Peel me a grape!

Whenever I promise myself not to write another post about robotic surgery, I see an ad or an interview doubling as an ad so full of misrepresentations that I have to reach out for an antiemetic.

Here's the latest, a June 18 piece on Bloomberg TV.  It is shocking because Bloomberg is so careful about accuracy in its news reports.  Of course, the video starts with a short ad, which is clearly labeled as such.  But they really should have kept that label in place for the duration of the video.

Did Intuitive Surgical pay for this piece or just provide the visuals?  For surely they did provide the visuals, as is clearly disclosed.

It appears that they also provided some answers.  When the interviewer asks at, 3:56, "What about the costs?" Dr. Michael Stifelman from NYU's  Langone Robotic Surgery Center responds, "There is a perception that robotics is going to be more costly. What we're finding is that, when put into experienced hands . . . those increased cost are somewhat nominal if anything.  The benefit for the patient is they're going to get out of the hospital earlier . . . less risk of blood loss, less pain, and most importantly . . . the costs to society.  Each patient will be able to get back to work more quickly than they would using a more traditional technique for these procedures."

Sorry, Dr. Stifelman, but all of those assertions are not supported by objective, peer-reviewed studies.  Your point about cost also ignores the purchase cost, disposables, and maintenance contracts associated with this equipment. You also appear to be subtly offering a comparison of robotic surgery with open surgery, as opposed to manual laparoscopic surgery.  Here's a more objective recent portrayal of the issue in a recent New Yorker article.  An excerpt:

Many hospitals, faced with the pressure to compete with high-tech programs, are advertising robots aggressively—on billboards, on YouTube, even at baseball games. Some may be overselling the benefits of the technology. Researchers at Johns Hopkins University analyzed the Web sites of four hundred U.S. hospitals and, in a study published in the Journal for Healthcare Quality, reported that the majority of sites claimed that robotic surgery offered an “overall better outcome,” and a third of the sites touted “improved cancer control.” (None of the Web sites mentioned risks.) A study by researchers at Columbia University investigated the marketing of robotic gynecological procedures and found that many hospital Web sites described robotic surgery as the “most effective treatment.”
Jason Wright, who worked on the Columbia University study and is the chief of gynecologic oncology at the university, told me that many claims made about robotic surgery aren’t based on clinical evidence. “When you see an ad for a drug on television, the claims that are made have to be backed up by scientific data,” he said. “There’s not the same level of scrutiny for devices.”

Intuitive Surgical loves Dr. Stifelman:

Dr. Michael Stifelman, Associate Professor of Urology and Director of Robotic Surgery at NYU Langone Medical Center, has been named the 2011 recipient of the Crystal Award, given by Intuitive Surgical, Inc., to surgeons who have contributed significantly to the advancement of clinical knowledge in the field of robot-assisted surgery. The company, which manufactures the da Vinci Si robotic surgical system, gave the award to Dr. Stifelman in a ceremony at its annual meeting in Boca Raton, Florida.

And the company also promoted his interview with Diane Sawyer as well as numerous entries on its DaVinci Surgery Community site.

But here's the great part.  While Dr. Stifelman talks, the video meticulously presents the visual story of a grape being peeled.  I wondered if a surgeon might tell us how relevant that is to prostatectomies, hysterectomies, and the like, so I did a Google search on the question, "Is surgery like peeling a grape?"

I was overwhelmed by the response.  What good fortune.  Here's a portion of that page from my browser, with videos going all the way back to 2010.  Surgery is like peeling a grape, and how lucky we are to be able to do that robotically.

Two heists

There are two major unsolved robberies in Boston.  The one that has received the most press attention is the 1990 theft of thirteen masterpieces, including this piece by Rembrandt, from the Isabella Stewart Gardner Museum.  That theft remains unsolved to this day, notwithstanding thousands of hours of detective work.

Wikipedia makes an error in its summary of the case: "Altogether, the stolen pieces are estimated to be a loss of $500 million, making the robbery the largest private property theft ever."

No, a much larger robbery began just a few years later, when the Partners Healthcare System was established.  The business concept was elegant: Establish a network, bookended by the two largest Harvard teaching hospitals and comprising a number of important community hospitals and thousands of primary care doctors and specialists.  Too big to be left out of any insurer's network, it was able to use its leverage to demand payment rates far in excess of those received by any of the other hospitals and physicians in the region.

My conservative estimate of the excess revenues annually received by this system is $200 million.  (I'm pleased to be corrected on this.)  In just 2.5 years, PHS extracted more value from the Massachusetts economy than the value of the Gardner's paintings.  Now, celebrating its 20th year, the total is in the billions.  The difference, though, is that this heist has been in the form of cash paid by the businesses, governments, and individuals in the region.  Why has nobody noticed?

More specifically, the major media in the state and the Attorney General, who supervises the so-called "public charity" represented by PHS, have failed to apply their analystic skills to ask the question:  If, as everyone knows, PHS collects excessive amounts of revenue, how can it be that its reported results are in the range of others who do not? 

Let me provide the quick and dirty answer: The true mastermind of this monetary transfer is the person who has been able to hide these funds.  The corporation's CFO has been the artist who has painted the picture year after year that the overall margin earned by PHS is within the range of other healthcare systems.

How?  There are several ways to increase the expense lines in an income statement.  Let me mention just two.

The first is to bury the money, literally.  Build new buildings that have little inherent value to society, excessive architectural features, low occupancy, and that have expected rates of return that are so low (or negative) that they would be derided in other industries. Why have no reporters questioned the business case for these structures? Each year, the operating costs of these buildings and depreciation offset the revenue line of the corporation, lowering net income.

The second is to establish reserve accounts that are excessive relative to what would be required.  Additions to reserves are debits against income in the year they are booked.  When a year's receipts are looking "too good," all you have to do is invent a need for some new or expanded reserve accounts before the fiscal year closes and park the cash there.  Here's a little secret:  No accounting firm that wants to keep such a major client will raise substantial objections to a healthcare system that chooses to adopt conservative standards for reserves.

It's time for an enterprising reporter to dive into these matters.  Ask the question:  Where did the cash go?  We all know it was collected.  If we look in the right places, we'll find out where it went, hopefully even before we recover the Rembrandt.

--

An afterthought: If I am shown to be wrong about the use of such accounting devices, we face an even more distressing conclusion, that the high rates received by PHS for two decades have been absorbed simply by the operating costs of the system.  Why is that thought distressing? Because it would signify that that the system is incredibly less efficient than others in the state, requiring an extraordinary level of revenues to treat essentially the same types of patients as seen by other academic medical centers, community hospitals, and physicians.  And, as evident from published data, at no higher levels of quality.

The AG-Partners deal: A view from a reader

It isn't often that I publish a comment as its own blog post, but this one is so thoughtful and comprehensive that I thought more people should see it.  The topic is the agreement reached by the Massachusetts Attorney General and Partners Healthcare System, one several of us believe to be a way of cementing PHS' market power for years to come.  [I have embedded explanatory links.]

There are so many aspects of this deal that are tailored to sound reassuring but are, in fact, hollow. Before any real information was available to understand how or if this approach could actually work, the Boston Globe was very eager to believe that a secret handshake between Partners and the Attorney General's Office would undo the damage caused by The Secret Handshake between Partners and Blue Cross that the Globe's own news division uncovered in 2009. It astonished me that without any information on how these "caps" would be enforced or monitored the Globe expressed such strong, unconditional support. How could they tell this deal would have the intended impact? For example, will this deal rely on the same insurers who kept silent for more than a decade (while doling out 10-15% annual price increases to Partners) to throw a flag on the field if they believe the cap is eclipsed? Or will there be a monitor keeping up with all of their contracts and systematically quantifying price increases/decreases in real time to ensure compliance? Will the increases be estimated projections or will actual total price increases be calculated as a look-back and adjustments made on actual service types and mixes? And the very simple physician market share math that Gene Lindsey laid out is of no concern even IF the caps can be enforced?

I'm afraid these admittedly tedious details matter quite a bit; an "estimated" 1.5% increase can easily become double or triple that as norms of care change and the clever people at Partners carefully select which services they decrease prices on by 5-6 % and which they increase prices on by 6 or 7 percent. And if Partners can add a number of physicians that effectively would give them all of the remaining unaffiliated physicians in Eastern Massachusetts, is that really a growth cap at all? The Globe blessed the deal (without reservation or caution!) in the absence of the answers to these reasonable questions and concerns; puzzling indeed.

I appreciate that your blog is a place where we can get a more realistic analysis of this situation rather than the blindly rosy acceptance of a story that hopes to put to rest an inconvenient political hot-potato. Ignoring the fact patterns of the past 20 years, and chalking up concerns with this deal as the wonky white noise of the sour grapes crowd, will not lead to an outcome the Commonwealth will be proud of in another 20 years. I continue to wonder what harm could possibly come of a transparent, thorough, fact-driven analysis of such an important settlement?

The future Gene Lindsey paints is all too possible and of national importance as other states look to Massachusetts to see what we will do to reign in costs. At least your blog will be one place where our national counterparts will see it was debated in the clear-eyed, analytical way it deserves. However it is a huge loss if, for the most part, our elected officials, local media, and public institutions choose not to insist upon and participate in a transparent and rigorously analytical process.

Annie's story

I have a shorthand saying about finding the underlying cause when a clinician is involved in harming a patient: If you can say, "It could have happened to anybody," the cause is not personal.

Unfortunately, though, there have been too many stories about nurses being blamed for errors in hospitals when the actual causes were underlying human factors problems or work flow poor designs or other systemic issues. 

There are very few stories about hospitals that have acknowledged this error of blame and apologized to the nurse and the community.

Here's one example of the latter, from Medstar Health.  Annie's story presents a message to us all about the need for a just culture in an organization--and about valuing the people with whom we work.

New roles and routes on WIHI

Madge Kaplan writes:

The next WIHI broadcast — New Roles, New Routes for Managing Populations — will take place on Thursday, June 19, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:

• Trissa Torres, MD, MSPH, FACPM, Senior Vice President, Institute for Healthcare Improvement
• D. Clay Ackerly II, MD, MSc, Associate Medical Director, Population Health and Continuing Care, Partners Healthcare; Assistant Chief Medical Officer, Non-Acute Services, Massachusetts General Hospital
• L. Gordon Moore, MD, Director, Ideal Medical Practices Project; Clinical Associate Professor, Department of Family Medicine, University of Rochester
• Jennie Chin Hansen, CEO, American Geriatrics Society

If you’re wondering why health care quality and clinical leaders have been talking a lot more with their counterparts in finance or IT, look no further than the latest value-based contract they’ve likely just entered into with a payer. Within a hospital, these leaders may be putting their heads together to figure out how to deliver better care and better value for whole populations of patients. How might their data systems, for instance, help them better understand the utilization patterns and needs of everyone they see with Type 2 Diabetes? Or, within an accountable care organization (ACO) comprising a major hospital system, several physician practices, and a skilled nursing facility, how can the representative senior teams guide operations to reflect new, shared responsibilities and forge new ways to work together?

It’s early going with these new types of arrangements, and no one has it all figured out. But as organizations from across the continuum of care get up to speed, they’re eager to share what they’re learning. We’ll provide this opportunity on the June 19, 2014, WIHI: New Roles, New Routes for Managing Populations, anchored by WIHI host Madge Kaplan and IHI’s Senior Vice President Dr. Trissa Torres. Dr. Torres, a long-standing medical director, has many years of experience from her work in Michigan developing greater collaboration between health care delivery organizations and surrounding communities to improve population health. At IHI, she is currently helping to frame the skill sets all leaders need to accelerate this type of change on a broader scale. The June 19 WIHI will also tap into the on-the-ground experience of Dr. Clay Ackerly, whose title at Partners Healthcare, “Associate Medical Director of Population Health and Continuing Care,” speaks to the new responsibilities he has and that are in store for leaders like him. Dr. L. Gordon Moore, with years of experience helping to redesign primary care, is now working with office practices to enlarge this vision to encompass population health.

Rounding out the June 19 WIHI panel is the CEO of the American Geriatrics Society, Jennie Chin Hansen, whose pioneering work in San Francisco helped lay the groundwork for the comprehensive and integrated national program known as PACE. She understands well the needs of older patients, an increasing number of whom now receive their health care in hospitals, clinics, and community settings that are operating under shared savings agreements with Medicare.

Everyone will walk away from the June 19 WIHI with some good ideas to carry forward, including your own ideas and experiences which the panelists are very eager to hear about. To get ready for the program, you might want to try out a population management assessment tool that IHI has developed. See you on June 19!

I hope you’ll tune in for this essential discussion and share your ideas and potential solutions. You can enroll for the broadcast here.

Julia's blog

Would you please help encourage one of our thoughtful and committed young doctors?  Julia Meade, one of the residents who attended last week's Telluride Patient Safety Resident Physician Summer Camp, was inspired by the experience to start a blog called The Hospital Docent.  She's posted a couple of entries in the last few days.

Would you please take a moment to welcome her to the blogosphere and comment on her posts? Perhaps you might want to suggest topics for future entries, too.

Also, please refer her blog to others who might be interested, ok?

Thanks!

Negotiating in the Colorado mountains

One of my roles as a faculty member to the Telluride Patient Safety Student and Resident Physician Summer Camps is to conduct a three-hour workshop on principles and strategies of negotiation.  The camps, after all, have a strong focus on the power of effective communication in reducing patient harm.  Negotiations occur all the time in clinical settings--between residents and nurses, between nurses and attendings, between clinical staff and patients and families--and our faculty leader Dave Mayer has asked me to provide some insights about negotiation to the students.

As I have noted on the Athenahealth Leadership Forum:

People who are likely to be the future leaders of health care institutions in America and abroad often come to me for career and training advice. My constant refrain is to learn the principles and framework of negotiation strategy. Negotiation can be defined as means of satisfying parties’ underlying interests by jointly decided action. You cannot be a leader if you do not know how to help a hospital’s constituencies understand that their interests are coincident with the purpose of your organization and if you cannot help them jointly decide on the actions needed to carry out that purpose. 

The Telluride workshop is a highly interactive session in which the students participate in negotiation simulations, followed by a debriefing of the results they achieve.  It is by comparing the disparate results from the same fact pattern that enable us to tease out what is effective and what is not effective in a negotiation.

There's one particular "negotiation" I like to conduct during the workshop.  I auction off a $10 bill, with the condition that both the winning bidder and the second place bidder have to pay me the amount of their bid, but only the top bidder wins the $10.  Here's a lovely summary of this game, offered by Derek, one of the participants, along with the lessons he learned.

Here are some of the students in action during one of the other exercises.

Learning patient safety in Telluride

It's such a privilege to return as a faculty member to the Telluride Patient Safety Student and Resident Physician Summer Camps, organized by Dr. David Mayer, vice president of quality and safety at MedStar Health. This is a lovely opportunity to meet a few dozen residents and medical students who compete to attend an intensive seminar or quality, safety, transparency, disclosure, and other topics that are unrepresented in medical school and residency training.  Here's a note, for example, from Julia Meade, who attended last week's residents' program, and is about to start her fellowship:

I received 1 hour of training on patient safety as a medical student and 2 hours as a resident physician. During my time in Telluride, I learned more on how to keep you and your loved ones safe than I have in 7 years of medical training.

The newly arrived medical students have already jumped right into the program.  Here's an initial blog post by Christine Beeson.  Some excerpts:

I am surprised at how important this little shindig is.  I knew many students applied, but I didn’t realize how carefully selected we all were. Before we had a chance to get puffed up from being flattered by that bit of information, we were reminded of the crippling truth of why we are gathered here---many students and faculty have been directly affected by a negative patient outcome, be it fatal or nearly fatal.  I was taken aback by the support and interest and frank seriousness of the whole matter.

I am so looking forward to the next few days. I can already foresee the dedication the students, faculty, and families with personal stories have. I am so excited to learn and soak up the many different techniques and tools with which we students can equip ourselves to tackle this hugely devastating and largely ignored/accepted tragedy. Wish us luck as we go on this journey of personal and professional growth!

Lessons from Hacking Medicine at MIT SDM

Hacking Medicine and the Rx It Offers for Innovation in All Industries

 

MIT SDM Systems Thinking Webinar Series

Date: June 16, 2014

Time: Noon – 1 p.m. EDT

Free and open to all

Register

About the Presentation

In this webinar, you will learn how to apply the hacking approach to your industry and domain. Based on their experience with MIT Hacking Medicine, MIT's Andrea Ippolito and Allison Yost will:

• discuss the hacking philosophy and the powerful promise of this approach;
• describe what is needed to short-circuit (and continue to short-circuit) the flaws in innovation; and   
• share their mantras for hacking healthcare and medicine and reveal ways to develop mantras for innovation in your organization.

Based at the Martin Trust Center for MIT Entrepreneurship, MIT Hacking Medicine brings together stakeholders who are passionate about changing the status quo in healthcare. The "hacking" approach fosters an ecosystem of empowerment for launching disruptive healthcare solutions. To date, more than 16 hackathons have been held across four continents, resulting in more than 600 idea pitches and the formation of more than a dozen companies.

 

A question-and-answer period will follow the presentation. We invite you to join us. 

 

Details/registration

Full steam ahead at Partners

For those of you in Massachusetts who still think that the deal between the AG and Partners Healthcare System will restrain the growth in this system's market power, check out excerpts from this current job posting from ZurickDavis, a health care executive search firm.  It sure doesn't look like PHS is feeling very constrained about network growth.

Partners Community Healthcare, Inc. (PCHI) is seeking a Vice President of Network Development (VP). The President and the Board of PCHI have created this senior position to lead the newly refined mission of PCHI, now the community physician enterprise of Partners Healthcare. The Vice President will work with the senior leadership across the Partners system to implement the community physician practice strategy, enhance the network, and further develop PCHI infrastructure to support alignment and coordination across the system. The new VP of Network Development will join PCHI at a uniquely opportune time.

PCHI is a founding member of Partners Healthcare, which was established in 1994 by two world renowned hospitals, the Massachusetts General Hospital and Brigham and Women’s Hospital. Partners Healthcare grew quickly and broadly in its first 20 years and PCHI was a key player in that growth and evolution.  PCHI has a $200M budget and has produced positive operating margins. The PCHI network has 600 PCP’s, 1,400 specialists, and includes 650,000 covered lives. 

The Vice President of Network Development reports to the PCHI President and is the leader who will drive the value proposition and make the case for joining the PCHI network. The VP will evaluate the markets and the opportunities for network expansion of the PCHI community physician enterprise. The Vice President will develop innovative business models and create incentives for community practices to join PCHI.

The new VP of Network Development will be a highly visible leader in PCHI and Partners Healthcare. S/he will collaborate with network development leaders at MGH, BWH, and the other Partners organizations. The VP will be at the helm of PCHI network expansion as the PCHI mission is being recast as Partners Community Physician Organization, the network of choice to attract and retain the best community practices and physicians.

The right candidate will be a recognized leader in the health care marketplace, a network builder, and a strategist with excellent relationships with physician leaders. A dynamic and innovative leader, he or she will have substantial experience in business planning and negotiating physician group network and business agreements.

Gene Lindsey's prediction seems supported by this recruitment:

While the AG’s office is monitoring price and preventing the acquisition of other hospitals or large medical groups, what will be really happening? What will be happening is that money will be flowing from the vast resources that already exist within Partners from their previous price and contract advantages to build and populate ambulatory care centers and practices in the communities of these new acquisitions. The paper talks about an additional 550 physicians. That is more than enough to take care of more than an additional 500,000 patients. Take the South Shore as an example. It is rumored that a new magnificent ambulatory facility will be built for 80 new PCPs. That would translate into at least 180,000 patients, if not more. The South Shore is growing but the population of the 16 towns that constitute its whole area from Quincy to Plymouth is less than 500,000. 

So where will the patients come from that will fill these new offices? My guess is that the patients will come from the existing practices of physicians on the South Shore. The deal prevents them from joining Partners as a group but it does not prevent them from individually relocating their employment and having their practices follow them. The future of finance in healthcare is not your price; it is the population that you serve. It will be very hard for existing practices on the South Shore to compete with the resources that will flow into the South Shore from Partners. About the time this transition is completed the prohibition on price increase will expire. By that time there will be little or no residual competition to balance the market. A five to ten year deal in healthcare is no deal at all.

Watch here for backsliding

Look at this comment in a story by WBUR's Martha Bebinger by a spokesperson for the Massachusetts Attorney General--as concern arises about her announced sell-out, er deal, with Partners Healthcare System:

Coakley’s spokesman says she is “committed to being transparent and allowing for feedback should a final agreement [with Partners] be reached.”

This is the same AG who plastered the airwaves a few weeks ago with this message:

In a resolution that would fundamentally alter the negotiating power of Partners HealthCare for 10 years and control health costs across its entire network, Attorney General Martha Coakley today announced a groundbreaking agreement with Partners that would allow the organization to acquire South Shore Hospital and Hallmark Healthcare.

While the press release acknowledged that the deal was subject to finalization, we all know that these kind of announcements are not meant as trial balloons.  Particularly during a gubernatorial campaign, you don't announce something like this unless you are sure the deal is done.

But perhaps the AG is having some second thoughts now: "Should a final agreement [with Partners] be reached." Bebinger notes:

In an unusual, perhaps unprecedented move, leaders from across the health care industry are calling for closer scrutiny of a deal that would cap prices for Partners HealthCare in the short term but would let the state’s largest hospital network add four more hospitals.

The pressure is mounting on Coakley just a few days before the state’s Democratic nominating convention where Coakley, a candidate for governor, is expected to gain enough delegate votes to get on the primary ballot.

This issue is big enough, in terms of the impact on the state economy for decades to come, to cost the AG the election.*  And she now knows it. My prediction: Watch for her to weasel out of this deal (or perhaps delay "finalization" until much later in the election cycle.)

---

* Disclosure:  I have donated money to two other candidates in this race, one of whom has now come out in opposition to the deal.

Oh, some of them are awake after all

A group of hospitals and a major multispecialty practice has finally woken up to the negative impact the AG-Partners deal will have in the Massachusetts health care market.  Here's the Boston Globe story and a companion from WBUR.

The problem, of course, is that these will be viewed as self-serving comments by the competitors of PHS.  More powerful comments would be those that come from the business community (like Associated Industries of Massachusetts, the Greater Boston Chamber of Commerce, the Business Roundtable, the MA Taxpayers Association; Health Care for All and other public advocacy groups and unions like SEIU 1199; and insurers.

Where are they?  Asleep at the switch, I'm afraid. Are they so intimidated as to not pursue their own self-interest?  And what about the Governor, and the gubernatorial candidates, and the attorney general candidates?

Considering informed consent

After watching the Michael Skolnik story here at Telluride, the residents and faculty broke into small groups to consider the issues involved in getting proper informed consent from patients who are about to undergo procedures.  Faculty member Kim Oates later reminded the residents, "The consent form doesn't replace the conversation. And the conversation is not a conversation unless it is a two-way conversation."

Although the focus was on the humanitarian reasons for engaging in proper consent procedures, faculty leader Dave Mayer also pointed out that informed consent breakdowns are a top reason for losing malpractice cases. He also reminded the residents of the value of encouraging people to seek second opinions, not only for the patients themselves, but also for the doctors: "We’re all biased towards doing the procedures we’re trained to do. If you think you’re not, you’re fooling yourself."

Here's a composite of pictures of the members of one of the breakout groups .

Barbara Rubino

Sam Kallus

Julia Meade

Jo Suh with Kim Oates

Nick Clark with faculty member Carole Hemmelgarn

Now, THIS is health care reporting

In an era of prosaic, he-said-she-said health care reporting by the estbalishment media in his own state and north of the border, Richard Asinof's coverage of the issue in ConvergenceRI provides a clinic for journalists everywhere.

Check out this recent story:

Politics is the story of who gets what, when and how, so there was nothing shy or surprising about the latest power move by CVS Caremark.

The retail pharmacy chain had been upset by the conditions imposed by Dr. Michael Fine, the director of the R.I. Department of Health, in a May 14 decision approving the licensing of seven MinuteClinics in Rhode Island, following an involved, lengthy public process before the R.I. Health Services Council.

In response, the Woonsocket-based corporate behemoth, which earned $126 billion in revenue and $8 billion in operating profits in FY 2013, went straight to the offices of Rep. Nicholas Mattiello, the new R.I. Speaker of the House, to get the conditions watered down.

Mattiello, in turn, called Gov. Lincoln Chafee. Behind closed doors, in private, in a meeting that included Richard Licht, head of the R.I. Department of Administration, and Peter Marino, director of the R.I. Office of Management and Budget, as well as CVS and MinuteClinic officials, discussions were held on how to cut out conditions that CVS didn't like. 

Asinof notes:

Mattiello proudly championed his successful intervention. “Speaker Mattiello . . . was pleased to have been able to facilitate a positive result for one of the state’s largest businesses that will be adding jobs through seven MinuteClinics. He will continue to oppose overbearing regulations that hamper the growth of Rhode Island’s economy.”  

Asinof adds substance to the story by presenting a section by section analysis of the changed conditions, showing their impact on real people in the state:

What was the problem with the initial conditions? CVS has not commented specifically in public about what it found to be unfriendly to business. What can be determined is what changes occurred between the initial and final, revised conditions. 

And then he concludes with the broad picture about this kind of policy intervention:

Beyond the immediate results of CVS being able to revise what it considered to be problematic conditions to its bottom line, the ability of political leaders to rewrite conditions behind closed doors raises questions about how future health care policy decisions will be made – and by whom. 

That ConvergenceRI, with limited financial resources, can produce this kind of piece on a regular basis is a gift to the people of Rhode Island.  It is also an example to the establishment media that their shallow coverage just does not make the grade.

Bad math leads to bad writing

You can cover your eyes to avoid the facts, but it doesn't change them.  A Boston Globe editorial praises the recent deal between the Massachusetts Attorney General and the state's dominant health care system.  I have called this deal a sell-out, but you don't have to adopt my view to see the logical flaws in the editorial.  Here's the key section:
 
Some critics have attacked the arrangement as merely enshrining the status quo, but it actually does a good deal more. Holding Partners’ annual rate increase to general inflation amounts to a real-dollar freeze on costs at the state’s leading provider over the next six and a half years. 

That’s significant — and something that would not otherwise occur. Over the last decade, Partners had regularly gotten increases in the 4 to 5 percent range, and sometimes higher. And the inflation of medical costs typically runs about 1.5 percent higher than general inflation, which makes the deal look even better.

As a further restraint, the deal stipulates that annual cost increase to insurers from Partners’ HMO contracts won’t exceed 3.6 percent, the state’s health care cost-constraint benchmark. (Those costs are driven by a combination of the rates charged for care and the number of times that care is delivered.) If Partners exceeds that cap, it will have to refund the extra to the insurers; other health care providers merely have to develop cost-control strategies. 

The editorial tries to find virtue in the deal by comparing it with Partners' monopolistic-like pricing over the past decade (actually almost two decades, but who's counting.)  That pricing has enabled the healthcare system to accumulate a huge balance sheet--in cash, in investments in unnecessary plant and equipment, in overstated reserve accounts.  It has also enabled it to have rates that are remarkably higher than other providers.  Remember this quote?

“What surprises me most is the difference between Partners and their next biggest competitor,’’ said Áron Boros, executive director of the Center for Health Information and Analysis, which compiled the report. He said Partners has been able to negotiate high prices with all insurers, unlike other systems. “None of them has the consistent success of Partners in driving prices up,’’ he said.

In all, billions of dollars above what was required to maintain high quality care and research. 

There is scarcely a provider group in America, much less Massachusetts, whose financial plan is not built on the idea of rates raising at the rate of inflation.  By holding PHS to that level, the AG has achieved a nullity relative to the industry.  But by applying that rate to the excessive level that exists for PHS right now, the AG has permitted the disparity between PHS and the other Massachusetts providers to grow.

The Globe Spotlight team pointed out all these issues a few years ago.  Now, its editorial board seems to have forgotten the facts presented by its colleagues in the other section of the newspaper.

What is it that you desire most?

Ok, I know it's a commercial for a life insurance company, but it is really well done and has a lovely message for us all.

Sound advice from North Carolina MDs

As our next group of residents arrive at Telluride for the 10th Annual TelluridePatient Safety Educational Roundtable and Summer Camps, it is good to remember this message from these North Carolina pediatric intensivists who are trying to eliminate preventable harm:

“The big focus has been recognizing that it’s a systems issue,” Norman said. “We’re really trying to remove the blame from an individual provider and saying, 'How can we make the system more efficient? How can we work toward delivering better, safer, more efficient care?'”

Some advice from a few years back

Some encouragement--and direction--to all of you who are engaged in  trying to improve the health care delivery system but face frustration with the pace of change.

From the Pirkei Avot: "It is not incumbent upon you to complete the work, but neither are you at liberty to desist from it."

Telling us what we want to hear, not the truth

Well, here's a pretty damning article from the Annals of Internal Medicine about the ethics of cancer centers, "What are cancer centers advertising to the public?"  Excerpt from the abstract: 

Background: Although critics have expressed concerns about cancer center advertising, analyses of the content of these advertisements are lacking.

Objective: To characterize the informational and emotional content of direct-to-consumer cancer center advertisements.

Design: Content analysis. 

Setting: Top U.S. consumer magazines (n  = 269) and television networks (n  = 44) in 2012. 

Measurements: Types of clinical services promoted; information provided about clinical services, including risks, benefits, costs, and insurance availability; use of emotional advertising appeals; and use of patient testimonials were assessed. Two investigators independently coded advertisements using ATLAS.ti, and κ values ranged from 0.77 to 1.00. 

Results: A total of 102 cancer centers placed 409 unique clinical advertisements in top media markets in 2012. Advertisements promoted treatments (88%) more often than screening (18%) or supportive services (13%). Benefits of advertised therapies were described more often than risks (27% vs. 2%) but were rarely quantified (2%). Few advertisements mentioned coverage or costs (5%), and none mentioned specific insurance plans. Emotional appeals were frequent (85%), evoking hope for survival (61%), describing cancer treatment as a fight or battle (41%), and inducing fear (30%). Nearly one half of advertisements included patient testimonials, which were usually focused on survival, rarely included disclaimers (15%), and never described the results that a typical patient may expect. 

Limitation: Internet advertisements were not included. 

Conclusion: Clinical advertisements by cancer centers frequently promote cancer therapy with emotional appeals that evoke hope and fear while rarely providing information about risks, benefits, costs, or insurance availability.

Clarissa helps teens ride the cancer coaster

Here's a beautifully written blog by a Duke University student.  She introduces herself as follows:

Hi! I am Clarissa and I am a two-time Acute Lymphoblastic Leukemia survivor!!  I am now 20 years old and a junior at Duke University.  I love school and learning. I hope that one day I can become a doctor, and save lives as my doctors saved mine.  My passion now, however, is helping others cope with the ups and downs of life as a cancer patient or survivor!

In my free time, I volunteer as a Patient Ambassador for Johns Hopkins Pediatric Oncology.  I speak at fundraising events for them and foundations they have partnered with.  At Duke, I am Vice-President of Blue Devils vs. Cancer, a student organization dedicated to fundraising for the Duke Cancer Institute and supporting the patients being treated there.  I also love to volunteer each year at Camp Sunrise, a one week camp, in August, for childhood cancer patients and survivors.  The camp is sponsored by Johns Hopkins Hospital and is truly incredible.  Finally, with the help of an organization called Cool Kids Campaign, my friend and I co-founded a support group in Towson, Maryland for teen cancer patients and survivors.  Everything I have been through has motivated me to give back to the hospital that saved my life and to make a difference in the lives of teens who have or have had cancer.  

We turn to the photo section of the site, where we find this note:

Here are the pictures from my journey through cancer treatment. They are here to show you the ups and downs, but most of all to show you it is possible to recover.

And then there is the blog itself, candid and vulnerable.  Here's an excerpt from a post this past February, called "The unfairness of life: A survivor's perspective."

Sometimes, it can be really hard to see the reason why things happen.  I have personally ceased to try and find the “why” in it all.  Within the last 6 months, I have learned that not 1, not 2, not 3, not 4, but 5 young people I know have relapsed.  Some are having bone marrow transplants.  Another of those young people lost her battle and passed away peacefully just this morning.  Others have relapsed for the second or third time and are attempting to beat the odds.  Many of these teens are my friends.  With that, I can’t help but wonder why.  I get angry, I cry, I pray, I hope, I hurt.

I have often thought that cancer can be as much of a blessing as a curse, because it unites people, refocuses people on what is important, and provides motivation to persevere.  These past few months have put me to the test, however.  After a while, it becomes less and less easy to find the good in so much bad.  It becomes harder and harder to feel safe, to realize that life cannot be the predictable journey for which we often wish.

After all the times my heart has sunk and my eyes have welled with tears in the last few months, after all of the helplessness and fear I have felt, I have only just today felt like I am once again on solid ground.  Why? Well, it is because I see the way these amazing young people are handling all of the incredible unfairness that they have been dealt.  I see the way their families, friends, and communities rally together to support them.  I see the way they smile and exceed the expectations of their doctors.  I see the way they persevere.  I see the way they handle tragedy with incredible grace and courage.

It is from their examples that survivors, like me, must learn.

And it is from Clarissa that we all learn, with gratitude.

How quickly it unravels

I am an unabashed proponent of the Lean philosophy in many settings, especially the clinical environment of a hospital. I've seen it work to provide better customer service, improve the work environment for the staff, and save money--a trifecta that's hard to beat!  But Lean quickly goes by the wayside without the enthusiastic support and encouragement and personal involvement of senior management.

A friend unfortunately got to see this transition in action during a recent visit to a primary care practice.  For several years, the Lean philosophy was at work and, while things were not perfect, morale was high and all people felt they were part of a team engaged in constant improvement and mutual support.  Visual clues abounded to provide all parties with a sense of how the work process was flowing. Patients felt that the system was designed to serve them.

With a change in leadership, that has quickly unraveled.

My friend witnessed all the elements of a dysfunctional system.  Lots of people sitting in the waiting room.  Long lines at the front desk.  Some staff people at the front desk were overly busy, while others sat without enough to do.  Waiting over an hour from the order for a simple blood test to when it was drawn.  Patients leaving without the blood test because they had to get back to work.  Front desk staff blaming "those" lab techs for slow service--yes, aloud, for all to hear.  Lab techs blaming "those" front desk staff for overloading them.  A physician reporting that phone calls from patients were taking more than 15 minutes to be answered, resulting in a high call abandonment rate.  And the ultimate sad moment when the patient asked the lab tech how long s/he had worked there: The response, "Six months . . . and that's six months too long."

Less draining and more sustaining on WIHI

Madge Kaplan writes:

The next WIHI broadcast — Making the Work of QI Less Draining and More Sustaining — will take place on Thursday, June 5, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:

• Chris Hayes, MD, MSc, Med, FRCPC, Harkness Fellow in Health Care Policy and Practice (IHI); Medical Officer, Canadian Patient Safety Institute
• Uma R. Kotagal, MBBS, MSc, Senior Vice President for Quality, Safety, and Transformation, James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center
• Julie A. Holt, RN, MSN, CENP, Vice President, Patient Services, Cincinnati Children’s Hospital Medical Center

If a systems approach is our best shot at improving the safety and quality of health care, a systems approach might also help address the added time and complexity that’s often a feature of improvement work itself. There are growing signs that even the most dedicated improvement champions and clinicians are overwhelmed by what’s required to meet new standards, regulations, and reporting requirements; and, even more troubling, front line staff are starting to resent and question the value of new quality initiatives and expectations. Add to this physician burnout, which has been a festering problem in the US since the 1990s, and the time is ripe for some solutions.

The WIHI on June 5, 2014: Making the Work of QI Less Draining and More Sustaining will zero in on these issues, by taking a fresh look at the disenchantment and ways to reduce the chance of overburdening staff and physicians with change. As part of his Harkness Fellowship at IHI, Chris Hayes has been hard at work on what he terms “maximally adoptable improvement” through the use of a model and guide he’s developing. His prototype, among other things, is testing a set of criteria that ideally should be met before improvement work begins — if the initiative is to succeed. Among the criteria: early staff engagement in the planning, a clear sense of the workload required, available resources, and ensuring that everyone sees the value in what they’ll be asked to do.

None of this is surprising to Uma Kotagal and Julie Holt from Cincinnati Children’s Hospital Medical Center (CCHMC). While CCHMC is deservedly known for its outstanding work on quality improvement and patient safety, Uma and Julie and others at CCHMC have become mindful of the burden constant change places on staff and health care providers. They’ll tell us about new efforts at CCHMC, still in the early stages, to make continuous improvement less draining and more sustaining.

I hope you’ll tune in for this essential discussion and share your ideas and potential solutions. You can enroll for the broadcast here.

Time to stop heading

For over 25 years, I have been coaching girls soccer--this year 12-year-olds--and part of my routine has been to teach the children how to head balls.  Stefan Fatsis explains the proper technique:

As a teenager in the 1970s, I watched Pele, when he played for the star-studded New York Cosmos, explain how to head a ball. First he pointed to his forehead. Then he placed the thumb and forefinger of each hand in front of each eye and opened them both wide. Then he dragged his thumb and index finger across his closed mouth. Moving his head and shoulders back in tandem to prepare to strike the ball, Pele demonstrated how the neck muscles needed to be tensed at the moment of impact.

But, as is often the case, the proper technique is not employed with the following result:

Failure to take Pele’s steps can result not only in a misdirected ball but in greater force imparted to the brain. That’s because a header is a collision that can cause the brain to shake inside the skull. “If you take a header off the back of your head or the side of your head and it whips your head around, there are much greater forces, 40 or 50 G’s, as opposed to a proper header where the G-force is under 20,” Dr. Robert Cantu, a colleague of McKee’s and the co-author, with Mark Hyman, of the 2012 book Concussions and Our Kids, told me recently.

Most prepubescent children aren’t capable of making the necessary preparations to head the ball; they’re just not strong enough or aware enough or coordinated enough. And if they do keep their eyes open and their mouths shut and strike the ball with their foreheads, their neck muscles, even if tensed, aren’t strong enough to prevent their heads from absorbing what often are elevated G-forces. 

So, I read with interest a Washington Post story about a decision from a Pennsylvania school:

The Shipley School in Bryn Mawr, Pa., instituted a “no-heading” policy for its middle school soccer teams earlier this month. The groundbreaking stance prohibits heading with game-sized balls in practice and will ask players to avoid heading the ball in games. 

Shipley Head of School Steve Piltch and Athletic Director Marc Duncan approved the policy in response to mounting evidence suggesting heading can cause lasting brain damage, particularly in children ages 14 and younger. Increased concussion rates in Shipley’s upper school soccer players also provided impetus.

I've decided this is the right thing to do.  Just as we apply the precautionary principle in environmental matters, we should apply it here.  Why take the chance of causing harm when it is not necessary?

Indeed, I could argue that it is more valuable for children of this age to learn how to use other parts of their body when trying to control an air ball. The game can be just as exciting and interesting if kids learn how to use their chest, their thigh, or other body parts in this situation.

Accordingly, I've decided to adopt this approach for the future: I plan to encourage my young charges to avoid using their head for air balls. As you can see below, I think they will still bring enough intensity to the game to make it very competitive!

Remembering the urban visionaries

Worth pausing to remember this day in 1893:

Governor William Eustis Russell signed a bill creating the Metropolitan Parks Commission, the nation's first regional park system. It was the result of planning and politicking by a group of far-sighted Bostonians concerned about rapidly disappearing open space. With its first funding, the new commission acquired over 7,000 acres in the space of 18 months. By 1900, it had protected 9,000 acres and built nine scenic parkways within 12 miles of Boston. Now managed by the Massachusetts Department of Conservation and Recreation, this system encompasses almost 20,000 acres and includes woodlands, beaches, swimming pools, skating rinks, bicycle paths, and — perhaps its best-known site — the Charles River Esplanade.  

The men behind this movement believed that people's physical, mental, and spiritual well-being all depended on being able to escape urban congestion. Charles Eliot, a leading voice in the call for preserving green spaces, explained, "The life history of humanity has proven nothing more clearly than that crowded populations, if they would live in health and happiness, must have space for air, for light, for exercise, for rest, and for the enjoyment of that peaceful beauty of nature which, because it is the opposite of the noisy ugliness of towns, is so wonderfully refreshing to the tired souls of townspeople."

Patient satisfaction: What matters?

I refer you to this excellent column by Bradley Flansbaum at The Hospital Leader. He notes:

We continue to hear about patient satisfaction.   Quality measures may be valid under study conditions, but if used improperly or applied in a dysfunctional environment, they help no one. However, we hew to their power, and the data sometimes compel us to work the score, not the patient. 

Why do the tests feel wide of the mark? Colleagues I speak with sense the results of the physician evaluations have small meaning; place little faith in their veracity; and would not judge another physician based on the results.  

This is no nihilist commentary. Read on to see where he takes this.

Two roads diverge

Which path will we take?

One the one hand, we have an unmistakable trend for large health care systems to try to expand their market reach by acquiring insurance companies.  The latest in this category is Ascension Health.  As reported in Modern Healthcare:

Ascension Health is in talks to acquire an unnamed insurance company that operates in 18 states, which would be a significant escalation in the brewing shift among hospital operators toward the business of selling health plans.

The St. Louis-based system owns 101 hospitals and is the nation's biggest not-for-profit healthcare provider. Ascension Health President and CEO Robert Henkel said during an investors conference in New York that the potential deal is one strategy to boost the system's capacity to accept the financial risk of value-based contracts with employers and insurers. “We anticipate that we'll take more risk,” he said. 

Meanwhile, an upstart emerges, exemplified by Oscar.  As noted by Crain's New York Business:

Oscar, with its clean user interface and playful consumer-facing ads, is trying to be the Amazon of health insurance.

Oscar's sleek user interface is also a point of pride for the company. Members can search for doctors who use electronic medical records or treat many patients their age. They can also look up their symptoms in Oscar's database and see a range of treatment options, complete with price estimates. By showing consumers that a visit to an asthma specialist could cost $200, but a primary care visit costs $100, they hope to subtly encourage cost-saving behavior. When members sign up, they get a $10 gift card to fill out a detailed health history questionnaire. That information helps Oscar pinpoint chronically ill (and therefore expensive) patients, and encourage them to seek treatment. 

Oscar is focused only on New York so far, but it has attracted capital and has the potential to expand. To use the term of art, it is scalable.  A savvy friend of mine puts it this way:

The millennial's don't give a hoot about the traditional hospitals and insurance companies. In fact, they are offended by this line of thinking and behavior.  They develop code and companies in the same speed we change lanes driving on the expressway. They are quick, nimble and very fickle.  They changed forever the communications industry in the world in less than 7 years - Facebook and Google. YouTube is less than 5 years old. It is the sharing economy. Zipcar, Hubway, pop-up stores. They have changed they way we buy and consume almost everything from news, information, clothes, stuff and things through Amazon and Apple and Netflicks.

This generation has no patience for stupid, analog, wasteful bureaucracy. iTunes thought they were immune (and they were a disruptor) and then came Spotify from Sweden which is 7 years old and owns 70% of the music market today.  Smartphones didn't exist until 2007 or 2008 and with that need to get information in different formats out instantaneously constantly without interruption.

So, with all their swagger and intelligence, how do the people who run hospitals believe that they can truly compete with the millennials who are hell bent on breaking down walls, dematerialising everything and bringing margins as thin as possible?

Is health insurance disintermediation the next part of disruption in the health care world?