What else are they buying?

I went to the Amazon page for my book Goal Play! recently to see what books people who bought my book also bought.  Some might be expected. Others were a surprise.

I certainly could see the connection with Edgar Schein's Helping.  In fact, Ed wrote the foreword to my book.

Likewise, Swen Nater's You Haven't Taught Until They Have Learned, based on the coaching philosophy and techniques of John Wooden.  These are remarkably similar to my own, although no coach has been or will be as good as Wooden!

There are several books on health care, like the ones by Marty Makary, Maureen Bisognano, and Leonard Berry.  Lots of shared lessons there.

But the one that tops the list is Daniel Kahneman's Thinking Fast and Slow.  As one reviewer says, "Kahneman’s book is a must read for anyone interested in either human behavior or investing. He clearly shows that while we like to think of ourselves as rational in our decision making, the truth is we are subject to many biases."  The parallels to the world of hospitals are obvious.

All in all, I am pleased to be in such good company.  By the way, stay tuned.  The audio book version of Goal Play! will be issued soon, joining the paper and Kindle versions

Courage Muscle, still available

Many people replied to yesterday's offer to get a free copy of Monique Doyle Spencer's, The Courage Muscle.  If you replied, a copy is on its way.  If not, there are still copies left.  Please submit a reply with your snail mail address, and I will extract that address from your comment and send you a copy.  If you have a chance, please review yesterday's comments.  I think Monique would have been happy to know that so many people would benefit from her book.

By the way, the book is available from Amazon, too, if you would like to purchase additional copies.  Also, for those in Boston, it is for sale at the Windows of Hope oncology gift shop in the Shapiro Building at Beth Israel Deaconess Medical Center.

The Courage Muscle, free

When Monique Doyle Spencer wrote The Courage Muscle, A Chicken's Guide to Living with Breast Cancer, she couldn't find a publisher willing to take the book on.  It was funny, you see, and all the publishers thought it was inappropriate to have a funny book about cancer.  She showed me a draft, and I said that our hospital would publish the book, and we did.  Since then, it has brought good-humored hope and advice to patients and families around the world.  As one reviewer said:  "It should become a textbook for the medical professions and a guidebook for all who must confront, or support those who do, breast cancer. It is a beautiful book, beautifully written, that sweetly balances gravitas, zaniness and one person's truth. The author's humanity is in full, accessible display for all to see, share and learn from."

Monique died on Thanksgiving weekend in 2011, and along with our fond memories of her, the book remains.  I happen to have several dozen copies, as does her husband Michael.  We have decided to offer them at no cost to the readers of this blog.  First come, first served, until we run out.  Just submit a comment with your name and snail mail address, and we will send one off to you in a few days.

To whet your appetite, here is a story about Monique's humor.  It occurred a few months before in 2011.  Michael tells it:

Bobby McFerrin gave a marvelous concert, showing his voice as an instrument, to a packed house at Symphony Hall.  Afterwards he came to the front of the stage and sat, legs dangling, to answer questions. After a bit, Monique plunged in, without being acknowledged, and asked about whether he was asked to do "Don't Worry Be Happy."  I could feel the audience cringe.  McFerrin gracefully answered the question and said he does not perform the song and was sorry to disappoint.  Monique shot back, "I did not say I liked it."  The audience broke out laughing and McFerrin fell to the floor and lay down on the stage, doing the same.

In appreciation: Ehud Kokia

Ehud Kokia resigned as CEO of Hadassah Medical Organization (HMO) this week.  I want to share some thoughts about him before time passes.  Why?  By presenting his example, I hope to give confidence to my skeptical or cynical readers that there are leaders in the health care system who are exemplary human beings.  During my time as a hospital CEO and in the two years since, I have had the privilege to meet a number of such men and women.

Ehud is emblematic of those people who take on the job for the best of reasons. They sign up not for ego boosting or self-gratification, but because they are kind and caring individuals who want to provide a service to their communities in the most humane and professional manner possible.  They want to advance knowledge among health care professionals in a way that supports patient-centered care.  They respect and admire all of the people in their organizations, from the custodians to the neurosurgeons, understanding that the best ideas can emerge from any place and any person.  Over the years, I have mentioned a few of the American CEOs who embody these values, but they also exist in other countries.  Ehud is one such person in Israel.

Ehud and I first met two years ago, when he was running Maccabi Healthcare Services, one of the four health maintenance organizations in Israel.  (You can think of each organization as a combination of a major primary care and multi-specialty practice and an insurance administrator, funded by the national health care fund.)  He was highly successful in enhancing the business and operational aspects of the firm, but also was a leader in improving the quality of care delivered to that system’s patients. Ehud later joined HMO, seeking the challenge of running the country’s preeminent academic medical center at Ein Kerem and an associated community hospital at Mt. Scopus.

Now, just fourteen months later, he has chosen to leave.  In that short time, he has secured the respect and affection of administrative and clinical leaders, but also many other folks throughout HMO.  He could have stayed for many years, but he selflessly decided that another type of person would be better suited to the job, as the circumstances facing HMO had changed dramatically in the period following his recruitment and arrival.

For someone who believes so strongly in the clinical, research, and training mission of an academic medical center--and in the people who carry out that mission--a decision to resign is painful and wrenching.  Ironically, it was the intensity of that belief that led Ehud to his decision.  I’d like you to hear that in his own words, so I conclude with excerpts of his email to the staff this week (with help from Google to translate from Hebrew to English).  This is a man who still has much to contribute the community, and I am sure he will serve elsewhere with distinction during his next chapters.

Last night, Monday, I announced my resignation to the Board as CEO of Hadassah. During the brief period in which I served in that role, I found a wonderful bunch of people who have seen our hospital as their home for years, who do everything possible to empower and enhance the institution.

I found a center here with enormous capabilities in medicine, research and teaching. I found many areas where the hospital leads not only Israel, but also in the world. We must all be aware of this fact and be proud of it.

Along the path of both my personal and professional life, transparency is a cornerstone in matters practical and administrative: I tried to share as much as possible with the various functional areas of the hospital and connect them as one leadership team. Accordingly, any information obtained at the level of senior management was brought to the attention of the wider management circles. Instead of "we" and "them", we tried to create a system view of "all together."

I place great importance on quality. I began a campaign to introduce processes of quality to every corner of our hospitals. Improving service delivery and ambulatory medicine outpatient clinics also received special attention. We refreshed Hadassah management ranks, both at the clinical department directors and senior management level in the organization. A new manager came to Mount Scopus, a new CFO, deputy director Ein Kerem hospital and quality management and strategic planning.  In recent months, I examined programs to promote the status of the Mount Scopus campus in order to exploit its capabilities.  In parallel, I took part in populating the new hospital tower [at Ein Kerem], and we watched the building come alive.

Against all this was a background of growing financial distress. After several months it became clear to me and my management team that the cash flow deficit was larger than had been reported and had continued for several years. We prepared a program to intervene in this area, but we all have in the near future a very significant overhaul of Hadassah.

Against this background and in view of the fact that the economic situation was not clear enough for both sides when I started in this job, I announced to the Board that I had decided to leave. I will do what is required to allow a proper and orderly transfer of the position to the next person.

Dear colleagues, what I take with me and strains my heart is the "Hadassah spirit"--friendships and human connections we created, the names and faces of wonderful people, and especially the knowledge that these relations will continue to exist despite the geographic distance. I wish with all my heart success at Hadassah in the future.

---
Photo credit:  Ofer Vaknin, Haaretz

Priority for Tweeters

Check out this story by Nancy Thomas in GoLocalProv.  Excerpts:

The idea takes what may have been considered an annoyance--theater or concert attendees using their cells during a performance--and flips it upside down. Now, Providence performing Arts Center will reward you for tweeting... by offering "Tweet Seats" to a small group of attendees who promise to tweet during the show.

Normally, tweeting at a cultural event is frowned upon by those around you, especially at a musical at PPAC, but on this night we were fully sanctioned. We were given a hashtag to use, a key part of tweeting effectively.  A hashtag identifies tweets around one particular topic.  For this night it was #MemphisPPAC.  We were required to include that hashtag in each Tweet. We were given seats in the last row of the lower level.  We respectfully turned our sound off, and our screen brightness to low, and waited for the production to start.

This is a great marketing idea, and you can already imagine the application to other venues--art exhibits, other types of performances.  Perhaps restaurants would move you up in the waiting queue if you promise to tweet during dinner.

We certainly wouldn't want it to be used to get priority in the emergency department triage process, but I wonder if there are some parts of health care delivery systems that might consider giving expedited service for tweeters.

Costs of Care essay contest winners

Neel Shah reports on the winners of the Costs of Care essay contest.  Recall the theme:

"Preference will be given to stories that best demonstrate the importance of cost-awareness in medicine. Examples may include a time a patient tried to find out what a test or treatment would cost but was unable to do so, a time that caring for a patient generated an unexpectedly a high medical bill, or a time a patient and care provider figured out a way to save money while still delivering high-value care."

All four essays are excellent, but I want to include one here by a patient, Erin Plute, from Emory University in Georgia:

The patient – blue-eyed, red-haired, and healthy but worried looking – guided the doctor’s hand to just below the angle of her jaw, where a small lump was barely palpable.  She had first noticed the swollen lymph node after a cold and thought nothing of it at the time.  But five months later, it was still there.  She knew it was nothing, but she couldn’t shake the thought that it might be related to the skin cancer she had had cut off of her shoulder one year earlier.  After all, melanoma can spread through the lymphatic system, and her dermatologist checked carefully for swollen lymph nodes at every appointment to make sure the cancer had not escaped the scalpel and metastasized.


Melanoma is a terrifying disease.  When caught early, it is easily treated by surgical excision.  When caught late, however, it is universally fatal.  The doctor smiled at the anxious 20-something-year-old woman in front of him, told her it was most likely nothing, and then wrote her orders for a CT scan to look for more inflamed lymph nodes.  You’re young, he told her, and if I were you, I would want this test to make absolutely sure that the cancer has not spread.   For the doctor, that was end of it – another satisfied patient, reassured by the advanced technology of modern medicine.


As a medical student, I have witnessed many discussions between health care providers about this type of hyper-vigilant patient.  These conversations usually go something like this:  “Mr. Smith’s cough is probably just a cold, but he wants an x-ray to make sure it’s not pneumonia.”  Or “Susie’s headache is probably just a migraine, but her mom wants her to get a lumbar puncture [spinal tap] to make sure it’s not a serious infection.”  Doctors and residents may express reservations, but if the test or treatment is reasonably justifiable, they frequently bow to the patient’s wishes.  After all, medicine is no longer the paternalistic discipline it once was; doctors today are supposed to enable patients to make their own decisions, not simply tell them what to do.  And why not order a test if there is a possibility, even a small one, that it will reveal useful information – especially if the patient’s insurance will cover the costs?


For the patient in this case – me – that visit was not the end of things.  I walked out of the doctor’s office feeling temporarily reassured; after all, he told me it was probably nothing, and I could always get the CT scan if I wanted to.  But as the days went by, I found myself worrying more and more. Weren’t the CT orders sitting on my desk at home proof that there was something to worry about?
  

On the other hand, I did not want a CT scan.  Though I was lucky enough to have insurance that would have covered the costs of the scan 100%, I knew that CT scans were expensive, and I did not want to undergo a test that would take time out of my busy schedule, expose me to radiation, and add to the social burden of health care costs.


So I made an appointment with a dermatologist.  She listened to my story, felt the lymph node, and then looked me dead in the eye and told me that there was absolutely nothing to be worried about. The lymph node was soft, it moved around – unlike cancerous nodes – and it was on the wrong side and the wrong place to be related to the cancer that I had had on my shoulder.  In five minutes, she was in and out the door and I was on my way, without a single test having been done.  This time, armed not with test orders but with more information about why I should not worry, I felt infinitely more reassured.


Doctors often talk about patients coming into clinic “with an agenda.”  They feel at odds with these patients, many of whom push for extensive testing.  Yet in the end, the ultimate goal of most patients is not the testing itself – it is the answers that testing will provide.  A provider who takes the time to fully explain the benefits and drawbacks of testing is likely to find that patients are much less desirous of exhaustive testing than they originally seem.  In doing so, they are doing a favor for both the patient and the health care system that bears the cost of unnecessary testing.

A lovely way to say thank you

The relationship between a cancer patient and her oncologist is often very special, enhanced by time spent together, by the up's and down's of the treatment regime, but ultimately by the trust that develops.  Patients are grateful for this experience, even if they know that result will not always be successful.  They offer gifts in return, some tangible and some intangible, and I have come to understand that such gifts are of lasting importance to doctors who have to deal with the mortality that is often associated with these diseases.

Here is a picture of one of the most lovely tangible gifts that I have seen.  This is a tapestry created by a cancer patient as a thank-you gift to her doctor.  It is in an office at Hadassah hospital in Jerusalem and so is seen by relatively few people.  I thought it deserved wider exposure as an example of the humanity that exists in the clinical setting.  In addition to showing the full piece above, I include a detail below so you can get more of a sense of the three-dimensionality, texture, and artistry.

Leaning at Mt. Scopus

I am in Jerusalem and joined with a colleague to conduct a couple of workshops for senior managers and physicians on the basics of Lean process improvement.  As I have noted before, the introduction of Lean into a hospital or any other complex organization is not something to be undertaken lightly.  Lean is not something you do, like a short-term project.  It requires a tremendous commitment on the part of the leadership, extensive training, and the patience to spend years on infusing the Lean philosophy throughout the organization.

Today's workshops at the Mt. Scopus campus of Hadassah Medical Organization were therefore meant to be introductory in nature.  We started with the excellent Toast Kaizen video produced by Bruce Hamilton of GBMP.  Using the seemingly simple preparation of toast in the domestic setting, Bruce demonstrates the various types of waste that occur in organizations.  He helps viewers see these forms of waste in a way that is elegant and simple.

We followed with two simulation games that are designed to teach a couple of aspects of Lean techniques and approaches.  The first game is intended to teach the value of the 5S  system of reorganizing spatial settings.  Students are given sets of numbers in different patterns and ask to perform functions with them.  The process gets easier and more accurate as they apply the steps of 5S improvement: (sort, set in order, shine, standardize, sustain).  As you can see below, our game provokes lots of laughter and engagement.  We seek to break down the defensive barriers to learning as we use non-work-related examples to teach the principles that can then be applied in the workplace.

The second game was designed to teach the difference between batch and continuous flow processes.  While there is a place for both in organizations, there is a tendency for hospitals to create batch processing where continuous flow processing might be more effective in serving customers and in enhancing the work environment.  Our group was divided into two teams, one performing a series of tasks (fold paper, stuff envelope, address envelope, stamp envelope) in a flow pattern and one doing the same in a batch process.  The frustration of the staff involved in the later stages of the batch process--as they awaited the work to arrive to them--was palpable, as you can see below!  Lesson learned.

Crouse MDs rap to halt HAC

Cheryl Clark -- @CherClarHealth -- at HealthLeaders Media reports:

Need a chuckle? Read my column today about how doctors in a Syracuse hospital risked embarrassing themselves to persuade their fellow docs and staff to work harder to prevent hospital acquired conditions. (HAC-No.) The funny funny video is at the end. 

It is also here:

Snow in the Holy Land

The view this morning in Jerusalem.  This has effectively shut down the city, as there is no snow removal capability.  In the words of a long-ago mayor of Cambridge, MA, "What the good Lord has brought, the good Lord will take away!"

Lesson from history

I am currently in Israel and had a chance the other day to visit a museum that dealt with the destruction of the Second Temple in 70 AD, during the Roman Era.  Posted on the wall was this plaque with a quote from the Babylonian Talmud.  I was struck by its relevance today to so many situations, whether in Israel or elsewhere in the world.

New care teams on WIHI

January 10, 2013: Navigating New Care Teams with Nurse Practitioners
(2:00 – 3:00 PM Eastern Time)

Featuring:
Susan B. Hassmiller, PhD, RN, FAAN, Senior Advisor for Nursing, Robert Wood Johnson Foundation
Daryl Lynch, MD, Vice Chair Ambulatory Medicine, Children’s Mercy Hospitals and Clinics (Kansas City); Director, Division of Adolescent Medicine
Cathy Rick, RN, PhD, FAAN, FACHE, Chief Officer, Office of Nursing Services, US Department of Veteran Affairs (VA)
Patricia Gerrity, PhD, RN, FAAN, Director, Eleventh Street Family Health Services of Drexel University; Associate Dean for Community Programs, Drexel University College of Nursing and Health Professions

As we look ahead in 2013, the health care improvement community has a lot on its plate. Just for starters: reducing avoidable hospital readmissions, building community coalitions to improve population health, building active partnerships with patients and families, achieving meaningful use of electronic health records, and redesigning primary care.

So what does the health care workforce have to do with meeting these challenges? Plenty. Caregivers must increasingly see themselves as change agents, and leaders must tap the strengths and talents of all their clinical staff in new and innovative ways.

That's why WIHI is pleased to kick off the new year, on January 10, with a show on Navigating New Care Teams with Nurse Practitioners. Our discussion will explore how nurse practitioners or advanced practice nurses are being deployed and woven into new, interdisciplinary, team-based delivery designs. Our guides are four individuals who are engaged in both pioneering and common-sense solutions to patient needs in ways that match the right caregivers with the right patients and the right needs.

At the Robert Wood Johnson Foundation, Susan Hassmiller has a bird’s eye view of where and how nurses across the US are contributing at the top of their education and training; Cathy Rick, at the VA, is overseeing the implementation of a new national strategic plan to better align nursing services with new systems of care for some six million veterans who use the VHA; Patricia Gerrity directs a nurse-managed community health center in North Philadelphia; and, in addressing the health needs of teenagers, physician Daryl Lynch has created deep and effective collaborations with nurse practitioners.

There are challenges to getting the care team right, and disagreements over roles and functions. But as you’ll learn from our guests on the January 10 WIHI, there’s also a new spirit of forging ahead given the growing emphasis on primary care in a rapidly reforming health care system. Global listeners: tell us how it works in your country. WIHI Host Madge Kaplan hopes you’ll tune in!

Please click here to enroll.

How cold is that?

Bostonians and others in cold climates will be amused by this weather forecast for Jerusalem, notably the entry for this coming Friday:

The important parts remained intact

Thanks to those of you who are helping my friend Boaz Tamir find the doctor who saved his sight after a tank battle during the Yom Kippur War in Israel in 1973.  For those who didn't read my earlier posting, please check it out here and pass the word far and wide.

The Israeli style of tank fighting was to leave the top hatch open and have the tank leader standing there, surveying the situation directly.  In that manner, the team could be more responsive to changing circumstances than if the hatch were closed and they were observing things through the small windows.  Of course, the disadvantage is that this leaves you exposed roughly from your midsection up.  That's how Boaz was sprayed with metal particles during the fighting.

At first he thought that he was blinded from dust particles, so he washed his eyes out, but then realized it was more serious.  When a member of the crew expressed concern about the lieutenant, he is reported to have laughed and said, "Well, I still have my **!  [As this is a G-rated family blog, you will have to fill in the blank, but you can guess to which below-the-waist items this 20-year-old man referred.]

Grateful patient seeks doctor

Can you please help a grateful friend find his doctor?

Here's the story.  In 1973, 20-year-old Boaz Tamir (left) was the leader of a defensive tank group on the Golan Heights in Israel when the Syrians attacked.  In the course of the battle, he was blinded by shrapnel and taken to the closest hospital for treatment.*  That small hospital was in Tiberias and ordinarily would not have had an eye specialist present.  But a young American doctor who had been visiting one of the Jerusalem hospitals for clinical rotations was assigned to this hospital in the periphery.  It turns out she was very adept at eye surgery and was able to remove the metal particles, and he recovered his eyesight.  In fact, although the treatment was not quite complete, once he could see, he "escaped" from the hospital and rejoined the tank batallion as it began the counter-attack toward Damascas.

Because Boaz left in such a hurry, he never had a chance to thank the doctor.  He later tried to track her down but was unable to find her.

Now, 40 years later, Boaz told me the story.  I said that, with his permission, I would begin a search for this doctor using our social media tools.

So here we are.  If you know a female eye surgeon (or perhaps a general surgeon) who spent some time in Israel during her training and might have been in Tiberias during the Yom Kippur War of 1973, would you please submit a comment on this blog post?  Or, if you know of someone who might know the surgeon, would you please contact that person and ask him or her to leave a comment?  Or, if you just want to spread the word through your channels, that would be great.  Thanks.

By the way, Boaz's eyesight is excellent, but he does have to wear sunglasses in the bright light, as seen here during a return visit to the site of the battle today.

--
* Portions of the battle are described in this 1987 thesis by Major Oakland McCulloch:

The other six remaining tanks of Captain Avakia's company were strung out along the T-Line Road under the command of Lieutenant Boaz Tamir. As a column of Syrian tanks thrust toward Lieutenant Tamir's sector the Israeli gunners quickly destroyed the two leading tanks, but the Syrian tanks just kept grinding forward in what
seemed to be irresistible numbers. The Israelis continued to score direct hits as the range between the two forces closed to less than three hundred meters. However, this close quarter fighting cost Lieutenant Tamir four of his six Centurion tanks. Lieutenant Tamir realized that he would not be able to stem the Syrian attack without reinforcements....

About the same time Colonel Ben-Shoham and his command group arrived in Nafekh, Lieutenant Tamir was commanding the only Centurion remaining on the Tap Line Road near the Purple Line. He reported a formation of about sixty Syrian tanks moving in his direction and requested reinforcements from Lieutenant Colonel Eres. His battalion commander, also involved in heavy contact, could only afford to send the Lieutenant one tank and a half-track. Lieutenant Tamir's two tanks waited for the Syrian tanks to close and started firing. They destroyed several T-55s but then several volleys hit both Centurions from the onrushing enemy tanks. One tank was severely damaged but managed to escape back in the direction of Nafekh, while Lieutenant Tamir's tank was destroyed by five direct hits in quick succession.

Pro Publica employs social media to find harm

Here is an interesting article by the folks at Pro Publica about how they used Facebook to do background research for an ongoing investigation into issues of patient safety.  The lede:

A typical investigation might proceed like this: a journalist spends months (or more) reporting, keeps it fairly hush-hush, writes several stories, and then monitors comments and the social web as reaction unfolds.

But for our ongoing investigation into patient safety, spearheaded by reporters Marshall Allen and Olga Pierce, we’ve launched community and crowdsourcing efforts long before we’ve published a single traditional story. We’ve developed a database of sources that is helping to inform the investigation as we report it. And we are using Facebook to create a space for patients, providers and journalists to discuss patient safety issues openly.

Dear men: Are proton beams less toxic?

A couple of weeks ago, I explained the business rational for the rapid expansion of proton beam radiation treatment facilities throughout the US.  Misguided reimbursement policies of the federal government aid and abet this land grab by investors and hospitals.

In their zeal to build, those hospitals attempt to portray to men that their treatment for prostate cancer using proton beams will be less dangerous than treatment using standard radiation, intensity-modulated radiotherapy, or IMRT.  That there is no basis for this assertion makes no difference during the marketing campaign.

Now comes some literature on the topic, reported in an article by Charles Bankhead at Medpage Today.  It is entitled "Proton Rad Tx Not Less Toxic."  The summary:

• Proton therapy for cancer is new, expensive and increasingly being utilized due in part to a theroretical potential reduction in toxicity compared with intensity-modulated radiotherapy.
• In this retrospective study of men with prostate cancer, ages greater that 65, there was no difference in gastrointestinal or other toxicities at 12 months post-treatment with proton therapy or intensity-modulated radiotherapy.

Excerpts:

Median Medicare reimbursement for proton therapy was $32,428 compared with $18,575 for IMRT.

"Our findings on toxicity should be considered in conjunction with our findings on cost," James B. Yu, MD, of Yale University, and co-authors wrote in conclusion. "We found that Medicare's reimbursement per patient for proton radiation therapy was 1.7 times that of IMRT.

"The relative reimbursement of new medical technologies needs to be considered carefully so that physicians and hospitals do not have a financial incentive to adopt a technology before supporting evidence is available."

 "Declaring that proton therapy is new, awarding it high reimbursements, and stating that it has theoretical dosimetric advantages is not acceptable," Mary Feng, MD, and Theodore S. Lawrence, MD, of the University of Michigan in Ann Arbor asserted in their commentary. "We need prospective clinical trials directly comparing protons to IMRT photons."

To date nine [proton radiation] facilities have begun operation, but eight others are in development. 

Beyond guns and gurneys

A friend sent a note a few days ago, citing an "an amazing op-ed on Newtown, Cerberus, and Steward" by a Boston Globe columnist.  The piece by Joan Venocchi was, indeed, hard-hitting about the fact that the private equity firm, Cerberus, owned both a major gun company and a hospital chain.

Any proceeds from the sale of Freedom Group now amounts to blood money. Why not invest it in a fund dedicated to the memories of those dead children and educators? Put it into schools or mental health programs. Pour it into something that nurtures and heals to atone for the fact that it flows from something that destroyed life, family and community.

She went further and called on the CEO of Steward Healthcare to take the lead on this proposal.

Well, yes, but the point that has been missed by the media relates to the ethical question of whether a private equity firm can properly represent the community's interest when it owns a chain of hospitals--irrespective of whether it also owns a gun company.

Over the course of several months, I set forth the business strategy of this and other private equity firms as they accumulate their portfolios of hospitals.*

There is nothing inherently wrong with for-profit ownership of health care facilities.  But if the purpose is to own the assets for a short period of time and flip them during an IPO or other financial maneuver, then questions of community purpose must arise.

Why is this an ethical question?  Private equity works by creating financial value for investors, with that value being extracted, first, during the pendency of the ownership.  How?  As I have summarized:

First, use the cash flow of the firm to produce interim equity returns.  Focus on EBITDA (earnings before interest, taxes, and depreciation).  Employ a capital structure with a very high percentage of debt (i.e., leverage up).  Minimize capital investments by not fully funding depreciation.  Sell off unnecessary assets.  These include things like the pathology laboratory, where you discontinue running your own laboratory.  Call Quest and sell them the business, agreeing to pay them laboratory fees.  Also, monetize the real estate value of your buildings, perhaps with sale-lease backs or outright sales.  Meanwhile, purchase physician practices that will produce referral volumes, offering above-market prices.  Pay your debt service costs, but extract as much cash as possible.

The next phase of gaining value for the private equity investors occurs when the assets are sold to the next round of investors.  To make this work, that next round of investors has to be persuaded that their return on capital will be comparable to that received for investments of equivalent risk in the marketplace.

Given the financial realities facing hospitals in the future, sale of this kind of asset in the public marketplace has to rely on the "greater fool" theory.  As I have noted:

[E]ven if you believe that more people will have health insurance than in the past, this does not mean that the fees paid to hospitals will be fully compensatory. Unlike private equity firms, which can maintain cash flow to their investors by employing a high degree of leverage and not funding depreciation, a public company rises or falls based on the total margins produced by the hospitals. Those margins will be under substantial pressure for years to come, especially as hospitals face the need to fund deferred maintenance. Further, as for-profit entities, those hospitals will have to pay local property, sales, and income taxes. They also lose their ability to use the federal tax code to help generate substantial philanthropy and to garner lower interest rates on bond issues.

What happens then? A company whose value has been stripped away becomes a self-standing business unit owned in the public equity marketplace, facing the same kind of cost pressures and reimbursement constraints of all other hospitals.  I have yet to find a financial analyst who believes that the ongoing return on that investment will be sufficient to support the capital improvements needed for renewal and replacement of the essential clinical purchases required by the communities in which those hospitals are located.

This is what raises the ethical issue.  Who stands by to rescue decapitalizing for-profit hospitals in community settings, particularly if a number of those hospitals are safety-net facilities serving the indigent in cities scattered throughout a state?  There are only two answers: (1) Purchase of those hospitals by cash-strapped municipalities, perhaps with state assistance or (2) acquisition by those hospitals by the dominant non-profit hospital chain in the state--probably in response to panicked concern by mayors, legislators, and the governor--enhancing its monopoly position.  Neither result would be in the public interest.

--
* Here's a listing of those posts:

July 1, 2010:  Verve and optimism versus caution and pessimism
September 20, 2010: Seven is not a natural
September 26, 2010: Accelerated depreciation
October 5, 2010:  When exuberance fades
October 12, 2010:  A new wave in Massachusetts
February 5, 2011:  Is the "greater fool" theory alive in the hospital world?
February 13, 2011:  I was not skeptical enough
February 23, 2011:  Expand and acquire to prepare for the IPO
August 15, 2012:  Let's do the numbers

Fireflies from The Jubilee Project

Every time I think that they have done as well as possible, the folks at The Jubilee Project publish a video that is even more compelling.  Watch it here and below.  Please share it widely over the next couple of weeks as I take a seasonal blogging break.

Intuitively obvious?

I hold no grudge against Intuitive Surgical, even though I think its marketing campaign to promote the use of its DaVinci surgical robot was overly clever in securing sales for a device with unproven clinical effectiveness.  How successful?  Well, sales growth has been in the range of 45% per year.

But there is an immutable law of health care finance:  "No one wins big for long."

Starting a few months ago, I heard of people who were selling the stock short, expecting its value to fall because the market for its surgical robots had become saturated.

Then, in April, reports emerged of product liability lawsuits being filed against the company.  This story summarizes one such lawsuit:

The lawsuit, filed by Gilmore McCalla, alleges that the death of his daughter, Kimberly McCalla, was caused by the surgeon’s mistakes during her hysterectomy, as well as by flaws in the robot’s design, such as badly-insulated surgical arms and overly-strong electrical current that can connect with healthy tissue. The da Vinci allegedly burned one of the woman’s arteries and her intestines. She died two weeks after the surgery. The lawsuit also claims that Intuitive Surgical did not give hospital staff adequate training on the robot’s use.

Citron Research gave its point of view on December 19:

Imagine a medical company with a single product — one which lacks any clinical data proving medical efficacy superior to other conventional treatments … or in case of one of its major applications, little to no advantage over no treatment at all.

Now imagine that same company’s product under a host of lawsuits that range from patient death after “routine” surgery, to a man defecating out of his penis.

Worse, imagine this one company being sued in the past  four weeks by some of the biggest name tort attorneys in the United States. Now imagine this company has a $21 billion market cap and a lofty forward P/E.

Citron believes that Intuitive Surgical’s stock price will soon suffer. The da Vinci robot-assisted surgery device is a solution in search of a problem — but one hell of a marketing machine.

Now, look how the stock market has reacted:

In health care, no one wins big for long.

New for 2013: The Pain Index

A recent report by the New York Times contained an excellent graphic showing the current percentage of uninsured people in each state.  The range is from a high of 24.6% in Texas to a low of 4.4% in Massachusetts.

I have combined this rate with the most recently reported CDC rate of obesity in each state to create what I call The Pain Index.  It is a simple sum of the two numbers.

The theory behind the total is that obesity is a rough guide for the level of unhealthiness in the population.  My hypothesis is that, when insurance is made available to people, they will use it, roughly in proportion to the degree they are unhealthy.

Yes, I know this is a crude metric, but I think it will be a relatively good predictor of the rate of increase in health care costs in each state over the coming years.  This will show up in the insurance premium rates offered in the health care exchanges and will also affect the need for state appropriations to pay for newly eligible Medicaid subscribers.

States with a Pain Index in the top decile are: Texas, South Carolina, Lousiana, Mississippi, and Arkansas.  Others with scores over 45 are Nevada, Florida, New Mexico, Georgia, Alaska, Oklahoma, North Carolina, Kentucky, Alabama, and West Virginia.

My advice to policy-makers:  Get ready!  My advice to health care CEOs:  This would be a really good time to focus on quality, safety, and front-line driven process improvement as the most effective way to reduce your costs and improve efficiency.

Percent     Obesity          Pain State   Uninsured        Rate        Index TX 24.6 30.4 55.0 NV 21.6 24.5 46.1 FL 20.7 26.6 47.3 NM 20.6 26.3 46.9 GA 19.7 28.0 47.7 CA 19.5 23.8 43.3 SC 18.8 30.8 49.6 LA 18.4 33.4 51.8 AZ 18.4 24.7 43.1 AR 18.3 30.9 49.2 MS 18.2 34.9 53.1 AK 18.0 27.4 45.4 OK 17.4 31.1 48.5 MT 17.2 24.6 41.8 ID 17.1 27.0 44.1 NC 17.1 29.1 46.2 WY 16.8 25.0 41.8 OR 15.8 26.7 42.5 NJ 15.1 23.7 38.8 KY 15.0 30.1 45.1 AL 15.0 32.0 47.0 IL 14.6 27.1 41.7 MO 14.5 30.3 44.8 CO 14.3 20.7 35.0 TN 14.3 29.2 43.5 UT 14.2 24.4 38.6 WV 13.9 32.4 46.3 NY 13.8 24.5 38.3 OH 13.6 29.6 43.2 WA 13.6 26.5 40.1 MD 13.3 28.3 41.6 VA 13.3 29.2 42.5 SD 13.2 28.1 41.3 KS 13.0 29.6 42.6 IN 13.0 30.8 43.8 MI 12.7 31.3 44.0 NE 12.3 28.4 40.7 RI 12.0 25.4 37.4 DE 11.5 28.8 40.3 DC 11.3 23.7 35.0 ND 11.1 27.8 38.9 IO 11.0 29.0 40.0 PA 10.9 28.6 39.5 NH 10.8 26.2 37.0 CT 10.3 24.5 34.8 ME 9.7 27.8 37.5 WI 9.6 27.7 37.3 VT 9.1 25.4 34.5 MN 9.0 25.7 34.7 HI 7.6 21.8 29.4 MA 4.4 22.7 27.1

Dear hospital CEOs: Commit.

An open letter to the 5754 hospital CEOs in America,

You have been granted a public trust.  It's time to commit, publicly.

President Obama has decided that a form of gun control will be on his agenda for the coming year: "The president signaled his support for new limits on high-capacity clips and assault weapons, as well as a desire to close regulatory loopholes affecting gun shows.... [The] opposition shows little signs of fading away."

All I am asking is that you publicly identify yourself with a position on this issue, for or against.

I know that many of you have a tendency to be quiet of matters of legislation when there appears not to be a connection with hospitals.  But this is a public health issue. The CDC reports 11,492 homicides from firearms (out of 16,799 total) in a year in its most recent figures (2009), a rate of 3.7 per thousand population. (The total rate of deaths by firearms is about three times this, with suicide being the largest category.)

We need your judgment and thoughtful consideration.  We need your convening authority to create opportunities for discussion and debate in your institutions and your communities, to help inform your position. We need you to make your views known to your senators and representatives in Congress.

As Hillel said:  "If I am not for myself, who is for me? If I am only for myself, what am I? If not now, when?"  Please reach deep and think about how you will feel if this issue is decided without your engagement.  You've spent years getting to your current position.  For what purpose if not to participate in one of the major issues facing our society?

Here are some excerpts of articles that might help you decide:

A doctor who lists his name as J. Stefan Walker recently posted this comment about limiting the availability of assault weapons on another website:

The Second Amendment settled the issue, but even before that it has been one of the fundamental rights and responsibilities of our free society to live with firearms. America would likely have been conquered by external invaders or internal fascists long ago had it not been for the reality that common citizens have ready access and skill in handling even advanced weaponry; similarly, the right to keep and bear arms insures that citizens will not be mere prey when criminals or others of malevolent or misguided intentions bear arms against the innocent. I do not question the motives of those who feel the answer to tragic gun violence is to restrict guns or types of guns; but I do question the logic, and the legality. The real issues involved in gun-related tragedies center around more responsible handling / ownership of firearms – and in better mental health resources for the public. Free people must accept the harsh realities of violence in the world – and accept the concomitant responsibility to bear arms of at least equal potency at the ready to protect those within our charge. This does not just mean the police and the formal military: simple math proves that approach will never guarantee adequate safety. There is just no way around these realities.

Here is a contrasting view by Leah Hagler Cohen on WBUR's Cognoscenti:

To feel is good.

It is a kind of intelligence. It’s a first response which may spur us — if we don’t hasten to deaden it — to further response: to action.

If the reason this latest event stands out from the rest has less to do with its uniqueness and more to do with the tender age of the majority of those killed, how shall we make use of our emotional response? How shall we let it — our grief — inform us? 

I am no policy maker. I have no expertise in violence or gun laws or mental illness or video games or the Second Amendment. I am only a mother. Even that is irrelevant. Would I feel any less if I had no children of my own? We are all in this together.

Here’s what we can do. We can tell our stories and listen to one another. We can educate ourselves about the issues and about who has the power to implement change. We can find creative ways to partake of that power and responsibility. We may even choose to reckon with ourselves — privately and collectively — about the role each of us played in the most recent tragedy, if only through silence and inaction. Others will have more practically useful ideas. I know only this: we start by being willing to feel.

Former hospital CEO Nick Jacobs adds:
 
Back in the eighties, much of the inpatient mental health system all but vanished in this country, and today behavioral health challenges continue to carry a stigma that is not only tenuous but also very detrimental to the well being of not only those challenged individuals but for all of us.  So, yes, behavioral health issues have clearly been a part of each of these attacks. And is that an easy fix?  I think not.  I believe the stigma associated with mental illness is a huge problem, and even if we seek help, it is many times not available.

Let’s discuss the third rail.  As a kid I grew up with guns and target shooting was one of my favorite family pastimes.   I can tell you that we never had a problem due to the fact that we owned those guns.  They were locked up; they were handled appropriately, and they were used for what they were intended.

However, when you see facts like:  There have been 62 gun-related mass murder attacks across this country since 1982, or that approximately 50 million people own about 250,000,000 guns in the U.S., you have to wonder about connectivity to this issue.

The chief medical examiner has said the ammunition was the type designed to  break up inside a victim’s body and inflict the maximum amount of damage,  tearing apart bone and tissue.  So what about gun control?   Do I believe that semiautomatic weapons, armor piercing bullets, extended clips, et al., contribute to the ease of access for these mass murderers? Yes, I do.  I would love to see controls regarding the above mentioned killing devices, but I do not believe this is the only solution.  Should people be permitted to own guns?  Yes.

There is no easy solution.  I would hate to see our schools and colleges become modified prisons.  I would hate to see our lives become self-imposed solitary confinement chambers, but clearly excessive access to kill-type weapons, inadequate access to behavioral health treatment, lack of understanding of drug interactions, and excessive exposure to violence seem to have created the perfect storm.