something about Mayo's use of a case treated elsewhere as part of its own publicity, with no acknowledgement of that fact.  (Here's the script again.)  I am at a loss to find the right words for this oddly deceptive presentation. What possible purpose was served by the omission?

Evidence about proton beam efficacy

Source: The National Association for Proton Therapy

Starting in 2011, I raised concerns about the proliferation of very expensive proton beam radiation therapy centers, made possible by investors who leverage the extra payments for use of this treatment modality that have been authorized by CMS and private insurers.  I asserted, based on my contacts in the radiation therapy profession, that the use of proton beam technology offered no significant advantage over lower cost intensity-modulated radiation therapy (IMRT) in most cases.  In short, I characterized proton beam developments as an example of the medical arms race, a rush by hospitals to compete on a high cost approach that offered little value to the public.

Now comes a thoughtful analysis published by the Health Technology Assessment Program of the Washington State Health Care Authority: Proton Beam Therapy, Final Evidence Report. The analysis was carried out by the Institute for Clinical and Economic Review (ICER), an independent non-profit health care research organization "dedicated to improving the interpretation and application of evidence in the health care system."

First, ICER gives the context for the early interest in this modality:

Initial use of proton beam therapy (PBT) focused on conditions where sparing very sensitive adjacent normal tissues was felt to be of utmost importance, such as cancers or noncancerous malformations of the brain stem, eye, or spinal cord. In addition, proton beam therapy was advocated for many pediatric tumors because even lower-dose irradiation of normal tissue in pediatric patients can result in pronounced acute and long-term toxicity (Thorp, 2010). There are also long-standing concerns regarding radiation’s potential to cause secondary malignancy later in life, particularly in those receiving radiation at younger ages. Finally, radiation may produce more nuanced effects in children, such as neurocognitive impairment in pediatric patients treated with radiotherapy for brain cancers (Yock, 2004).

Then, they set up the current issue of concern:

The construction of cyclotrons at the heart of proton beam facilities is very expensive ($150-$200 million for a multiple gantry facility); accordingly, as recently as 10 years ago there were fewer than 5 proton beam facilities in the United States (Jarosek, 2012). More recently, however, the use of PBT has been expanded in many settings to treat more common cancers such as those of the prostate, breast, liver, and lung. With the growth in potential patient numbers and reimbursement, the construction of proton centers has grown substantially. There are now 14 operating proton centers in the U.S. Eleven additional centers are under construction or in the planning stages, and many more are proposed.

The bulk of the report looks at the best available evidence:

We focused primary attention on randomized controlled trials and comparative cohort studies that involved explicit comparisons of PBT to one or more treatment alternatives and measures of clinical
effectiveness and/or harm.

The summary:

We judged PBT to have superior net health benefit for ocular tumors, and incremental net health benefit for adult brain/spinal tumors and pediatric cancers. We felt PBT to be comparable to alternative treatment options for patients with liver, lung, and prostate cancer as well as one noncancerous condition (hemangiomas). Importantly, however, the strength of evidence was low for all of these conditions. We determined the evidence base for all other condition types to be insufficient to determine net health benefit, including two of the four most prevalent cancers in the U.S.: breast and gastrointestinal (lung and prostate are the other two). 

Not exactly a ringing endorsement for adding billions of dollars to America's health care budget.  The original concept behind PBT was to have just a few across the country, to which patients who could most benefit would travel.  The idea was not to have as many as currently exist and are planned.

The results published by ICER hold little sway with the hospitals that have bought these machines.  Here's a sample web page from the The University of Florida Health Proton Therapy Institute:

In case you can't read the small image, it says:

Proton radiation is most effective in the treatment of localized cancers that have not metastasized or spread to other parts of the body.
 
These include:

• Breast cancer
• Prostate cancer
• Head and neck cancer
• Cancer in children
• Lung cancer
• Brain cancer
• Pancreatic cancer
• Lymphoma
• Sarcoma
• Eye cancer

Click through on any of those links and you can find clinically unsupported assertions about the benefits of this technology.  Taking prostate as an example:

Traditional prostate cancer treatment involving surgery or radiation carries the risk of serious toxicity and side effects. The potential long-term impact of these side effects on quality of life forces men to make a difficult choice during a stressful time. Proton radiation for prostate cancer treatment, however, offers an innovative method of radiation treatment intended to lower the risk of prostate cancer treatments and side effects.

For treating cancer of the prostate, proton therapy offers multiple benefits:

• Excellent control of tumors, thanks to more precise targeting of radiation
  
• Lower risk of damage to healthy tissue surrounding the prostate cancer
  
• Better quality of life for patients undergoing prostate proton therapy treatments
  

An alternative to traditional prostate cancer treatment, proton radiation for prostate cancer delivers precise doses of radiation with a lower risk of side effects.

With ICER's help, we now see that this verbiage is a lie.

So what we have in place in America is simply this:

Federal reimbursement policy supports the construction and operation of high cost, unnecessary machines.

Investment bankers rely on the above to offer hospitals financing plans, operational plans, and marketing plans for something the public doesn't need.

Hospitals engage in direct-to-consumer advertising in which they present misleading and inaccurate information about the benefits of the machines.

And we wonder why US health care costs keep rising.

Some thoughts on overuse of sedatives, opiates, and stimulants

A recent article over at the Why is American Health Care So Expensive blog discussed the patterns in overuse of sedatives, opiates, and stimulants, noting:

There is no good evidence that these medications are either safe or effective when used long term. In fact there is good evidence that they are NOT safe, and quite a bit of circumstantial evidence that they are not effective. We prescribe many times the number of controlled substances now than we did a decade ago, and overall Americans are not less anxious or less in pain or better able to concentrate than they were before. Those of us who prescribe opiates to patients with chronic pain very rarely see the pain become significantly more manageable though we do see the patients become less active and more likely to ask us for ever increasing amounts of the medications which don't work very well.

I, as a cutting edge physician of my generation, prescribed these drugs with enthusiasm, glad to be able to lessen the burden of anxiety, pain or distraction in my patients. Eventually I noticed that these patients were having real problems, including emergency room visits for confusion or for increased pain, worsening of their pre-existing breathing problems, severe constipation requiring hospitalization, one died by deliberately overdosing. Others' deaths were probably hastened. More subtle has been the increasing number of people who are becoming inactive, apathetic and stuck in poverty who appear to live mostly for their prescription medications. This group of people are not being identified at all by statistics on overdose.

Ok, that sounds like the problems that can come from a single doctor treating a patient.  But the problems can be compounded when a patient is seeing more than one doctor.  A 2014 BMJ article by Anupam Jena and colleagues reviewed the frequency and characteristics of opioid prescribing by multiple providers in Medicare.  They found:

Concurrent opioid prescribing by multiple providers is common in Medicare patients and is associated with higher rates of hospital admission related to opioid use.

Some doctors are bucking the trend, but it takes a concerted effort, patience, and thoughtfulness.  I note this piece from NPR on treatment of migraines, where Dr. Carolyn Bernstein notes:

"The majority of [desperate patients] have really been suffering a number of years and they're really miserable with the pain," Bernstein says. They say, " 'I hope you have a magic pill,' and of course there is no magic pill."

... [P]atients receive a thorough medical history that includes headache patterns, disability and mood assessments. Then the center works with patients to try to identify what triggers their headaches and how they can avoid those triggers in the future.

Some people find relief through exercise. "I write an exercise prescription probably as often as I write a prescription for medication," Bernstein says. She acknowledges it's sometimes difficult to encourage a patient with cracking head pain to get up and exercise. But even a little can help, and according to Bernstein it doesn't have to be jogging for miles and miles. It can be yoga, tai chi or even just a little stretching.