The importance of being earnest and NICE

UK's National Institute for Health and Care Excellence is widely admired both in the country and abroad for the rigorous manner with which it develops guidance on the use of new and existing medicines, treatments and procedures within the NHS.  (We have no such body in the US.)

It is hard to imagine (not!) that some of its deliberations are controversial.  How wonderful then to see this language used in describing the qualifications desired for an analyst position the Institute is seeking to fill:

“Excellent oral and written communication skills, including the ability to communicate highly complex ideas to a range of audiences where there are significant barriers to acceptance which need to be overcome in a hostile, antagonistic or highly emotive atmosphere.”

(Thanks to Marco D. Huesch, MBBS, Ph.D., assistant professor at the USC Sol Price School of Public Policy, for this lead.)

Tom still reminds us of a Reason to Ride

One of my great pleasures when I was CEO of a hospital was to engage in philanthropic efforts by grateful patients who wanted to support the research or clinical activities of the doctor who had served them.  I would offer my personal involvement, and I would also make sure our development office provided planning and on-site support to the events. In my mind, these kinds of events were a symbol of the very human relationships between providers and patients, and I always felt them worthwhile even if they didn't bring in the kind of dollars that one might solicit from major donors.

A prime example of this was an event initiated by Tom DesFosses, a brain cancer survivor.  After finishing his treatment, Tom took a solo bike ride of several hundred miles throughout New England to celebrate.  Then he started up an annual fund-raising event--called A Reason to Ride--to raise money for Dr. Eric Wong's research program.

Back in 2009, I wrote about this ride and quoted Tom:

"For me, this ride will be very emotional, but in another way it will give me incredible joy. It will give me time to reflect on how blessed I am to be a cancer survivor, and to think of others who are not able to join me on this quest. I hope other cyclists will join me on this ride to help raise greatly needed funds for life-saving cancer research."

Each year, dozens of Tom's friends, cancer survivors, and friends of other cancer patients join the ride.  Now, Tom and his crew take total responsibility for planning and running the event.  A stalwart supporter has been Jim Boland, owner and operator of four New England-based Fuddruckers restaurants, seen above at right with Dr. Wong (left) and Tom (middle).

Today's ride was a great success.  We hope to see you next year!

There goes the random walk hypothesis!

My daughter recently mapped the path of her one-year-old son shortly after he learned to walk.  Here it is:

Wise words from my friend Boaz Tamir

On this eve of the New Jewish Year, the fog grows thicker and the horizon seems to be moving ever-further away: We face uncertainty, confusion and daily challenges to our assessments of what the morrow may bring. Once our slogan was, "Every plan serves as a basis for change;" but the in the current pace of change, we must adopt a slogan of, "Changes are the basis for never-ending planning."

The changes are multi-dimensional: technological innovations; global climate change, civil uprising and political unrest, drastic adjustments in public consciousness, consumer awareness and the political arena and the rearrangement of global and local systems are bringing about epic transformations. These are leading to a destabilization of the validity of established economic, political and managerial paradigms and their usefulness as a base for the development of economic-political polices and sustainable business strategies.

What should we wish for others and for ourselves as this New Year begins?

1. That we learn to adjust to reality, even if we have no theory to explain it.
2. That we learn to view chaos as a lever for creativity, disruption as an advantage and crisis as an opportunity.
3. That we are wise enough to create systems that blur hierarchical boundaries, whose stability stems from constant movement in fluid surroundings.
4. That we replace the paralyzing anxiety brought about by uncertainty with the ability to grow in a storm.
5. That we exchange pride with modesty, answers with questions and certainty with investigation.
6. That we succeed in integrating internal and external strengths as we enlist workers and managers to cope with an environment full of contradictions and disharmony.
7. And to those who have lost their way in the fog: We hope that they will be able to return to their foundations – to interpersonal relations, the foundations of culture, and to be willing to learn from organizational frameworks and cultures that have survived for thousands of years.

Happy New Jewish Year,
Boaz Tamir, Zicheron Yaakov, September 5th, 2013

I wasn't cynical enough about the proton beam industry

I've posted a number of stories about the manner in which the medical-financial complex has pushed through the construction of very high cost proton beam machines, creating a market for a service that has limited clinical support.  It turns out I wasn't cynical enough.

Here's a report from The Advisory Board Company entitled, "Achieving financial success in proton therapy in 2013." Here's the imperative laid out in the report:

This turns the scientific method on its head. Instead of conducting research to determine if proton beam therapy is clinically more efficacious that traditional radiotherapy, we are told to conduct trials designed to substantiate the superiority of this technology. Here's the advice:

Facing heavy payer scrutiny and patient recruitment challenges for large-scale randomized controlled clinical trials, proton centers will need to augment clinical trials while refining strategies for engaging private payers. For tumor sites facing scrutiny, proper patient selection, recent data, and messaging will be very important.

In other words, pick the patient sample to support the desired conclusions.

Meanwhile, another report sets forth marketing advice. Here it is:

As proton centers enter the market in 2013, administrators will need to adapt referral strategy to a new environment.   Changing market forces, including the proliferation of centers,  an expansion in clinical eligibility, trends in physician-hospital relationships, and healthcare reform create new marketing imperatives. 

Now, centers will focus not on a largely exclusive, trans-regional marketplace, but focus much more intensely on finding patients within their own backyards, raising the need to convert exploratory self-referrals.

Let's think about the meaning of: "Convert exploratory self-referrals."  We're going to take ordinary people suffering from cancer and persuade them that this technology is the answer to their problems.  So direct-to-consumer marketing will be applied to this patient population.

Well, it's worked before, e.g., with the da Vinci surgical robot.  Who can blame these guys for taking a leaf out of that book?

Are Surgibuns™ for you?

Not all health care innovations come out of NIH R01 grants.  Here's one developed by Lisa Corcoran, an OR nurse who was tired of wearing the bouffant caps that are popular in the medical field. Her Surgibun™ hair covers are disposable and latex free and the woven and non-woven materials meet the Standard for the Flammability of Textiles CPSC 16 CFR Part 1610.

She's trying to introduce them to the marketplace.  Check them out here. In addition to the healthcare world, they would be excellent in the food and restaurants sectors and in any area in need of hair caps and protectors.

There are protons in Europe, too

Speaking of proton beams, while they populate like rabbits in the US based on a financial model that includes overpayment for prostate irradiation, there are real debates going on in Europe about their efficacy.  Here are excerpts from an article from the British Medical Journal:

Critics say the NHS should not be spending so much money on a treatment that has not been subjected to randomised controlled trials and for which there is little evidence of long term efficacy or safety. In April, an article in the BMJ questioned whether the government’s £250m investment was premature. “For most indications,” reported a review of the evidence in February, no firm conclusions could be drawn about the superiority of protons over photons and it was “sobering to observe that no phase III trials have been performed.”

The debate has been clouded in the UK by a focus on the widespread use of proton therapy in America for the treatment of prostate cancer. This is a red herring, says Adrian Crellin, a consultant clinical oncologist at St James’s University Hospital, Leeds and the Department of Health’s national lead for proton beam therapy: “We have quite specifically excluded prostate cancer as a standard indication for treatment because there’s no evidence.”

In fact, the application of proton therapy in the UK is limited to just 15 rare cancers— three adult and 12 paediatric—that have the clearest evidence, including base of skull chordomas and chondrosarcomas and primary paraspinal tumours. Referrals to overseas treatment centres, which will continue until the NHS units are up and running in 2017, are subject to approval by a national clinical panel that takes account of a range of other factors, including the timing of radiotherapy in relation to other treatment and the stage and pathology of the cancer.

Meanwhile, we see some caution in the Netherlands:

Roelofs explained that the Netherlands takes a somewhat cautious approach when it comes to introducing new treatment regimes, as evidenced by its health insurance board, which will only reimburse proven technologies. For many years, there was concern about the lack of evidence for proton therapy, a situation that led to the instigation of ROCOCO - an ongoing international multicentric in silico trial comparing photons, protons and carbon ions. 

The idea is that before a patient is referred for proton therapy, simulated plan comparisons must reveal a significant dosimetric benefit of protons. This advantageous dose distribution then needs to be translated into clinical benefits, such as reduction of side effects, using proven complication prediction models. "This general in silico concept was picked up by the health insurance board to be enough evidence to reimburse," Roelofs said. The board has stated four model-based indications: head-and-neck, lung, prostate and breast cancer, where patients are eligible for reimbursement, as well as the standard indications: intraocular tumours, chordoma/chondrosarcoma and paediatric tumours. 

But they recognize that the jury is still out and so study is needed.

Another government requirement is that all patients treated with protons in the new centres are included in standardized clinical trials with uniform outcome measurement, requiring close collaboration between sites. "All four initiatives have been working on this proposal for years, so there's already good collaboration between them," Roelofs explained. "We're working together to set up one registry for protocols. When you have four centres treating in the same way, collecting the data in the same way, this will enable you to perform comparisons more easily. I think it will help create the evidence for proton therapy that is still needed." 

In the US, there is not a requirement that efficacy be demonstrated.  Only safety.  So the capital markets have leaped on the technology as a way to draw in the dollars.  Hospitals sign the mortgage to create a competitive advantage.  The medical arms race continues, enhanced by a national association!

September 13 deadline for HOPE Award nominations

 

Nominations for the MITSS HOPE Award are Due by Friday, September 13, 2013. 

 

Now that Labor Day has passed, it's time to get those nominations in for the 2013 HOPE Award.  Don't miss the opportunity to recognize someone who is making a difference.  Self-nominations are welcomed, and submissions from anywhere in the United States and Canada are encouraged.

Click here  or visit www.mitsshopeaward.org for eligibility criteria and submission requirements, to download a nomination form, check out past winners, and much, much more!

This prestigious award is being sponsored by RL Solutions, and the winner will receive a cash prize of $5,000 to continue their important work.

Learning from patients, made easy and effective

An article in The Guardian tells of a lovely and simple approach for really listening to patients and using their feedback, from Spiral Health's 40-bed rehab center in Blackpool (UK). Thanks to Samantha Riley, Director of Insight at NHS England, for the tip.  Excerpts:

A group of people representing all stakeholders in our hospital community – managers, healthcare assistants, therapists, nurses and patients – gather together to analyse patient feedback and decide on action points. Our staff and patients have loved being involved, and it is interesting to hear feedback on problematic issues from so many different perspectives.

Before we start, we collect patient views by conducting friendly bedside interviews. Each patient is asked to talk to us about two things that are working, two things that are not working and two things that people would like to see if they came back to the unit again. The interviews are more of a chat than a formal process and we work hard to make patients feel at ease. We also remind them that negative feedback is as important as glowing praise. Older generations sometimes don't like to make a fuss, even if something is troubling them.

As we are determined to be open and honest about the feedback we receive – negative and positive – we have a display in our reception area that highlights issues raised and what we are working on.

Some people have said we are brave to invite criticism, but we feel strongly that if we are going to be truly patient-centred we must listen hard to them and learn from them. If we were just content to ask tick-box questions of our patients, would the results really be worth the paper they were written on?

Calling the trustbusters!

The case for market concentration driving higher health care prices, which could be predicted by virtually any economist, is being proven over and over.  It happens in the UK.  It happens in the US.

A story in Modern Healthcare.com sets forth the latest study, by the Center for Studying Health System Change, documenting the phenomenon.  The lede:

Bargaining leverage, not the cost of providing complex care, is the main reason why some hospitals can demand prices twice as high as their competitors' and still get contracts to treat privately insured patients, according to a new study.

The analysis by the Center for Studying Health System Change of actual payments to hospitals and physicians by private insurers in 13 U.S. cities found that the most expensive hospitals got rates as much as 60% more than the lowest-priced competitor for inpatient care, and prices that were double the competition for outpatient care. 

And here's a familiar argument (one that our friends at Partners Healthcare habitually made about the Eastern Massachusetts market):

Expensive hospitals have long argued that providing medical education and the best equipment available drives their costs. But the study authors cast doubt on that because their research was based on how much each hospital's rates exceeded Medicare payments for the same services. Since Medicare rates are adjusted to reflect patient case-mix complexity and the cost of capital equipment, those factors shouldn't explain why some hospitals get more than others relative to Medicare's rates.

Let's recapitulate, citing a conclusion noted in a recent New York Times article:

If there is one thing that economists know, it is that market concentration drives prices up — and quality and innovation down.

 

The body politic has chosen to look the other way.  Will greater price and outcome transparency make an iota of difference when the largest provider group in a given metropolitan area dominates the landscape?  I doubt it, in our lifetimes.  The article cited above notes:

 

The entities with the most bargaining power, and thus the highest mark-ups, are the “must-have” hospitals—that boast good reputations, large numbers of services and desirable locations, the authors found. “Even in metropolitan areas with many competing hospitals and hospital systems, these must-have hospitals can command unusually high prices,” they wrote. 

Congratulations to Dr. Minter-Jordan

I missed this announcement earlier this summer but am very pleased to repeat it now.

Dr. Myechia Minter-Jordan took over as the new president and CEO of The Dimock Center on July 1. Dimock is a community health center serving the Roxbury section of Boston--the second largest health center in the city--offering a variety of important programs to people in that part of town. 

Myechia served as chief medical officer at the center since 2007.  I had the pleasure of getting to know her and working with her during my tenure as CEO of BIDMC.  She is a spectacular choice for the head of the center.  As the article in the Bay State Banner notes:

The 41-year-old Minter-Jordan is also dedicated to improving the community health-care model. And she wants to make sure The Dimock Center, already a recognized leader in community health care, will continue to lead the way.

“I relish the opportunity to talk … about issues that impact the Latino and black community,” she said. “I think it is important to me to bring the voice of community health centers to that discussion.

“We can’t stop there. We have to keep moving until it is recognized by all that community health centers are really the model … to create a place for patients and family where all their needs are met,” she added.

Still nothing from CMS, but Blue Shield of CA acts

One of the mysteries of the medical arms race is why the CMS administrators who have served in the Obama Administration (Don Berwick and Marilyn Taverner) never took action to eliminate the unjustified Medicare subsidy of high cost proton beam machines.

So, bravo to Blue Shield of California for doing just that, even in the face of inaction at the federal level.  Here's the story from the Los Angeles Times.  Excerpts:

As hospitals race to offer the latest in high-tech care, a major California health insurer is pushing back and refusing to pay for some of the more expensive and controversial cancer treatments.

Blue Shield of California is taking on this high-cost radiation treatment just as Scripps Health in San Diego prepares to open a gleaming, $230-million proton beam therapy center this fall, only the second one in California and the 12th nationwide.

This week, Blue Shield began notifying doctors statewide of its new policy for early-stage prostate cancer patients, effective in October. The San Francisco insurer says there's no scientific evidence to justify spending $30,000 more for proton beam treatment compared with the price it pays for other forms of radiation that deliver similar results.

"Proton beam is really the perfect example of all that is wrong with our healthcare system," said Cary Gross, a researcher at the Yale School of Medicine who recently compared outcomes for 30,000 Medicare patients who received proton beam or standard radiation. "The rush to adopt proton beam is far outpacing the amount of evidence to support its use."

In December, Gross and other Yale researchers published a study that analyzed 30,000 Medicare patients who received proton beam therapy or standard radiation for prostate cancer. Supporters of proton therapy say it helps those patients avoid common side effects from radiation such as incontinence and erectile dysfunction.

But the Yale researchers found that there was no difference in terms of side effects a year after treatment. Yet Medicare paid more than $32,000 for a course of proton beam treatment, compared with less than $19,000 for conventional radiation.

Survival of the fattest

Best quote of the day by Alan Sager, professor of health policy at Boston University, from an article in FierceHealthFinance:

"The most profitable hospitals are the ones that are able to command higher payments. We again see the survival of the fattest where profitability has more to do with their market leverage than with efficiency."

Indolentomas: What is and is not cancer?

Check out this recent article and accompanying video by George Lundberg on Medscape entitled, "What Is and Is Not Cancer?"  Dr. Lundberg reviews the tendency in medicine to label many types of lesions as cancer, and he notes that this is a form of over-diagnosis that can be harmful.  Here are some excerpts:

Cancer cells -- anaplastic, dedifferentiated, capable of autonomous growth, utterly out of control until destroying their host -- are, however, not just one thing. We are learning more every day that cancer is many different diseases, even thousands or tens of thousands of different diseases.

For a long time, it made sense to try to eradicate all cancers, as early and as completely as possible. Mass efforts were launched to find cancers wherever they were and destroy them. Since the earliest cancers seemed to evolve from some identifiable premalignant conditions, wouldn't it make sense to also nip those in the bud? Sounds logical.

But, as with many exuberant efforts, this one got out of control. Many lesions that were called "cancer" really were not cancers at all in behavior, and this fact began to be recognized in large numbers of patients. These unfortunate victims have experienced massive psychological and physical harm and costs without any clear benefits achieved by finding and treating their "noncancers."

Pathologists never can really predict how any one cancer will behave. But after many decades of matching histologic patterns with the natural history of diseases, we are actually pretty good at predicting which lesions will be really bad actors and which seem likely to lie around indolently.

Cure rates from aggressive therapy on those "indolentomas" are 100%. But, so would the outcomes have been of nondiscovery---100% cure of nondisease.

Ceasing to name lesions that are most likely indolentomas by that fearsome word "cancer" is the first step. Almost any patient who hears the word "cancer" applied to their pathologic findings experiences their hair catching on fire. Even if the word is cushioned by physicians with modifiers like "in situ," "early," "precancer," "on the way towards cancer," "caught it in time," and the like, the patent simply wants to get it out of their body. A surgical sell by a surgeon becomes really easy.

Will there be missteps? Certainly. Will there be resistance to change? You bet. Will there be unintended consequences? Most assuredly. Will some of those trial lawyers jump with glee at the possibility of underdiagnosis and new opportunities at lawsuits for "failure to diagnose"? Yes, but we must use our science and professionalism on behalf of the patient's best interests and collectively tell the lawyers and the hospital risk managers to take a flying leap.

Science marches on. Let's listen to it and lead from the front.

Dr. Lundberg cites a recent JAMA article by Laura Esserman and colleagues on this topic.  Entitled,  "Overdiagnosis and overtreatment in cancer: an opportunity for improvement." it is well worth reading.  Here's the abstract:

Over the past 30 years, awareness and screening have led to an emphasis on early diagnosis of cancer. Although the goals of these efforts were to reduce the rate of late-stage disease and decrease cancer mortality, secular trends and clinical trials suggest that these goals have not been met; national data demonstrate significant increases in early-stage disease, without a proportional decline in later-stage disease. What has emerged has been an appreciation of the complexity of the pathologic condition called cancer. The word “cancer” often invokes the specter of an inexorably lethal process; however, cancers are heterogeneous and can follow multiple paths, not all of which progress to metastases and death, and include indolent disease that causes no harm during the patient’s lifetime. Better biology alone can explain better outcomes. Although this complexity complicates the goal of early diagnosis, its recognition provides an opportunity to adapt cancer screening with a focus on identifying and treating those conditions most likely associated with morbidity and mortality.

Reducing hospital acquired infections to reduce costs

What's one of the best ways to reduce health care costs?  Stop hospital acquired infections.

JAMA posts an article outlining the costs of the most common such infections.  An excerpt:

On a per-case basis, central line–associated bloodstream infections were found to be the most costly HAIs at $45,814, followed by ventilator-associated pneumonia at $40,144, surgical site infections at $20,785, Clostridium difficile infection at $11,285, and catheter-associated urinary tract infections at $896. The total annual costs for the 5 major infections were $9.8 billion, with surgical site infections contributing the most to overall costs (33.7% of the total), followed by ventilator-associated pneumonia (31.6%), central line–associated bloodstream infections (18.9%), C difficile infections (15.4%), and catheter-associated urinary tract infections (<1%).

There is only one thing wrong about the article, the policy conclusion:

As hospitals realize savings from prevention of these complications under payment reforms, they may be more likely to invest in such strategies.

Here's where they are wrong on this point.  You do not have to institute so-called "payment reform" to incent hospitals to eliminate infections.  Even under a fee-for-service rate design regime, hospitals that engage in work flow redesign to eliminate infections find improvements in efficiency, reduction in length of stay, and higher utilization of high fixed cost facilities.  While there might be some revenue loss from a reduction in complications, that is more than offset by these other considerations.  There is a strong business case to be made regardless of rate design.  Many of the most dramatic improvements in elimination of hospital acquired infections have occurred in hospitals during a fee-for-service regime.

Labor Day 2013 -- Time to revisit the approach

The US Department of Labor notes:

Labor Day, the first Monday in September, is a creation of the labor movement and is dedicated to the social and economic achievements of American workers. It constitutes a yearly national tribute to the contributions workers have made to the strength, prosperity, and well-being of our country. 

The vital force of labor added materially to the highest standard of living and the greatest production the world has ever known and has brought us closer to the realization of our traditional ideals of economic and political democracy. It is appropriate, therefore, that the nation pay tribute on Labor Day to the creator of so much of the nation's strength, freedom, and leadership — the American worker. 

This is very much the case, but the day also should bring attention to how the labor movement can, under today's conditions, bring about continued progress for families in the country.  Unfortunately, in many respects, the movement has become as calcified in its beliefs and techniques as the very corporations with which it vies.  It often suffers from boards that do not engage in best governance practices, from a lack of transparency about its finances and other operations, and from the kind of political activism that is divisive rather than collaborative.

Labor in America has experienced a drop in membership, and one reason might be that the traditional approach to organizing--one based on getting to know and understand the concerns of potential members at a personal level--has given way to corporate campaigns and the use of big money that fail to engage individuals with a sense of purpose and identity.

Several years ago, I introduced Marshall Ganz at a speech he was giving, and I was struck at the disconnect between the exemplary words he was using in his talk and the practices of the SEIU, the largest union in the health care arena.  I noted:

[H]is impressive speech about the nature of community organizing and, in particular, the importance of having an underlying set of values to serve as the moral basis for a movement.

Having now watched the SEIU for several years, I was struck by the contrast between Marshall's prescriptions and this union's mode of operation. As I listened to his talk, I realized that the union has, in many ways, lost its soul as it has gained power and influence. It has become part of the "they" that is the target of community organizing. Instead of drawing on the resources available to it -- the courage, passion, creativity, and commitment of workers -- it relies on money and power to gain more money and power.

My book, How a Blog Held Off the Most Powerful Union in America, deals with one such example, when the SEIU conducted a multi-year corporate campaign against my former hospital--seeking to denigrate the reputation of the hospital and the people working in it to bypass the normal democratic approach to union certification.  David P. Boyd, Professor of Management at Northeastern University, wrote a foreword for the book.  He noted:

In this book, Paul Levy offers a compelling historical narrative of labor-management relationships over a tumultuous five-year period. While the story itself is riveting and the stakes compelling, it is more than simple case narrative; rather it is a morality play about an attempt at power dominance which, if realized, would have foreclosed employee engagement. Through such tactics as “neutrality agreements” and “card checks,” a powerful union sought to become hostage-taker of a hospital’s financial and reputational halo. Levy knew such an approach would usurp the primary goal of the hospital to preserve and enhance patient care. It would also deny employees the right to debate and determine the environmental parameters within which they worked. Thus the principles in play were no less than institutional purpose and individual prerogative.

As one of our nurses said at the time:

I believe in our practice, mission and values. I understand the concept of free speech, but it certainly hits a sensitive spot when people purposely set out to mar reputations through smear campaigns.

What an incredible waste of time, effort, and money by this union.  Let's hope that it and others will find a new focus for their efforts.

UK: Market concentration leads to higher prices

In what should be an implicit advisory to the United States as geographically powerful ACOs become the norm, the UK Competition Commission has found that most patients in UK private hospitals are paying more than they should for treatment because of a lack of local competition.

CC Chairman and Chairman of the Private Healthcare Inquiry Group, Roger Witcomb said:

‘The lack of competition in the healthcare market at a local level means that most private patients are paying more than they should either for private medical insurance or for self-funded treatment.

"The lack of available and comparable information, often less than is available to NHS patients, also makes informed choices—which could help drive competition—for these patients difficult."
 
The BBC News summarizes that the financial results of this market power are clear:

Hospital groups BMI, Spire and HCA had been "earning returns substantially and persistently in excess of the cost of capital", the commission said.

How much does this amount to?  The conservative estimate is £173 million to £193 million a year.

"No insurer has countervailing buyer power that can fully offset the market power of BMI, Spire and HCA," the commission's provisional findings said.

The commission recommended moves to make more information available about the quality of hospitals' services and the level of fees charged by consultants. [Note to US readers: "Consultants" = "doctors".]

It also suggested that operators owning a cluster of hospitals in one area should have to sell off some of them. 

Disruptive noises from Pennsylvania

I'm not sure how I missed this, but it is still timely and worth noting.  In June, a new Disruptive Health Technology Institute was created at Carnegie Mellon University, in collaboration with Allegheny Health Network and Highmark, Inc.  The insurance company, Highmark, will make its claims data available to DHTI researchers.  By mining that data, the researchers will make suggestions to CMU researchers as to fruitful areas that might benefit from new technologies.  The focus will be on accessibility of medical diagnostics, behavior change, chronic disease management, data mining, improved endoscopy, improved diagnostic ultrasound and infection prevention. The DHTI will then fund a small number of those ideas each year, eventually building a large library of research studies that might generate disruptive technologies in the field.

As the story notes,

Alan Russell, who will serve as the director of DHTI and as both executive VP and chief innovation officer for the Allegheny Health Network, says that healthcare is a field that needs to be shaken up.

For sure!

In July, Lynn M. Brusco was chosen to be executive director.  She is well qualified for the role, having served as vice president and chief relationship officer at the Pittsburgh Life Sciences Greenhouse (PLSG) and director of the PLSG Accelerator Fund.

We'll look forward to the results from this new institute.  I also see a potential for an alliance with our friends at the National Center for Human Factors in Healthcare.  I imagine they will have a lot to share over the coming years.

Doctors tweet about IWantGreatCare

My post about the IWantGreatCare patient evaluation program prompted some interesting conversation among UK doctors on Twitter.  I'm not suggesting this is a statistically valid sample of physician responses to the program--after all, these are doctors who feel comfortable talking about such matters on Twitter--but it is an indication that IWGC is adding some value to the doctor-patient relationship. The doctors also note a desire to get more participation from patients and steps they are taking along those lines. I conclude that this is a work in progress, and it will be good to get more updates over the coming months.

First, Clare Rees @doccmr (a pediatric surgeon) noted she was impressed with Oliver Warren @DrOliverWarren (surgeon) on his engagement with the patient in the example I posted.  He responded:

Thank you! Bit nerve wracking sometimes but right thing to do.

Then Dermot O'Riordan @dermotor (surgeon and medical director in Suffolk) led us to his blog post on the issue:

I must confess it was an anxious leap of faith to start asking patients to take cards home and rate me anonymously. I have read lots of stories about the pitfalls of unmediated review sites, e.g. TripAdvisor.

I have been giving them to every patient I have seen in clinic for three months. To start with nothing happened. A couple of weeks later I received my first review & it wasn't that flattering: I wondered if I was doing the right thing.

However I persevered and further reviews started to come in. Fortunately some were much more positive and it is always nice to hear good things. Most patients after all do trust, respect and value their doctor, in contrast to many other professions. In addition I have received constructive comments that I have tried to learn from.

Without this sort of feedback I might never know how I am perceived by patients. The response rate is still not high but I feel that it is an incredibly powerful rebalancing of the doctor-patient relationship for the patient to know that I have invited them to feedback. It does involve trusting the patient but it is important to remember that the patient is trusting me to operate on them!

I am convinced a system such as this can play a major role in changing the culture of medicine towards transparency and putting the patient in charge. It also plays a major role in providing patient feedback for doctors to support their revalidation. A number of clinicians whom I spoke to were highly positive.

Clare noted reactions and then asked:

Every single parent has been surprised to be asked - need to change #culture.  What's your response rate? I give them to everyone but very few give feedback.

Oliver answered:

Three packs of cards used 30 responses. Estimate about 1 in 20.

Dermot said:

Mine's bit lower but don't only do it for the response but cos change dynamic of consultation/trust.

Clare:

OK not just me then!

Dermot:  

But those that do respond do seem to like you.

Clare joked:

Guess I should look at the half full part of the glass more often!

I'd like to hand out iPad with link to improve response rate, but then it wouldn't be anonymous.

In a separate thread, Dermot has a conversation with Richard Bogle @RichardBogle (cardiologist), who notes:

The only thing we have to fear is fear itself.

Dermot replies:

Totally agree. The patient survey produced by @gmcuk was unhelpful. Using @iwgc changes consultation but accept is a big step.

Richard comments, too, on the previous system:

The 360 degree patient feedback is totally useless. It represents about 0.1% patients seen and is self selected.

Then they discuss how to get more responses from patients:

Dermot: Clinic nurse gives it to every patient I see.

Richard: I have the link to iwgc on my website and also a friends and family test on the site. I put the web address on all correspondence. The website gets lots if hits but no responses on iwgc. I think I will start using the cards.

Dermot: I too put my @iwgc URL in footer of all letters. Not sure if produces that many responses.

Communication Counts

Sign seen at the George Washington University Hospital:

Those are the basics!  Good for them to make it explicit. I'd love to hear from patients, families, and staff how it's working.

Badge buddy residents work together on adverse reporting

"Every resident should know how to make an adverse event report," says Nate Margolis, M.D., a fifth-year resident training in New York University's Radiology Residency Program.  (Nate is co-chair of the NYU School of Medicine’s House Staff Patient Safety Council.)

Nate's right, of course, and indeed this is now a requirement of the ACGME, the governing body of residency programs in America:

The Sponsoring Institution must ensure that residents/fellows have access to systems for reporting errors, adverse events, unsafe conditions, and near misses in a protected manner that is free from reprisal.

But this capability is often missing, the victim of a prejudice on the part of many hospitals against resident involvement in this kind of activity.  Often, too, residents feel cowed by a perception that their future career prospects will be damaged by honest reporting.  The situation is complicated, too, for residents who rotate through several hospitals.

Nate and his colleagues decided to help solve this problem using a “badge buddy”—a simple, effective tool to assist residents with the process of reporting events at the multiple hospitals in which they train.  Here's a video describing the initiative, which was strongly supported by the Committee of Interns and Residents (CIR), as well as the senior leaders at NYU.

IWantGreatCare

A group in the UK called iwantgreatcare.org has been running a consumer evaluation website about doctors and hospitals.  Analogous to TripAdvisor, people can post quantitative rankings as well as qualitative comments.  It covers 100% of the NHS hospitals and over 200,000 doctors.  All information is absolutely transparent to the public, the clinicians, and the hospitals.

I can already hear the complaints:  "Our patients are sicker."  "People don't understand enough about medicine to properly judge us." "This is just going to be a complaint board."

Taking the last objection first, well, no.  It turns out that the vast majority of people are actually pleased with their medical care and use the site to send a positive, thankful message to their caregivers.  Here is a touching example:

Everybody finds the GU clinic a bit scary. It just is. For me it's a bit more than scary. I was sexually assaulted 10 years ago and find the examinations difficult after my experiences. After the assault I was examined by a male doctor... it was traumatic to say the least. Just to add insult to injury I have also had cells removed from my cervix (bear with me I am trying to build up a scenario) so I have been examined by various doctors, nurses, blah blah. The point is this. Dr [Robin] Bell is extraordinary. His approach, helpful manner and wit are second to none. I have NEVER ever felt so at 'ease' (relatively speaking) when having said examination. Having seen him twice now I can honestly say I will not see any other GU doctor unless I really have to. I was nervous the first time I went to his clinic; nervous about the examination and (wrongly so) the fact, he is of course, a man! Pah! No female has ever treated me with such tenderness. I would like to thank Dr Bell and I meant to say it today but after my last visit I called my mum (confidant and aide) and cried (for quite some time) about the fact it was ok, that a man had dealt with me and it had gone well. I cried that my fear was over; believe me the police examination was horrific. I can't recommend Dr Bell highly enough. I never ever thought I'd get the chance to conquer the fear of a male examiner... but I did and he's the best :-) Who is in control? His patient :-) 

But sometimes, there are complaints.  Here's one, along with the response by the doctor, posted within 24 hours:

Saw my mother after an examination of her bowel because her GP was worried about something serious. Spent more time talking to student doctor than to my mum and kept asking me questions instead of my mum. She wears hearing aides but isn't stupid! She was still worried about her stomach pains but all he cared about saying was that it wasn't cancer. He is very professional and smart and probably very clever and not rude but he didn't address my mother's worries and talked down to us both a bit. Would ask for a different doctor next time.

Response from Mr Oliver Warren 

Thanks for your feedback. I'm very sorry that you feel I didn't live up to the high standards of care I expect from myself and that we all strive for at Chelsea and Westminster Hospital. I would never presume that someone who requires hearing aids is stupid, and would never wish to give the impression of talking down to a patient or a relative; it can sometimes be really difficult to get the balance right between explaining things in a way that people understand and aren't too complicated, and oversimplifying. Likewise with reassurance; many of our patients are very much focused on cancer, and ensuring they don't have it. On this occasion I read the concerns of your mother and you incorrectly. We try to ensure that the medical students are fully involved and seen as part of the team at our teaching hospital. Balancing their educational needs with the needs of patients can also sometimes be fraught with difficulty in a busy clinic. I would be delighted to organise a second opinion with a colleague if this would be of any help or benefit and am grateful for your feedback.

I don't know, but I bet the information collected here is more useful than the kind collected by Press Ganey and other such patient evaluation services.  Yes, this site suffers from a self-selection bias, but it would be difficult to know in which direction the bias acts.  As mentioned, lots of the comments are laudatory and appear to give people a chance to show gratitude.  If I were running a hospital, I would be sharing these results broadly among my staff, looking to see where trouble areas might be occurring.  As the site notes: "Quantitative and qualitative feedback for organisations, departments, wards and clinics gives real insight with data that actually allow continuous improvement and is proven to engage front-line clinical teams."  I would also celebrate the success of consistently fine reviews.

The site makes no representation that it is evaluating clinical decision-making and outcomes.  That's not the point. It collects reactions from patients in three categories:  Trust, Listening, and Recommend.  You don't have to be a genius to understand that these characterizations are going to be made anyway by patients to their families, friends, and associates.  Doesn't it make sense to hear them directly if you are running a hospital or physician practice?

Mindfulness now!

Here's a humorous take-off on the concept of mindfulness, perhaps distinct from that codified by medical education guru David Mayer, but agreeing with him on the hoped-for time frame.

Getting sleep versus staying engaged with the patient

Lisa Rosenbaum has posted a thoughtful piece over at The New Yorker entitled "Why Doesn't Medical Care Get Better When Doctors Rest More?"  After introducing a story about a patient, she says,

A few days later, the resident caring for the patient neared the teaching hospital’s witching hour: whether or not his work was done, he had to leave at 6 P.M. That’s because, a decade ago, largely in response to widespread concerns that tired residents were making too many errors, the Accreditation Council for Graduate Medical Education enacted nationwide rules that limited the number of consecutive hours residents can work. Five years later, a review of the data suggested that, on average, the rules had failed to make our nation’s teaching hospitals any safer. Proponents of the reforms argued that the rules had neither gone far enough nor been properly enforced. Accordingly, in 2011, first-year residents were limited even more—to sixteen-hour shifts, rather than the thirty hours previously allowed. Training programs scrambled to comply.

Rosenbaum then leads to some of the intangible aspects of the work hours rules:

The data evaluating the impact of the 2003 reforms suggest that, when it comes to patient safety, little has changed in teaching hospitals. But when it comes to preparing young doctors to manage disease, the training environment has been completely transformed.

While these studies suggest the complex nature of patient safety—that manipulating one variable, like hours worked, inevitably affects another, like the number of handoffs—there is another tradeoff, more philosophical than quantifiable. It has less to do with the variables within the system and how we tinker with them, and more to do with what we overlook as we focus relentlessly on what we can count. 

Near the end of the article, she starts a story:

As a third-generation physician, I did not think the cultural transformation of our educational environment would affect my fundamental sense of what it means to be a doctor. But the other night I had a phone conversation with my mother, who’s also a cardiologist. 

I'll leave it to you to read the rest. 

Bending the Map

As I am reading the book The Lost Art of Finding Our Way by John Edward Huth, I am struck by a correspondence between the kind of confirmation bias experienced by a physician who has engaged in diagnostic anchoring and a phenomenon called "bending the map" that is experienced when people get lost in the wilderness.  Here's the quote from the book:

The correspondence between a mental or physical map and our perceptions helps us stay oriented, but one of the first stages of getting lost involves a process called "bending the map." The phrase comes from the sport of orienteering, in which competitors find their way around a series of waypoints that are revealed to them on a map at the start of the race.  Competitors can become lost and believe they are in one place indicated on the map and mentally try to force features they see to line up with ones indicated on the map even when the correspondence is poor.

Denial is an effective psychological defense mechanism, and map bending is one form that lost persons often engage in. A lost person might first believe he is located at a certain point on the map, but things around him do not seem quite right. He pays attention to details that confirm what he already believes to be true, ignoring all evidence to the contrary.  A lost person may be looking for a creek that flows south on the map. In his mind he's sure that he has arrived at the creek. It flows east, yet he conveniently ignores this fact and follows it anyway.  It can take some time, but there comes a moment when an eerie realization hits him that something is wrong and he doesn't know why.

The parallels to doctors who have settled prematurely on a patient's diagnosis are compelling.  Evidence that supports the conclusion is accepted.  Contrary evidence is ignored.

Recall the story Jerome Groopman tells in his book How Doctors Think:

One of my patients was a middle-aged woman with seemingly endless complaints whose voice sounded to me like a nail scratching a blackboard. One day she had a new complaint, discomfort in her upper chest. I tried to pin down what caused the discomfort--eating, exercise, coughing--to no avail. Then I ordered routine tests, including a chest x-ray and a cardiogram. Both were normal. In desperation, I prescribed antacids. But her complaint persisted, and I became deaf to it. In essence, I couldn't think in a different way. Several weeks later, I was stat paged to the emergency room. My patient had a dissecting aortic aneurysm, a life-threatening tear of the large artery that carries blood from the heart to the rest of the body. She died. Although an aortic dissection is often fatal even when discovered, I have never forgiven myself for failing to diagnosis it.  There was a chance she could have been saved.

I wish I had been taught, and had gained the self-awareness, to realize how emotion can blur a doctor's ability to listen and think. Physicians who dislike their patients regularly cut them off during the recitation of symptoms and fix on a convenient diagnosis and treatment. The doctor becomes increasingly convinced of the truth of his misjudgment, developing a psychological commitment to it. He becomes wedded to his distorted conclusion.

While Jerry focuses here on the situation where dislike of a patient leads to diagnostic anchoring, we now understand that it can apply in many situations, irrespective of the doctor's personal feelings about the patient.

Let's go further, though, and see if the following emotional reactions also apply to physicians. Huth says:

Suddenly, the lost hiker recognizes that his map and his perceptions don't line up.  Panic sets in. The emotional centers of the brain send out warning signals, and perceptions get distorted with a fight-or-flight reaction.  Massive amounts of adrenaline flood the mind and body. Breathing and heart rate increase. The person refuses to believe that he's lost and runs frantically in a direction that he's sure will lead back to the trail, only to get deeper into trouble. First one possibility, then another races through his overtaxed mind, and yet he cannot gain any certainty.

"Woods shock" is the term for this kind of anxiety attack brought on by the realization that the subject is lost. 

I have seen woods shock occur to physicians. I have seen it in clinics and on the floors and ICUs.  I have seen it during case reviews, when doctors are describing adverse events and trying to figure out what went wrong. When denial sets in, I have seen the figurative equivalent of "running frantically in a direction that he's sure will lead back to the trail." The flailing and emotion distress that occurs is painful to watch and, I'm sure, to experience for these people who have been trained not to be wrong.  Rationalization comes into play.  Blame of other parties--the nurses, the labs, the residents--is a common response.

In a post almost three years ago, I summarized a talk by Pat Croskerry from Dalhousie University, Halifax, Nova Scotia.  Pat says we need to spend more time teaching clinicians to be more aware of the importance of decision-making as a discipline. He feels we should train people about the various forms of cognitive bias, and also affective bias. Given the extent to which intuitive decision-making will continue to be used, let's recognize that and improve our ability to carry out that approach by improving feedback, imposing circuit breakers, acknowledging the role of emotions, and the like.  In summary, let's see if we can protect our clinicians from bending the map and experiencing woods shock.

Most wired?

Now that I am a "civilian," I get to experience the health care system like most of you. I marvel at the degree to which customer service mechanisms used by service providers in other sectors do not exist in health care. Please understand that I am not talking about the quality of care, or empathy, or attentiveness offered by doctors, nurses, rad techs, lab techs and the like.  On that front, I remain tremendously impressed.  Indeed, I am even more impressed that they can offer such fine care now that I get to witness the logistical "systems" in place to do the humdrum things that are required to provide service, work flows whose design not only makes things harder for patients but also for providers.  Examples:

I contact my PCP who recommends that I see a specialist.  The PCP is on the patient information portal, but the specialist is not.  This means that I cannot use the portal to set up an appointment.  Can I do it by email? No, I am told.  I must call the specialist's office.  This results in several back and forth telephone calls, using up the precious time of both the patient and the desk clerk.  An opportunity to benefit from the asynchronous nature of email or other electronic scheduling is lost.

I need to have an image made before seeing the specialist.  His office tries to enter the order for the image, but the system kicks it out because my insurance company does not have the name of my PCP in its records.  The person entering the order does not have the authority or ability to inform the insurance company of this piece of data, although it is known to her.  Instead, the specialist's office has to contact me, and then I have to contact the insurance company, and then I have to call the office back and tell them that I have done so, and then the order can be entered.

Then, because electronic scheduling does not exist, I have to call the radiology department to get an appointment for the scan.  Here's the first bit of good news.  The scan and the radiologist's reading is inserted into my electronic medical record so the specialist has access to it before my appointment. Indeed, I have access to the report, too, through the patient portal (oddly, in that the specialist does not participate in the patient portal.)

But my PCP and the specialist recommend that I see yet another specialist.  I search for his information and find that he uses the patient portal.  I go to my page in the patient portal and attempt to add him as one of my doctors so I can make an appointment electronically, but the following message appears saying that I must have an initial appointment with him before I can do so: 

 

Ah, Catch-22!

There is no email available for him, so I am left to call his clinic and make an appointment.

By the way, this occurs in a physician practice organization that regularly receives awards for being part of one of the "most wired" health care institutions in the country. And, truly, it deserves that honor compared to many others, but the kind of lacunae I describe above are indicative that the standard against which such awards are granted is low compared to what you would expect in many other industries.

Oh, also, the Press Ganey survey I received after the appointment with the first specialist had no questions related to any of these problems.

See them for who they are and not for the illnesses they have

Jane Carmody is Chief Nursing Officer at Alegent Creighton Health in Omaha, Nebraska.  She publishes a regular note from the CNO for the hospital staff.  This personal account moved me, and I reprint it with her permission.

Courage. My sister is about nine years older than me. For about ten years she has battled carcinoid tumors, and it is starting to take its toll.  I visit her about every weekend I can; she lives in Des Moines. I have to say how I admire her courage. She is a nurse and worked for years at her small town clinic with the physician and the nurse practitioner. They “huddled” every day (although they did not call it that) and discussed the patients for the day and who would need follow up, who would be called and who would come in for a “RN check.”  She was well known in the town. 

She retired a couple of years ago and tells me now, “Never retire…stay working as long as you can…it is hard for a nurse to retire…the work is too exciting and interesting…”.   I know she looks at me and wishes she were in good health, and I so I am careful not to complain about work schedules or work pressures because she would love to have them.

Over the past few months, she has progressed to a cane and soon I am sure a wheel chair. She hated the idea of a cane at first, so I took her an umbrella and bought cane tips. That way she looked stylish. She progressed to a 4-prong cane and has difficulty getting around. 

On a recent visit we took her shopping. My sister loves shoes, purses and hair and skin products…and certainly not the inexpensive ones. We thought about taking her to the mall so she could shop at Von Maur (her favorite) and yet the mall only provides wheel chairs…she hates that. So, we took her to Target: They have motorized carts and she had so much fun. Gave her freedom to shop and to knock down displays…she said she was so “embarrassed” to have to use the riding carts, but she had so much fun. She has lost most of her hair and so she wears lots of hats and so we bought matching ones.

I tell this story because she is courageously and gracefully managing. It reminds me of how you all experience the courage of your own patients and families and how we have to remind ourselves to see them for who they are and not for the illnesses they have. Please pray with me for my sister and all those suffering. She starts another round of radiation this week because the tumors grow more on her spine.  This further weakens her status and yet not her hope, humor and courage. 

Medical residents taking the lead on quality improvement

A note from my friends and colleagues at the Committee of Interns and Residents (CIR): 

Although medical residents are often the first line of contact for most patients in academic medical centers and teaching hospitals, medical residency offers little in the way of formal training on skills needed to keep patients safe from medical errors or on how to deliver high-quality, cost-effective care.

To cope with the pressures of today’s health system and new rules requiring clinically competency in patient safety, the national organization representing 13,000 of the nation’s interns and residents is launching the first online platform to give doctors in training information, tools, and best practices they need to deliver care that keeps patients from harm.  CIR calls the new site QIGateway, and it is a repository of research, case studies, and tools related to quality improvement and patient safety that are relevant to medical residents and interns. 

This new platform is more than just an important resource for physicians in training.  It reflects the leadership residents and interns are taking to reduce medication errors, reconcile medications, and make sure patients are discharged and transferred properly so they don’t return to the hospital unnecessarily. This leadership is important because by 2015, the Accreditation Council for Graduate Medical Education (ACGME) will require all resident physicians to demonstrate clinical competency related to quality improvement and patient safety.  Teaching hospitals are under pressure to avoid patient errors and to make sure they are teaching these competencies to doctors in training.

Check out this video.  (If you cannot see the video, click here.)

Safety and quality excellence in Gillette, WY

I'm always on the lookout for firms and institutions that embody a strong culture of quality and safety--in the work environment and in the products and services they produce or deliver.  While health care has its special characteristics, there is always something new to learn from places that have done this well.  Common features emerge, though:

Top-level leadership for whom excellence is an expectation and whose own behavior exemplifies what they expect for others in their organization;

Disdain for benchmarking against industry averages: People who understand that there is no virtue in benchmarking to a substandard norm;

A work environment in which front-line staff are empowered and encouraged and expecteded to call out quality and safety problems, with a special focus on near-misses, those conditions that represent systemic flaws in the organization, the time bombs that will one day lead to harm.

I've found the latest example of this combination of attributes in Gillette, Wyoming, at a family-owned firm called L&H Industrial.  The business of the firm is to provide repair services to the mining industry and to fabricate those huge and complicated parts and machines that are used to retrieve coal, gold, and other products in the ground.

The two brothers who own the firm, Jeff and Mike Wandler, say the following:

L&H Industrial considers safety to be the most important component of our success. Keeping our employees safe is our first priority. Our mission is zero Lost Time Accidents (LTA’s).

They have recently passed the four-year mark on this objective, an outstanding result considering the work their folks do:  Welding, heavy lifts, grinding, and so on.  One brother explains, "We have engineered unsafe practices out of this company."

Citing the field work their folks do, fixing and installing heavy equipment at coal mines and elsewhere, the brothers say:

We are responsible for the safety of our employees no matter where they’re working. L&H Industrial makes field service safety a priority with frequent trainings and peer monitoring.  Our on-site service business relies on our safety record - we don’t take that lightly. 

Quality is the company's other pillar:

The goal is that zero quality problems reach our customers.  Product quality is monitored through inspections at each step and non-conformances are documented and root-caused so corrective actions can be implemented to prevent recurrence.

Validation of this approach recently occurred when the firm was ask to fabricate and assemble a replacement lower roller assembly for NASA's Crawler Transporter, the world's largest self-powered land vehicle.  Wikipedia notes:

The crawler-transporter has a mass of 2,721 tonnes (2,721,000 kg; 6,000,000 lb) and has eight tracks, two on each corner. Each track has 57 shoes, and each shoe weighs 1,984 pounds (900 kg). The vehicle measures 131 by 114 feet (40 by 35 m). 

The specifications for this job are extremely demanding.  The metal tolerances are exacting.  There is essentially zero margin for error when a huge space rocket is being rolled from the fabrication building to the launch pad.  L&H received this job after an extremely competitive solicitation, with dozens of NASA engineers reviewing the company's opoertaional plans and facilities.

All in all, an impressive record and one with lots of lessons for those of us in the health care world.

Thirsty Thursdays are about to resume

A faculty member reports to me that a significant percentage of Emergency Room patients at St. Elizabeth's Hospital on Thursday nights come from a nearby college and arrive with a diagnosis of alcohol poisoning.

I was not aware of this cultural phenomenon in The Heights.  But it is has been place for some time, as this article summarizes:

Thursday is the new Friday for college students. On most campuses, early morning classes don’t exist on Fridays, so why not start the weekend even earlier? It’s hard to say no to booze, brews and a good time.

And aided and abetted by local pubs with ad leaders like this: "Thursdays have become one of Boston’s best nights for college students and young professionals!!"

On a related topic, the New York Times reports:

Five beer brands were consumed most often by people who ended up in the emergency room. They were Budweiser, Steel Reserve, Colt 45, Bud Ice and Bud Light.

My unscientific survey in our neighorhood near this college supports this finding, with a clear preference for the Budweiser products, as shown by the types of empty cans found on the streets and near the transit stations the morning after.

If you can't do one thing well, add another

A recent article in HealthLeaders Media covers a new trend, provider organizations branching out into the insurance industry.  Here's the lede by Margaret Dick Tocknell:

Health systems are increasingly taking on new roles and becoming health insurers. Spurred by healthcare reform, the creation of health insurance exchanges, and a shift to population health, health systems are assessing the opportunities of becoming a payer against the risk of taking that step in the ever evolving healthcare industry.

A growing number of health systems are deciding that it is worth the risk. In a June survey of more than 100 hospitals and health system across the country, 34% responded that they already own health plans. Another 21% said they plan to launch a health insurance plan by 2018, according to the Advisory Board Co., a Washington, D.C.-based research and consulting firm.

There are groups that have done this with notable success, like Geisinger, but as the article notes, "jumping into the health insurance game is not a parlor game.... [D]ecades ago hospitals and health systems lost a lot of money trying to take on capitation and broader risk.  Also, shifting from provider to provider-payer is a huge cultural change that involves thinking beyond managing facilities and capacity to a more holistic approach to patient care."

Here's what I think, based on unscientific site visits, surveys, and discussions with hospital leaders.  The vast majority of hospitals--and especially academic medical centers--have barely begun to crack the operational problems that exist in their facilities.  The quality and safety of patient care are substandard, compared to what they might be and what has been demonstrated in comparable facilities.  The degree of patient-centeredness, likewise, needs major work.  Finally, the engagement of front-line staff in process improvement efforts is scattered.

CEOs and Board of Trustees are understandably ill at ease with all of the changes occurring in the health care world, but it feels like the management consultants have been hard at work persuading this audience that the solution to the changing health care environment is to look outward rather than inward.  Grow and consolidate with mergers and acquisitions to create scale in a given geographic area.  And, now--as reflected in this article--bolt on an insurance plan with which you will share risk.

The problem is that the current generation of hospital CEOs and other C-suite members have no experience with these new business formats.  Even if these plans and activities appear to be attractive in the consultants' pro forma presentations, executing them is distracting and demanding and requires a different skill set that has led the current generation to their current positions.

Hospital CEOs would be better off creating trusting and reciprocal clinical relationships with other institutions and practices along the spectrum of care.  Likewise, they would be better off learning how to negotiate with insurers in the new environment by helping to develop commercial relationships that are mutually advantageous.  Meanwhile, let's get really good at providing a safe and high quality clinical environment, with an intensive and extensive partnership with patients, while engaging our staff in the kind of process improvement that leads to a better work environment and greater efficiency.

Twitter advice for hospital executives

Here's a really well done (and somewhat self-referential) story about how hospital executives should think about using Twitter by Helen Adamopoulos over at Becker's Hospital Review.