"A monkey could practice primary care"

In case you missed this a few weeks ago, here's a well done story by Karen Brown, who followed several primary care residents and got a good sense of why many people choose not to go into this field.  The story was funded by a fellowship from the Association of Healthcare Journalists and the Commonwealth Foundation.  (To be clear, the quote in the title above is not mine, and certainly not my view!)  Excerpts:

These young doctors are in the middle of their residency at Baystate Medical Center, a hospital affiliated with Tufts University Medical School. They’ve completed four years of medical school – so they’re already MD’s – and are now in the hands-on part of their training.

Michael Rosenblum is a residency director.

“If you get people before medical school and even at the beginning of medical school, there’s a huge interest in primary care,” says Rosenblum. “The vast majority of medical students want to develop relationships and see patients over time. And then we see that kind of peter off.”

Brown notes:

Most doctors I’ve met going into primary care talk about their sense of social justice. They want to work for underserved communities. Or to fill a critical need. It’s rare to hear people list the superficial trappings of the job as a driving factor. And that’s not surprising, Tischer says, given what they hear about the field.

But then money and prestige raise their heads:

But perhaps even more discouraging is what the money disparity says about the status and prestige of primary care.

“Here are these type A competitive people that have been at the top of their class like since kindergarten,” says Gina Luciano, who co-directs Baystate’s primary care residency. “They tried to get into the most prestigious colleges. It’s always very competitive, very competitive, very competitive.”

So when they get into residency, she says, they want to stay on the up escalator. “And you have all of these mentors that are telling you, ‘you could do cardiology, you could do critical care.’ It feels really good that here are these really prestigious things to go into in medicine. It’s hard, I think, to be swayed from that.”

Dr. Andrew Morris-Singer, who runs the advocacy group Primary Care Progress, calls this the “hidden curriculum” of medical education. And not always hidden very well.

“There’s also explicit statements like, ‘You’re too smart to be a primary care doctor.’ ‘This is a dead field.’  Or my favorite, ‘A monkey could practice primary care. Why would you do that?’” says Morris-Singer. “So it’s a whole range of things, but the basic admonition is: ‘Hey, it’s a waste of a medical education.’”

Some stay true to their passion of wanting to be create deeper relationships with patients, but with a twist:

Levitt is planning to become a hospitalist – the person who oversees basic care in a hospital. His salary will be similar to a primary care doctor, but he will have set hours, and at the end of each shift, he’ll hand over patient responsibility to the next person.

Levitt says he would consider going back to primary care if he found the kind of private practice that would make him happy, but that’s not what he saw in residency. Across the country, residents often work in urban, hospital-affiliated community clinics where health and social needs are complex, and offices often under-staffed. Since revenue often depends on the number of patients seen, there’s pressure to push them through in 15-minute increments.

Ups and Downs of Health Care Costs and Reform

Madge Kaplan writes:

The next WIHI broadcast — The Ups and Downs of Health Care Costs and Reform — will take place on Thursday, February 12, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:

• Donald M. Berwick, MD, MPP, FRCP, President Emeritus and Senior Fellow, Institute for Healthcare Improvement
• David Cutler, PhD, Otto Eckstein Professor of Applied Economics, Harvard University, Harvard Kennedy School of Government, Harvard School of Public Health

 

There are lots of health care issues to speculate about in the coming year. Here in the US, the ongoing expansion of health insurance coverage is an ambitious work in progress that continues to face plenty of political and legal headwinds. And then there’s the still glaring and still growing $3.9 trillion national price tag of US health care. Some are encouraged that health spending is slowing, but do we have any strong evidence that improvements in the quality of care, safety, and IT, coupled with payment reforms that increasingly tie reimbursements to quality and value, are key factors?

Fortunately, we have two individuals to turn to for their thoughts on these matters and many more. Don Berwick and David Cutler are my guests for the Feb 12, 2015, WIHI: The Ups and Downs of Health Care Costs and Reform. Each brings important improvement, policy, and economic perspectives to the table to help make sense of the current environment and what’s ahead.

Against the backdrop of the Affordable Care Act and other significant initiatives, our guests will offer their assessments of recent progress with better care and lower costs, and where efforts need to continue to yield even bigger benefits. We’ll also touch upon the following: global payments and the various payer-led financial carrots and sticks in play right now designed to improve health care delivery; the state of statewide reforms, Medicaid expansion, and community-led, population health-driven experiments; and the bright spots and storm clouds on the horizon with respect to policy makers, politicians, and the public where there are still major divides.

What are your questions for Don Berwick and David Cutler? Please join them and me on February 12. You can enroll for the broadcast here. We'd also appreciate it if you would spread the word about the show via Twitter.

Support for competition in the West

The decision by MA Attorney General Maura Healey to oppose the deal allowing expansion of Partners Healthcare System and promising to sue the corporation if it tried again just got a boost from the West.  As reported by Lisa Schencker in Modern Healthcare:

A federal appeals court affirmed on Tuesday that Idaho-based St. Luke's Health System violated state and federal antitrust laws when it acquired a medical group in 2012, delivering the Federal Trade Commission another victory in its first major case challenging a physician deal.  

St. Luke's had argued that the acquisition would help it improve care for the communities it serves. But the FTC, the Idaho attorney general and the health system's Boise-based competitors—St. Alphonsus Health System and Treasure Valley Hospital—said the merger would decrease competition, translating into higher prices for consumers.

The appeals court found that it wasn't enough for St. Luke's to say the acquisition would improve care. The court said St. Luke's also would have had to show that competition wouldn't suffer.

It's a decision that could have implications for other health systems across the country.

“Providers considering acquisitions can't take comfort in the fact that they have laudable goals, that they're trying to achieve efficiencies,” said David Ettinger, a lawyer for St. Alphonsus and a partner with the law firm Honigman in Detroit. “That alone is not sufficient to avoid antitrust concerns.”

The best line in healthcare, evah!

Barry Ritholtz posts this recent episode of Last Week Tonight with John Oliver.  In the course of describing how much the pharmaceutical industry spends on marketing versus research and development, Oliver says (shortly after 2 minutes in):

Drug companies are a bit like high school boyfriends.  They're much more concerned with getting inside you than being effective once they're in there.

The T shuts down

Hundreds of thousands of people sit in their homes or stranded at work (like those in hospitals) unable to ride the Boston transit system today:

The T announced tonight: “On Tuesday, all MBTA rail services (Subway, Trolley, and Commuter Rail) will be suspended all day while maintenance crews continue to clear snow and ice from tracks, the third rail and switches.

“Mechanical forces will continue to assess the damage done to subway cars, trolleys, locomotives and passenger coaches. Bus service will be available on an extremely limited basis with various buses on snow routes. Buses will run with delays due to traffic congestion and local street conditions,” the statement adds.
 
I hearken back to a piece I wrote for Commonwealth Magazine in 2011 about essential infrastructure like this. I'm so sorry to have been correct, but this happens over and over again in this state.  Excerpts:

"The metropolitan area transit system is the current poster child for this built-in dynamic that leads us to put off infrastructure investments. The MBTA is severely underfunded with regard to maintenance and upgrades of the regional bus and subway system. On the Orange Line, 120 cars built between 1979 and 1981 need to be replaced. On the Red Line, 74 cars from 1969 are well past their useful life. More than half of the MBTA’s 82 commuter rail locomotives date to the 1970s, and nearly all are at or past the manufacturer’s recommended lifespan of 25 years.

"Public officials, having depleted one-time financial fixes, lurch about for long-term funding solutions, while the system deteriorates more each year.

"If we neglect infrastructure, we will always pay more in the long run. But an equally important—and far less widely appreciated—lesson is that building a political constituency for infrastructure investments is a job that must be taken on by the public agencies themselves, a role often neglected by those appointed to run those agencies.

"I fear we are repeating today the same shortsighted approach that cost us so dearly with regard to our water and sewer infrastructure and the horrific despoliation of Boston Harbor. Well-intentioned public servants are tip-toeing around the need for major investments in the regional transit system, using terms like “reform before revenue” to delay action. But the delays that result from the lack of investment are substantial and growing."

Selling your right of privacy at $5 a pop

CommonHealth's Martha Bebinger has an interesting story about insurance products that reward and punish subscribers for their relative compliance with "healthy living" activities.  It's an excellent depiction of the choices consumers will make to garner insurance premium credits . . . or face the penalties.

Smith earned $10 this month just for using the program. She’ll get another $10 every month that her average score is 60 or higher. 

“That’s $20 essentially free money just by making modestly healthy decisions and going to the store, which are things I’m going to do anyway,” Smith says.

Who pays? Her health insurance plan, Harvard Pilgrim Health Care.

The goal is “to get people to understand the value of what they’re putting in their mouths,” says Sue Amsel, a senior product portfolio manager at Harvard Pilgrim.

But on the downside:

And he takes $5 off his health insurance deductible for every 30-minute workout. Rubin has to be at a GPS-confirmed gym or connect through a device like Fitbit. If he does not exercise three times each week, Rubin will lose $5 for every workout he misses. That’s the pact Rubin signed, and offers his employees, through a company called Pact Health. 

I'm struck by three things:

One, that people are willing to give up details of their private lives to a company for as little as $5 in reward or penalty;

Two, that there’s "very little research that proves health incentives actually improve health."

“We’re not quite there yet,” says Gary Bennett, a professor of psychology, global health and medicine at Duke University. “While the early research in using incentives to promote more healthful behaviors is extremely encouraging, we haven’t seen the kind of larger durable changes that we really need to see to believe that incentives can promote longer term improvements in chronic disease rates.” 

Three, that what appears to be healthy in this program was noted in another CommonHealth story as being problematic.  A commenter notes:

How does this jibe with "The dark side of kale?" 

Care Opinion enables patient driven care

I love the sense of invention that pervades much of Australian health care.  I guess when you are surrounded by "the largest moat in the world," you spend a lot of time thinking about how to make things better for your homeland.

I remember that many of the "innovations" in patient safety and quality that we adopted at my former hospital were in fact shamelessly stolen from excellent work that had been done by people in Oz.  So it came as no surprise to me to learn of this attempt at patient and family engagement.  It's called Care Opinion.

My readers know that I'm an advocate for patient driven (not just patient centered) care, and Care Opinion meets my standard because people can engage in it easily, in real time, and in so doing, get their message to the right people, who can then respond.

It self-describes as:

An independent site about your experiences of care and support services, good or bad. We pass your stories to the right people to make a difference.

The site promises:

• Care Opinion gives you a public voice to share your experience about the services you use.
• Care Opinion will always try to make sure that the right people will hear your story.
• Sharing your stories about health and care services on Care Opinion can help make services better.
• Care Opinion is safe, confidential and independent of services and authorities.
• Reading the stories that other people share on Care Opinion may help you choose the best care providers.
• Care Opinion works across health services, as well as care and support. Whether your story is about care or health or both, we publish it and deliver it to the right people locally, whether they work in care or health.

It is transparent about how effective it is:

Plus, it's interesting to get an overall sense of how people are feeling:

Check out the site, and see what you think.  Is this what you've been waiting for in your jurisdiction, health system, or other health care service organization?

When you have no place to put the snow

I'm not a DPW guy, so these are just some ideas for municipal officials in eastern Massachusetts who've run out of room for where to put the snow.  (Yes, I'm a water guy, but the water I dealt with was in pipes!)  By the way, I've heard from at least one university administrator who's also said that he's run of snow storage space on campus.

I've already talked about dumping snow in the Harbor.  This would immediately create more locally situated venues for disposal, reducing truck route distances, and also eliminate the need for staff to spend hours (and energy) melting snow at the "snow farms."  I'm sure the state environmental officials would allow this on an emergency basis, as they have already in at least one case.

Beyond that, you can use parking garages and surface lots (public and private) to stage neighborhood street cleanups.  You announce that cars can move there at an allotted time while snow removal equipment trucks remove snow from the streets, especially large, dangerous snow banks.

You can use a lane of main streets for swing space parking (like they do for funerals) for neighborhood snow removal.  Cars can park on the main street while their street is being plowed properly.

Beyond that, you can get creative, like using campaign style neighborhood snow brigades to make sure hydrants are shoveled out, sidewalks are passable, crosswalks are clear, etc.

Meanwhile on the human services side of things, let's draw on the high-tech and Internet resources of the area.  For frail elders, let's install Nests or other remote reading thermostats in their homes so that their heat can be monitored and their air tested for carbon monoxide.  I bet Google would donate a few thousand.  For food delivery, let's recruit Peapod-like services.

In short, its time to redefine the role of the "urban mechanic" to the new era.

One down, two to go

The new CEO of Partners Healthcare system says bigger is not necessarily better, but then he says the network is going to expand:

“A real important part of our strategy if we’re restricted in the local market is we have to look regionally, nationally and internationally. So I’d say look at the globe and spin it around and we’re going to look everywhere.”

The thought makes my head spin, too.  I just wish they would get better at delivering safer and higher quality care here.  The system could start, for example, by adopting the many thoughtful and useful suggestions published by Atul Gawande, perhaps its most famous and widely admired faculty member.

But I guess our new Attorney General should feel all right about the corporation's lack of interest in local expansion, so let's put PHS aside for a moment and think about what other time bombs are ticking on her watch.

Steward Healthcare

The most important has to be the future of Steward Healthcare, the private equity-owned entity that purchased the former Caritas Christi chain of hospitals in the state.  According to this story in Commonwealth Magazine, the CEO promised a health care network that would "provide high quality care at much lower cost than the big Boston teaching hospitals." In so doing, if it could "win over residents and businesses near the hospitals, it would not only turn a profit for Cerberus but lower health care costs overall." Well, there is no sign that is working.

But meanwhile, the company has engaged in commonly employed private equity approaches to remove cash from the business. As Commonwealth noted, for example:

In April, Steward granted 99-year leases on 13 of its medical office buildings to an Arizona real estate firm for an up-front payment of about $100 million. Steward is now renting those same buildings back from the Arizona firm under 12-year leases. The terms of Steward’s leases have not been disclosed. Steward has also not disclosed whether it kept the cash generated by the deal or the money went to New York and Cerberus’s investors. 

There were equivalents to this kind of sale-leaseback deal elsewhere in the system.  The labs, for example, were sold:

Quest Diagnostics (NYSE: DGX), the world's leading provider of diagnostic information services, and Steward Health Care System LLC (Steward), New England's largest community-based accountable care organization and one of the nation's largest Pioneer ACOs, today announced that Quest has acquired the remainder of Steward's outreach laboratory service operations. Under the arrangement, Quest will provide outreach laboratory testing services to physicians, nursing homes and other providers previously serviced by Steward.

This issue that could arise is what happens to the Steward hospitals if the system fails or falters, now that the hospitals are less resilient because a portion of their asset value has been sold off. It would probably be wise for the AG to conduct an analysis of the options before her if the private equity company decided to exit the Massachusetts market.  The previous AG signed an agreement that gives the office considerable review authority over the company.  How might that authority be used by the new AG? Is she able to track funds and see what money is actually being used in Massachusetts versus being delivered directly or indirectly to Cerberus investors? Is there more ability than was employed previously to ensure sufficient notice of possible closures?  Apparently the former AG was surprised when Steward decided to close Quincy Medical Center.

When it comes to the second largest system in the state, it would be better to avoid surprises.

Blue Cross Blue Shield of Massachusetts

While virtually everyone offered an opinion to the judge in the case, the largest insurance company in the state was silent on whether the expansion of Partners should be approved.  It also acted to increase the disparity in payments among hospital networks, even after those disparities were documented by the previous AG as being one of the major causes of health care inflation in the Massachusetts. A study commission is supposed to review this issue of disparities and make recommendations to narrow them.  What's the AG's role in that process?  Might she, for example, pursue a reference pricing approach that would require an insurer to justify payments rates outside of a normal band?

BCBS of MA has also persuaded the state to adopt a policy that shifts risks from the insurance company to doctors and hospitals but has made no adjustment to its capital structure to compensate for that savings. Will the AG consider clawing back excessive earnings given the company's new risk profile?

All other financial service industries have been able to reduce administrative and transaction costs over the years.  What is it about this company that gives them a pass? As premiums rise, the percentage the company keeps for administration and profit stays the same. Here's another area worthy of attention by the new Attorney General.  Shouldn't we expect some technological improvements and the resultant savings to passed along consumers?

False memories generate persuasive truths

Please click through to read this recent article I posted over at the athenahealth Leadership Forum. As always, we welcome your comments.

Note:  This is not (in any way) about Brian Williams.  I wrote it before his recent disclosures.

Just the Right Dose

There's a useful new book out by Marijke Vroomen Durning. It's called Just the Right Dose: Your Smart Guide to Prescription Drugs & How to Use Them Safely.

This is simply, a handy guide for normal people. Marijke is a nurse who enjoys writing patient education information to help people understand their medical and health conditions.  She says this is what nurses like to do but often don't have time in hospital settings.

Why the book?  Marijke notes: "Studies have shown that patient misunderstanding of instructions on prescription medicine labels is common, resulting in medication and drug errors, and treatment not working effectively. Many of these people take the medicines themselves, but many also are responsible for making sure a family member in their care, such as a child or a disabled parent, takes their medicine."

The book (in e-format or paper) will help you answer questions like these:

All we're asking for is 30 billion dollars

As the Red Sox, Celtics, Bruins, Revolution, and Patriots well know, Bostonians are experts at the art of sarcasm.  But they apply it to the other local "sport," too, the sport of politics.

Here, Janssen McCormick has started a gofundme campaign to maintain and rebuild the city's beleaguered transit system, the MBTA or "T."  The description:

The MBTA is outmoded, unsafe and incapable of withstanding the rigors of New England winters. When one link in its corroded chain breaks the whole system is thrown into disarray, when multiple links break at once the entire city and region collapses into massive gridlock. Trains are kept decades beyond their service life because for decades nobody in state government wanted to take responsibility to fund maintenence and modernization of public transit.

So here's where you come in. If the internet can help one working class guy in Detroit who struggles every day to get to work surely we can help the hundreds of thousands of working class people in Boston who rely on the decrepit MBTA to get them to work, school, doctors appointments or the grocery store.
All we're asking for is 30 billion dollars (GoFundMe limited this to 300 million dollars though). 

As of this writing, only $10 has been contributed, but I sense a bandwagon pretty soon.

Commonwealth Magazine has called the history of the T a textbook case in civic dysfunction.  I addressed the issue on this blog also, here and here.

The city is hoping to become the site for the 2024 Summer Olympics.  Let's just hope the international Olympic governing body is not watching the local news.

Throw the snow in the Harbor! (A reprise.)

What's wrong with this picture?

This is a scene of the South Boston Seaport "snow farm," where truckloads of snow from city streets are unloaded and then pushed around by heavy machinery to make room for the next loads.

What do you see right behind the snow piles?  Boston Harbor.

Where is that snow going to go when it finally melts?  Into Boston Habor.

Several years ago, I suggested that during major snow accumulations, the state DEP should grant the City of Boston a waiver to dump the snow into the Harbor.

Why does it matter?  It matters for no other reason that it takes longer to clean the streets when you have to go through this routine of hauling and pushing, hauling and pushing.  It won't solve all the problems, but it will help.

After several large snowfalls, those city streets become dangerous obstructions to emergency traffic and cause intense traffic jams.  That's what's happening right now.  Here are some recent tweets on Twitter from Adam Gaffin at Universal Hub:

Surface road front of Federal Reserve Building is blocked off by 2 police cars. Accidents on xway mean no where to put cars

Here ya go. Yep its backed up (Summer out of the seaport is!) 

Are there any police offers in Kenmore directing traffic? Lights not working. 

Don't even bother with Memorial Drive.

Evening crawl hour in full force on Atlantic by Summer: Nobody's going anywhere

Huntington by MDA a parking lot. Honking horns does nothing, folks, just FYI. Ambulances cannot get through, either.

Roads in #Southie are so bad that Uber drivers don't want to come here, and that's the only real transit system we have.

Holy crap! Washington St in Brighton a cluster f*ck. Broken down bus has everything shut down @ Oak Sq.

Storrow east backed up to bu exit. WORLDCLASS CITY

The #traffic in #Boston is no joke. Mass Ave is a complete mess. It has this #mbta bus 25 mins to go 6 blocks.

In appreciation: Margaret Hamburg

(New York Times photo)

One of the toughest jobs in the government is that of FDA Commissioner.  Why?  Because of the whipsaw of public opinion and the pleasure that Congresspeople take in berating the agency.  In short, the ongoing complaint is that you have acted too fast to approve a drug or other product that then hurts people; or that you have waited too long to allow a "life-saving" drug to enter the marketplace.

Some FDA Commissioners have tried to use the agency as a bully pulpit for their personal ideology.  That is a recipe for failure, as it makes all your other regulatory decisions suspect.

In contrast, Dr. Margaret Hamburg just tried to do a good job and build a team of professional people who were devoted to the public good.  To an extent not always seen in the agency, their watchword was to trust the science and make judgments based on the best evidence.

Not all will agree with every determination they made, but that is the nature of such things.  That she led the agency with integrity is beyond dispute.  As citizens, we owe her a debt of gratitude as she leaves.

Good progress in NYC

Jennifer J. Salopek at Wing of Zock reports on some excellent goings-on in New York City.  Bravo to CIR and SHM for stepping in.  Without taking anything away from this initiative and the pedagogical creativity displayed here, wouldn't it be nice if residency programs more broadly were actually complying with the ACGME's CLER program so this kind of third-party investment would not be necessary. Unfortunately, as I have noted, those "requirements" have been vacuous and enforcement of them has been toothless.

The Committee on Interns and Residents Policy and Education Initiative (CIR PEI) and the Society of Hospital Medicine (SHM) jointly have announced an ambitious new resident training pilot initiative specifically designed to address the gaps for which graduate medical education has been recently criticized. Resident Quality Improvement Clinics at two pilot sites, Harlem Hospital Center and Bronx-Lebanon Hospital Center, will bring learners together in multidisciplinary teams for didactic and experiential learning.

Farbod Raiszadeh, MD, PhD, is founding director of CIR PEI’s Quality Improvement Innovation Institute (QII2). He notes that, despite requirements, less than 20 percent of U.S. medical schools and residency programs offer training in patient quality and safety. “There is really a need for these kinds of resources and projects,” he says.

The QI Clinics will have four main components:

• A large-scale didactic process open to all learners in the pilot hospitals, delivered grand rounds-style once a month
• Workshops for residents to work in small groups to design and develop QI projects
• Virtual support via webinars and offline contact with faculty who are not in the hospital
• Access to e-learning modules and mentors via SHM Access.

“This smart design takes the needs of all learners into consideration, particularly time-constrained residents, by delivering an intense day once a month, then spreading out the rest of the interactions,” says Raiszadeh.

Spike out Sepsis returns!

For those who are in the vicinity of Columbus, Ohio, or could be on June 27, it's time to register for the annual Spike out Sepsis volleyball tournament.  Details are here.

This is a production of the Sepsis Alliance.  As noted on their webiste:

Sepsis Alliance is a charitable organization run by a team of dedicated laypeople and healthcare professionals who share a strong commitment to battling sepsis. The main goal for Sepsis Alliance and the people who work behind the scenes is to raise sepsis awareness so it can be prevented, detected, and treated early enough so that no harm is done. There are more than 1.6 million cases of sepsis every year in the U.S. Every two minutes, someone in the United States dies of sepsis. This adds up to well over a quarter of a million people every year. Sepsis is the third leading cause of death in the U.S. (after heart disease and cancer), which is more people in one year than those who die of breast cancer, prostate cancer and AIDS, combined.

The Sepsis Alliance team is working on producing as much information and educational material as is possible to help the general public become aware of this often deadly condition and for professionals who can then help the public learn about sepsis when it does strike.

You can send money even if you don't want to play in the sand in June!

It IS more precise, argues Shaywitz

David Shaywitz and some others at Twitter have had some not so nice things to say about this recent post I wrote quoting an article by Michael Millenson.  While I've urged them to post comments here (where you get more than 140 characters), they haven't yet.  So I'll try to summarize the major points while the issue is still ripe here on the blogosphere.  (David is very clear to disclose that he's with DNAnexus, a company in the genomic and health data management space.)

The general premise is that Michael and I shouldn't be so negative about a new government program designed to support "Precision Medicine."

David links first to an article in which he expressed the excitment of being present for the President's East Room announcement.

As an executive at a relatively young and decidedly ambitious company, it’s hard to describe the excitement and sense of remarkable possibility you experience sitting in the East Room hearing the President of the United States emphasize the fundamental importance of exactly what it is you believe you and your colleagues are doing.   Entrepreneurs are perennially encouraged to follow hockey great Wayne Gretzky’s advice, and skate to where you think the puck will be going.  Now, imagine feeling that the President has just fired the puck in your direction.

In short, he frames the issue this way (you can read the details):

It’s difficult not to be struck by both the audacity and the difficulty of the President’s initiative.  Developing effective cures for complex disease is generally far more complicated than identifying a single causative gene. 

Nevertheless, there are conspicuous examples of progress.  

After further back-and-forth on Twitter, David notes: "My point is ACCE framework central to personalized medicine," and cites this article he wrote at Forbes.com:

The questions to ask about screening are captured by the ACCE framework (which I recently highlighted in the context of data from wearables, but which was originally developed for genetic testing).

Analytic validity – do the tests reliably and consistently measure the mutations they say they measure?

Clinical validity – how well does a positive test predict the likelihood of a cancer due to BRCA gene dysfunction?  To what extent can a negative test be relied on to conclude that a patient is not at elevated risk of cancer due to BRCA gene mutation?

Clinical utility – does a positive test provide actionable information?  King writes that “Among women who carry mutations in BRCA1 or BRCA2, surgical intervention, in particular risk-reducing salpingo-oophorectomy, reduces risk of both ovarian and breast cancer and reduces overall mortality.”

Ethical, legal, and social implications: What are the implications of population-level screening?  For example, might a negative screening test provide a false sense of security, resulting in reduced vigilance, and an ultimately an increase in non-BRCA-related breast cancers?

Comments welcome! 

Wash your hands, or get buzzed!

Here's a clever device and system, designed at the MIT Media Lab, that helps clinicians remember to wash their hands.  An excerpt:

Called MedSense Clear, the system revolves around a badge worn by hospital staff. The badge can tell when a worker comes near or leaves a patient’s side, and whether that worker has used an alcohol-based sanitizer or soap dispenser during those times. It also vibrates to remind workers to wash up. The badge then sends data to a base station that pushes the data to a Web page where individuals can monitor their hand-washing, and administrators can see data about overall hand-hygiene compliance among staff.

The question, I guess, is whether the buzzing will end up being another cause of alarm fatigue--only to be ignored or bypassed in some way.  The results of the initial study was promising:

A 2014 study in the Journal of Infection and Public Health concluded that compliance with WHO hand-washing rules jumped 25 percent in one month when staff used MedSense in a 16-bed hospital unit at Salmaniya Medical Complex in Bahrain. 

We have to wonder if this is the Hawthorne Effect at work. How persistent is the effect? Time will tell.

Hand washing should be optional

I couldn't make this up, from the Washington Post:

Sen. Thom Tillis (R-N.C.), at the end of an appearance Monday at the Bipartisan Policy Center, volunteered a story about “his bias when it comes to regulatory reform.”

Tillis said he was at a Starbucks in 2010 talking to a woman about regulations and where businesses should be allowed to opt out. His coffee companion challenged him, asking whether employees there should be required to wash their hands.

“As a matter of fact I think this is one where I think I can illustrate the point,” he recalled telling her. “I don’t have any problem with Starbucks if they choose to opt out of this policy as long as they post a sign that says we don’t require our employees to wash their hands after leaving the restroom. The market will take care of that. It’s one example.”

Here's the video version.

I think we should extend this to hospitals, nursing homes, and the like.  After all, the market will take care of that, too.  A few extra cases of c. diff and people will run to the competition.

Right?

Not so precise

Michael Millenson is unusually prescient about health care matters, often anticipating by years issues that become major public policy concerns.  In a Forbes.com article, he riffs off of President Obama's recent call for "Precision Medicine."  Here are some excerpts :

Yes, President Obama’s new $215 million Precision Medicine Initiative supports important science, but it also bolsters biotech branding in a way the science doesn’t always support.

In [the] State of the Union address, which preceded the detailed proposals sent to Congress, he spoke of “the right treatment to the right patient at the right time.” But branding an industry as “precision medicine” doesn’t make it so. There’s still uncertainty in many test results, uncertainty by clinicians over proper clinical indications for using current tests and equivocal evidence for cost-effectiveness.

Michael uses the example of three different breast cancer tests meant to determine whether a certain type of breast cancer will recur, in the hope of helping to avoid the physical, emotional, and financial costs of unneeded chemotherapy.

An analysis by BiomarkerBase found that just 12 of the 125 biological targets used by these competing tests are shared, and no one gene is used by all three. More importantly, results of the three – Genomic Health’s Oncotype DX, Agendia’s Mammaprint and Prosigna from nanoString Technologies ­– often disagree.

As an article in the journal Tumor Biology put it, these assays

differ in the technological platforms used for assessment of gene expression, in the number of genes and in the specific genes that are being tested, in the patient populations used for their development and validation, and in their clinical utility.

Pay particular attention to “validation” and “clinical utility;” i.e., evidence the tests help patients. Breast cancer is a deadly serious problem, accounting for between a quarter and a third of all cancer cases, and it is the second-leading cause of cancer-related deaths. But like other cancers, it’s also complex, with the prognosis depending upon the mix of molecular subtypes and other patient-specific factors.

Precision, anyone?

Michael concludes:

Americans love the glittering prospects of new technology, and Congressional Republicans were quick to jump onto the president’s biotech bandwagon. However, a more accurate description of present reality comes at the end of a White House blog ballyhooing stories of how “precision medicine is already working to cure Americans.” It reads: “We’ve only begun to tap into [the] potential for precision medicine to improve care and produce new treatments.”

One might call that the precise truth.

This whole issue becomes more relevant as health insurance and Medicare start to pay for these kinds of tests more and more.

Six years later, time for another try

Back in 2009, I set forth an agenda for the then-incoming CEO of Partners Healthcare System, suggesting:

If there is any organization in the state that has the potential to demonstrate the potential for an integrated health care delivery system, it is PHS. But, it will come as no surprise to participants in that system that this has not yet happened. The long-standing rivalry between the two flagship hospitals has meant that rationalization of tertiary and quaternary clinical service between the Brigham and the MGH has often been deferred. Previous Partners CEOs have focused their efforts on integration of back-office and other business aspects of the system, leaving clinical integration essentially untouched. Gary will face an interesting and important choice as to how and if he will address this unachieved potential benefit to the region. If the Partners system first sets an internal example, it might then be possible to achieve a broader rationalization of care in cooperation with the other academic medical centers (BIDMC, Boston Medical Center, and Tufts). We all need to garner these economies to control costs in the over-served Boston marketplace.

Well that didn't happen.  Here we are six years later,  and the same themes remain.  Joan Vennochi at the Boston Globe notes:

Partners needs a new business plan, one that emphasizes its core mission to provide great medical care, instead of market dominance through mergers with other hospitals. And provable cost control is essential for what is now the most expensive health care network in Massachusetts. The future must be focused on better, not bigger.

Partners never merged hospital assets; instead, between the Brigham and the General, it created two giant, co-existing hospital systems which still compete with each other. A much-cited New York Times editorial, written when critics of the deal first came forward, suggested the state should never have signed onto the merger that created Partners in the first place. Today, knowledgeable observers believe neither hospital would be sad to cut the ties that bind them. Indeed, especially within Mass. General, there was extensive internal opposition to the merger deal with South Shore Hospital and the spending caps that were part of it.

Unraveling Partners seems unlikely. That means the next leader will have to figure out a way to get these two institutions on the same page when it comes to corporate mission.

Where did this money come from?

Here's some news from the financial markets:

SUNNYVALE, Calif., Feb. 2, 2015 (GLOBE NEWSWIRE) -- Intuitive Surgical, Inc. (ISRG), the industry leader in robotic-assisted surgery, today announced that its Board of Directors has authorized the Company to repurchase up to $1.0 billion of the Company's outstanding common stock.

"We continue to use our cash to invest in our business by advancing our technology, growing our presence outside of the U.S. and driving adoption of robotic-assisted minimally invasive surgery," said Marshall Mohr, Chief Financial Officer, Intuitive Surgical.  "We also seek to return excess cash to our shareholders, and this authorization gives us the flexibility to act given the right opportunity."

How much "excess cash" might the company have?  Well, this financial analysis from Bloomburg suggests that they are loaded, holding about $2.5 billion in cash as of the last quarter (top right-hand figure).

Don't forget to floss . . . and take your drugs

An MD friend is a substance abuse counselor here in Massachusetts.  She reported to me that a substantial percentage of her clients have been able to maintain their addiction through supplies of opiates prescribed by dentists. In all the recent talk about excessive use of opiates, I had never heard about this source.

So I wondered if there has been any study of this by the profession or coverage of this issue by the media.  After a search, I found this 2010 report from the Tufts Health Care Institute Program on Opioid Risk Management.  Excerpts:

The top specialty prescribing IR [immediate release] opioids in the United States is family practice (approximately 15% of prescriptions written), but this is closely followed by dentistry and internal medicine (both approximately 12% of prescriptions). It is estimated that more than 12 billion dosage units of opioids are dispensed annually in the United States. If dentists write 12% of prescriptions, they prescribe an estimated 1 to 1.5 billion doses of IR opioid products annually. As the epidemic of abuse largely involves IR opioid products, it seems that dentists may be writing opioid prescriptions that are being ingested in the context of nonmedical use or abuse.

When asked about doses of IR opioids that dentists suspect patients have left after a third molar extraction, 36% of dentists expect patients to have leftover drugs, which could be a major source for abuse. Other common procedures showed a similar pattern of doses given, days of therapy, and suspected doses left over.

The survey also examined dentists’ experiences with drug diversion and substance abuse—36% did not ask new patients if they had a history of substance abuse. Other key findings were that 76% of dentists estimated that 1% to 20% of their patient population were substance abusers.

58% believed they were the victims of prescription fraud or theft; the most common methods were fake pain symptoms (43%), patient claims their prescription was stolen (28%), forged written prescriptions (14%), and altered pill quantity (14%). 

Well, these findings were certainly consistent with my friend's report, and the report of the Tufts conference had some thoughtful recommendations.  So was there any follow-up?

An article appeared in the Journal of the American Dental Association with this conclusion:

Dentists can play a role in minimizing opioid abuse through patient education, careful patient assessment and referral for substance abuse treatment when indicated, and using tools such as prescription monitoring programs. 

Dentists cannot assume that their prescribing of opioids does not affect the opioid abuse problem in the United States. The authors suggest that dentists, along with other prescribers, take steps to identify problems and minimize prescription opioid abuse through greater prescriber and patient education; use of peer-reviewed recommendations for analgesia; and, when indicated, the tailoring of the appropriate and legitimate prescribing of opioids to adequately treat pain. The authors encourage dentists to incorporate practical safeguards when prescribing opioids, consistently educate patients about how to secure unused opioids properly, screen patients for substance use disorders and develop a referral network for the treatment of substance use disorders.

I checked the ADA site to see what guidance the industry association might offer to help dentists carry out these general recommendations. There is a page from 2005 entitled "Statement on the Use of Opioids in the Treatment of Dental Pain."  Among other things, it says:

Dentists who prescribe opioids for treatment of dental pain are encouraged to be mindful of and have respect for their inherent abuse potential.

Dentists are encouraged to recognize their responsibility for ensuring that prescription pain medications are available to the patients who need them, for preventing these drugs from becoming a source of harm or abuse and for understanding the special issues in pain management for patients already opiate dependent.

The most recent article I have found is this interview from Medscape:

I think that dentists in practice as well as those still in undergraduate dental schools and certainly those in specialty programs need more information and educational efforts on treating patients in both active disease (addiction) as well as in the various forms of recovery. 

I may be understating what's available and happening out there, but none of this gives me much confidence. My substance abuse counselor friend says that dentists remain a major source of these drugs and are therefore supporting addiction.  Who will step in and make real changes? When will the media investigate and report on this issue?

Help the snowbirds: Transparency as an enforcement tool

Elisabeth Rosenthal at the New York Times has a gift for taking what is right in front of us and unnoticed and making it evident.  She does it again in this story about elderly "snowbirds" in Florida who are persuaded by doctors there to undergo unnecessary tests. The lede:

Like many retirees, one couple from upstate New York visit doctors in their winter getaway in Florida. But on a recent routine checkup of a pacemaker, a cardiologist there insisted on scheduling several expensive tests even though the 91-year-old husband had no symptoms.

“You walk in the door, and they just start doing things,” said Sally Spencer, 70, who canceled the tests after her husband’s longtime doctor advised her by phone that none of them were needed.

The couple’s experience reflects a trend that has prompted some doctors up north to warn their older patients before they depart for Florida and other winter getaways to check in before agreeing to undergo exams and procedures. And some patients have learned to be leery after being subjected to tests — and expenses — that long-trusted physicians at home never suggested.

This is truly disturbing and disgusting behavior.  And it's not like it takes a complicated analysis to prove:

When researchers from Dartmouth last year looked at the number of tests and imaging studies received by Florida Medicare patients in the last two years of life, with the exception of the panhandle, totals were far above the national average, said Dr. Elliott Fisher, director of the Dartmouth Institute for Health Policy and Clinical Practice. Other areas that showed high rates of testing and imaging in the study included Arizona, California, southern Nevada and South Texas, all also popular for sun-seeking retirees; New Jersey and New York City also scored high, though, too.

You would have thought that CMS, the Medicare agency, would have noticed it and engaged in some kind of enforcement action.  Apparently it has:

The Medicare Fraud Strike Force, a joint initiative of the Department of Health and Human Services and the Department of Justice, was formed in response to widespread fraudulent claims in South Florida, and its periodic “takedowns” have charged far more providers in Miami than in the other cities where it operates.

But the practices apparently persist.  It is hard for a government agency to diligently review the practices of each doctor--although some "big data" algorithm could likely prove helpful to find enforcement targets.

Now, my economist friends will say that the solution to the problem would be to move away from fee-for-service payments to doctors, substituting some kind of capitated approach, in order to eliminate incentives for overuse. Elliott Fischer, for example, is quoted in the article:

“It’s mostly based on how much doctors do in a system where you make more by doing more. Financial incentives and more entrepreneurial doctors are very important to what we’re seeing.”

An alternative risk-based  pricing method, however, would require patients to be part of a closed managed care system or accountable care organization.  For political reasons, though, Congress will not limit patient choice in that manner, retaining instead a PPO format for Medicare.  In this environment, the northern "home" ACO can have little influence over the patient or doctor while the patient is in the warm states.

So the only answers to this problem are more vigorous enforcement by CMS and more diligence on the part of patients. It is in the latter arena that CMS could be more proactive. What if CMS took a step to help patients shop around and be alert to potential over-testing--transparency.  For example, what if the agency simply published, for each doctor in these jurisdictions, the rate at which they conducted the top third or fourth ranked tests, compared to an acceptable benchmark.  Let's give some useful tools like this to consumers so they can be more diligent for themselves.

Do you know you're in my lane?

An excellent video about texting while driving:

Success in Ipswich

Back in 2012, my colleague and I ran some workshops for senior management and clinical leaders introducing the Lean philosophy and some of its practices at Ipswich Hospital NHS Trust.  As noted at the time:

We started with an introduction based on the Toast Kaizen video produced by and featuring GBMP president Bruce Hamilton.  Then it was off to gemba, the "factory shop" floor, where the class members shadowed a member of the staff. The idea was to practice observation skills and try to identify the various types of waste found in all organizations. 

The class members gained a new appreciation for the degree of difficulty faced by their colleagues in doing their everyday jobs.  They noticed impediments, inefficiencies, and work-arounds.

Later, I gave everyone a homework assignment, which was to answer the following question: 

"Waste exists in Ipswich Hospital because the people who work here are uncaring and lazy. True or False? Provide evidence in support of your answer." 

I suspected (and hoped!) that the answer would be "false," and it always was.  People understood that the well-intentioned and hard working people in the hospital face the common problems of complex organizations.  

Phil Windsor offered the following answer:

To say waste exists at Ipswich Hospital because the people who work here are uncaring and lazy is a statement that couldn't be further from the truth. 

The people that work at Ipswich are uncaring and lazy is a generalisation as extreme as saying they are all angels. Let's be real, we all have our bad days, but an organisation whose primary function is the health and welfare of others can not attract a workforce who are naturally lazy and uncaring. If that was your disposition why would you work at all. 

Wasted resources are a result of our inability to re-use the by product of our activity. It may be argued that it's ok to accept a degree of this and it may also be argued that everyone is entitled to an off day. The question is how much are we willing to accept and how much better would the world be if we all accepted a bit less?

Well, it appears that Phil and his colleagues really went to work applying lessons from this experience and more.  In a note today from surgeon Isam Osam:

Since taking the role he has transformed the emergency department. Lean is about a culture and incremental improvements. This is a great example!

And he linked to this story from the Ipswich Star:

Ipswich Hospital’s emergency department one of the top 10 performing for hitting Government target for seeing patients in four hours 

Ipswich Hospital bosses praised the “amazing” work of emergency department staff last night, as it emerged the unit was among the top 10 in the country for seeing patients within four hours.  

New figures released by NHS England put the Heath Road trust as the eight best out of almost 140 departments for hitting the Government target of seeing, treating and admitting or discharging 95% of patients in that timeframe, between October and December. It averaged 95.7% in the three months, according to the data.

Bravo to Phil and others on the team!  As noted in the story:

“It is a fantastic tribute to not only our amazing emergency department team, but in fact the whole hospital."

The judge saw through the lie

In a Boston Globe story, here's how Priyanka Dayal McCluskey reports on how the outgoing CEO of Partners Healthcare System described the deal that was turned down today by Suffolk Superior Court Judge Janet L. Sanders:

“The judge has said ‘no’ to an agreement that we believe would have paved a pathway to delivering high-quality care closer to home for patients and their families in a lower cost community-based setting."

Well, no.  First of all, there was no need for PHS to acquire these hospitals to achieve proper care management for patients.  All it takes is an agreement to coordinate care and share access to medical records.

Second, hospitals that would be incorporated into the PHS system would gradually assume the pricing advantages of this near-monopoly supplier and would not be lower cost community hospitals (compared to other community hospitals.)

Third, the agreement would have permitted PHS to recruit doctors in the vicinity of these hospitals, moving them from lower cost systems to the higher physician rates of pay enjoyed by the PHS doctors.

Attorney General Healey had it just right when she said that the proposed agreement was a case of the cart leading the horse. As many of us had noted, the commitments to lower costs contained therein were unsupportable and unenforceable. Instead, implicitly building on the findings of the state Health Policy Commission, she suggested:

“One of the greatest challenges our state faces is rising health care costs,” Healey said. “I’d like to see how [Partners’] work in the market is helping to contain costs.”

(By the way, should this case ever reopen, it would be good to see how an unfettered US Department of Justice would behave. Their position in this case was strange, compared to their other activities in the country.  One must assume that it was based on the Administration's desire to help a fellow Democrat in her gubernatorial campaign.)

In case you are interested, here's the full ruling by the judge. It is worth reading, at a minimum, the first few pages.

Marching, but where? Moscow, I fear.

Melanie Evans and Bob Herman at Modern Healthcare report that "a new task force made up of providers, insurers and employers has committed to shift 75% of its members' business into contracts with incentives for health outcomes, quality and cost management by January 2020."

What's up? Well, the theory is that risk-based payment mechanisms like "accountable care, bundled payments and other contracts with the potential for rewards or penalties based on quality performance and better cost control" will bring about greater efficiency and higher quality in the health care system.  It is argued that the current system, mainly based on fee-for-service schemes, leads to overtreatment and waste.

In the midst of all the excitement, there are very few thoughtful observers who raise questions about the march.
 
I've devoted a lot of columns here to the unanswered questions and potential unintended consequences associated with risk contracts.  I've also been hard on the health care industry for a lack of analytical rigor when it comes to designing public policy prescriptions to deal with rising health care costs.  I don't want to go through all those arguments now, but let's just outline some as yet unanswered concerns:

1) As risk is shifted from insurers to providers, what adjustment will be made in the insurers' cost of business, and how will those adjustments be passed along to consumers.  A reduction in risk should be accompanied by a reduction in capital reserve requirements of insurers:  How and when will those huge investment accounts be reduced and redistributed to the public?  Likewise, if payments are made on the basis of annual population rather than individual claims, when will the insurers stop adjudicating claims data and reduce the size of their staff involved in these functions?  When and how will those savings be passed along to consumers?

2) The decisions by ACOs to take on more risk is already driving mergers and acquisitions as those entities try to expand their risk pools.  That market concentration acts to increase the leverage of the providers over local insurers, driving up rates (whether fee-for-service, capitated, or bundled).  How can we be sure that whatever savings might emerge from risk contracts are not offset by the greater market power of provider groups vis-a-vis insurers?

3) What will be the internal distribution of risk and reward for the various physician specialties within ACOs?  How will that negotiation take place? Is there any reason to believe that the current fee schedules which offer higher relative payments to proceduralists than cognitive specialists will not form the base for ACO internal transfer pricing?  If there is a surplus within an ACO, which doctors will get which share?  Likewise, if there is a deficit?

4) Similarly, what will be the internal distribution of risk and reward for the various entities within ACOs--the tertiary care centers, community hospitals, multispecialty clinics, and post-acute care facilities.  If there is a surplus within an ACO, which facilities will get which share?  Likewise, if there is a deficit?

5) What will be the governing structure of ACOs?  If, as is often the case, the large tertiary centers hold the cards, how can the other players within the ACO rest assured that they will be treated fairly in matters of risk and reward allocation?

6) And finally, if quality metrics are not properly drawn, don't risk-based contracts offer the potential for undertreatment of patients, swinging the pendulum too far in the other direction?

“If all you're going to do is you're going to put providers at risk for cost, but you don't have a robust system for measuring quality, then you're not leaving patients better off,” said Dr. Ashish Jha, a Harvard University health policy professor.

We are all pleased, of course, to see the following kind of optimism:

“As a doctor, I am very excited about the direction this is going,” said Dr. Stephen Ondra, chief medical officer of Health Care Service Corp. “For much of my career, payers and providers had an adversarial relationship that often created win-lose choices.”

But I fear that Dr. Ondra and his like-minded colleagues are naive.  The adversarial relationship he sees today may very well be replaced by a new set of adversarial relationships--between physician specialties; between tertiary and other health care facilities; and, sadly, between patients and ACOs. The main drivers of health care costs are not overuse related to fee-for-service care.  As I have noted here, they start with the changing demographics of society.  Fee-for-service is way down the list.  Quoting myself:

If we were being rational and rigorous about policy prescriptions, we would rank order these causes and determine the costs and benefits of policies that might offset them.  For example, we cannot change demographic patterns, but it could make sense to introduce public health programs to promote exercise and proper nourishment.  We could change the compensation system for primary care doctors so they could spend more time with patients.  We could subsidize physician education so they wouldn’t have to earn so much to pay off loans.  We could reform malpractice laws to reduce defensive medicine. And we could certainly engage in full-scale process improvement training of doctors and implementation of those techniques in hospitals to reduce the extra medical costs associated with harming patients.  (Those of us who have done the latter have demonstrated conclusively the cost savings, not to mention the mortality and morbidity benefits.)

But, our public policy leaders have not done this.  Instead, they assert that pricing-based over-treatment is the key problem, and they offer capitated rate plans and bundled payments as the solution.  If you look closely, you will find that most of those proposals come from payers, either insurance companies who have a corporate desire to shift risk to providers or government officials who are trying to reduce appropriations.  Or from economists, who have a tendency to simplify market behavior and blame everything on pricing regimes.  As I have said, when you have a hammer, everything looks like a nail.

We shouldn’t dismiss a change in the payment system just because it might benefit the insurers or the government, but we also shouldn’t adopt it just for that reason -- or because it fits into economists’ idealized models.  Instead, we should determine how big a portion of the over-treatment problem comes from the payment system versus other causes.  And then we should rigorously review the experience of such regimes and evaluate their costs and benefits.  We should also determine how practical it is to implement a new pricing regime. 

I have a deep seated feeling that the march that is seen as so optimistic today might start to feel more like Napoleon's attack on Moscow, nicely represented in the chart above from Edward Tufte.

Lynne: Initial CMS Evaluations of Readmissions Have Serious Flaws

Joanne Lynn M.D., Director of the Center for Elder Care and Advanced Illness at Altarum Institute, wields a scalpel and a battle axe in her recent criticism of initial CMS evaluations of readmissions. The lede:

The Centers for Medicare and Medicaid Services (CMS) has quietly put out two evaluations of the readmissions work– and both documents are remarkable for their failure to evaluate the programs fairly or to provide insights as to what works in what circumstances.

Excerpts:

The readmissions/discharges metric that CMS and its evaluators use for categorizing success or failure is seriously flawed.  There is no reason why a 20% reduction in the now thoroughly discredited readmissions/discharges ratio is the best target. A more informative target would clearly focus on providing a reliable, well-characterized set of services that work to the advantage of patients and families and that also reduces total costs.

Much of the problem with the measures probably has roots in national leadership still conceptualizing the transitions work as being dominantly the responsibility of hospitals and their staffs, while people living with serious chronic conditions need a more comprehensive, community-anchored, population-based approach. Even so, responsible evaluation would require, at the very least, a close examination of actual numerators and denominators in order to interpret the simplistic and routinely misleading ratio. 

The most important issue is whether the CCTP (Community-Based Care Transitions Program) program is helping to improve transitions and keeping people who are living with fragile health in a more stable condition while living in the community, thereby reducing hospitalization. It would be easy for the evaluation to show that the supplemental services are desirable. Evaluators could test whether enrolled patients had many fewer medication errors, many more patients and families confident in their self-care, many more social services in place, and much more medical support in the community. However, the current evaluation does not address these points.

These first forays into evaluation of the readmissions work are quite disappointing. There are contractors and participants who know much more, and there are evaluation methods that would be much more revealing. The work on care transitions has been a powerful catalyst toward more comprehensive care planning and service support for people living with fragile health. It is time to push CMS and PCORI and any other funding agency, contractor, or grantee to do the work that informs managers and policymakers about what to do next, given what we’ve learned in the work so far.

John Q. Sherman Award for Excellence in Patient Engagement

It's time again for the John Q. Sherman Award for Excellence in Patient Engagement.

This year’s award will be conferred by Standard Register Healthcare in partnership with the National Patient Safety Foundation’s (NPSF) Lucian Leape Institute at the 2015 NPSF Patient Safety Congress in Austin, Texas on April 30 and the award-winning program will be featured on EngagingPatients.org.

Last year the award was given to the Open Notes Collaborative and Dr. Nasia Safdar, hospital epidemiologist for the University of Wisconsin Hospital.

 

Who was Mr. Sherman?  Here's background:

Founder of Standard Register, John Q. Sherman was a leading philanthropist in Dayton, Ohio with a deep commitment to healthcare and his community. At the onset of the Great Depression in 1928, he led the campaign to raise over one million dollars in just 30 days to build Good Samaritan Hospital. He left a legacy that lives on today through the company’s support of Dayton’s Samaritan Homeless Clinic, in the launching of EngagingPatients.org and now through the John Q. Sherman Award program.

This year's deadline is February 28. Here are the details.

Sampson engages through Chop Chop

I love Sally Sampson's enthusiastic persistence with regard to teaching kids about tasty good food.  She has been publishing Chop Chop magazine for some time now, and each issue is a treasure of ideas and stories.  The magazine is widely endorsed by pediatricians and is distributed through children’s hospitals, health centers, public schools, afterschool programs, Indian reservations, and community organizations. ChopChop is also available at newsstands and by subscription.

Here's the latest set of blog posts. I like this one on knife skills, with this introduction:

Slicing, dicing, chopping, and cutting: it’s hard to cook without using a knife to prepare the ingredients! Hard, but not impossible. A pizza cutter makes a perfectly excellent cutting tool for soft things that aren’t too big: bananas, for example, or tofu. And scissors are great for snipping up herbs and greens. But if an adult in your family thinks you’re ready and is willing to supervise you, it might be time to learn to use a sharp knife in a safe and responsible way. We got some tips from knife maker Adam Simha of MKS Design in Cambridge, MA.