In memoriam: Marc Roberts

Sometimes unexpected news takes your breath away, and this was one such instance.  I just learned that Marc Roberts died this past weekend.

We never worked together, but we led parallel lives for decades--he in academia studying and writing about major societal issues like energy and health care, while I would work in organizations in the same fields.

In this announcement from Harvard, Professor Michael Reich said, “Marc’s insights, his intellect, and his humor on all sorts of issues will be sorely missed by his colleagues and his students around the world.”

Exactly: Insights, intellect, and humor.   Missing one, he could have been any of many academics who conduct research and write about topics, but the combination was unbeatable.  I loved his company.  I never tired of it and was left craving more after our visits.

It wasn't always serious stuff, though.  As a house gift for the Cape Cod house he and Mary Ann owned, I gave them a tide clock.  He had a great laugh when I told him to make sure he adjusted it for Daylight Savings Time!

I know we all have to go eventually, but I just wish Marc hadn't had to go so soon.

How to make sure no one will report the next time

From a Washington Post report on the CDC anthrax problem:

Farrell had been reassigned following the June incident, and his future at the CDC was uncertain before his resignation this week. Sean Kaufman, a biosafety expert who also testified at last week’s congressional hearing on lab issues at the CDC, said Farrell had unfairly been made a scapegoat.

“Michael immediately reported this incident. He did what he needed to do as a scientist. And when he did that, the repercussion was a loss of a job,” said Kaufman, a former CDC employee who conducted a training in Farrell’s lab as recently as this spring. “This is nothing but pointing a finger and holding a scientist responsible for something that’s a systemic issue within an organization.”

Kaufman said the hasty departure of Farrell, whom he described as a meticulous scientist, father of two boys and Navy veteran, could discourage other employees from reporting future lab incidents and ultimately undermine safety.

And how motivational is this?

“These events should never have happened,” CDC Director Tom Frieden said, even as he noted that no one had been sickened or harmed. “I’m disappointed, and frankly I’m angry about it.”

Hey, man, this was on your watch.  You arrived in June 2009.  And you were not a stranger to the place, having worked there from 1990 to 2002. 

It is better for a leader to take ownership than to blame others.

This one won't be on the daVinci website

The Baltimore Sun reports on a study:

Using robotic techniques to remove a cancerous bladder doesn't reduce the risk of complications compared with conventional "open" surgery, according to a new comparison of 118 patients conducted by surgeons at the Memorial Sloan Kettering Cancer Center in New York.

The study, detailed in the New England Journal of Medicine, marks the first ongoing comparison of the risks and benefits of the two techniques. Past studies concluded that the robotic technique meant less time in the hospital and fewer complications but they were done by looking back at the records of already-treated patients.

"There's been a lot of hype surrounding robots and it's been hard to gain perspective," said Dr. Vincent Laudone, one of the coauthors.

"Bottom line: It looks like it was pretty much a wash," Laudone told Reuters Health. For patients, it means "if you're going to a surgeon who is experienced in traditional surgery and recommends traditional surgery, that's a reasonable recommendation."

"These results highlight the need for randomized trials to inform the benefits and risks of new surgical technologies before widespread implementation," he and his colleagues concluded.

Really? What a great idea.

We must dream just right

A nugget from Gene Lindsey:

The tension arises from the image of the perfect being balanced against what it is practically possible to accomplish. This is the hardest step for dreamers like me. Dreaming small is hard. Dreaming too big leads to failure and frustration. Like “Goldilocks,” we must dream just right.

MDs in Missouri say, "Show me."

Here's a fascinating story in Governing about Missouri's approach to alleviating a physician shortage in rural areas.  (Thanks to the folks at Commonwealth Magazine for the tip in one of their daily newsletters.)  The lede:

A new Missouri law allows recent medical school graduates to practice primary care in underserved areas without completing a residency in a teaching hospital.

The Missouri State Medical Association, the law’s chief backer, is calling it an unprecedented effort to help deal with doctor shortages in rural and other underserved areas, but opponents raise questions about whether circumventing the traditional path to the exam room will do more harm than good. 

The article goes on to explain:

Missouri’s law, signed by Gov. Jay Nixon earlier this month, carves out a new classification called “assistant physician.” The law allows medical school graduates who have completed their licensing exams but haven't finished a residency to practice immediately in underserved areas. These graduates have to join a primary care practice of a “collaborating physician” who agrees to accept responsibility for an assistant physician. An assistant physician, who can legally be called a doctor, has to practice continually with his or her collaborating physician for one month before being able to serve independently.

My buddy Rosemary Gibson, a board member at the Accreditation Council for Graduate Medical Education, doesn't like the idea.  She is:

warning other states not to follow Missouri's lead because rural residents are sicker, older and poorer, on average, than the country as a whole. She said the Missouri law goes well beyond the scope-of-practice laws that have popped up in state legislatures. 

“On the surface, it looks like a quick fix, but I think it really behooves [policymakers] to do their homework, to understand what it means to have a graduate of a medical school be called doctor, to have prescriptive authority for powerful drugs like narcotics, to accurately dose and treat people,” she said. “Primary care is not simple. If you have a lot of older people living in rural areas, they have a lot of co-morbidities [such as diabetes combined with heart disease].”

I've run the story by other experts in medical education.  Another buddy, Dave Mayer, said:

I don't like the new law either. But it made me think and ask myself the following question: What is worse...Putting a new medical school graduate on an acute care hospital floor July 1st and asking them to take care of many hospitalized patients into the evening with little in-house supervision or asking a new medical school graduate on July 1st to take care of a few non-acute, non-hospitalized patients in a clinic where there is another fully trained/completed residency MD on site during the time they are working? Both have serious flaws but the second non-acute scenario sounds less scary to me. 
 
Of course, it can be a false choice to compare one scenario to the other, but the point is well made.  What's your take?

Ties that bind

Martha Bebinger over at Commonhealth gets it quite right when she describes recent comments submitted to the Trial Court about the AG-Partners Healthcare System proposed settlement:

Quite an “only in Massachusetts” moment.

Patriots owner Robert Kraft and leaders of Raytheon, Suffolk Construction and Putnam Investments have all filed letters in support of an anti-trust agreement that would not normally see the light of day before a judge approves the deal. The opposition includes public health professors, a group of top economists and politicians battling Attorney General Martha Coakley in the governor’s race.

Most of the supporters focus on Partners’ leadership in the medical community and don’t dive into the details of its alleged anti-trust practices and the proposed remedies.

John Fish, chairman and CEO at Suffolk Construction, says Partners is “vital to the city and region’s economy.” 

Suffolk is the largest general contractor in Massachusetts, with double the volume of the next ranked firm.  Health care facilities are a major business line for the firm.

For those outside the state--and perhaps for some of those inside--let's review the association this latter commenter has with the Partners health care giant.  In so doing, I don't mean to impugn anybody's reputation or the quality of his work--or his commitment to the community or any heartfelt personal feelings he may have about the deal--but I do mean to suggest that there are business relationships present that are worth noting and rightfully could have been included in the story.

A major tenant in Patriot Place in Foxboro is Brigham and Women’s/Mass General Health Care Center. Regular readers will recall when I wrote about this 75,000 square foot facility in 2009. Here's a picture:

Guess who built that structure?  Suffolk Construction.

The Patriot Place structure is not the only PHS building completed by Suffolk.  A major one in the Longwood area is 420,000 square foot Shapiro Cardiovascular Center.  Here:

And then there is this advanced modality suite at Brigham and Women's Hospital. And a forthcoming 620,000 square foot research center at Brigham and Women's Hospital.

If we assume very conservative construction costs ($1000 per square foot is not unusual in the Longwood Medical Area), the capital cost of these buildings likely exceeds $1 billion. Now to be fair, Suffolk has also done work for other hospitals in the Boston area, including a small addition at a community hospital owned by BIDMC, but clearly the major construction in town has been at the PHS facilities.

Given Suffolk's relationship with other hospitals on those other building projects and their opposition to the AG's deal, if you were a major construction firm, wouldn't you choose to remain neutral?  Why would you risk annoying Partners' competitors by affirmatively supporting the agreement?  Perhaps this is what Martha meant by an "only in Massachusetts" moment.

MIT SDM Conference on Systems Thinking

Systems Thinking for Emerging, Evolving, and Established Leaders

October 8, 2014, at MIT

MIT SDM Conference on Systems Thinking for Contemporary Challenges

"Systems Thinking for Emerging, Evolving, and Established Leaders" is the theme of the 2014 Massachusetts Institute of Technology Conference on Systems Thinking for Contemporary Challenges, sponsored by the System Design and Management program. The event will be held on October 8 at MIT in Wong Auditorium.

 

Speakers will include leaders from industry, government, and academic sectors who will discuss:

• How to use systems thinking to align and lead functionally and geographically dispersed teams that are tackling complex challenges;
• Ways to monitor progress and results;
• Benefits achieved, lessons learned, and next steps for developing leadership within organizations and individuals; and
• How systems thinking has advanced organizational objectives and benefited their careers.

Back-to-the-classroom sessions will be offered on October 7 for SDM alums and others interested in learning about the latest MIT research in systems thinking. For more information on attending these sessions, please contact SDM Industry Codirector Joan Rubin.

 

Speakers for the above events include MIT SDM faculty, as well as industry experts from The MITRE Corporation, NASA, Hacking Medicine, the US Air Force, and more. There will be ample time for Q&A and networking.

 

We invite you to join us!

 

Details

Registration

Why America is a great country

I was at a restaurant and tore off the paper napkin ring.  To my amazement, I saw that it was patented, number 6644498 to be exact.

It dates back to 2001.  Here's the abstract:

A continuous strip of individual napkin ring blanks that can be separated to form a plurality of napkin rings. Each individual ring blank extends between a leading edge and a trailing edge and includes a first adhesive area and a second adhesive area. A line of perforation is formed between the leading edge of one ring blank and the trailing edge of the preceding ring blank such that the ring blanks can be separated from each other. Each of the ring blanks includes a pair of angled locating surfaces formed near its leading edge and a pair of angled locating surfaces formed near its trailing edge to provide a visual indication of the line of perforation between the ring blanks.

Note that the adhesive is not part of the patent, but how it is placed is a key element:

In accordance with the present invention, the adhesive area positioned on both the front and back surface of the napkin ring is a conventional adhesive as is currently used in the industry. The adhesive area must be strong enough to hold the napkin ring in place around a set of silverware and napkin.

How can you live in America and not appreciate the genius of our patent system?  I mean it.  Without patent protection, this advance likely would never have made it to the marketplace.  Would that have mattered?  You bet.

Kevin Drum at Mother Jones also noticed this (in 2009) and explained more about its value to the world:

The patent is not for anything to do with the napkin ring itself but for the packaging method: they're sold on a roll instead of in a box.  This is apparently a boon to wait staff and busboys everywhere.

Continuum of Care on WIHI

Madge Kaplan writes:

The next WIHI broadcast — From Prehospital to In-Hospital: The Continuum for Time-Sensitive Care — will take place on Thursday, July 24, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:

• Kedar Mate, MD, Vice President, Institute for Healthcare Improvement (IHI)
• David Williams, PhD, Improvement Advisor and Founder, TrueSimple
• Jonathan R. Studnek, PhD, NRP, Quality Improvement Manager, Mecklenburg EMS Agency (North Carolina)
• Kevin Rooney, MBChB, FRCA, FFICM, Consultant in Anaesthesia and Intensive Care Medicine; Professor of Care Improvement, University of the West of Scotland

When it comes to reliability, it’s hard to beat the track record of paramedics and EMTs. Whether it’s speed, knowing just what to do in the event of an accident, serious injury, gun violence, or heart attack, or the amazingly calm and reassuring way emergency responders go about their work, there are plenty of reasons to heap praise on this group of individuals. This also includes how patients are cared for during that ambulance ride to the hospital emergency department.

Could our opinion of EMTs get even higher? Maybe so, now that emergency medical services (EMS) are becoming part of fully integrated health care systems and paramedics are being trained and equipped to initiate even more life-saving and beneficial treatments in the field. This is the evolution we’re going to look into on the July 24 WIHI: From Prehospital to In-Hospital — The Continuum of Time-Sensitive Care.

Our guides — Kedar Mate, David Williams, Johnathan Studnek, and Kevin Rooney — have a compelling story to tell about dramatic changes underway with EMS, not just in the US but globally. The very use of the term “prehospital” reflects new strategies and capabilities to respond more effectively to patients suffering heart attacks, strokes, and traumatic injuries. In a growing number of communities, the suite of possible activities and early interventions have become part of overall best care, continuous with what happens next in the hospital. Patients at risk for septic shock are also being targeted for early recognition and initiation of treatment by EMS staff.

Advances in remote technology and communications are enabling many of the changes taking place with the most urgent types of medical events. But this isn’t the full story. EMS systems are also starting to bring their expertise and sometimes routine care to the bedsides of patients who live in remote rural areas, to elderly patients who are homebound, and to people with behavioral health issues — all requiring medical attention and support, but not necessarily a trip to the hospital​.

We hope you’ll join us on July 24 to learn more and to share your journey with prehospital care. You can enroll for the broadcast here.

Time for HOPE Award nominations

Recognize someone who is doing great work!

Nominations are now being accepted for the 2014 MITSS HOPE Award.  This prestigious award is being sponsored by RL Solutions, and the winner will receive a cash prize of $5,000 to continue their important work.

Take this opportunity to honor someone who is making a difference.  Note that self-nominations are welcomed, and submissions from anywhere in the United States and Canada are encouraged.

Nominations are due by Friday, September 19th, 2014, and the award will be presented at the MITSS 13th Annual Dinner and Fundraiser to be held on Thursday, November 13th, 2014, at the Westin Boston Waterfront, Boston, Mass.  Click here or visit www.mitsshopeaward.org for eligibility criteria and submission requirements, to access an online nomination form, check out past winners, and much, much more!

Not at the beach

We have to award the best quote of the season to the Boston Globe's Shirley Leung:

You don’t have to go to the beach to look for flip-flops this summer. There’s a pair in the gubernatorial race.

She then tells the story of how two candidates changed their positions with regard to the Attorney General's deal with Partners Healthcare System.

For my part, I don't care if they changed their positions, as long as they have come to realize the flaws in the deal.

Robots invade the rest of the world

There's a lot of good news in this story by Jaimy Lee at Modern Healthcare, but there is also a warning.  The good:

Intuitive Surgical saw its revenue and income fall again in the second quarter as sales of its da Vinci robotic surgery systems continued to drop.

The use of robotic surgery systems in gynecologic procedures such as hysterectomies continued to decline, and that trend is not expected to reverse, company officials noted during a call with investors.

The warning:

Worldwide procedure volume for the company's products went up 9%, led by . . . a higher number of urologic procedures outside of the U.S.

This reminds me of what happened when demand for cigarettes went down in the US.  The tobacco companies then focused on new markets abroad.  The company reports:

The da Vinci Surgical System is being used in hundreds of locations worldwide, in major centers in the United States, Austria, Belgium, Canada, Denmark, France, Germany, Italy, India, Japan, the Netherlands, Romania, Saudi Arabia, Singapore, Sweden, Switzerland, United Kingdom, Australia and Turkey.

Gary Schwitzer presents comments, though, that suggest that some of our Canadian friends are looking at this all a bit more rationally:

With surgical robots popping up all over Ontario and other provinces, eventually the public will be asked to cover the costs of these robotic surgeries. Perhaps these robots should be regionalized to maximize efficiencies and thereby lower operating costs? However, every institution wants to be on the cutting edge and have their own robot. Currently in Ontario there are daVinci robots in London, Ottawa, Hamilton and at 5 sites in Toronto. A number of high-volume community hospitals have successfully raised funds to purchase a robot in the near future. With the proliferation of robots, individual institutional volumes will be lower, driving up costs per case. Perhaps regional robotic centres of excellence in each province would be more efficient and cost effective.

Will other countries learn from the US experience?

A sign of the times

There's a good article by Paul Demko at Modern Healthcare about narrow networks, "Providers, insurers grapple with narrow-network backlash." Here's the lede:

Narrow networks are a reality of the new health insurance landscape. Nearly half of all insurance plans sold on the public exchanges in 2014 were narrow network plans, defined as those with less than 70% of area hospitals included, according to an analysis by the research firm McKinsey & Company.

But given that reality, insurers and providers need to do a better job of providing consumers with accessible, easily understandable information about networks when they shop for coverage. That was the message conveyed by participants in a panel discussion about network adequacy on Monday in Washington sponsored by the Alliance for Health Reform.

Need to do a better job?

Sorry, but didn't they think about this beforehand? If we add in the expanded use of high-deductible plans, there is a sea change in what "insurance" actually means. I'd have hoped the industry was more attuned to consumer response than to look back and say, "We need to do a better job."

Coaching through failure

I hope you enjoy my latest submission at the athenahealth Health Leadership Forum.

And please be sure to read Jim Conway's commentary on that site.

Thanks.

Barry opines on the AG-Partners deal

Barry Carol often offers thoughtful comments on this blog about health care issues in general and about Massachusetts in particular (even thought he lives out of state.)  He has chosen to comment to the Trial Court about the proposed settlement between the Attorney General and Partners Healthcare System.  He, like others, submitted comments in time for the July 21 deadline.  We all later learned that the AG had asked for a postponement, so that the case will not be heard until after the September gubernatorial primary in which she is a participant.

I've previously posted excerpts from Professor Alan Sager's comments, as well as my own.  I'm sure there are many more that will be submitted in objection to this deal.  If you have filed comments, please send them to me at goalplayleadership [at] gmail [dot] com, and I'll do my best to publish excerpts.  Thanks!

Here's Barry's filing:

I would like to offer a comment on the Attorney General – Partners Health System proposed agreement.

First, I think the proposed deal does not do enough to mitigate the significant price premium paid to the Partners Health System facilities compared to competing hospital systems for similar work and comparable outcomes. These price premiums are paid because of PHS’ dominant local and regional market power. The resulting higher healthcare costs and health insurance premiums make it more difficult for Massachusetts employers to raise wages as much as they might otherwise.

To mitigate this problem, I think there needs to be full price transparency from all providers and all payers. Confidentiality agreements that currently preclude disclosure of actual contract reimbursement rates need to be eliminated so both patients and referring primary care doctors can more easily determine the cost of care before services are rendered and compare prices charged by all providers in the market. We want as much care as possible to be delivered by the most cost-effective high quality providers and we need full price transparency to facilitate this.

I also think insurers should be able to contract with either Massachusetts General Hospital or Brigham & Women’s instead of having to either accept both hospitals in their network or neither.

To the extent that patients like to go to higher cost hospitals that offer better amenities even if they don’t affect medical outcomes, insurers need to be able to charge insured members enough more to go to those facilities to get their attention. Tiered insurance networks should be encouraged.

Healthcare in Massachusetts is the most expensive in the country, I believe. Since the 2006 reforms signed by then Governor Mitt Romney were largely a model for developing the Affordable Care Act, healthcare developments in Massachusetts are closely followed at the federal level. I think the proposed deal with PHS shortchanges the people of Massachusetts and is way too favorable for PHS.