Huh? HUH?

I've written at length about the push given to capitated contracts by Blue Cross Blue Shield of Massachusetts--and have suggested a number of public interest-related questions about this corporate policy.

The company doesn't like it to be called capitation. You decide.  Here's the short summary from an article in Health Affairs:

Its principal elements are a five-year term; an annual global budget based on each group’s historical per member per month spending; a quality-based system of performance bonuses; and regular reports from Blue Cross on the group’s spending, service use, and quality of care. 

Ok, so let's just call it capitation with the potential for some bonuses based on tracking sixty-four measures (thirty-two each for inpatient care and for ambulatory or outpatient care) covering the process of care.  Why do I call it capitation? Because it is.

And I'm also not going to comment on whether tracking 64 separate quality metrics can actually influence doctor and nurse day-to-day behavior on the floors, the ORs, and in the ICUs to improve quality over what would occur anyway.

That's not what brings me back to the topic today.  It is this line from the same article:

Although the medical groups each have an annual global budget, Blue Cross pays them fee-for-service throughout the year. All payments for medical care are debited against the group’s budget, whether the services are delivered by providers inside an Alternative Quality Contract group or by unaffiliated providers. At the end of each year, Blue Cross conducts a reconciliation exercise with each group, paying it any money left in the budget or recouping what the provider spent over the agreed-upon global budget. 

Read that again: "Blue Cross pays them fee-for-service throughout the year."

Now, BCBS of MA has been going around the state (and the country) for many years decrying the use of fee for service--and yet it maintains this underlying billing system.

It must costs millions of dollars each year to process the claims from provider groups and compile this information in this form.  Simple question:  Why is it necessary?  Why not just send a check each month for 1/12 of the annual budget?  There is simply no need to do a reconciliation.  If the provider group beats the budget, they keep the money.  If they exceed the budget, they absorb the loss.

Is there some information need that BCBS is providing?  Well, no.  Maintaining the FFS fiction clearly is not necessary to inform the provider organizations of the quantity of work they've done.  They already know what work they are doing.  (In fact, they use that information for internal transfer pricing purposes to compensate their individual doctors and hospitals.)  In short, the providers already have it within their sole power to analyze activity levels and choose or not choose to make changes in clinical patterns to achieve greater efficiency and quality. 

Why doesn't the "insurer" here act to reduce transaction costs?  (I call it an "insurer" because it has essentially shed its risk-taking function.)  Maybe the answer is that, if the "insurer" always gets to keep a fixed percentage of the premium dollar for administrative costs, it might as well incur those costs.

Or maybe it's just some form of corporate paternalism, indicating the company's fundamental lack of trust and faith in the provider organizations.  If I had a choice where to put my trust, I know which I would choose.

Monitoring stress of patients in ICUs

Here's a link to an intriguing paper produced by Julia Somerdin, a participant in the MIT System Design and Management program.

She states the challenge:

A cost-effective, reliable, and real-time information system for monitoring the stress of patients in intensive care units (ICUs) is missing from current ICU systems. This presents an important opportunity because [among other things]:

• ICU patients, often unable to report on their stress and pain levels, rely primarily on nurses' training and knowledge—yet, because nurses can visit patients only periodically, pain can only be assessed intermittently;
• Pain and stress ratings are often subjective, even guesswork, and nurses treating the same patients often disagree with each other because of their varying levels of training and experience.

She offers an approach:

ICU Cam enables non-invasive monitoring of stress and pain using a remote smart camera mounted on top of a patient's bed. Its capabilities include:

• remotely measuring stress during complex dexterity tasks, such as surgery; and
• transfer of reliable real-time results to physicians via data visualization.

With these tools:

The embedded software system consists of four modules:

1. Camera server-side data collection and processing
2. Networking module for Wi-Fi transmission
3. Client-side data receiver
4. Graphical user interface that provides data regeneration and interpretation.

With these results:

During lab testing, ICU Cam measured heart rate and heart rate variability with over 96 percent accuracy. Additional benefits may include:

• Early detection of pain to help doctors provide early relief to patients incapable of self-reporting;
• Reduced length of ICU stay, resulting in substantial savings for hospitals and insurance companies; and
• Increased ICU efficiency and reduced nurse workload.

I'm sure she'd like to know your reactions to all this!  Please comment here.

A video that should be required viewing in Colorado

Regular readers may have picked up on the fact that e-Patient Dave deBronkart and I are friends, dating back to our time as classmates at MIT.  He has a classic story from the 1960s that is familiar to his friends, but now it is available for the world to hear.

Go to this site and start the video at minute 11.

I love how he brings the story around to the them of his speech, letting patients help.  But I also just love the story.  It should be required viewing in Colorado as part of the marijuana education efforts there.

An NHS GP asks, "How long do I continue to push my luck?"

David Shepherd has been a GP with the National Health Service for over two decades and also trains doctors in that profession.  He recently published this story:

I made a serious drug error last year. There, I said it - confession is good for the soul. Fortunately, no one was harmed but this was the first time in 23 years as a GP that I got it that badly wrong. The story is worth telling in detail as it contains important lessons for me, my practice and the wider NHS.

 In a nutshell I prescribed an antibiotic (No, that wasn't the sin – there was a genuine indication!) to a frail patient in a care home whose records unambiguously contained a correctly coded allergy to that drug. The drug was prescribed, dispensed and the full course given before the error came to light. Had the patient had a significant reaction, in his/her frail state, it could easily have caused death or hospital admission.

David has a thoughtful protocol he applies regularly: 

This has served me well for 23 years.

As we review the rest of the article, we come to see that the cause of the error appears to be being over-extended and tired: 

In August 2014 I experienced one of the busiest days I have known in general practice. I worked from 7:45am, foot continuously on the accelerator, until after 6:30pm with no break for coffee or lunch or tea. I probably managed to pass urine once. For the first time in 22 years I was unable to complete the work I needed to do that day before being late for our Partnership meeting that evening. It was a 13.5 hour day and I cycled home exhausted. I slept fitfully and woke early, my mind racing with the events of the previous day and thoughts for the coming one.

The fateful visit occurred later the same day, at the end of another full-on morning with no break and no lunch, with only a few minutes to get back to the surgery to lead the meeting. The patient, who I knew well, was acutely ill and needed a prescription. In my rush . . . I missed the drug allergy on my patient printout. I can’t remember whether I checked and just missed it or whether I just didn't check. 

I rushed back to people waiting for me and the meeting went well. Then with my mind buzzing I set about catching up with all the tasks and letters and path results that had come in that morning and afternoon and the work I had been unable to complete the previous day. I wrote up the visit. The computer warned me about the drug interaction but I flicked through ignoring it along with all the other non-clinically relevant warnings that come up.

The realization was delayed: 

A week later I was reviewing the patient’s notes for some reason and to my horror realised what had happened. I printed out the visit slip – yes the allergy was there. I tried re-issuing the drug – yes the computer did warn me. The really scary thing is that despite being a conscientious GP for 22 years, despite predicting that something like this would happen (though not to me!) and despite teaching safe prescribing habits to GP registrars for 15 years, I did not realise what was happening at the time. I was just overloaded and hitting me so I'm more careful in future isn't necessarily going to help.

As I have reported: 

Terry Fairbanks (Director of the National Center for Human Factors Engineering in Healthcare) notes that most errors are skill-based errors, or errors that occur when you are in automatic mode, doing tasks that you have done over and over--indeed tasks at which you are expert. 

He explains, "When you are in skills-based mode, you don't think about the task you are about to do. Signs don't work! Education and labeling don't work when you are in skills-based mode. Most medical errors are in the things we do every day."

Accordingly, vigilance and training are not the answer to skill-based errors. Neither is punishment:

"While discipline and punishment has a role when there is reckless behavior, applying discipline to skill-based errors will drive reporting underground and will kill improvement."

Being tired and stressed can be a contributing factor, as was the case here. And David uses this story to make a case for a more rational patient loads for NHS GPs:

Much is made of learning from the airline industry in making the NHS safer. However, NHSE, DoH and the government are not credible in this matter. The current contractual arrangements mean that there is no point beyond which a GP cannot be pushed and NHSE is quite intent to keep on pushing. This is in stark contrast to flight crew safety rules which "recognize the universality of factors that lead to fatigue in most individuals and regulates these factors to ensure that flight crew members in passenger operations do not accumulate dangerous amounts of fatigue.  Fatigue threatens aviation safety because it increases the risk of pilot error."

It is absurd that GPs are trusted to decide on the patient with chest pain in front of them and on commissioning for populations but are denied the ability to decide on a safe workload in their own practices.  

He concludes with a warning:

And if no solution is forthcoming, General Practice will have crossed, by NHSE’s action, from ‘if’ serious patient harm occurs to ‘when’ but it will be the GP who is hung out to dry. I find myself asking a question I never dreamt I’d ask, ‘Is it ethical to be a GP?’ Should I continue to work within this system, knowing there is a real chance of inadvertently harming a patient, when it deliberately and incompetently denies me the means to minimise that risk? 

So how long do I continue to push my luck?

HemOnc.org offers value

Way back in 2012, I wrote about a wiki Peter Yang created to share clinical knowledge about his field. I was pleased to receive this update from him:

Thank you again for previously supporting our efforts at HemOnc.org to create a collaborative free hematology/oncology reference. We're excited that ASCO's Journal of Oncology Practice just published a manuscript we submitted about the website, which is still going strong and being regularly updated after over 3 years. 

That article notes:

From its inception in November 2011, HemOnc.org has grown rapidly and most recently has detailed information on 383 drugs and 1,298 distinct chemotherapy regimens (not counting variants) in 92 disease subtypes. There are regularly more than 2,000 visitors per week from the United States and international locations. A user evaluation demonstrated that users find the site useful, usable, and recommendable.  

Future enhancements, including more metadata about drugs and increasingly detailed efficacy and toxicity information, will continue to improve the value of the resource.

Congratulations to this team for a job well done and for their contributions to so many people around the world!

In memoriam: John Costa, Sr.

There are thousands of these stories across the county--and indeed, in every country--but this one left me with a warm feeling, and I thought you might like to see it.

There is a local company, BC Tent & Awning, that provides tents to people for weddings and other celebrations.  We used them for a family affair a couple of years ago, and they were lovely.  Well, we're now on the mailing list, and we recently received this note about the death of the family patriarch, John Costa, Sr.  Beyond telling John's story, it presents a microcosm of a certain period in recent American history: This was an era in which, without question, complaint, or entitlement, everyday people provided service to their nation, their communities, and their families.

Take a look!  Here are some excerpts:

It is with a heavy heart that we share news of the passing of Bob’s father John Costa Senior. Mr. Costa was a hard working family man who touched the lives of so many people in his 101 years on this earth and B.C. Tent would not exist without him. Bob always credits his parents as the true founders of B.C. Tent & Awning. The company started in his parent’s garage here in Avon. Bob’s parents were in their 60’s and would answer phones, send out invoices, help with installations, clean the tents, sew the drop cloths and much more. The only compensation they wanted was knowing they were part of the success of their son.

Well into his 80’s Mr. Costa worked periodically in the warehouse alongside people who were a quarter of his age. In his 90’s and 100’s he continued to visit the office and brighten the company with his personality and spirit helping the company stay relaxed during our busy seasons and entertained in our off seasons.

Mr. Costa graduated from Mechanical Arts High School in Boston as the first high school graduate in his family.  Over the next few years John began dating Constance Helene Smith and juggled his day job at the water meter company with playing music with the Jackie Ford Band. John was drafted into the US Army in 1941 and expected to be discharged by the time of his planned spring 1942 wedding. After Pearl Harbor the wedding was rescheduled to Dec. 28th 1941 and his stay in the Army was extended.

Serving in the war, John was stationed in Ireland, England, Algeria, Morocco, Italy, France, Belgium, and Germany. During his military duty John documented his experience with journals, photographs, and letters to his ‘darling’ Connie.

After returning from the war, John and Connie started a family and settled in Avon with their 4 boys John, Paul, Donald & Bob. John often worked 3 jobs during this time. He spent his working years with the United States Postal Service, the Army National Guard as well as working as a custodian at Avon High School and even working as a Driver Education Instructor. John retired in 1980 but quickly found a new project providing skills and guidance to his son Bob’s newly formed B.C. Tent & Awning Company.

In 2011, the company was proud to honor John and his contributions to the company by inducting him into the B.C. Tent & Awning Hall of Fame and presenting him with the Golden Sledgehammer award. We also created a John J. Costa Training Center in December 2014. Mr. Costa helped shape not only the company but all the individuals that he came into contact with through the years.

The Secret Language of Doctors

In the firmament of admirable doctors, Brian Goldman is a shining star.  I'm not just talking about this TED talk--Doctors make mistakes. Can we talk about that?--which has had over one million views. More generally, he shines a light on aspects of the practice of medicine that are so embedded and pervasive that they are scarcely noticed.

So, it was with anticipation that I read his new book, The Secret Language of Doctors (to be published on April 1, but available for pre-order now.)  It turns out that you can read this book on two levels.  One is the way it's described in its squib:

In The Secret Language of Doctors, bestselling author Dr. Brian Goldman opens up the book on the clandestine phrases doctors use to describe patients, situations and even colleagues they detest. He tells us what it means for someone to suffer from incarceritis, what doctors mean when they block and turf, what the various codes mean, and why you never want to suffer a horrendoma. Highly accessible, biting, funny and entertaining, The Secret Language of Doctors reveals modern medical culture at its best and all too often at its worst.

Yes, on that front, what's presented is entertaining, giving the reader a vicarious view of the inside culture of hospitals.

But I suspect that Brian's goal goes beyond entertainment.  The book presents a warning to the profession that the argot it employs is indicative of educational and structural problems.  Brian slips these points into the middle of his stories.  You could almost miss them.  At one point, he pauses to talk about efforts to create "slang police" to solve the language problem he has documented so well.  Instead, he says, we should "listen for trends that indicate problems that need to be addressed."  Here are some examples:

Doctors call obese patients whales because they aren't being taught that obesity is a disease.  They aren't given equipment to transport bariatric patients safely. They arem't given the tools to operate on these patients effectively.  Instead of [trying to ban] the slang, why not provide the education and support needed to diagnose and treat bariatric patients?

Instead of condemning slang such as cockroach and frequent flyer, teach ER physicians and nurses to attack the underlying reasons patients visit ERs over and over and over again.

If ERs have trouble with geriatric and psychiatric patients, then maybe the solution is to give such patients ERs of their own.

Better places for undesirable patients, better training and better equipment only go so far.  The greater challenge is how to get young doctors to want to treat them.  Both medical schools and hospitals need to recruit leaders and other role models who enjoy caring for twenty-first-century patients.

The alternative?

If doctors don't take up the call, then the other solution is to find different health professionals who like these patients more than doctors do. [For example,] nurse practitioners are salivating at the chance to pick up the slack.

This is all worth a look.  The book will appeal to the lay public. But, I'm hoping that lots of doctors read it, too, to help them think about the underlying meaning of what they are saying in the corridors, break rooms, ICUs, and ORs.

Three years makes a trend

Priyanka Dayal McCluskey reports that Steward Health Care System, owned by the private equity firm Cerberus Capital Management, has finally given the state a portion of the accounting data concerning its 2013 operations.  The system, which operates 10 hospitals in Eastern Massachusetts, showed a loss of $55 million on revenues of $2.1 billion.

Last year, Commonwealth Magazine reported that the system had lost $22 million on operations in 2012, down from a larger operating loss in 2011.  At the time, the company said:

[T]he numbers are in line with the company’s business plan, which calls for turning around each of its individual hospitals within three years. “We are exactly where we expected to be in terms of quality, sustainability, and financial performance,” he said.

These numbers should not be taken to mean that Cerberus has not done well on the deal.  Private equity firms, as noted by Warren Buffett, are marvelous at extracting cash from their operating units.

Later, the business will be resold, often to another leveraged buyer. In effect, the business becomes a piece of merchandise.

But that is more difficult here. When it comes time to flip this investment, the likely buyers would be large for-profit hospital systems. As those companies tend to hold on to their assets and run the hospitals with a long-term view in mind, they will look at the actual bottom line performance of the system. A persistent negative operating margin is not good news for the company's exit strategy, especially when revenue-producing assets have been sold off for short-term cash gains.

As I have noted, this transaction will have a tail that will leave Massachusetts policy-makers with difficult choices.

But it sure is nice to see the company's ads at Logan Airport.

Where are the obvious and hard questions?

I don't want this to seem like I am picking on any one newspaper, but this one has the most "ink" in our region and therefore its reports carry the most weight in terms of public understanding and opinion.  The most frustrating thing to see is when a corporation spouts off its "message," and the newspaper lets it just sit there without asking the obvious and hard questions.

In today's story, Partners Healthcare System, in response to concerns raised by the Attorney General and the Health Policy Commission, promised that it would raise rates for 70 newly acquired doctors "only" by the rate of inflation for the next five years.  No one asked what would happen after that.

More seriously, there's this excerpt:

At the beginning of 2016, the Harbor doctors will join the group of about 1,500 physicians at Brigham and Women’s Hospital. Officials at Partners and Harbor said the deal will improve the coordination of patient care and eventually lower costs.

“This integration will ultimately reduce health care costs by providing South Shore patients with a thoughtful, coordinated approach to their health care,” said Dr. Jessica C. Dudley, chief medical officer of the Brigham and Women’s Physician Organization.

The obvious questions are:

How will you reduce health care costs?
By reduce, do you mean an absolute reduction or a reduction relative to inflation or prior trends?
What do you mean by ultimately?
What assurances will you make to the public and to policy-makers that it will happen?
How will this reduction be measured and reported?
Will you be transparent about the total medical costs per patient seen by doctors in this group, now and in the future?

Well, either the questions weren't asked, or there was insufficient space in the newspaper to print the answers.  Either way, an unsupported assertion gets introduced into the public record with no chance of validation or rebuttal.

S(uch) S(trange) M(edicine)

SSM Health, one of the nation's largest hospital and health care systems, has adopted a statement of values which includes the following:

• Excellence
  We expect the best of ourselves and one another.
• Stewardship
  We use our resources responsibly.

I'm sure they do many good things (and have gotten lots of awards) but there is one exceptionally bad thing they are doing that deserves review.  It's outlined in this blog post by Al Lewis and Vik Khanna.  Here are some excerpts:

The pitch is that Vik could get a package of six screenings, available for a limited time for the promotional price of $179 (total “value” $2,300), with an additional Know-Your-Numbers lipid panel assessment for just $99. Combine both offers and get an additional $20 off, with a total price of just $258. The six-test package of screenings includes:

• Echocardiogram ultrasound
• Stroke/carotid artery ultrasound
• Abdominal aortic aneurysm ultrasound
• EKG
• Peripheral artery disease (PAD) test
• Hardening of the arteries test (also called the Arterial Stiffness Index or ASI)

What's the problem?  The problem is that these tests are not only generally useless, absent a clear case of medical necessity, but they are also affirmatively not recommended by those organizations who study such things.  The authors note:

For the sake of consistency, we look first to the published recommendations of the United States Preventive Services Task Force (USPSTF) which is the closest thing we have to an independent, credible arbiter of data on preventive services. In cases where the USPSTF has not made a recommendation, we look to the literature.

Abdominal aortic aneurysm ultrasound: Rated “B” only for men aged 65 to 75 with a history of smoking. It’s a C for men in that age with no smoking history, “I” or inconclusive for women 65 to 75 who’ve smoked, and a D (more harmful than helpful) for women in this age range with no smoking history.

Stroke/carotid artery ultrasound: rated a D for all adults who are asymptomatic. Someone with symptoms doesn’t need a screening; they need a workup and therapy.

Echocardiogram ultrasound: the USPSTF doesn’t even have a recommendation on this, so we look to the literature. A large, long-term study from Norway, published in JAMA Internal Medicine in 2013, concluded that echo has no prognostic value. This jibes with the recommendations of the American Society of Echocardiography, articulated at Choosing Wisely, that echo is overused even in people who are symptomatic and should be avoided in people who have no reason to get one.

Electrocardiography or EKG: USPSTF rates this a D for adults with no symptoms and of inconclusive value even for people in moderate or high risk categories.

Peripheral artery disease (PAD) test: The USPSTF rates this screen as I or inconclusive. They do say, however, that the incidence of PAD in the general population is unknown. While this testing has value in people who are symptomatic, they were not coy about its value in people with no symptoms: “The USPSTF found no evidence that screening for and treatment of PAD in asymptomatic patients leads to clinically important benefits.”

Hardening of the arteries test (also called the Arterial Stiffness Index or ASI): The USPSTF has no recommendation on this. But, the American Heart Association, which typically doesn’t softsell cardiac goods and services, completely disses this test [as] not recommended (Class III).

The authors suggest that commercial interests might be prompting these activities by SSM:

They . . . understand medical guidelines.  They choose to ignore them, in order to create followup revenue for the (mostly false) positives that these tests will inevitably reveal.  And the reason they are practically giving them away is that they not covered by insurance because the Affordable Care Act requires health plans to cover only screens that are A or B rated by the USPSTF.  However, all the followups will be well-reimbursed.

I reach no conclusion except that this program violates SSM's statement of values:

• Excellence
  We expect the best of ourselves and one another.
• Stewardship
  We use our resources responsibly.

Bundles on WIHI

Madge Kaplan writes:

The next WIHI broadcast — Bundles and Buy-In for Value-Based Care — will take place on Thursday, March 12, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:

• Mark P. Jarrett, MD, MBA, Chief Quality Officer, Sr. Vice President & Associate Chief Medical Officer, North Shore-LIJ Health System
• Susan Browning, MPH, FACHE, Vice President, Neurosciences, Head & Neck Surgery/ENT and Ophthalmology, North Shore-LIJ Health System
• Katharine Luther, RN, MPM, Vice President, Institute for Healthcare Improvement
• Mark Hiller, MBA, Vice President for Innovative Solutions & Leader, Premier Bundled Payment Collaborative, Premier
• Alice Ehresman, RN, Healthcare Quality Specialist, Baystate Health

There’s no question that public and private payers in the US are moving toward more global payment arrangements with health care providers. But the picture of how health care delivery systems take up the challenge is still coming into focus. Forming or becoming part of an accountable care organization (ACO) has been one dominant response. And a growing number of health care organizations are redesigning common patient care procedures in order to enter into agreements that reward value over volume, and that tie payment to successful deployment of specific bundles of care.

It’s tempting to think of all this rejiggering as resting heavily on a hospital’s or office practice’s CFO or whoever draws up contracts with payers. But there’s so much more to it. That’s why we’ve assembled a terrific panel for the March 12, 2015 WIHI: Bundles and Buy-In for Value-Based Care. Our guests from North Shore-LIJ Health System and Baystate Health are in the thick of matching necessary staffing and cross-continuum teams to newer global payment arrangements for joint replacement, coronary bypass surgery, and stroke care. Baystate’s Alice Ehresman is working full time on operationalizing the care associated with bundled payments. NS-LIJ’s Dr. Mark Jarrett will keep our focus on the culture change required because, while the new processes may be better for patients, providers often find them challenging to adjust to. This can cause some resistance as NS-LIJ’s Susan Browning recently wrote about in a Health Affairs blog post.

We are fortunate to be able to get up close to this issue and to identify some challenges and opportunities all organizations are facing. That’s where Premier’s Mark Hiller comes and IHI’s own Katharine Luther come in. They’re both harnessing learning about global payment implementation from across the country so that everyone benefits.

So, are your care teams ready for value-based payments? Does everyone understand the relationship between better patient care and potential savings? Are there some new skill sets and mindsets required of doctors and nurses and support staff that need to be called out and called for, rather than just taking everyone’s buy-in and readiness for granted? We’re going to dig into all of this and more on the March 12 WIHI.

You can enroll for the broadcast here. We'd also appreciate it if you would spread the word about the show via Twitter.

Minute for Medicine

Several of my buddies associated with the Telluride Patient Safety camps have started a new venture called Minute for Medicine to provide useful video clips to hospitals.  Produced by Solid Line Media, the offering includes 52 one-minute episodes containing quick, entertaining hits on several different hospital operational areas that are key to providing the safe and high quality care to patients. These videos can then be displayed to staff as part of an ongoing quality and safety program.

As noted:

Separated into 7 easy to follow categories, topics range from Shared Decision Making to Hand Hygiene, and everything in between. The videos are short, fun and entertaining. But most importantly, these videos remind healthcare professionals to think about important patient safety topics every week.

The idea is that many hospitals and health systems that are engaged in the quality and safety journey do not have the wherewithal to develop these kinds of materials from scratch.  So this is a way to provide a simple, turnkey solution to share such information without having to develop it themselves.  Each episode can be customized with the customer's logo in several spots within the video animation and can be hosted both internally and online on its YouTube channel or webpage.

You can see a sample and the full listing of topics here. 

(Note:  I have no financial interest in this venture.  I'm just hoping my friends are successful!)

Ezine from America's Essential Hospitals

There's a new online magazine--Walls Down--from America's Essential Hospitals (formerly the National Association of Public Hospitals and Health Systems), which represents more than 250 hospitals that care for the nation's poor and underserved.

Check it out here.  It is very well done and tells some important stories. You can subscribe to get automatic updates.

Bending the cost curve, up

Here's a quiet but powerful article that is an indictment of the oncology drug industry and public policy surrounding that industry.  It's called "Pricing in the Market for Anticancer Drugs," in the Journal of Economic Perspectives.*

The summary:

In this paper, we discuss the unique features of the market for anticancer drugs and assess trends in the launch prices for 58 anticancer drugs approved between 1995 and 2013 in the United States. We find that the average launch price of anticancer drugs, adjusted for inflation and health benefits, increased by 10 percent annually—or an average of $8,500 per year—from 1995 to 2013. We argue that the institutional features of the market for anticancer drugs enable manufacturers to set the prices of new products at or slightly above the prices of existing therapies, giving rise to an upward trend in launch prices.

This chart illustrates the phenomenon:

What are the institutional features of the market that make this possible?

Generous third-party coverage that insulates patients from drug prices, the presence of strong financial incentives for physicians and hospitals to use novel products, and the lack of therapeutic substitutes. Under these conditions, manufacturers are able to set the prices of new products at or slightly above the prices of existing therapies, giving rise to an upward trend in launch prices.

The phenomenon is aided and abetted by the Federal government:

By law, Medicare does not directly negotiate with drug manufacturers over prices for prescription drugs covered under the Part B benefit or the oral anticancer drugs covered under Medicare’s pharmacy “Part D” benefit. Section 1861 of the Social Security Act, which requires that the Medicare program cover “reasonable and necessary” medical services, precludes consideration of cost or cost-effectiveness in coverage decisions. Consequently, Medicare covers all newly approved anticancer drugs for indications approved by the FDA.

Meanwhile:

At the time of FDA approval, most drugs are on-patent, and so manufacturers are temporary monopolists. 

Elsewhere:

Insurers in states without these requirements and large employers that self-insure have more leeway to determine coverage policies, yet, in the rare instances where third-party payers have tried to place meaningful restrictions on patients’ access to anticancer drugs, they have relented under pressure from clinicians and patient advocacy groups.

--
*The authors are:

David H. Howard, Associate Professor, Department of Health Policy and Management, Rollins School of Public Health, and Department of Economics, Emory University, Atlanta, Georgia. Peter B. Bach, Member in the Department of Epidemiology and Biostatistics, Attending Physician in the Department of Medicine, and Director of the Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York City, New York. Ernst R. Berndt, Louis E. Seley Professor in Applied Economics, Sloan School of Management, Massachusetts Institute of Technology, Cambridge, Massachusetts. Rena M. Conti, Assistant Professor of Health Policy, Departments of Pediatrics and Public Health Sciences, University of Chicago, Chicago, Illinois.

Stop their expansion? Hell, shrink them.

Priyanka Dayal McCluskey's Boston Globe article reports on concerns by the MA Attorney General that the acquisition of a physicians group by Partners Healthcare System will raise costs in the eastern Massachusetts health care market.

Just five weeks after its plans to merge with a big suburban hospital were rebuffed, the state’s most powerful health system is moving to complete an acquisition of a smaller doctors group that will strengthen its foothold in the Eastern Massachusetts medical market.

The move by Partners HealthCare to take over Harbor Medical Associates, a practice of about 70 physicians on the South Shore, immediately drew fire from Attorney General Maura Healey.

Adding Harbor Medical to its physician network — already 6,000 strong — will allow Partners to raise the prices those doctors charge. The state Health Policy Commission, which tracks medical spending, has said Partners’ acquisition of Harbor Medical would permanently raise prices by more than 41 percent a year, adding $8 million to annual spending.

But that's not all it would do. The acquisition would also cement in the referrals of those doctors to PHS hospitals, which are also priced well above average. So not only would local MD visits become more expensive: Follow-up secondary and tertiary care would also.

The AG and the story miss out on a key element of this scenario, the compliance of the major insurer in the state, Blue Cross Blue Shield of MA.  Had not BCBS agreed to a contract term that allowed PHS to expand its base of physicians, those doctors would not have been able to have been offered higher rates in the first place.  They might then have chosen to become affiliated with another network or to have remained independent.  (Why do I only mention BCBS?  Because it is, by far, the dominant insurer in the state--with more subscribers than all the others combined--and the other small companies are forced to follow its lead on such issues.)  Why is there no investigation by the AG into BCBS contracting practices?

I wonder, too, why the AG and the newspaper do not expand on the implications of such statements as this.

"Harbor Medical’s chief executive, Dr. Peter A. Grape, and Brigham and Women’s Hospital’s president, Dr. Elizabeth G. Nabel, added in a joint statement that the deal will give South Shore patients better access to specialists at Brigham."

This is a prima facie admission of discrimination on the part of this Harvard teaching hospital:  You get better access to us only if you are referred by a PHS doctor.

And it is likely also an admission that the Epic EHR being installed by PHS also is being used in a discriminatory fashion:  You only get interoperability between your local doctor's and the hospital's electronic health record if both entities are part of the PHS system?

It's time for the AG to take PHS to task for continuing exploitation of its existing market power, to pursue anti-trust measures to shrink the system down, in addition to opposing its expansion.  It's time for the AG to insist on true interoperability of EHRs in the state--on which hundreds of millions of dollars in government-supported investments are being made--to allow full choice by patients and referring physicians.  It's time for the newspaper, too, to point out the inherent inconsistencies in the PHS statements and actions: Report on the existing use of market power, not only increments to it.  A good first step would be to check out that PHS billion dollar Epic EHR system and see how costly it will be for a non-PHS physician group or hospital to exchange patient medical records.

Not significant enough to warrant enhanced statistical tracking

Photo: Frank Franklin II/Associated Press

A doctor friend notes this section from a Wall Street Journal article:

So-called runway excursions are much more serious problems overseas than in the U.S. Still, three years ago the Federal Aviation Administration decided such events were significant enough to warrant enhanced statistical tracking—similar to daily data gathered about near-collisions on runways between aircraft.

And then observes:

Just imagine if there were a Federal Medical Administration or equivalent who could decide that HAI's or endoscope infections "were significant enough to warrant enhanced statistical tracking" - and there were a methodology and mandate to do it! Instead, we exert no oversight over this at all. Just amazing. 

Indeed, see here for a recent example.

"Grief is my twin"

My colleague Carole Hemmelgarn is the guest columnist over at Educate the Young this week.  Please read this thoughtful and moving piece.  Excerpts:

March 8^th starts National Patient Safety week and it is with great irony that I write this blog because it is the anniversary of the day my daughter, Alyssa, died from medical errors. I am grateful for the focus being made in the field of patient safety.

However, I want to bring the focus back to the human side of patient safety and that is the patient and family after harm has occurred. There is this aftermath, which is rarely spoken of, and it is what happens to those survivors living without their child, spouse, parent or sibling years down the road.

I’ve come to realize grief is my twin. It will never go away and we have learned to coexist. Please understand grief is not always bad. I find solace in my grief because we speak the same language.  

What most people don’t realize is loss of a loved one, and in particular, a child, changes so many things.

1. Marriage changes.
2. Your children are affected.
3. Your relationship with family members change.
4. Friendships change…..

The most difficult are the milestones your child will not experience: moving through elementary, middle, and high school, not graduating from college, getting a job, married or having children. These events go on for years and this is the aftermath not seen.

Will these truths be handed down from Mt. Sinai?

As I read this person's quote at the start of the article, my thought was that the only thing lacking to achieve success was modesty:

“We’re pursuing problems that are computationally and intellectually exciting, and where there is the potential to change how doctors treat patients in two or three years,” Mr. Hammerbacher said.

The line shows up in a Steve Lohr New York Times story about  Mt. Sinai hospital where:

[T]he goal is to transform medicine into an information science, where data and computing are marshaled to deliver breakthroughs in the treatment of cancer, Alzheimer’s, diabetes and other chronic diseases. Mount Sinai is only one of several major medical schools turning to data science as a big part of the future of medicine and health care. They are reaching out to people like Mr. Hammerbacher, whose career arc traces the evolution of data science as it has spread across the economy.

The impetus comes from other fields:

Chronic diseases, Dr. Schadt explained, are not caused by single genes, but are “complex networked disorders” involving genetics, but also patient characteristics such as weight, age, gender, vital signs, tobacco use, toxic exposure and exercise routines — all of which can be captured as data and modeled.

“We are trying to move medicine in the direction of climatology and physics; disciplines that are far more advanced and mature quantitatively,” he said.

Oh, climatology, where models remain in formative stages after years of research.  Or, physics, where the hoped-for general laws that describe the universe or quanta or both are in constant flux.

Don't get me wrong.  I love that they are trying.  But, please let's be realistic about both the development of the science and the speed with which diffusion of new diagnostic and therapeutic regimes infuse the health care system.

As I came to the end of the article, I found myself hoping that there might be a touch of that modesty after all:

[Mr. Hammerbacher] is optimistic about his initiative’s prospects, but has come to appreciate that the mysteries of the human body may be more resistant to math than finance or social networks are. Today he speaks less about quants taking over than about their lending a hand. “We’re not the most important people,” he said, “but we can help.”

In memoriam: Claude Brenner

It is with great sadness that I pass along word of the death of Claude Brenner, MIT '47.  So many of us associated with the Institute have had the good fortune to know Claude as the ultimate gentleman, unfailingly thoughtful and good humored. Oh, and brilliant, too, but a person whose intelligence was always subservient to his kindness and humanity.  I know I am joined by many who will miss him so much.

He had a fascinating history and broad interests, as indicated in this summary from the Council for the Arts at MIT:

Born in South Africa, Claude Brenner arrived in New York with his family for a two-year stay ten days before Hitler invaded Poland. Atlantic crossings being unwise, the two years ultimately became nine. Brenner matriculated at MIT in June of 1944 at 15, receiving an SB in 1947 and an SM in 1948 in aeronautical engineering. He went home to South Africa and then on to Britain to a job with de Havilland Aircraft Company in Britain. Returning to this country, he embarked on a career that spanned aircraft design and performance, nuclear warfare, defense electronics, laser systems, renewable energy, and at the end a variety of other fields as a consultant.

Brenner is not retired. He is between engagements.

 

Claude loved MIT and contributed to its life in many ways.

As an undergraduate, Brenner sang in the Glee Club and acted in Dramashop, was editor-in-chief of The Tech, and a member of student government. He was elected president of his class and later president of the Alumni Association. He served a term on the Corporation and continues as a member of two visiting committees. He sang barbershop lead with the founding Logarhythms.

 

He was also active in Jewish matters on campus as the MIT Hillel Board Chairman and a founding member of MIT Hillel Foundation.

 

As chair of the MIT Museum's collections committee, he once invited people to contribute to a novel project.  But please no slide rules (!), as he wrote in 2009:

 

Objects. Those are what matter. Sherry Turkle, Abby Rockefeller Mauze Professor of the Social Studies of Science and Technology, has determined that young people who choose a career in science or technology were first motivated by an object in their childhood. For me it was a trio of South African Airways Junkers Trimotors sitting on the tarmac at Johannesburg's Germiston (now Oliver R. Tambo) Airport in 1937 on a Sunday afternoon outing with my mother and sister when I was eight years old. The wonder of those machines sparked a passion for model airplanes and a determination to be an aeronautical engineer, an ambition fulfilled at MIT ten years later.

 

And objects are what matter to the MIT Museum. When the Corporation established the museum 38 years ago as the MIT Historical Collections, it was fondly referred to as the Attic of MIT. Generations of students rushed to donate a variety of objects, mostly that most iconic of all MIT artifacts, their slide rules. The slide rule somehow defined us. We had them engraved with our names. We carried them from class to class in their cases dangling from our belts. We even glorified them in our rousing cheers to inspire our teams to greater effort. You must remember "e to the x du dx, e to the x dx! Secant! Cosine! Tangent! Sine! 3.14159! Square root integral udv, slipstick, slide rule, MIT!" Many a team was spurred to victory by those words. 

 

Deborah Douglas, the museum's curator of science and technology, is using this anniversary exhibition to experiment with some of the newest ideas in curatorial practice. She is inviting alumni-together with the larger MIT community-to help create this exhibition by nominating objects, commenting on objects, and sharing stories. In time this digital repository will become like OpenCourseWare, a boundless resource for those who want to learn about and engage with MIT. Now the museum will have a way of collecting numerous stories and connecting directly with you; and you, in turn, will connect with others.

 

So think on it. Perhaps that inspirational object from your happy days at the Institute? Or something from your profession? But please, no slide rules, unless it's really unusual, if not unique. In addition to robots, ship models, instruments, devices, hacks, and the world's largest collection of holography, the museum also holds one of the world's largest collections of slide rules. 

Why is this news? Why is it new?

Dana-Farber Cancer Institute, our local comprehensive cancer center, deserves the greatest respect and appreciation for its many contributions to the community, the region, and the world.  But when this press release was issued on February 26, I had to wonder why it was news, and why it was new. Excerpt:

New patients with cancer can now see a specialist as soon as the following day at Dana-Farber/Brigham and Women’s Cancer Center in Boston. 

“A cancer diagnosis creates tremendous anxiety and uncertainty for both patients and their families,” said Dr. Craig Bunnell, Chief Medical Officer at Dana-Farber. “Not everyone wants or needs to come as quickly as the next day, but for people who do, such quick access to the expertise, care and support they need is tremendously reassuring.”

“Providing next day access immediately following a cancer diagnosis is part of our commitment to patient-centered care,” said Michael J. Zinner, chairman of the Department of Surgery at Brigham and Women’s Hospital (BWH). 

Well, sure.  We all understand that.  The opposite is awful, as I related in this 2012 story about my late friend Sonya from St. Thomas, VI, after her visit to DFCI, which I did not identify at the time:

In the winter of 2010, when I was still CEO of Beth Israel Deaconess Medical Center, Sonya called me to say she was in Boston for some tests. Biopsy results received on a Friday afternoon indicated two forms of cancer. She was in a turmoil. The people at one of Boston’s most distinguished cancer centers had given her this verdict and then told her they would set her up to meet with a medical oncologist in ten days.

Ten days? You give a woman test results showing two forms of serious cancer; she is over a thousand miles from home, staying alone in a hotel; and the best you can do is get her an appointment ten days hence? It is hard to imagine a more cruel act. We had dinner the next night, and she told me the story. I said, “We will do better for you.” I took her medical records and sent an email at 10 pm that night to several doctors at BIDMC, asking them to think about how we could help.

I called Sonya the next day, Sunday, at about 1pm, saying that someone was likely to be in touch. She replied, “Dr. Awtrey [our gynecological oncologist] already called me. He spent two hours on the phone with me this morning telling me what to expect and possibilities for treatment and promising to coordinate my care with the other departments. His secretary will pick up my medical records from your office tomorrow morning.” 

The next morning, Chris Awtrey’s secretary came by the office, and I asked her to express my appreciation to him for reaching out to Sonya on a Sunday. She looked at me with great seriousness and said, “Oh, there is no reason to thank him. Dr. Awtrey believes that the most important part of his job -- before performing any treatment -- is to spend as much time as necessary with a woman to help her be less anxious about her disease. That is the way he is. I can’t think of a more admirable person. It is such a privilege to work with him.”

Now, I know in my heart that DFCI doctors are also kind and caring. Why it took until this month to revise their procedures to give the kind of care that we would want for any member of our family is a puzzle to me. I hope and trust that their past standard of care was an anomaly among cancer centers, that their new approach is a long-standing norm around the country.

Unasked questions about global payments

The Boston Globe reports that Blue Cross of Blue Shield of Massachusetts is expanding its capitated, or "global payment," form of medical reimbursement.

The Massachusetts health care industry’s traditional system of paying doctors for every office visit, test, and procedure may be nearing its end.

Blue Cross will essentially pay doctors a set amount to care for their patients but payments will ultimately be tied to how well doctors and hospitals score on a variety of quality measures.

The company CEO is quoted:

“This is definitely a new phase. It’s a very important signal to the community and to the market that we want to continue to advance payment reform, promote accountability for quality and costs, and continue to move away from the fee-for-service system.”

The story takes as a given the possible benefits of this approach, but gives short shrift to any alternative points of view.  Beyond that, with all the encomiums included in the story, it lacks any mention of some very important unanswered questions. I've noted these before, with reference to issues that ought to be reviewed by the state's Attorney General:

[BCBS of MA] 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?

Are you a clumper or a splitter?

The Economist reports about an experiment in the National Health Service:

On February 25th it emerged that local authorities, clinicians and George Osborne, the chancellor of the exchequer, were proposing to transfer control of the £6 billion ($9.3 billion) of public money spent on health care in Greater Manchester to local hands. They want to create a health and wellbeing board, made up of NHS and local-government representatives, to administer a single budget for the conurbation. A trial version is expected to take shape in April. 

The city region’s doctors and hospitals will still be bound by national targets for things like waiting times, and subject to national regulations and inspections, but the board is a welcome idea nonetheless. It is bottom-up, pushed by local figures rather than imposed by the government, and it advances two positive trends.

The first is the integration of health and social care. Long-term conditions like diabetes, dementia and depression are now responsible for 70% (and rising) of Britain’s state health-care spending. They require a mixture of medical and non-medical attention.  

The second positive trend is that regional conurbations are becoming more powerful. Manchester has led the way: in 2011 ten local councils in and around the city formed a “combined authority” to manage services and infrastructure jointly.

But the initiative will also test Britons’ willingness to tolerate regional variation (or “postcode lotteries”, as tabloid newspapers call it). Andy Burnham, the opposition Labour Party’s shadow health secretary, warned that Manchester’s proposals could turn the NHS into a “Swiss cheese”, with some parts more autonomous than others; taking the “national” out of the National Health Service. 

The newspaper concludes:

Public services can be nationally uniform or locally accountable. They cannot be both.

Whether you live in the UK or not, what's your take?  Is this a good approach or not?  How would you measure success? Does it matter whether we consider the short term or the long term?

Darzi fellows at Royal Brompton

It was such a pleasure to meet four of this year's holders of Darzi Fellowships in Clinical Leadership, a program named in honor of Ara Darzi, one of world's leading surgeons at Imperial College London, who also devoted time during his career to the public service, as noted here:

In December 2006 NHS London asked Darzi to "develop a strategy to meet Londoners' health needs over the next five to ten years" and so his report Healthcare for London: A Framework for Action was published on 11 July 2007. Largely implemented, it recommended the development of academic health science centres and the introduction of more primary services in one place: polyclinics. The plan for moving care from hospitals to GP-led polyclinics was largely thwarted by GP opposition, but his call for trauma, acute stroke and heart attack services to be centralised in specialist units achieved was seen as successful and was widely copied.

The fellowship named in his honor:

is one of the most successful clinical leadership development programmes in London, with over 200 Fellowships having been awarded to date. This innovative programme provides a cohort of clinicians, who are typically in the early stages of their career, with a unique opportunity to develop the capability necessary for their future roles as clinical leaders.

Fellowship posts are twelve months in duration and require that time away from normal work or training.  Over that time fellows work on a major project (or in some cases a number of projects) covering service change, quality and safety improvement or leadership capacity building, under the guidance of a nominated sponsor - usually a Medical or Clinical Director or equivalent.

Seen above are the four fellows in residence at Royal Brompton & Harefield NHS Foundation Trust, where under the guidance of individual mentors and Dr. Libby Haxby, lead clinician in clinical risk, they are pursuing areas of interest to them and their hospital. They are an impressive group, who will surely be among the clinical leaders of the future.  From the left:

Julian Lentaigne, respiratory and intensive care medicine, whose project is "Improving communication and aftercare on discharge from intenisve care."

Andrea Fischer, pharmacist for critical care, whose project is "IT-system design across the hospital; improving digital care records."

Claire Boynton, anaesthetics and ICU, whose project is: "Customer service improvement in ICUs."

Elsa Ng, pediatric cardiac pharmacy, whose project is "Digital care records: Change management."

Buffett explains private equity

As I read this excerpt from Warren Buffett's annual letter to shareholders, all I could think of was the private equity acquisition of the Caritas Christi health care system.  As I have noted, this transaction will have a tail that will leave Massachusetts policy-makers with difficult choices.  Just think of the implications of a hospital system being considered "a piece of merchandise."  What plans are being made now to protect the provision of essential health care services in several Massachusetts communities?

When owners wish to cash out entirely, they usually consider one of two paths.  [A competitor or] the Wall Street buyer. For some years, these purchasers accurately called themselves “leveraged buyout firms.” When that term got a bad name in the early 1990s – remember RJR and Barbarians at the Gate? – these buyers hastily relabeled themselves “private-equity.”

The name may have changed but that was all: Equity is dramatically reduced and debt is piled on in virtually all private-equity purchases. Indeed, the amount that a private-equity purchaser offers to the seller is in part determined by the buyer assessing the amount of debt that can be placed on the acquired company. 

Later, if things go well and equity begins to build, leveraged buy-out shops will often seek to re-leverage with new borrowings. They then typically use part of the proceeds to pay a huge dividend that drives equity sharply downward, sometimes even to a negative figure.

In truth, “equity” is a dirty word for many private-equity buyers; what they love is debt. And, because debt is currently so inexpensive, these buyers can frequently pay top dollar. Later, the business will be resold, often to another leveraged buyer. In effect, the business becomes a piece of merchandise.

If patients only knew

Austin Frakt and Aaron Carroll offer this fantastic perspective on patients' lack of knowledge about the relative risks and benefits of common treatments.  The conclusion:

Even though some patients may benefit somewhat from being ill informed, it seems wrong to argue that we should keep them in the dark. Many of the studies in the systematic review show that people report that they would opt for less care if they better understood benefits and harms. Improved communication could better serve patients and might improve the efficiency of our health system if patients focus on getting the types of care for which the benefit outweighs risk of harm.

It’s also possible that unrealistic expectations of care help patients cope with disease or provide them with some sense of control. Feeling hopeful about one’s future is not to be dismissed. But those unrealistic expectations don’t come cheap. We should at least consider the price that we pay for being uninformed.

Brandi speaks out on heading in youth soccer

I've never met Brandi Chastain, but I've admired her playing for years, and now I have discovered that we agree on a major issue with regard to youth soccer--heading.  Her observations--that heading in soccer should be removed for players aged 14 years and younger, although training in heading technique could start at younger ages with appropriate pedagogy and protection--are a refinement on the points I have written about before.

Check out this PBS Newshour story here and watch her video interview here:

Medical students see hospice up close

Photo by Gabe Souza, Portland Press Herald

Here's a wonderful story from University of New England medical school in Maine by Kelley Bouchard at the Portland Press Herald.  It relates the experience of pairs of medical students who chose to spend some deep immersion time at Gosnell Memorial Hospice House. (One of the students, Caitlin Farrell, is an alumna of the Telluride Patient Safety Camp.)

McVan and Farrell are among four students in UNE’s College of Osteopathic Medicine in Biddeford who, at their own request, spent recent weekends living and working at the home for terminally ill patients. The pilot Hospice Immersion Project provided unique exposure to end-of-life care in a nation whose medical schools are giving short shrift or largely ignoring a growing demand for training in long-term, palliative and hospice care. It also was an intense introduction to the realities of dying and death for students on the cusp of becoming physicians.

Admitted in pairs, the second-year med students spent two days learning from hospice staff and helping to care for patients and their families. They stayed in suites where people had died and their loved ones mourned. They followed nurses and physicians on their rounds and journaled about what they saw and heard. They got to know patients and their families and learned what it takes to care for people in their final hours.

There were some surprises:

“I was surprised how uplifting it was,” Gaul said. “Of course it was sad, witnessing the loss of each patient, but it also was a celebration of each patient’s life. The communication and the energy that each nurse and physician brought to each patient was amazing. It was beautiful to see.”

The students then reported back on their experiences to their classmates:

Farrell urged her classmates to be compassionate but honest with their patients when dealing with issues related to death and dying. And to embrace and promote hospice care as a way of experiencing death as a natural part of life.

“We don’t have a choice in this,” Farrell said. “We have to have these conversations. We as physicians can’t act out of fear.”

Pledging for quality in Australia

It's only 11 days, or 10 days, or 9 days till Change Day 2015 (March 11) in Australia.  I'm not sure how many days are left because that darned International Date Line always gets me confused.  (Maybe that's why Australia often beats America to the punch in terms of safety and quality improvement in hospitals: It has a one day head start!)

In any event, it's not to late to join in (locally or vicariously) with Mary Freer and the other organizers.  Well over 13,000 people have done so, and the range of pledges is remarkable.  Here's the gallery.

Here's a good personal one from Margie Grant in Victoria:

To always find out the “patient story.” Remember they are a person first and their illness is second.

In contrast, here's one from a big group:

The Australasian College for Emergency Medicine (on behalf of its 4265 Fellow and trainee members) pledges to promote the implementation of our Quality Standards for Emergency Departments to support EDs in improving the care they deliver to patients requiring emergency care in Australia.  

Alone or together, your ideas can make a difference to the quality of care in Oz.  Take a look and make a pledge.