If you ever needed an indication of why the public remains confused about the issue of health care costs and insurance premiums, look no further than a story in today's Boston Globe entitled, "Insurers seeking smaller rate hikes." It is not that the reporter has done a poor job. Quite the contrary. The structure of the piece is good, and the story is fair and accurately reported. It is just that the current exigencies of newspaper production make it impossible to devote sufficient space in a daily story to portray the whole picture. So, in an understandable effort to give equal time to divergent viewpoints, the story ends up as a "he said-she said" exposition, leaving out underlying facts and context that might help the public understand why we are where we are.
So, let's deconstruct and expand the story to give more insights.
When the undersecretary of consumer affairs and business regulation sets forth her view of the rightness of the Governor's intervention in the rate-setting process, she neglects to mention that the intervention was arbitrary and found to be legally deficient by appellate boards in the state government. In essence, she attempts to proclaim economic and regulatory virtue in actions that fundamentally had a political origin during the last gubernatorial campaign.
She fails to mention that the underlying costs of providing health care have not changed very much. So insurance companies, bowing to political pressure, have been forced to come down hard on those providers whose contracts happen to have come up for renewal. These have often not been those with higher reimbursement rates. In essence, the administration's intervention succeeded in increasing the payment differential between the have's and have not's among the providers, contributing to the very factors disclosed by the Attorney General that lead to higher, not lower, health care costs.
When she says that the answer to the world's problems is to move to global payments, she makes no commitment to the idea that payment disparities among providers will be eliminated as part of this move.
When the Blue Cross Blue Shield spokesperson says that the proposed premiums are inadequate to cover costs, he leaves out the fact that this insurer has systematically overpaid certain providers, relative to other providers, for their services. These divergent payments are reflective of market power, as opposed to higher quality or other measurable factors, and, as noted, are a major contributor to the cost of health care in the state. He also leaves out the fact that early contracts to persuade or reward providers to sign the company's new global contract regime were particularly generous, especially in the early years of those contracts, increasing the company's costs.
When the head of the association of health plans (which does not include BCBS) continues her long-standing practice of blaming providers for all the problems, she not only neglects the contribution of the inefficient administration of her members, but she too fails to distinguish between those providers who enjoy above-market rates and those who are paid less. Why? Because her members, too, have been forced by market power concerns into paying some providers more for no net benefit to society.
In short, the entire story consists of each party passing blame to another or inappropriately taking credit for something that deserves no credit. Over the nine years I was running a hospital, I came to see the debate often set forth in this manner. It has some cathartic value for the insiders, but it offers little to the public that is helpful. It suggests to the medical profession, too, that the people who move money around to pay for health care have little or no understanding of the underlying demographic and societal factors that are determinative of health care costs, or of the manner in which process improvement and transparency could help bend the cost curve and improve clinical outcomes and the public health.
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Aside: Some recent developments in which insurers are attempting to introduce products based on tiered networks, or charging different copay's rates based on which provider you visit, are good news. But without publicly available date on clinical outcomes, these efforts run the risk of failure because the (undeserved) reputational advantages enjoyed by certain providers will trump the price differential in people's minds. You can get a sense of that in many of the comments on this story.
It took years after the introduction of low-cost long distance service by MCI and others in competition with AT&T for the latter's market share to drop below the 60th percentile, and the service provided was identical. People's habits die hard, even in the face of accurate information. How much more so when no information is offered to demonstrate that a move to a lower cost provider will result in service of equal or better quality.
Tuesday, February 15, 2011
Monday, February 14, 2011
Breathing more easily
Do you remember this post from 2009, where I praised Children's Hospital Boston for an asthma intervention program that provided advice and assistance to families? The summary:
Using a combination of interventions (e.g., counseling about drug dosages, HEPA filters for vacuum cleaners, rodent control measures), they dramatically reduced the number of asthmatic incidents for the children in several of Boston's neighborhoods. A subsidiary benefit was a huge reduction in the number of emergency room visits.
Well, now comes the business issue, summarized in an excellent article by Cheryl Clark at HealthLeaders Media.
It costs about $2,600 per child, but avoids $3,900 in hospitalization costs over a two-year period, hospital officials say. Elizabeth Woods, MD, who directs the hospital's initiative, says cost analyses point to a 1.46 return on investment. The hospital has papers in press that illuminate its progress.
So, where's the problem?
"That's a saving to society, not to the hospital," Woods says.
So here's a great program, but one whose success could hurt the hospital's bottom line, one that costs money and reduces business.
This, of course, is the argument for bundled payments for chronic illnesses and/or capitated payments for all medical service. In this article, Atul Gawande leaps to that conclusion. And there is something to be said for that.
But the short term business analysis sometimes fails to account for all of the items that inure to the benefit of a hospital for doing "the right thing."
Here's a sample of that broader view, the reduction in ventilator associated pneumonia and other hospital acquired infections in a hospital's intensive care units. As above, the direct result was a reduction in costs to insurance companies, Medicare, and Medicaid, and a commensurate reduction in revenues to the hospital. But, and this is a big but:
On the business front, it has contributed to a reduction in length of stay in our ICUs. We were able to avoid the multi-million dollar capital cost of expanding our ICU capacity. Indeed, we were able to create capacity out of the existing facilities and improve throughput.
Hospitals today often face limitations on their ability to raise capital. Avoiding a new fixed expense like that, while effectively creating capacity, can make business sense even if some short-term revenues are lost.
Also, some hospital costs are variable, not fixed. Some of that $3900 saved at Children's Hospital, for example, is certain to be related to supplies that will no longer need to be purchased. Likewise, some portion of nursing and respiratory therapy resources can either be reassigned to other cases, or if the trend is long-lasting, simply avoided by having fewer staff people over time.
And, of course, as noted by the CHB official, "Some of the losses might be made up by not providing worthless or futile care."
So, before we make the leap to a new payment regime, let's be a bit more complete in our analysis.
Using a combination of interventions (e.g., counseling about drug dosages, HEPA filters for vacuum cleaners, rodent control measures), they dramatically reduced the number of asthmatic incidents for the children in several of Boston's neighborhoods. A subsidiary benefit was a huge reduction in the number of emergency room visits.
Well, now comes the business issue, summarized in an excellent article by Cheryl Clark at HealthLeaders Media.
It costs about $2,600 per child, but avoids $3,900 in hospitalization costs over a two-year period, hospital officials say. Elizabeth Woods, MD, who directs the hospital's initiative, says cost analyses point to a 1.46 return on investment. The hospital has papers in press that illuminate its progress.
So, where's the problem?
"That's a saving to society, not to the hospital," Woods says.
So here's a great program, but one whose success could hurt the hospital's bottom line, one that costs money and reduces business.
This, of course, is the argument for bundled payments for chronic illnesses and/or capitated payments for all medical service. In this article, Atul Gawande leaps to that conclusion. And there is something to be said for that.
But the short term business analysis sometimes fails to account for all of the items that inure to the benefit of a hospital for doing "the right thing."
Here's a sample of that broader view, the reduction in ventilator associated pneumonia and other hospital acquired infections in a hospital's intensive care units. As above, the direct result was a reduction in costs to insurance companies, Medicare, and Medicaid, and a commensurate reduction in revenues to the hospital. But, and this is a big but:
On the business front, it has contributed to a reduction in length of stay in our ICUs. We were able to avoid the multi-million dollar capital cost of expanding our ICU capacity. Indeed, we were able to create capacity out of the existing facilities and improve throughput.
Hospitals today often face limitations on their ability to raise capital. Avoiding a new fixed expense like that, while effectively creating capacity, can make business sense even if some short-term revenues are lost.
Also, some hospital costs are variable, not fixed. Some of that $3900 saved at Children's Hospital, for example, is certain to be related to supplies that will no longer need to be purchased. Likewise, some portion of nursing and respiratory therapy resources can either be reassigned to other cases, or if the trend is long-lasting, simply avoided by having fewer staff people over time.
And, of course, as noted by the CHB official, "Some of the losses might be made up by not providing worthless or futile care."
So, before we make the leap to a new payment regime, let's be a bit more complete in our analysis.
Sunday, February 13, 2011
I was not skeptical enough
A recent webinar held by Day Pitney LLP made me wonder if my previous post may have understated the skepticism that should be applied to private equity purchases of hospitals.
The session was held on February 9 and was entitled, "Recapitalizing Not-for-Profit Hospitals with For-Profit Equity Capital." It had excellent and lucid presentations by Sandford Steever, Editor of The Health Care M&A Monthly; Wayne Ziemann, Managing Director of Alvarez and Marsal Healthcare Practice Group; and Lori Braender and Bruce Boisture of Day Pitney. The slides are here.
The theme of the day was that health care reform activities over the coming years will require massive capital investments to comply with the new federal law and associated regulations and to create accountable care organizations. This is a problem for not-for-profits, which are are often locked out of capital markets or have difficult access to such markets. In contrast, for-profits have an easier time raising capital.
One panelist then reported, though, that for-profits and not-for-profits have generally earned virtually identical after-tax profit margins. He also noted that equity holders demand a high return, in the range of 25 to 30 percent.
These remarks led to a series of questions from the audience: If for-profits are identical to not-for-profits with regard to after-tax profit margins, how can those puny margins be sufficient to justify investment by equity markets? Or putting it another way, if equity holders are demanding a 25-30% return, how do they earn that return if after-tax margins are the same as not-for-profits. Does this depend on flipping the properties in an IPO or to another private equity firm?
The initial reply was startling, "It is an apparent contradiction occurring in the market today."
Expanding on that, it was noted that private equity entry in this field is different from the for-profit hospital companies that have purchased properties in the past. "Private equity firms envision exiting, and not in the far future. Betting that there will be a buyer at some time in the future is the exit strategy. It is quite a gamble. They are banking a lot of health care reform and consolidation in the industry. Beyond that there is not much that is well defined."
Beyond that, there was a suggestion that the play in the marketplace right now is a "bet on a business plan" -- hoping that access to strategic capital will give these companies a competitive edge in the marketplace and grow market share. It is a bet on a transformation in the health care industry -- different payment models, being a low-cost, efficient provider, and wringing out inefficiency and overtreatment. "It is a heck of a bet to make," noted one panelist.
We were reminded that for-profit investors believe that community-based governing bodies lead to poor business decisions by not-for-profits. (This thought parallels the "stale bologna sandwiches" comment noted in my earlier post.) This belief, though, is interesting in light of a comment by one panelist who noted that not-for-profits have done better than for-profits with regard to building integrated networks of care and coordination of electronic health records.
Finally, though, there were two sobering comments from the panelists. The one: "It is kind of like the gold rush in years past."
The other was worse: "A third possibility beyond an IPO or sale to another investor is that the firm will simply shut down."
It was on this point that I concluded last week: Investors may come and go, but the community depends on its local hospital to provide high quality service. It is the residents of the community who are left holding the bag if the hospital corporation reaches the conclusion that ownership is not financially viable.
The session was held on February 9 and was entitled, "Recapitalizing Not-for-Profit Hospitals with For-Profit Equity Capital." It had excellent and lucid presentations by Sandford Steever, Editor of The Health Care M&A Monthly; Wayne Ziemann, Managing Director of Alvarez and Marsal Healthcare Practice Group; and Lori Braender and Bruce Boisture of Day Pitney. The slides are here.
The theme of the day was that health care reform activities over the coming years will require massive capital investments to comply with the new federal law and associated regulations and to create accountable care organizations. This is a problem for not-for-profits, which are are often locked out of capital markets or have difficult access to such markets. In contrast, for-profits have an easier time raising capital.
One panelist then reported, though, that for-profits and not-for-profits have generally earned virtually identical after-tax profit margins. He also noted that equity holders demand a high return, in the range of 25 to 30 percent.
These remarks led to a series of questions from the audience: If for-profits are identical to not-for-profits with regard to after-tax profit margins, how can those puny margins be sufficient to justify investment by equity markets? Or putting it another way, if equity holders are demanding a 25-30% return, how do they earn that return if after-tax margins are the same as not-for-profits. Does this depend on flipping the properties in an IPO or to another private equity firm?
The initial reply was startling, "It is an apparent contradiction occurring in the market today."
Expanding on that, it was noted that private equity entry in this field is different from the for-profit hospital companies that have purchased properties in the past. "Private equity firms envision exiting, and not in the far future. Betting that there will be a buyer at some time in the future is the exit strategy. It is quite a gamble. They are banking a lot of health care reform and consolidation in the industry. Beyond that there is not much that is well defined."
Beyond that, there was a suggestion that the play in the marketplace right now is a "bet on a business plan" -- hoping that access to strategic capital will give these companies a competitive edge in the marketplace and grow market share. It is a bet on a transformation in the health care industry -- different payment models, being a low-cost, efficient provider, and wringing out inefficiency and overtreatment. "It is a heck of a bet to make," noted one panelist.
We were reminded that for-profit investors believe that community-based governing bodies lead to poor business decisions by not-for-profits. (This thought parallels the "stale bologna sandwiches" comment noted in my earlier post.) This belief, though, is interesting in light of a comment by one panelist who noted that not-for-profits have done better than for-profits with regard to building integrated networks of care and coordination of electronic health records.
Finally, though, there were two sobering comments from the panelists. The one: "It is kind of like the gold rush in years past."
The other was worse: "A third possibility beyond an IPO or sale to another investor is that the firm will simply shut down."
It was on this point that I concluded last week: Investors may come and go, but the community depends on its local hospital to provide high quality service. It is the residents of the community who are left holding the bag if the hospital corporation reaches the conclusion that ownership is not financially viable.
Ropeik takes on risk
My colleague and friend David Ropeik takes on a risky subject in this op-ed in the Washington Post, and he gets it right. He points out the flaws in an EPA proposal to give more weighting to death from cancer than from other diseases. Here are some excerpts:
. . . It would give an advantage to regulations to control carcinogenic chemicals in the air, for instance, and disadvantage rules to control particulate air pollution, which contributes to cardiovascular deaths - which are far more common but, we think, less scary. As unpleasant as it may seem to argue against the cancer premium, it could increase the overall environmental death toll in America.
. . . We need to recognize that, just as there are physical risks that we study and try to manage, there are very real risks from the perception gap that also need to be recognized, studied and accounted for in policymaking. Getting risk wrong is risky.
Wouldn't it make more sense to be more afraid of what's more likely to kill you?
Yes, but that's not how we perceive risks. Risks have psychological and emotional characteristics that make some feel scarier than others, the probabilities notwithstanding. A long, painful cancer death may not be any worse than a long, painful heart disease death, but we think it would be, and feel we can't control it, and that makes cancer more feared.
That is precisely what a new proposal at the Environmental Protection Agency is trying to acknowledge. When assessing whether a new regulation would be worth the money, the agency projects how many lives it would save vs. the costs of implementing it. But now, the EPA suggests that death by cancer is so frightening to the public, cancer deaths should carry greater weight in its calculations than deaths by other causes.
This is an approach that may have some ethical and emotional appeal, but it carries serious dangers for us all.
. . . Under its "cancer premium," the [value] of lives saved from cancer would be 50 percent more than that of lives saved from other causes of death. So this premium would incorporate our greater fear of cancer into the analysis of whether regulations are worth the cost. That may seem pretty democratic: Cancer is scarier, and shouldn't our government protect us from the things we're more afraid of?. . . It would give an advantage to regulations to control carcinogenic chemicals in the air, for instance, and disadvantage rules to control particulate air pollution, which contributes to cardiovascular deaths - which are far more common but, we think, less scary. As unpleasant as it may seem to argue against the cancer premium, it could increase the overall environmental death toll in America.
. . . We need to recognize that, just as there are physical risks that we study and try to manage, there are very real risks from the perception gap that also need to be recognized, studied and accounted for in policymaking. Getting risk wrong is risky.
We use tools such as toxicology and epidemiology and economics to identify and analyze how to deal with those physical threats. We should also use neuroscience and psychology and sociology and economics to recognize the dangers posed by our misperceptions and to analyze those threats the same way we analyze and manage any others.
That can help us handle the gap between the facts and our feelings about the facts.
Friday, February 11, 2011
We didn't start the fire
This was forwarded by a friend. If you are of a certain generation, you are bound to like it.
Whether you are a Billy Joel fan or not, you probably remember his great song, "We Didn't Start the Fire."
Here it is, set to pictures. It's a neat flashback through the past half century. I never did know all the words. Turn up volume, sit back and enjoy a review of 50 years of history in less than 3 minutes! Thanks to Billy Joel and some guy from the University of Chicago with a lot of spare time and Google.
Top left gives you full screen. Top right lets you pause. Bottom left shows the year. The older you are, the more pictures you will recognize. Anyone over age 65 should remember over 90% of what they see. But it's great at any age.
We didn't start the fire.
Whether you are a Billy Joel fan or not, you probably remember his great song, "We Didn't Start the Fire."
Here it is, set to pictures. It's a neat flashback through the past half century. I never did know all the words. Turn up volume, sit back and enjoy a review of 50 years of history in less than 3 minutes! Thanks to Billy Joel and some guy from the University of Chicago with a lot of spare time and Google.
Top left gives you full screen. Top right lets you pause. Bottom left shows the year. The older you are, the more pictures you will recognize. Anyone over age 65 should remember over 90% of what they see. But it's great at any age.
We didn't start the fire.
Missing news from friends on Facebook?
A Facebook post by Kellie Mairs:
Have you noticed that you are only seeing updates in your newsfeed from the same people lately? Have you also noticed that when you post things like status messages, photos and links, the same circle of people are commenting and every……one else seems to be ignoring you?
Don’t worry, everyone still loves you and nobody has intentionally blocked you. The problem is that a large chunk of your friend/fan list can’t see anything you post and here’s why:
The “New Facebook” has a newsfeed setting that by default is automatically set to show ONLY posts from people who you’ve recently interacted with or interacted the most with (which would be limited to the couple of weeks just before people started switching to the new profile). So in other words, for both business and personal pages, unless your friends/fans commented on one of your posts within those few weeks or vice versa – you are now invisible to them and they are invisible to you!!
HERE’S THE FIX: Scroll down to the bottom of the newsfeed on the homepage and click on “Edit Options”, click on “Show Posts From” and change the setting to “All Of Your Friends and Pages”
Simply posting an update about it won’t do any good because lots of your friends/fans already can’t see your posts by default. You’ll either have to send out a message to everyone on your list (which I’m not even sure business pages can do and is a rather tedious method) or post an event explaining the situation like this one and invite your entire fan base and/or friend list. You can also tweet about it hoping that most of your fellow facebookers are also on Twitter.
Shame on Facebook for altering the default setting and not telling people about it!
Thursday, February 10, 2011
Huge barriers to effective relationship formation
During Ernie's class at MIT, the students and I were discussing why it is so hard to implement process improvements in clinical settings. I suggested that one aspect of the problem was that doctors, no matter how well intentioned, were not trained in such matters. Further, I suggested that there is very little in the career advancement pattern of successful doctors in academic medicine that rewards attributes that are so important in most other fields of endeavor, i.e., interpersonal skills and teamwork.
Well, along comes Linda Pololi, an MD who has been doing research at the Women's Studies Research Center at Brandeis University, who today conducted a seminar about her new book, Changing the Culture of Academic Medicine. (Dartmouth College Press.) The book is mainly about the perspectives of women faculty in medical schools, but it also has observations from men. It is based on extensive surveys and interviews with faculty members from a number of prominent medical schools.
Not only did Linda confirm my hypotheses, she provided thorough documentation of a pattern among the faculty of medical schools that can hardly fail to have an impact on those trained in the system.
Here are some excerpts:
Our data show that the way medical schools are structured and the norms of behavior among faculty can create huge barriers to effective relationship formation . . . a medical school environment that could at times negatively impact patients and our system of health care as a whole.
Problems with personal interactions in the academic medical culture emerged as a central theme in our interviews. . . . Comments about relationships tended to arise spontaneously rather than be elicited by the interviewer. . . [and] both women and men spoke similarly about relationships in the interviews.
Two fundamental worrisome experiences . . . were a sense of disconnection and having few trusting relationships with colleagues and supervisors.
Interviewees described an intensely individualistic, competitive environment where rewards usually went to individual accomplishments. . . .[I]ndividuals and institutions tended to function on behalf of their self-interest, making decisions and choices that benefited themselves rather than contributing to the common good -- and sometimes came at the expense of the common good.
The system is designed to create barriers at all levels to collaboration and collegiality.
Numerous faculty complained of not being recognized as a person beyond their professional role. No attention was paid to what people were feeling. . . . [T]his refusal to engage them as individuals had a depersonalizing effect. The culture seemed to ignore the qualities that made them able to address human needs and show compassion and sensitivity to others.
We found little indication that medical schools cultivated appreciation of people's efforts. Rather, the focus was on finding fault.
Now, let's draw the connection between all this and patient care. It is obvious that process improvement is hampered when there is a lack of trust, collegiality, and collaboration among the medical staff. But sadder still, consider the implications for those being treated. Linda notes:
There is a parallel between disconnection and emotional detachment among medical school faculty and ineffective communication between doctor and patient. If faculty feel disconnected and cannot communicate among themselves, they are less likely to create good relationships with students and patients. Similarly, in a culture where faculty and administrators themselves do not receive consideration and compassion, it is less likely that they will treat students and patients with compassion.
And what about improving quality and safety and reducing harm to patients?
Research shows that physicians remember for decades mistakes they have made, feeling guilty and humiliated and isolated in their shame. Only by creating transparency, so they can discuss mistakes openly, can these destructive feelings be relieved. Equally important, open discussion enables the physician and others to learn from these mistakes and prevent them from recurring.
If the training ground of American physicians works against this common sense view of the world, is there any doubt as to why we have such problems in patient care? Clinical and administrative leaders in hospitals must strive to undo the culture that is embedded in these centers of learning and help those who have devoted their lives to alleviating human suffering to start, first, to alleviate their own suffering and sense of loneliness and isolation.
Well, along comes Linda Pololi, an MD who has been doing research at the Women's Studies Research Center at Brandeis University, who today conducted a seminar about her new book, Changing the Culture of Academic Medicine. (Dartmouth College Press.) The book is mainly about the perspectives of women faculty in medical schools, but it also has observations from men. It is based on extensive surveys and interviews with faculty members from a number of prominent medical schools.Not only did Linda confirm my hypotheses, she provided thorough documentation of a pattern among the faculty of medical schools that can hardly fail to have an impact on those trained in the system.
Here are some excerpts:
Our data show that the way medical schools are structured and the norms of behavior among faculty can create huge barriers to effective relationship formation . . . a medical school environment that could at times negatively impact patients and our system of health care as a whole.
Problems with personal interactions in the academic medical culture emerged as a central theme in our interviews. . . . Comments about relationships tended to arise spontaneously rather than be elicited by the interviewer. . . [and] both women and men spoke similarly about relationships in the interviews.
Two fundamental worrisome experiences . . . were a sense of disconnection and having few trusting relationships with colleagues and supervisors.
Interviewees described an intensely individualistic, competitive environment where rewards usually went to individual accomplishments. . . .[I]ndividuals and institutions tended to function on behalf of their self-interest, making decisions and choices that benefited themselves rather than contributing to the common good -- and sometimes came at the expense of the common good.
The system is designed to create barriers at all levels to collaboration and collegiality.
Numerous faculty complained of not being recognized as a person beyond their professional role. No attention was paid to what people were feeling. . . . [T]his refusal to engage them as individuals had a depersonalizing effect. The culture seemed to ignore the qualities that made them able to address human needs and show compassion and sensitivity to others.
We found little indication that medical schools cultivated appreciation of people's efforts. Rather, the focus was on finding fault.
Now, let's draw the connection between all this and patient care. It is obvious that process improvement is hampered when there is a lack of trust, collegiality, and collaboration among the medical staff. But sadder still, consider the implications for those being treated. Linda notes:
There is a parallel between disconnection and emotional detachment among medical school faculty and ineffective communication between doctor and patient. If faculty feel disconnected and cannot communicate among themselves, they are less likely to create good relationships with students and patients. Similarly, in a culture where faculty and administrators themselves do not receive consideration and compassion, it is less likely that they will treat students and patients with compassion.
And what about improving quality and safety and reducing harm to patients?
Research shows that physicians remember for decades mistakes they have made, feeling guilty and humiliated and isolated in their shame. Only by creating transparency, so they can discuss mistakes openly, can these destructive feelings be relieved. Equally important, open discussion enables the physician and others to learn from these mistakes and prevent them from recurring.
If the training ground of American physicians works against this common sense view of the world, is there any doubt as to why we have such problems in patient care? Clinical and administrative leaders in hospitals must strive to undo the culture that is embedded in these centers of learning and help those who have devoted their lives to alleviating human suffering to start, first, to alleviate their own suffering and sense of loneliness and isolation.
At Ernie's class @ MIT
I was a guest lecturer last night at Professor Ernst Berndt's course at MIT's Sloan School, entitled "Economics of the Health Care Industries." The students represent a variety of backgrounds, and we had great discussions about a full range of issues in hospital management.I added a new weapon to my arsenal in the Socratic method -- a promise that anyone who made a particularly insightful comment would be featured here on this blog. You see them in the accompanying pictures.
I also had an opportunity to suggest the first of four essay topics for the class. These will be turned in on Monday, and I promised to print the best ones here. Stay tuned for those next week.
I gave them a very tough topic, but it is quite timely and represents an actual problem facing provider groups here in Massachusetts and elsewhere. Here it is:
First, read this blog post. Then, the question is: What methodology would you propose for the allocation of an annual global payment, to divide it up among primary care doctors, community hospitals, tertiary hospitals, specialist doctors, nursing homes, etc. -- all of whom are involved in caring for a given population of patients? How would you make the transition from the current fee-for-service approach?
This is investigative reporting
The Las Vegas Sun conducted an extensive investigation of the quality of care delivered by hospitals in that section of Nevada. It took two years of research by reporters Marshall Allen and Alex Richards, along with help from lots of support staff. They made use of hundreds of thousands of pieces of information. The material was presented in a multi-part series through 2010. Here is the video summary offered by Brian Greenspun, publisher and editor.
This series exemplifies the potential power of the media in focusing public attention on one of the country's major public health hazards -- being treated in a hospital. To a greater or lesser extent, a similar story could be written in most American cities. But it would take a commitment to write stories that go beyond parroting corporate press releases or believing the advertisements of self-satisfied medical institutions. Perhaps a little less coverage about the weather would free up reporters to dig through a different kind of snow job.
Congratulations to the Las Vegas Sun for showing the way.
If you cannot see the video, click here.
This series exemplifies the potential power of the media in focusing public attention on one of the country's major public health hazards -- being treated in a hospital. To a greater or lesser extent, a similar story could be written in most American cities. But it would take a commitment to write stories that go beyond parroting corporate press releases or believing the advertisements of self-satisfied medical institutions. Perhaps a little less coverage about the weather would free up reporters to dig through a different kind of snow job.
Congratulations to the Las Vegas Sun for showing the way.
If you cannot see the video, click here.
Wednesday, February 09, 2011
Pauline Chen on WIHI
A Legible Prescription for Health CareThursday, February 10, 2011, 2:00 PM – 3:00 PM Eastern Time
Guest: Pauline W. Chen, MD, Columnist, The New York Times; Author, Final Exam: A Surgeon’s Reflections on Mortality
Have you heard the one about the backlash to Accountable Care Organizations (ACOs)? Actually, there’s no such thing...yet. But there could be, suggests Pauline Chen in her latest “Doctor and Patient” column, if ACOs take off without fully appreciating that patients have to buy into the concept. And that won’t happen if they’re not part of the discussion and the design, and offered more than legal lingo.
Anyone interested in a bridge between patients and practitioners and health care reform has no better voice these days in a major media outlet than Dr. Pauline Chen. WIHI host Madge Kaplan is pleased to welcome Dr. Chen to the program on Feb 10 to discuss the issues she brings to light with her writing, often drawing on her own day-to-day experiences seeing patients and conversations she has with other colleagues. On this edition of WIHI, Dr. Chen wants to spend some time talking about language, especially the words doctors use with one another when describing patients; the unintended barriers created the more doctors and nurses don protective, infection-protecting garb; the mounting weight of patient satisfaction surveys; and more.
Pauline Chen says the more she delves into tough topics, the more her own habits have changed. Perhaps that’s the effect her writing has had on you, too. Come join a timely discussion with someone who often reminds us that it’s human beings who either uphold the status quo or change the dynamics in health care, no matter how many good, prescriptive ideas are out there. We look forward to your participation on this next WIHI!
To enroll, please click here.
Jubilee presents Beautiful
Here's the latest video from the Jubilee Project. As always, when you view it, a donation will be made to a charity, in this case Becky's Fund.
If you cannot see the video, click here.
If you cannot see the video, click here.
Ethical blinders?
Is this a case of ethical blinders?
Today's New York Times has an important story about the ineffectiveness of removal of lymph nodes for certain women with breast cancer. That is a significant result of clinical research. But read this:
Experts say that the new findings, combined with similar ones from earlier studies, should change medical practice for many patients. Some centers have already acted on the new information. in Manhattan changed its practice in September, because doctors knew the study results before they were published.
And they felt no need to spread the word quickly to other hospitals and to breast cancer patient advocacy groups and help women across the world avoid the surgery and its after-effects? (As noted in the article, "It can cause complications like infection and , a chronic in the arm that ranges from mild to disabling.")
Today's New York Times has an important story about the ineffectiveness of removal of lymph nodes for certain women with breast cancer. That is a significant result of clinical research. But read this:
Experts say that the new findings, combined with similar ones from earlier studies, should change medical practice for many patients. Some centers have already acted on the new information. in Manhattan changed its practice in September, because doctors knew the study results before they were published.
And they felt no need to spread the word quickly to other hospitals and to breast cancer patient advocacy groups and help women across the world avoid the surgery and its after-effects? (As noted in the article, "It can cause complications like infection and , a chronic in the arm that ranges from mild to disabling.")
La gala del nadar es saber guardar la ropa
A December article in Scientific American by Dr. Alvaro Pascual-Leone, "Get Better at Math by Disrupting Your Brain," makes some fascinating observations about brain function. It is short and worth reading. A few excerpts:
We tend to believe that our brains work as well as they can.
Being better in math does not mean being smarter at everything. But we assume that, at least within a given domain, better behavioral performance implies superior brains, because we take it for granted that the brain is working as well as it can to optimize behavior.
However, a growing number of instances in clinical neurology and a growing body of research in cognitive neuroscience reveal that this assumption is incorrect. . . . For example, if the brain optimizes behavior, disruption of normal brain activity ought to lead to a loss of function, and never to enhancement. And yet, in some instances, disruption of brain activity . . . can result in a paradoxical behavioral improvement.
Behavior after damage, or after the modulation of activity in a given brain area, reflects the capacity of the brain and its networks to adapt to the disruption. The final behavioral consequence of a brain injury may be worsened performance, but also, paradoxically, improved performance, or even recovery from the deleterious consequences of a pre-existing insult or disease.
Read the article to understand the title of this blog post!
We tend to believe that our brains work as well as they can.
Being better in math does not mean being smarter at everything. But we assume that, at least within a given domain, better behavioral performance implies superior brains, because we take it for granted that the brain is working as well as it can to optimize behavior.
However, a growing number of instances in clinical neurology and a growing body of research in cognitive neuroscience reveal that this assumption is incorrect. . . . For example, if the brain optimizes behavior, disruption of normal brain activity ought to lead to a loss of function, and never to enhancement. And yet, in some instances, disruption of brain activity . . . can result in a paradoxical behavioral improvement.
Behavior after damage, or after the modulation of activity in a given brain area, reflects the capacity of the brain and its networks to adapt to the disruption. The final behavioral consequence of a brain injury may be worsened performance, but also, paradoxically, improved performance, or even recovery from the deleterious consequences of a pre-existing insult or disease.
Read the article to understand the title of this blog post!
Tuesday, February 08, 2011
Is this the image you want to portray?
Is anybody else put off by the fact that this newsletter from the American Medical Association takes advertising from drug companies and displays it so prominently at the top of the front page and on the right side of that page, also?
Monday, February 07, 2011
Teach the doctors, please!
If you read the Boston newspapers, you would think that the most important thing going on in health care is a proposal to move from one kind of insurance payment scheme to another. Reporters seem willing to accept relatively unsupported and undocumented assertions that global payments are working. You have to be persistent to find these sentences in this story:
But other doctors and health care executives cautioned against drawing definitive conclusions from the insurer’s early results. They have not been independently reviewed and may not be easily reproduced statewide.
If it is working, why do reporters not demand more transparency to demonstrate it? Why this instead?
Blue Cross did not release specific performance results for doctors groups.
Why no mention in these stories of alternative approaches being taken by other insurers?
Why hold off, too, on this really important statement until after the page turn and deep at the end of this story?
Both supporters and critics of global payment agree that any mandate should be flexible, and phased in slowly, so patients and providers can adjust. Thomas A. Croswell, chief operating officer of Tufts Health Plan, suggested a five-year transition.
Much is often made of Atul Gawande's superb writing about the use of check lists and other quality and safety process improvements. If you read carefully, though, you will see that he seldom mentions progress in the medical schools with which his and other Boston hospitals are affiliated. While we wait five years or more for the new pricing regime, why don't the insurers, the state government, and other stakeholders put pressure on the region's four medical schools to introduce and emphasize the science of process improvement in their curriculum?
Local readers might be interested to know that the process improvement world is alive and well in other regions, irrespective of insurance payment regimes. Two of the heroes in this arena, Brent James and Bob Wachter, recently had a conversation about how to teach quality and safety improvement.
Dr. James gave some history of his efforts at Intermountain Health. Dr. Wachter asks:
We did other things that were really important. The first is that we built firmly on the foundation of medicine. By that point, we'd understood that there's a whole bunch of jargon with improvement, but you didn't have to use any of it; you could describe the whole thing in the language of medicine. So rather than asking the natives to learn quality improvement jargon, we spoke the language of the native. The second thing was that in order to graduate you had to complete a successful improvement project. Our aim was to get hands-on experience that was real. And boy did that ever turn out well.
Here is an article about a system clinical safety and effectiveness (CS&E) course taught at the University of Texas. An excerpt:
But other doctors and health care executives cautioned against drawing definitive conclusions from the insurer’s early results. They have not been independently reviewed and may not be easily reproduced statewide.
If it is working, why do reporters not demand more transparency to demonstrate it? Why this instead?
Blue Cross did not release specific performance results for doctors groups.
Why no mention in these stories of alternative approaches being taken by other insurers?
Why hold off, too, on this really important statement until after the page turn and deep at the end of this story?
Both supporters and critics of global payment agree that any mandate should be flexible, and phased in slowly, so patients and providers can adjust. Thomas A. Croswell, chief operating officer of Tufts Health Plan, suggested a five-year transition.
Much is often made of Atul Gawande's superb writing about the use of check lists and other quality and safety process improvements. If you read carefully, though, you will see that he seldom mentions progress in the medical schools with which his and other Boston hospitals are affiliated. While we wait five years or more for the new pricing regime, why don't the insurers, the state government, and other stakeholders put pressure on the region's four medical schools to introduce and emphasize the science of process improvement in their curriculum?
Local readers might be interested to know that the process improvement world is alive and well in other regions, irrespective of insurance payment regimes. Two of the heroes in this arena, Brent James and Bob Wachter, recently had a conversation about how to teach quality and safety improvement.
Dr. James gave some history of his efforts at Intermountain Health. Dr. Wachter asks:
[Y]ou and others have written about the culture of medicine being so individualistic. It sounds like we came into this with a culture that you would expect would create tremendous variation from doctor to doctor.
Dr. James replies:
Looking back, that's absolutely true. Of course it came to be called the craft of medicine, a cottage industry, where it's based on purely personal expertise, personal perfection, if you will. Speaking as somebody out of a surgical background—that concept is so central to what it means to be good, I mean for your patients, the best you can be. You don't want to lose that personal dedication. But you start to extend it a step further. Where it ended up for us was a form of Lean.
And later, he relates:We did other things that were really important. The first is that we built firmly on the foundation of medicine. By that point, we'd understood that there's a whole bunch of jargon with improvement, but you didn't have to use any of it; you could describe the whole thing in the language of medicine. So rather than asking the natives to learn quality improvement jargon, we spoke the language of the native. The second thing was that in order to graduate you had to complete a successful improvement project. Our aim was to get hands-on experience that was real. And boy did that ever turn out well.
Here is an article about a system clinical safety and effectiveness (CS&E) course taught at the University of Texas. An excerpt:
Unfortunately, most front-line caregivers complete their professional training with almost no exposure to even rudimentary QI concepts or methods....
The University of Texas MD Anderson Cancer Center began such a course in 2005 ... and its success led us to implement courses in four of the six health campuses in the University of Texas system....
The purpose of the CS&E course is to provide physicians, other key clinicians, and administrators the skills and knowledge required to lead breakthrough change initiatives. After initial success at UT MD Anderson Cancer Center, all presidents of the UT System health care institutions approved a proposal in 2007 to develop and implement CS&E programs on their own campuses. A UT CS&E Steering Committee with representatives from each campus was established to provide oversight for the course expansion, and in 2008 the University's Regents provided funding from the UT System's malpractice liability reserve fund.
We are very quick to find a rivalry between Texas and Boston in other fields. Let's start one here, where lives hang in the balance.Saturday, February 05, 2011
Is the "greater fool" theory alive in the hospital world?
In the last four decades, we have witnessed a series of investment "bubbles" that have all collapsed. It seems that there is no end to the number of people with cash who will be intoxicated by a good story line, even when there is little substance to back it up. All of these stories depend on the capital markets to bolster the price of investments, counting on the "greater fool" theory: There is always someone who will take on a bad investment at just the wrong time, providing a good return to those who are lucky enough to escape before the crash.
In the early 1990s, ENRON was entering the market with a new electricity trading division. A business partner of mine was asked by one of the largest government pension funds to evaluate a proposal to invest $250 million in the start-up. He came to me a few weeks later, saying that he was having trouble evaluating the deal. They could not give a substantive answer to the basic questions: How will each transaction make money? What will be your competitive advantage in this business? What do you expect your market share to be? When he would ask the ENRON guys for a business plan, their answer was, "We did it in natural gas. We can do it in electricity. Trust us."
My friend advised the pension fund not to invest. It did so anyway, apparently because of personal relationships between the fund managers and people at ENRON. As we now know, the fiction behind ENRON's financial plan eventually led to its collapse.
A bit later, Bernie Ebbers was building a telecommunications company called WorldCom. His approach was to play on the stock market's desire for growth by acquiring other long distance phone companies. As the market capitalization of the company grew, its stock price rose -- notwithstanding a surplus in long distance capacity in the country and declining profit margins. The thing that finally stopped Ebbers was that the government would not let him continue to acquire companies (for antitrust reasons). Then, finally, he had to run the business as a business and make a profit, and he could not. Collapse followed.
More recently, we have all witnessed the subprime debacle, the sale of unsecured insurance products, and the like. As above, these were examples of money chasing money, of stated valuations with no inherent relationship to the actual value of the business enterprise.
What is the next bubble? Might it be private investment in hospitals and hospital systems?
I have discussed above the rationale for and some of the financial techniques involved in private equity acquisitions of hospitals. These acquisitions also tend to have great political support: A financially troubled hospital system will have a more secure pension plan, pay taxes to municipalities and the state, and the like. The private equity firm rescuing the system is seen as a "white knight" and makes commitments that sound very persuasive.
As time goes along, some of those early statements are quietly modified. This Boston Globe article, for example, reports that one private equity firm "also committed to pumping another $400 million in capital improvements into the system over the next four years, although [its CEO] acknowledges that those funds may come from hospital revenues in coming years, rather than from [the private equity firm] itself."
We also learn that strong commitments to local involvement can diminish. At a recent conference, one private equity official derisively talked about the inadequacies of local lay leaders eating their "stale bologna sandwiches" at Board of Trustees meetings, to draw a contrast with the unsentimental businesslike behavior of a board chosen by his firm.
Those seeking to regulate the behavior and financial decisions of for-profit hospitals will find that their post hoc authority will likely be insufficient to protect the public interest from a depletion of plant and equipment and from a plan that is mainly meant to burnish the pre-tax and pre-depreciation short-term earnings of the firm so that it is ready for the initial public offering or resale to another private equity firm.
Who gets hurt if these deals go bust when the next generation of owners takes over and discovers that creating the margin to generate the expected return is very hard in the hospital world? Well, that very last set of investors, the "greater fools." But, as we have seen in the examples above, the hurt goes much further. Hospitals, though, are in a special category. Investors may come and go, but the community depends on its local hospital to provide high quality service. It is the residents of the community who are left holding the bag if the hospital corporation reaches the conclusion that ownership is not financially viable.
Perhaps I am being too pessimistic, but this feels very much like those conversations I had in the 1990s. Let's hope that I am wrong. So in the meantime, enjoy the Super Bowl and root for the good guys to win.
In the early 1990s, ENRON was entering the market with a new electricity trading division. A business partner of mine was asked by one of the largest government pension funds to evaluate a proposal to invest $250 million in the start-up. He came to me a few weeks later, saying that he was having trouble evaluating the deal. They could not give a substantive answer to the basic questions: How will each transaction make money? What will be your competitive advantage in this business? What do you expect your market share to be? When he would ask the ENRON guys for a business plan, their answer was, "We did it in natural gas. We can do it in electricity. Trust us."
My friend advised the pension fund not to invest. It did so anyway, apparently because of personal relationships between the fund managers and people at ENRON. As we now know, the fiction behind ENRON's financial plan eventually led to its collapse.
A bit later, Bernie Ebbers was building a telecommunications company called WorldCom. His approach was to play on the stock market's desire for growth by acquiring other long distance phone companies. As the market capitalization of the company grew, its stock price rose -- notwithstanding a surplus in long distance capacity in the country and declining profit margins. The thing that finally stopped Ebbers was that the government would not let him continue to acquire companies (for antitrust reasons). Then, finally, he had to run the business as a business and make a profit, and he could not. Collapse followed.
More recently, we have all witnessed the subprime debacle, the sale of unsecured insurance products, and the like. As above, these were examples of money chasing money, of stated valuations with no inherent relationship to the actual value of the business enterprise.
What is the next bubble? Might it be private investment in hospitals and hospital systems?
I have discussed above the rationale for and some of the financial techniques involved in private equity acquisitions of hospitals. These acquisitions also tend to have great political support: A financially troubled hospital system will have a more secure pension plan, pay taxes to municipalities and the state, and the like. The private equity firm rescuing the system is seen as a "white knight" and makes commitments that sound very persuasive.
As time goes along, some of those early statements are quietly modified. This Boston Globe article, for example, reports that one private equity firm "also committed to pumping another $400 million in capital improvements into the system over the next four years, although [its CEO] acknowledges that those funds may come from hospital revenues in coming years, rather than from [the private equity firm] itself."
We also learn that strong commitments to local involvement can diminish. At a recent conference, one private equity official derisively talked about the inadequacies of local lay leaders eating their "stale bologna sandwiches" at Board of Trustees meetings, to draw a contrast with the unsentimental businesslike behavior of a board chosen by his firm.
Those seeking to regulate the behavior and financial decisions of for-profit hospitals will find that their post hoc authority will likely be insufficient to protect the public interest from a depletion of plant and equipment and from a plan that is mainly meant to burnish the pre-tax and pre-depreciation short-term earnings of the firm so that it is ready for the initial public offering or resale to another private equity firm.
Who gets hurt if these deals go bust when the next generation of owners takes over and discovers that creating the margin to generate the expected return is very hard in the hospital world? Well, that very last set of investors, the "greater fools." But, as we have seen in the examples above, the hurt goes much further. Hospitals, though, are in a special category. Investors may come and go, but the community depends on its local hospital to provide high quality service. It is the residents of the community who are left holding the bag if the hospital corporation reaches the conclusion that ownership is not financially viable.
Perhaps I am being too pessimistic, but this feels very much like those conversations I had in the 1990s. Let's hope that I am wrong. So in the meantime, enjoy the Super Bowl and root for the good guys to win.
Friday, February 04, 2011
Power outages foil criminal behavior
As we head into the weekend following a week of snow and power outages, it is diverting to consider the latest "stupid crook" story, this one from Silver Spring, MD. The essence:
As the burglar was rifling through the rooms in that house, the homeowner's son arrived and startled him. The burglar jumped out a window and fled. The son called police, who searched the house. They were stunned at what was found: a cellphone, charging in an electric socket, that didn't belong to the homeowner. The phone led police to Cody Wilkins, who is now charged in 10 burglaries. Police say that Wilkins's home lost power in the storm and that he needed a place - anyplace, it seems - to charge his phone. In his haste to flee, he left it charging.
As the burglar was rifling through the rooms in that house, the homeowner's son arrived and startled him. The burglar jumped out a window and fled. The son called police, who searched the house. They were stunned at what was found: a cellphone, charging in an electric socket, that didn't belong to the homeowner. The phone led police to Cody Wilkins, who is now charged in 10 burglaries. Police say that Wilkins's home lost power in the storm and that he needed a place - anyplace, it seems - to charge his phone. In his haste to flee, he left it charging.
Blurred boundaries between news and opinion
Is this happening with your home town newspaper? It used to be that there was a separation of news and opinion columns. I am not saying that editorial and personal biases were ever missing from news stories; but I am saying that columns containing opinions were clearly labeled as "opinion." That seems to be gone now. We are presented with news stories that subtly present the reporter's opinion as part of the news.
Here is an example from today's New York Times and Boston Globe (the same story by Anthony Shadid):
The Egyptian government broadened its crackdown of a 10-day uprising that has shaken its rule yesterday, arresting journalists and human rights advocates across an edgy city, while offering more concessions in a bid to win support from a population growing more frustrated with a devastated economy and scenes of chaos in the streets. (This part is news.)
The campaign was a startling blend of the oldest tactics of an authoritarian government — stoking fears of foreigners — with the air of sincerity of a repentant order. (This part is opinion.)
And another from the Globe:
US Representative Barney Frank announced yesterday that he plans to seek another term, increasing the possibility of a battle — the first in 30 years — between two sitting Massachusetts congressmen over a single congressional district. (News.)
Frank, 70, an irascible (opinion), liberal (news) Newton Democrat....
I am not saying either opinion is wrong. (I don't know Mubarak, but the characterization of Barney is dramatically understated.) What I am saying is that you would expect the newspapers of record to be better about separating reporting from opinion on their front pages. In my view, the story should tell the story, leaving readers to form their own opinions. Opinions should be clearly set forth in stories labeled as opinion or analysis, whether on the front page, the editorial page, or the op-ed page.
Here is an example from today's New York Times and Boston Globe (the same story by Anthony Shadid):
The Egyptian government broadened its crackdown of a 10-day uprising that has shaken its rule yesterday, arresting journalists and human rights advocates across an edgy city, while offering more concessions in a bid to win support from a population growing more frustrated with a devastated economy and scenes of chaos in the streets. (This part is news.)
The campaign was a startling blend of the oldest tactics of an authoritarian government — stoking fears of foreigners — with the air of sincerity of a repentant order. (This part is opinion.)
And another from the Globe:
US Representative Barney Frank announced yesterday that he plans to seek another term, increasing the possibility of a battle — the first in 30 years — between two sitting Massachusetts congressmen over a single congressional district. (News.)
Frank, 70, an irascible (opinion), liberal (news) Newton Democrat....
I am not saying either opinion is wrong. (I don't know Mubarak, but the characterization of Barney is dramatically understated.) What I am saying is that you would expect the newspapers of record to be better about separating reporting from opinion on their front pages. In my view, the story should tell the story, leaving readers to form their own opinions. Opinions should be clearly set forth in stories labeled as opinion or analysis, whether on the front page, the editorial page, or the op-ed page.
How to get into Chuck E. Cheese when you are middle aged
For those of you not familiar with Groupon, it is an internet-based discount coupon service, targeted for individual cities throughout the country. An offer is sent out, and if enough people sign up for it, the discount is awarded. Groupon is known for its humorous descriptions of the service or commodity being offered.
Today's Boston offer has the most clever description I have seen. Will 20 people snow-struck people who have spent weeks trapped in their homes looking in the mirror sign up? Health care experts advise me that this most assuredly is not covered under the Blue Cross Blue Shield global payment plan! Here goes:
Today's Boston offer has the most clever description I have seen. Will 20 people snow-struck people who have spent weeks trapped in their homes looking in the mirror sign up? Health care experts advise me that this most assuredly is not covered under the Blue Cross Blue Shield global payment plan! Here goes:
Med-Spa Treatment from Boston Plastic Surgery Associates in Concord. Three Options Available.
Maintaining a youthful visage helps get you into hip nightclubs, such as Chuck E. Cheese's, where sentient mice dance wildly in rooms entirely filled with balls. Live it up at the club with today's Groupon to Boston Plastic Surgery Associates in Concord. Choose from the following options:
- $175 for 50 units of Dysport (a $300 value)
- $129 for three laser hair-removal treatments (up to an $800 value)
- $129 for a photofacial skin-rejuvenation intense-pulsed-light treatment (a $450 value)
Dr. Brooke Seckel of Boston Plastic Surgery Associates is a medical Ponce de Leon, immersed in a perpetual quest for age-defying noninvasive and nonsurgical therapies to keep his patients budding and boisterous. The photofacial rejuvenation treatment gives hardened mugs a science-fiction makeover via beams of intense pulsed light, thought to gently remove pigment, brown spots, blood vessels, and shrink enlarged pores. Worry lines are whisked away with Dysport injections, which are similar to Botox injections, smoothing out the area between the brows for clean lightning-bolt-scar application. Patients can also punish their naughty shampoo-stealing pelts with three laser hair-removal treatments on either the lips, chin, sideburns, front of neck, back of neck, underarms, feet, hands, or ears (a $500–$800 value per area for three treatments). All prospective baby faces need to call ahead for an appointment.
Thursday, February 03, 2011
Shaw got it right
George Bernard Shaw wrote The Doctor's Dilemma, Preface on Doctors in 1909. It is fun to read some excerpts:It is not the fault of our doctors that the medical service of the community, as at present provided for, is a murderous absurdity. That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity. But that is precisely what we have done. And the more appalling the mutilation, the more the mutilator is paid. He who corrects the ingrowing toe-nail receives a few shillings: he who cuts your inside out receives hundreds of guineas, except when he does it to a poor person for practice.
Scandalized voices murmur that these operations are necessary. They may be. It may also be necessary to hang a man or pull down a house. But we take good care not to make the hangman and the housebreaker the judges of that. If we did, no man's neck would be safe and no man's house stable. But we do make the doctor the judge... I cannot knock my shins severely without forcing on some surgeon the difficult question, "Could I not make a better use of a pocketful of guineas than this man is making of his leg? Could he not write as well—or even better—on one leg than on two?"
Why doctors do not differ
The truth is, there would never be any public agreement among doctors if they did not agree to agree on the main point of the doctor being always in the right. Yet the two guinea man never thinks that the five shilling man is right: if he did, he would be understood as confessing to an overcharge of one pound seventeen shillings; and on the same ground the five shilling man cannot encourage the notion that the owner of the sixpenny surgery round the corner is quite up to his mark. Thus even the layman has to be taught that infallibility is not quite infallible, because there are two qualities of it to be had at two prices.
But there is no agreement even in the same rank at the same price. During the first great epidemic of influenza towards the end of the nineteenth century a London evening paper sent round a journalist-patient to all the great consultants of that day, and published their advice and prescriptions; a proceeding passionately denounced by the medical papers as a breach of confidence of these eminent physicians. The case was the same; but the prescriptions were different, and so was the advice.
Now a doctor cannot think his own treatment right and at the same time think his colleague right in prescribing a different treatment when the patient is the same. Anyone who has ever known doctors well enough to hear medical shop talked without reserve knows that they are full of stories about each other's blunders and errors, and that the theory of their omniscience and omnipotence no more holds good among themselves than it did with Moliere and Napoleon.
But for this very reason no doctor dare accuse another of malpractice. He is not sure enough of his own opinion to ruin another man by it. He knows that if such conduct were tolerated in his profession no doctor's livelihood or reputation would be worth a year's purchase. I do not blame him: I would do the same myself.
But the effect of this state of things is to make the medical profession a conspiracy to hide its own shortcomings. No doubt the same may be said of all professions. They are all conspiracies against the laity; and I do not suggest that the medical conspiracy is either better or worse than the military conspiracy, the legal conspiracy, the sacerdotal conspiracy, the pedagogic conspiracy, the royal and aristocratic conspiracy, the literary and artistic conspiracy, and the innumerable industrial, commercial, and financial conspiracies, from the trade unions to the great exchanges, which make up the huge conflict which we call society. But it is less suspected.
Statistical Illusions
Public ignorance of the laws of evidence and of statistics can hardly be exaggerated. There may be a doctor here and there who in dealing with the statistics of disease has taken at least the first step towards sanity by grasping the fact that as an attack of even the commonest disease is an exceptional event, apparently over-whelming statistical evidence in favor of any prophylactic can be produced by persuading the public that everybody caught the disease formerly.
Thus if a disease is one which normally attacks fifteen per cent of the population, and if the effect of a prophylactic is actually to increase the proportion to twenty per cent, the publication of this figure of twenty per cent will convince the public that the prophylactic has reduced the percentage by eighty per cent instead of increasing it by five, because the public, left to itself and to the old gentlemen who are always ready to remember, on every possible subject, that things used to be much worse than they are now ... will assume that the former percentage was about 100.
Flame throwers would work nicely
Now, why didn't I think of this, instead of suggesting that we throw the snow in the Harbor?Sixty three years ago Boston received so much snow that then Mayor James Curley took a look at it and began pleading with then MIT President Dr. Karl Compton for help. “I am very desirous that [MIT] have a competent group of engineers make an immediate study as to ways and means of removing the huge accumulation,” he wrote, “…be it by the use of flame throwers or chemicals or otherwise.”
Courtesy of the MIT Alumni Association.
Wednesday, February 02, 2011
Our patients are sicker
What more do we need to know? The British Medical Journal published a study showing that Peter Pronovost's program to reduce central line infections in Michigan saved lives.
A new study finds that a safety checklist program developed by a Johns Hopkins doctor has reduced patient deaths in Michigan hospitals by 10 percent, in addition to nearly eliminating bloodstream infections in health care facilities that embraced the prevention effort.
The research, published in the British Medical Journal, is the first to show a drop in patient mortality in hospitals using the Hopkins program. Previous studies have found major reductions in bloodstream infections from using the checklist when inserting catheters or central lines to give patients medication, fluids or nourishment.
Well, duh. But I guess it is important to have scientific verification. But I can almost hear the comments from some places: "That wouldn't work here. Our patients are sicker."
So, how long will it take for this approach to be used across the country? This study is based on work from nine years ago. If this is like other innovations in medical care, it will take a decade and a half more to spread.
Here's my proposal to jump-start it. Publish the monthly rate of central line infections for all hospitals on a public website. CMS, IHI, the Dartmouth Atlas group or some other organization could do this in a nano-second, creating a voluntary website, giving each hospital a password through which it could enter its own data. There is no need to audit the figures. We can trust people to be honest.
And, at the bottom of the website, the host could list the hospitals that have chosen NOT to publish.
Then, you would see the power of transparency.
A new study finds that a safety checklist program developed by a Johns Hopkins doctor has reduced patient deaths in Michigan hospitals by 10 percent, in addition to nearly eliminating bloodstream infections in health care facilities that embraced the prevention effort.
The research, published in the British Medical Journal, is the first to show a drop in patient mortality in hospitals using the Hopkins program. Previous studies have found major reductions in bloodstream infections from using the checklist when inserting catheters or central lines to give patients medication, fluids or nourishment.
Well, duh. But I guess it is important to have scientific verification. But I can almost hear the comments from some places: "That wouldn't work here. Our patients are sicker."
So, how long will it take for this approach to be used across the country? This study is based on work from nine years ago. If this is like other innovations in medical care, it will take a decade and a half more to spread.
Here's my proposal to jump-start it. Publish the monthly rate of central line infections for all hospitals on a public website. CMS, IHI, the Dartmouth Atlas group or some other organization could do this in a nano-second, creating a voluntary website, giving each hospital a password through which it could enter its own data. There is no need to audit the figures. We can trust people to be honest.
And, at the bottom of the website, the host could list the hospitals that have chosen NOT to publish.
Then, you would see the power of transparency.
Tuesday, February 01, 2011
Lessons from Cairo
I think most of us would be hard-pressed not to be inspired by the moral power of the crowds in people in Egypt as they throw off a form of government that they find repressive. But, it is about the US reaction to all this to which I turn today. It is the subject of New York Times columns by David Brooks and Nicholas D. Kristof.
Both authors noted the ham-handed manner in which the United States deals with authoritarian regimes and with popular movements for freedom.
Brooks notes,
Kristof says,
I wonder if sometime around 50 years ago a great mental tide began to sweep across the world. Before the tide, people saw themselves in certain fixed places in the social order. They accepted opinions from trusted authorities.
You will excuse me if I draw the connection to health care. I hope you don't think it inapposite.
I do not think that it has been a fifty year trend in health care, but a more recent one. Patients and families have decided that they should be equal partners in the process of diagnosis and treatment. They believe that they have a right to the information that can represent life or death, health or suffering. As Brooks would put it, "treatment that once seemed normal now feels like a insult." Opinions from trusted authorities no longer carry the weight they used to. Questions are being asked. Answers are being demanded.
A few weeks ago, author Charles Kenney asked the question, Isn't there a compelling -- perhaps even overriding -- moral component to transparency?
I responded,
The answer, of course, is yes. Doctors and others pledge to do no harm. How can you be sure you are living by that oath if you are unwilling to acknowledge how well you are actually doing the job? As scientists, how can you test to see if you are making improvements in evidence-based care if you cannot validate the "prior" against which you are testing a new hypothesis? At the most personal, ethical level, how can you be sure you are doing the best for people who have entrusted their lives to you if you are not willing to be open on these matters?
But transparency threatens the status quo. In the medical world, status quo confers power, influence, prestige, and money on those who have had a reputational advantage. A close friend and colleague put it this way:
Transparency in self-interested institutions who are making fortunes by deluding themselves and the public that they and only they know what the community wants and needs is a very dangerous concept.
The agents of change in this battle will be the same people who are turning things over in Egypt. Normal people who have experienced pain and suffering, or even just disrespect, in the health care system are starting to find their voice. Like the US in the international arena, the powers that be in the government and their agents, having been captured by the powerful forces of the medical and hospital profession, are slow to react and are protective of the status quo.
Both authors noted the ham-handed manner in which the United States deals with authoritarian regimes and with popular movements for freedom.
Brooks notes,
The . . . thing we’ve learned is that the United States usually gets everything wrong.
Policy makers always underestimate the power of the bottom-up quest for dignity, so they are slow to understand what is happening.
Then their instinct is to comfort the fellow members of the club of those in power.
Then, desperately recalibrating in an effort to keep up with events, they inevitably make a series of subtle distinctions no one else heeds.Kristof says,
Yet one thing nags at me. These pro-democracy protesters say overwhelmingly that America is on the side of President Mubarak and not with them. They feel that way partly because American policy statements seem so nervous, so carefully calculated.
The upshot is that this pro-democracy movement, full of courage and idealism and speaking the language of 1776, wasn’t inspired by us. No, the Egyptians said they feel inspired by Tunisia — and a bit stymied by America.
Everywhere I go, Egyptians insist to me that Americans shouldn’t perceive their movement as a threat. And I find it sad that Egyptians are lecturing Americans on the virtues of democracy.
Brooks provided a broader context for all of this:I wonder if sometime around 50 years ago a great mental tide began to sweep across the world. Before the tide, people saw themselves in certain fixed places in the social order. They accepted opinions from trusted authorities.
As the tide swept through, they began to see themselves differently. They felt they should express their own views, and these views deserved respect. They mentally bumped themselves up to first class and had a different set of expectations of how they should be treated. Treatment that had once seemed normal now felt like an insult. They began to march for responsive government and democracy.
You will excuse me if I draw the connection to health care. I hope you don't think it inapposite.
I do not think that it has been a fifty year trend in health care, but a more recent one. Patients and families have decided that they should be equal partners in the process of diagnosis and treatment. They believe that they have a right to the information that can represent life or death, health or suffering. As Brooks would put it, "treatment that once seemed normal now feels like a insult." Opinions from trusted authorities no longer carry the weight they used to. Questions are being asked. Answers are being demanded.
A few weeks ago, author Charles Kenney asked the question, Isn't there a compelling -- perhaps even overriding -- moral component to transparency?
I responded,
The answer, of course, is yes. Doctors and others pledge to do no harm. How can you be sure you are living by that oath if you are unwilling to acknowledge how well you are actually doing the job? As scientists, how can you test to see if you are making improvements in evidence-based care if you cannot validate the "prior" against which you are testing a new hypothesis? At the most personal, ethical level, how can you be sure you are doing the best for people who have entrusted their lives to you if you are not willing to be open on these matters?
But transparency threatens the status quo. In the medical world, status quo confers power, influence, prestige, and money on those who have had a reputational advantage. A close friend and colleague put it this way:
Transparency in self-interested institutions who are making fortunes by deluding themselves and the public that they and only they know what the community wants and needs is a very dangerous concept.
The agents of change in this battle will be the same people who are turning things over in Egypt. Normal people who have experienced pain and suffering, or even just disrespect, in the health care system are starting to find their voice. Like the US in the international arena, the powers that be in the government and their agents, having been captured by the powerful forces of the medical and hospital profession, are slow to react and are protective of the status quo.
Policy makers always underestimate the power of the bottom-up quest for dignity, so they are slow to understand what is happening.
Then their instinct is to comfort the fellow members of the club of those in power.
Then, desperately recalibrating in an effort to keep up with events, they inevitably make a series of subtle distinctions no one else heeds.Monday, January 31, 2011
Tectonic forces at work
We are about to witness the clash of two tectonic plates in health care. The creation of Accountable Care Organizations, combined with a movement towards capitated and other types of bundled payments, will be forces towards integration of care across the continuum. From primary care to tertiary care to skilled nursing and rehabilitation, principles of care management will combine with financial incentives to create ever more concentration in the health care market. Proprietary electronic medical records systems and "captive" doctor organizations will work towards reducing consumer choice in this new environment.
You already see health care companies engaged in this and advertising it as an attribute. Here, for example, one company notes: [Q]uality care is not just about the care in one institution – it’s what happens between institutions. And if we don’t pay close attention to those gaps – which means measuring and acting to improve the information flow – the patient will suffer. (And, you already see health care companies engage in deceptive behavior with regard to referrals, too, like here.)
Yet, at the same time, patients and their advocates will be demanding more choice. Fully trained in consumerism in other fields, they will expect the same in health care. They will want internet-based transparency of clinical outcomes, along with tons of disease-specific information, so they can seek out and obtain the best possible care for themselves and their loved ones. They will press captive doctors to allow them to be referred to out-of-network health care companies that appear to provide better, safer, and/or more compassionate care.
How will this crash of the tectonic plates be resolved? One answer is to ignore consumer preference and rely on monopoly-like organization of care. We know from other fields, however, that this not only results in monopoly pricing, but it slows down innovation. Think of the Bell System in years past, which provided integrated service, from telephone instruments to long distance calling. Many people alive today do not know that the Bell System conspired to limit people's choice to the extent that you were not allowed to connect a non-Bell telephone in your house. The company argued that doing so would cause irreparable harm to the network and knock out telephone service for miles! You could not buy your phone. You had to rent it for a monthly fee, payable forever (see below). Actually, it was even worse than that. Your bill also included a fee for every extension outlet in your house, even outlets that did not have telephones attached.
And, if you wanted to make a long distance call, there was only one provider, AT&T Long Lines, the one affiliated with your local Bell operating company. You paid by the minute: There was no unlimited service based on a fixed monthly fee. Why? Because they could.
Eventually, the government broke up the Bell System when upstart competitors wanted to sell telephone sets and other companies wanted to offer long distance service. Standards were established that allowed anyone to use the local network and get access to dial tone. Eventually, even that monopoly was broken when other telephone companies and cable companies were permitted to string wires into the neighborhoods. And then, even those technologies faced competition from cellular networks and voice-over-internet.
Is there a lesson from all this for health care? You bet.
The heart of the problem in health care has two dimensions. First, electronic medical records are often based on proprietary systems, limiting interoperability between health care networks. Second, doctors are captive members of a provider network, often one controlled by a region's major hospital or health care company.
As computer guru John Halamka would note, the first problem is gradually going away, in a technical sense. With the advent of national data standards, it will be easier and easier to electronically connect patient records across multiple providers. There are already clear demonstrations of full integration in place, where two or more organizations have found it to be in their mutual interest. But we can expect geographically strong networks to resist this. It will take government action to enforce interoperability.
The second problem, though, requires a Bell System-like solution. As long as physician groups are owned by or otherwise financially affiliated with hospitals, the doctors in those groups will not have the freedom to refer folks to the facilities that are optimal for patients. We can make all the claims we want about the need to have a closely tied physician network to provide integrated health care delivery, but those claims are vacuous. Such systems tend to be driven by -- and serve -- the hospitals and the specialists in them rather than the community-based physicians.
Ask this question to any primary care doctor you know who is part of a hospital-based network: "Do you feel you have the freedom to send a patient to a hospital in another network? " At best, they will say, "If I really feel strongly about it, I can do so." But, if they are honest, they will say, "I don't dare do that very often, if at all. My continued participation in the contracting benefits of my network depend on sending my patients to affiliates in that network."
It is time to break this system wide open and prohibit corporate affiliations between community-based providers and hospital-based health care delivery networks. Let's free up the community doctors to make referral choices based on publicly available data about clinical outcomes, quality of service, and other items that matter to their patients. If global payments become the norm, the PCPs should "own" the payment and then apportion it among secondary and tertiary providers who best serve their patients. Let the marketplace decide which hospitals rise or fall in this environment.
Short of that, we will retain Ma Bell in health care. Then, the answer will be the one given by Lily Tomlin (aka, Ernestine, the telephone company operator):
"Next time you complain about your phone service, why don't you try using two Dixie cups with a string. We don't care. We don't have to. We're the Phone Company!"
If you cannot see the video below, click here.
You already see health care companies engaged in this and advertising it as an attribute. Here, for example, one company notes: [Q]uality care is not just about the care in one institution – it’s what happens between institutions. And if we don’t pay close attention to those gaps – which means measuring and acting to improve the information flow – the patient will suffer. (And, you already see health care companies engage in deceptive behavior with regard to referrals, too, like here.)
Yet, at the same time, patients and their advocates will be demanding more choice. Fully trained in consumerism in other fields, they will expect the same in health care. They will want internet-based transparency of clinical outcomes, along with tons of disease-specific information, so they can seek out and obtain the best possible care for themselves and their loved ones. They will press captive doctors to allow them to be referred to out-of-network health care companies that appear to provide better, safer, and/or more compassionate care.
How will this crash of the tectonic plates be resolved? One answer is to ignore consumer preference and rely on monopoly-like organization of care. We know from other fields, however, that this not only results in monopoly pricing, but it slows down innovation. Think of the Bell System in years past, which provided integrated service, from telephone instruments to long distance calling. Many people alive today do not know that the Bell System conspired to limit people's choice to the extent that you were not allowed to connect a non-Bell telephone in your house. The company argued that doing so would cause irreparable harm to the network and knock out telephone service for miles! You could not buy your phone. You had to rent it for a monthly fee, payable forever (see below). Actually, it was even worse than that. Your bill also included a fee for every extension outlet in your house, even outlets that did not have telephones attached.
And, if you wanted to make a long distance call, there was only one provider, AT&T Long Lines, the one affiliated with your local Bell operating company. You paid by the minute: There was no unlimited service based on a fixed monthly fee. Why? Because they could.
Eventually, the government broke up the Bell System when upstart competitors wanted to sell telephone sets and other companies wanted to offer long distance service. Standards were established that allowed anyone to use the local network and get access to dial tone. Eventually, even that monopoly was broken when other telephone companies and cable companies were permitted to string wires into the neighborhoods. And then, even those technologies faced competition from cellular networks and voice-over-internet.
Is there a lesson from all this for health care? You bet.
The heart of the problem in health care has two dimensions. First, electronic medical records are often based on proprietary systems, limiting interoperability between health care networks. Second, doctors are captive members of a provider network, often one controlled by a region's major hospital or health care company.
As computer guru John Halamka would note, the first problem is gradually going away, in a technical sense. With the advent of national data standards, it will be easier and easier to electronically connect patient records across multiple providers. There are already clear demonstrations of full integration in place, where two or more organizations have found it to be in their mutual interest. But we can expect geographically strong networks to resist this. It will take government action to enforce interoperability.
The second problem, though, requires a Bell System-like solution. As long as physician groups are owned by or otherwise financially affiliated with hospitals, the doctors in those groups will not have the freedom to refer folks to the facilities that are optimal for patients. We can make all the claims we want about the need to have a closely tied physician network to provide integrated health care delivery, but those claims are vacuous. Such systems tend to be driven by -- and serve -- the hospitals and the specialists in them rather than the community-based physicians.
Ask this question to any primary care doctor you know who is part of a hospital-based network: "Do you feel you have the freedom to send a patient to a hospital in another network? " At best, they will say, "If I really feel strongly about it, I can do so." But, if they are honest, they will say, "I don't dare do that very often, if at all. My continued participation in the contracting benefits of my network depend on sending my patients to affiliates in that network."
It is time to break this system wide open and prohibit corporate affiliations between community-based providers and hospital-based health care delivery networks. Let's free up the community doctors to make referral choices based on publicly available data about clinical outcomes, quality of service, and other items that matter to their patients. If global payments become the norm, the PCPs should "own" the payment and then apportion it among secondary and tertiary providers who best serve their patients. Let the marketplace decide which hospitals rise or fall in this environment.
Short of that, we will retain Ma Bell in health care. Then, the answer will be the one given by Lily Tomlin (aka, Ernestine, the telephone company operator):"Next time you complain about your phone service, why don't you try using two Dixie cups with a string. We don't care. We don't have to. We're the Phone Company!"
If you cannot see the video below, click here.
Sunday, January 30, 2011
Should there be a billing code for compassionate care?
Back in 2009, Dr. Amy Ship gave a moving acceptance speech when she received the annual Compassionate Caregiver Award from the Schwartz Center.
The most memorable tag line from the speech was, "There is no billing code for compassion." This resonated with so many of us -- patients and providers -- in part because it set forth the proposition that compassionate care should be an inherent aspect of medical services. The idea that some portion of a doctor's or hospital's payment should be tied to such an essential human value seemed ludicrous.
Or is it? A recent survey conducted by the Schwartz Center, entitled "The state of compassionate care in the United States," indirectly raises the issue. Those patients and doctors surveyed were overwhelmingly in favor of the idea that compassionate care was important to the successful treatment of patients. They agreed, too, that compassionate care makes a difference in how well a patient recovers from illness. Indeed, they believed that good communication and emotional support can make a difference in whether a patient lives or dies.
But there was a gap between what patients said was most important to them, in terms of compassionate care, and what they actually experienced during recent hospitalizations. And, looking forward, both patients and doctors are worried that the changes being made in our health care system will make it more difficult for providers to offer compassionate care.
Now, if we remove the word "compassionate" from the above discussion and instead insert "safety," "quality," "avoiding hospital acquired infections," or the like, our immediate response would be that we need to change the system of hospital and physician payments to provide financial incentives to change things for the better. Whether we might propose a pay-for-performance approach or some kind of global payment to encourage improvement, the current environment seems very comfortable with using the payment system to nudge behavior in the right direction.
So, why not pay for compassion? Surely, we can name those aspects of care that are most closely tied to compassion, and we can likewise document whether they occur.
While I will let this debate play out in the comments below, let me start it off by saying that I believe this would be a mistake. So many discrete aspects of medical care are already monetized that is hard to imagine a payment regime that would actually focus sufficient financial attention to motivate a doctor along the spectrum of less-to-more compassion. Beyond that, the idealist in me is offended by the idea of paying someone to, in essence, be more humane. In my view, this is not a matter of remuneration. It is a matter of societal values and a training program and ongoing supervision that imbues practice with those values.
But, let's hear what you have to say. Should there be a billing code for compassionate care?
The most memorable tag line from the speech was, "There is no billing code for compassion." This resonated with so many of us -- patients and providers -- in part because it set forth the proposition that compassionate care should be an inherent aspect of medical services. The idea that some portion of a doctor's or hospital's payment should be tied to such an essential human value seemed ludicrous.
Or is it? A recent survey conducted by the Schwartz Center, entitled "The state of compassionate care in the United States," indirectly raises the issue. Those patients and doctors surveyed were overwhelmingly in favor of the idea that compassionate care was important to the successful treatment of patients. They agreed, too, that compassionate care makes a difference in how well a patient recovers from illness. Indeed, they believed that good communication and emotional support can make a difference in whether a patient lives or dies.
But there was a gap between what patients said was most important to them, in terms of compassionate care, and what they actually experienced during recent hospitalizations. And, looking forward, both patients and doctors are worried that the changes being made in our health care system will make it more difficult for providers to offer compassionate care.
Now, if we remove the word "compassionate" from the above discussion and instead insert "safety," "quality," "avoiding hospital acquired infections," or the like, our immediate response would be that we need to change the system of hospital and physician payments to provide financial incentives to change things for the better. Whether we might propose a pay-for-performance approach or some kind of global payment to encourage improvement, the current environment seems very comfortable with using the payment system to nudge behavior in the right direction.
So, why not pay for compassion? Surely, we can name those aspects of care that are most closely tied to compassion, and we can likewise document whether they occur.
While I will let this debate play out in the comments below, let me start it off by saying that I believe this would be a mistake. So many discrete aspects of medical care are already monetized that is hard to imagine a payment regime that would actually focus sufficient financial attention to motivate a doctor along the spectrum of less-to-more compassion. Beyond that, the idealist in me is offended by the idea of paying someone to, in essence, be more humane. In my view, this is not a matter of remuneration. It is a matter of societal values and a training program and ongoing supervision that imbues practice with those values.
But, let's hear what you have to say. Should there be a billing code for compassionate care?
Unguarded waterfront
An important warning at Walden Pond, in case you were thinking of swimming yesterday.
Throw the snow in the Harbor!
As I was walking home last night, I saw this scene on Arlington Street in downtown Boston. I was reminded of a story I heard the other day on WBUR's Radio Boston about the problems being faced by Boston and other communities as they engage in snow removal from municipal streets. One aspect of the problem is that state environmental officials have prohibited Boston and other coastal communities from disposing of street snow in the Harbor.Now, I don't think anyone can contest my environmental bona fide's. After all, I ran the agency that accomplished the Boston Harbor Cleanup, one of the world's largest environmental remediation projects. But this is one rule that I just don't understand.
Yes, I know that snow on city streets picks up all kinds of chemicals and pollutants from the city environment, and I know it also picks up salt and chemical de-icers during its residence time.
But, instead of dumping this snow in the harbor, it gets trucked -- using thousands of gallons of fuel which create all kinds of air emissions -- to inland locations. What happens there? It melts, and those same pollutants enter the ground water system. Or they go into city storm drains, where they end up where? Boston Harbor.
Perchance some of the melted snow goes down storm drains that empty into the city's combined system, which sends the wastewater to the Deer Island sewage treatment plant. In that case, such contaminants that are captured are concentrated in the sludge at the plant, which is eventually made into fertilizer, from which the chemicals leach out onto farmland somewhere. The contaminants that are not captured in the sludge go out through a tunnel 9.5 miles long with the plant's effluent to Massachusetts Bay, the receiving water for . . . Boston Harbor.
I just don't see the point. Why don't we save the extra expense so Boston and other coastal communities can use that money for things like environmental education in the local schools?
When snow falls from the sky, it goes directly into the Harbor. Let's follow Nature's lead.
Standard of review
A comment by an eight-year-old girl, exiting last night's tap dance performance by Savion Glover: "That was better than American Idol!"
Saturday, January 29, 2011
Cleaning for a Reason
From a friend:If you know any woman currently undergoing chemotherapy, please pass the word to here that there is a cleaning service that provides free housekeeping -- once per month for four months while she is in treatment. All she has to do is sign up and have her doctor fax a note confirming the treatment.
Cleaning for a Reason will have a participating maid service in her zip code area arrange for the service. The organization serves the entire USA and currently has 547 partners to help these women.
Be a blessing to someone and pass this information along.
Thursday, January 27, 2011
Website for parents
I'm taking a step away from health care for a moment to offer something that might be of interest to parents. One of my former soccer players, Dr. Alexis Lauricella, sends the following note.
But first this question: How can someone who in my mind is 14 be a Ph.D? Of course, as was always the case, I am really proud of her.
Here's the note:
I just wanted to let you all know that I started a website for parents about child development. I have always felt particularly frustrated by the fact that there are very few services and very little information available to help parents become the best parents they can be. This is only the beginning, but I wanted to create a website/resource where parents can learn about basic child development and parenting information. If you know anyone who is a parent, who may become a parent, or in anyway may benefit from basic child development resources (e.g., teachers, nurses, pediatricians, etc) please feel free to pass along this website and the Facebook page (See below for links) and please feel free to sign up yourselves! The website has resources and a few blog posts and I tend to post articles and interesting resources daily on the Facebook page.
PlayLearnParent Website
PlayLearnParent Facebook Page
PlayLearnParent Email: playlearnparent [at] gmail [dot] com
PlayLearnParent on Twitter: ARL@playlearnparent
I would really appreciate help getting this out to people, so please feel free to pass this along to anyone. And thanks to everyone who has already "liked" PlayLearnParent on Facebook or has taken a look at the website!
But first this question: How can someone who in my mind is 14 be a Ph.D? Of course, as was always the case, I am really proud of her.
Here's the note:
I just wanted to let you all know that I started a website for parents about child development. I have always felt particularly frustrated by the fact that there are very few services and very little information available to help parents become the best parents they can be. This is only the beginning, but I wanted to create a website/resource where parents can learn about basic child development and parenting information. If you know anyone who is a parent, who may become a parent, or in anyway may benefit from basic child development resources (e.g., teachers, nurses, pediatricians, etc) please feel free to pass along this website and the Facebook page (See below for links) and please feel free to sign up yourselves! The website has resources and a few blog posts and I tend to post articles and interesting resources daily on the Facebook page.
PlayLearnParent Website
PlayLearnParent Facebook Page
PlayLearnParent Email: playlearnparent [at] gmail [dot] com
PlayLearnParent on Twitter: ARL@playlearnparent
I would really appreciate help getting this out to people, so please feel free to pass this along to anyone. And thanks to everyone who has already "liked" PlayLearnParent on Facebook or has taken a look at the website!
Global warming in the extreme?
Hmm, perhaps the headline writer on Boston.com needs a chemistry lesson.
At least it feels that way!
Actual image of commuters in Boston this morning after the recent series of snowstorms.
Wednesday, January 26, 2011
Residency Work Hours on WIHI
New Models for Residency Work Hours
Thursday, January 27, 2011, 2:00 PM – 3:00 PM Eastern Time
Guests:
Christopher P. Landrigan, MD, MPH, Director, Sleep and Patient Safety Program, Brigham and Women’s Hospital
David B. Sweet, MD, FACP, Program Director, Internal Medicine Residency, Summa Health System
James F. Whiting, MD, Surgical Director, Maine Transplant Program and Surgical Residency Program Director, Maine Medical Center
Donald Goldmann, MD, Senior Vice President, Institute for Healthcare Improvement
If you survey the American public on efforts to restrict the number of hours medical residents can work without sleep or time off, there’s overwhelming support for new rules and regulations. The relationship between lack of sleep and the increased likelihood of impaired judgment and medical errors seems like a no-brainer to most patients. The bigger challenge is to convince residents themselves – and, perhaps even more, those who teach new physicians – that work hour limits make sense...and can be implemented without compromising continuity of care or interfering with education and training. Still, a growing number of residency program leaders are discovering that the only way to move this debate forward is to dig in and start innovating and doing things differently.
David Sweet and James Whiting are two such program directors who will be joining WIHI host Madge Kaplan on January 27 to describe what residency training can look like in systems grounded in patient safety, greater teamwork, better handoffs, increased supervision, and educational redesign. The changes at Summa Health System (16-hour limits are the norm for all residents) and Maine Medical Center are noteworthy; they join a growing number of residency programs not just doing the bare minimum to comply with Accreditation Council for Graduate Medical Education (ACGME) rules, but seeking to create new and better models of care.
Christopher Landrigan’s research on sleep deprivation and patient safety, along with Don Goldmann’s knowledge of hospital improvement and the goals of residency training, will deepen the conversation and round out what is sure to be a rich discussion. Both Drs. Landrigan and Goldmann appreciate the challenges residency programs now face to institute critical changes, but reform also opens up all sorts of possibilities. We hope you’ll join us on the next WIHI.
To enroll, please click here.
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