Sunday, January 05, 2014

Focus on the gold standard

I'd like to make a number of subtle and not-so-subtle points today, and I hope you'll stick with me.

A friend and I have ongoing debates about whether Obamacare will make a difference in the practice of medicine in the US and whether that difference will be, for the most part, good or bad.  Interestingly enough, we often find ourselves taking the opposite viewpoints from what we each argued a month or two earlier!  Here's where I have come out after a nice winter break and having now viewed many health care institutions and societal arrangements around the world.

You cannot bolt on a communitarian solution to a health care system that is inherently impersonal and inhumane and expect that the resulting framework will have humanitarian characteristics.  That, for all the commentary, is what Obamacare is trying to do and what its advocates proclaim is the future.  They argue that changes in payment methodologies, an emphasis on preventative care and so-called "wellness,"* and integrated health care delivery systems will inexorably move us down the path to the Triple Aim:  Improving the experience of care, improving the health of populations, and reducing per capita costs of health care.

I would like to think that these folks (many of whom are close friends and distinguished experts) are right, but I think they are fundamentally wrong in their expectation that any externally imposed institutional framework will achieve those results.  Please recognize that I am not in any way arguing against the tenets of Obamacare--universal access to health insurance and removal of nasty rules about pre-existing conditions and lifetime coverage limits.  Nor am I making this argument because the President misrepresented the potential of the law when he promised access, choice, and lower costs.  Indeed, I accept (reluctantly) that his set of promises was a necessary political precondition for getting anything through Congress and changing the shameful situation of millions of uninsured Americans.

Rather the issue is this: As we see from examples around the world, even where there is universal access to health care and where there is coordination across the spectrum of care from birth to hospice, the actual delivery of care as felt and seen by patients and families is simply substandard.  By substandard, I mean that it seldom meets what I would call the gold standard: "The kind of care you would want for members of your own family."  What does that standard imply?  It implies a partnership between caregivers and patients and families of the sort so eloquently outlined by e-Patient Dave deBronkart and his medical partner-in-arms, Danny Sands and by Ted Eytan, Jim Conway, and Pat Sodomka.  It implies a change in the way work is carried out in hospitals and other health care facilities, one that is respectful of front-line staff and empowers and encourages them to identify process improvement opportunities. It implies a full integration of human factors measures designed to offset the physical and neurological cognitive errors that human beings make, as MedStar's Terry Fairbanks has persuasively described.  It implies a full integration of the principles of crew resource management into the hierarchical environment that has to exist in procedural settings, as practiced by Marck Haerkens and others. It implies an expanded view of health care system responsibilities in the community, of the sort practiced by Jeff Thompson and his engaged staff at Gundersen Lutheran.**

As you look at that list, you see that such changes are seldom if ever brought about by government fiat, whether legislative or regulatory.  Likewise, they are virtually never the result of pricing designs or other actions by private or public payers.  Neither are they dependent on such government rules or payer actions. Instead, they rise from within when the leadership of health care organizations--i.e., senior administrative and clinical leaders, supported by their governing bodies--have the desire, guts, and commitment to make them happen.

I've decided that it is distracting to expect the kind of global changes envisioned by the Obamacare advocates.*** The nature of change is that there will be industry leaders and industry laggards.  In other fields, the "disruptive" organizations eventually overcome the incumbents and drive industry-wide structural change.  In health care, this is less likely because of the geographical constraints on care delivery.  While technology might mitigate some of those geographic factors, much of care will always require physical accessibility between patients and caregivers.

In light of this dispersed industry structure, I view my personal advocacy role as one quite different from many of my friends and colleagues.  You see it in the masthead of this blog: I am an advocate for patient-driven care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement.  I do not believe in global change, though, nor do I expect it to arrive or even be helped much by government leaders in Washington, London, Amsterdam, or Jerusalem. I aim not to change the world but to try to help organizations and leaders who are committed to this general direction and are willing to take the personal and professional risk that it is, quite simply, just the right thing to do.  Those brave people, paradoxically, are usually the ones who, like Contra Costa's Anna Roth, are most modest about what they know, about how to accomplish change, and about progress to date.

With luck, publicity about our successes might help create a broader movement in support of the gold standard, but I am not counting on that.  Meanwhile, we'll do our best to make life (and death) better for the patients and families and clinicians in those health systems that care and act like they care. That will be reward enough.

* Stay tuned on this front to a forthcoming book by Al Lewis and Vik Khanna.
** Beneath and around all those elements, the gold standard requires a different kind of training and reward system for physicians and other clinicians.  By this, I do not mean a financial reward system.  Such has been shown to be ineffective in so many settings.  No, we need a reward system that is meaningful to those well-intentioned people who have devoted their lives to eliminating human suffering caused by disease.  I'll return to that in future blog posts.
*** Take it further. As a thought experiment, or Gedankenexperiment, just consider what would have happened if we had simply expanded Medicare to the entire population. As we have seen, even this well-intentioned single payer system has never been able to escape from politically inspired rules and payment regimes that have done little to help us meet the Triple Aim, much less the gold standard outlined above.


Gary M. Levin said...

You describe our current and future health system issues very well. Our underlying system is so broken that a 'quick fix' will not will make the system much worse by adding a lot of chaos. This was a rush job to sooth the masses.Politics becane an overriding issue, and the end result is what we have now. Planned and chosen by people who do not understand the complexity of our system. Simply paying for health care does not address non uniform coverage, even with a standard set by the Federal Government forinsurers. I doubt very much whether our present providers and hospitals can or will deliver on these standards. I came across an op-ed in the web site by Eugene Robinson, It goes something like this,

Here is a short extract from the first paragraph,

""Now that the fight over Obamacare is history, perhaps everyone can finally focus on making the program work the way it was designed. Or, preferably, better.
The fight is history, you realize. Done. Finito. Yesterday’s news.
Any existential threat to the Affordable Care Act ended with the popping of champagne corks as the new year arrived. That was when an estimated 6 million uninsured Americans received coverage through expanded Medicaid eligibility or the federal and state health insurance exchanges. Obamacare is now a fait accompli; nobody is going to take this coverage away."


Paul, you are a very highly respected authority in this field and in the social media world. I am fearful that social media is not adequate to making the necessary changes. It is a good beginning to inform the consumer, however essentially we are speaking to the 'choir'

It is time for real bring real attention to the fatal flaws of this law. It must be amended, Firstly after giving it much thought for 12 months, it should be put on hold while a solution is found.

Perhaps letters to Congress would help, but they do not listen. The AMA is a joke waffling on this matter, seeking to be a reasonable negotiator, however the government is not negotiable. Any government that would take away a basic right forcing citizens to purchase anything cannot read the constitution. It bumps up against the right for citizens to overthrow the government in a peaceful manner.

The time has come fo individual physicians and hospitals to individiually decide without conspiracy to boycott, slow down or refused the ACA entirely. Our patients will understand....They will support physician's efforts in this regard. They don't want to be extorted either. This plan is not about affordability, access, nor quality care. It was written for insurance companies, and pharma. I hope you will join with me in this effort.

- See more at:

Unknown said...

I suspect many of us fall into the category of "reluctant pessimist" and this blog states that case quite eloquently

Paul Levy said...

Sorry, Gary. Not interested in that approach. I cannot imagine putting health care insurance on hold for millions of people, even if improvements to the law might be possible.

In any event, that's really not the point I was arguing. There's good work to be done in America's health care institutions. I'd rather focus my time and energy on that.

Paul Levy said...

BTW, if you'd like to see Terry Fairbanks' actual presentation instead of just the slides (or both), here is the link to the youtube of that south carolina presentation:

John Gallagher said...

Thanks, Paul. What I appreciate about this is the sense of ownership you take for this. It really isn't about blaming the government or waiting for them to fix a flawed law. For me, it is about ME being naive enough to believe that the work I do (to help Healthcare organizations remove waste from their system, and to coach the executives in these organizations how to see that waste so THEY can coach their teams), will have an impact on the Triple Aim. Thanks for sharing.

DCpatient said...

Paul, very thoughtful and well-written, but I do think it give short shrift to the power of incentive changes. Yes, ultimately it will take that transformation of healthcare workflow and culture, but what spurs those changes? We’ve all spoken to folks inside health systems who know what the right thing is and who want to do it, but it goes against the financial viability of the institution. Change will not happen without the policy and payment structure to support – whether from government or the market.

C Johnston said...

Interesting point. Two issues with the approach of stating that what health care needs is good leadership and that Obamacare won't solve its problems:

1. I don't see this as particularly sustainable or replicable. It is equivalent to saying that we need more people like Steve Jobs to promote innovation in the American economy. If having good leadership is the only real solution, how do you recommend (if at all) improving the poor performance of the American health care system?

2. Why do current health care leaders support the Obamacare approach? If you are arguing that leadership matters and leaders say that Obamacare will improve care, I think you have to speak to this point. Here is a link about a poll in which "93 percent of hospital executives think Obamacare will make health care better" (, and today on Meet The Press, the CEO of Mayo Clinic said, "We need to modernize the payment system to drive better outcomes to pay for results. We need to take advantage of tech." Both of these are central tenets of Obamacare.

Anonymous said...

As the friend with whom Paul has had all these debates (many quite pointed), I think the commenters have missed his point entirely. Without putting words in his mouth, which he will correct if I do, my interpretation of his post is that it is nothing less than a call to arms - not to do anything at all about Obamacare, but simply to do *the right thing.* And the right thing in care of sick people is easily identified, and again eloquently stated by him - to give the care you would like to have given to your own family.

If one thinks about insurers, hospital administrators, doctors and yes politicians, it is stunningly clear that no one at all is doing the right thing. At best, they are doing it up until the point where it might conflict with their own interests, but usually not even that. Paul's point is that no government can do the right thing for you.

Don't want to do the right thing? (this part is my own opinion) Then a law like Obamacare comes along which, despite all its flaws, has accomplished what no one else has in many decades - begin the process of change in a way that now has gained momentum of its own. We may not end up where we thought we wanted to, but we will surely not end up where we started, and that is all for the better. Use the gold standard to make that ending work for your patients - and for your family.

Bill Springer said...

I fully agree with your observation that we are a long way from what we'd like to see as our future state health care system, and that government itself will not be the primary catalyst in making progress here. It will be local visionaries and leaders who are willing to push their health care organizations forward. What I do hope for is that the government can help enable the flow of information/data to allow consumers and payers to identify and reward those innovators by giving them greater volume. It will be local competition and money that will help determine winners and losers, and these are elements that the government, private insurers and consumers can influence and align with progress towards that future state of health care.

Paul Levy said...

Dear DCPatient,

I hear you when you say "We’ve all spoken to folks inside health systems who know what the right thing is and who want to do it, but it goes against the financial viability of the institution." But the truth of the matter is that the things I talk about are good for business under any kind of payment system. We proved that at my former hospital, as have others. Waiting for "the right incentives" is just an excuse.

Paul Levy said...

Dear C Johnston:

You ask: "Why do current health care leaders support the Obamacare approach?" Complicated answer. Part of the reason is that it gives acquisitive CEOs a government-sanctioned opportunity to grow their empires.

Part of the answer is that few people in positions of responsibility in a hospital setting want to be known as opposing the federal government--which, after all, finances 30-40% of their clinical operations.

Part of the answer is that hospital leaders like the idea that their patients will have insurance, rather than being a bad debt burden.

And, of course, part of the reason is that hospital people believe in the idea of universal coverage.

But my post is really not so much about that. It is about doing the right thing regardless of the government construct under which one operates. I focused on the US, but please note that I was also referring to the rest of the world, most of which has a more extensive nationalized system than ours.

Unknown said...

I believe, and I think then thrust of Paul's post is, as well, that

a) The ACA is not perfect but was achieved through deals with the devil, but it was the only way to get something passed that had the potential to drastically improve the status quo;

b) The ACA is necessary but not sufficient to achieve the Triple Aim. Without changes in financial incentives, vanishingly few organizations will do the right thing, since health care is not really a free marketplace (outside the self-pay market).

But even with ACOs and even Meaningful Use incentives, many provider organizations will continue to do just what is necessary to check the box so they can show they achieved a quality benchmark or performed a meaningless task. Witness organizations that are giving patients relatively content-free visit summaries so they achieve "meaningful use" and receive federal incentive dollars.

In the end, the ACA is laying the groundwork for more provider organizations to do the right thing. But not all of them will.

Once we create a true market with transparency of data, cost, and quality, then the cream will rise to the top and the substandard organizations that are just checking the boxes will lose market share.

Paul Levy said...

Nope, sorry Danny, that is not my thrust at all. I don't believe the ACA is necessarily laying the groundwork for provider organizations to do the right thing. And, in spite of being an economist, I do not believe that poorly performing places will lose market share. We also disagree mightily about financial incentives.

I believe that high performance organizations will be such because the leadership of those places choose to make it happen, virtually irrespective of governmental policies and payer policies. I do not think such actions occur in support of the Triple Aim, and I often find focus on the Triple Aim to be a distraction from the kind of improvements that can occur.

Test your premises this way: Did your exemplary relationship with e-patient Dave depend in an significant manner because of government or payer policies? I think not. It occurred because of your devotion to your patients and your understanding of the benefits of the kind of partnership that can arise in such circumstances.

Paul Levy said...

Bill Springer,

It would be excellent if such local competition emerged, but mergers and acquisitions by health care systems--encouraged by the law and without objection by the government--are actually leading to greater concentration of market power in many jurisdictions.

Bobby Franklin said...

Paul, You have now on at least a couple of occasions defended Obama's lying to the public in order to ram this disaster through. Now that the people are aware of those lies and are being hurt because them things are falling further into chaos. You are defending government corruption, which we all know is built into the system, but when the public is told to just sit back and accept it we are headed for a very dangerous state of affairs.
The fact is, these lies have led to more people being hurt then helped. People are paying more and getting less if they are able to get anything at all.
If you truly care about helping people, and I know you do, you should stop defending a corrupt government and work for a plan that would truly benefit everyone. This mess is only going to get worse and will cost lives. This is very serious stuff. Those of us that don't have the financial means and political connections will suffer the most.

Paul Levy said...

Hi Bobby,

I don't think I have defended the President about lying or misleading or whatever you want to call it before this post. In fact, I have been talking about his overstatements from the moment he started down the path on this legislation.

By the way, there is enough lying to go around on the part of lots of people in DC! Romney's dissembling on this this issue was a clear example.

In summary, I think this plan is, overall, good for the country, but it will not deliver all that was promised. It will, however, help lots of people get insurance who currently don't have it. I'm willing to live with the adverse consequences of the plan to help achieve that result.

Bobby Franklin said...

Hi Paul,
There is no getting away from the fact the President lied about this. Pointing to Romney's doing the same thing is no justification for it. Maybe I am naive, but on something as critical as this issue I believe everyone involve should have had accurate and complete information before moving forward with this. The goal should not just be making sure everyone has health insurance as that is no guarantee they will be able to afford it or have decent coverage. We should be focusing on the best ways to get people working in a system that works for them. Right now people are confused and scared, and with good reason. Our health care system was not a disaster before. It had problems that could have been fixed without tearing the whole thing apart. We have so many creative people in this country who have terrific ideas about how to make this work. Unfortunately, Jonathan Gruber is not one of them.
We have to entrust those who are going to put giving people more choice and access to health care ahead of those who see this as a way to control and dictate to people.
As I have said before, I have learned much from you and we are very much in tune with each other when it comes to managing a workplace. We differ very much in how we see the role of government in our daily lives. We both believe strongly in allowing people to be free to make decisions and be creative. You seem to believe government is a positive force in encouraging that while I see it as a major impediment. I suppose we are informed by our experiences.
I do hope this madness can be straightened out before more people are hurt or worse. I know you feel that way too.

Linda Galindo said...

"I am an advocate for patient-driven care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement." Me too.

I would like to work the solution from the patient side. What 3 questions would you have everyone who was able, ask their elected representative to get them thinking and, what 3 questions would you have the patient ask their provider to more fully own getting patient-driven care?

I have started my 3 questions on the patient side.
1. How much will it cost in total? I do not want to know what insurance will cover, I want to know total cost. (I do this before I go in for the service. It is usually an amusing series of phone calls and transfers but it is clearly educating the provider(s) because usually they don't know.)
2. Do you have a financial interest in the product or service you are referring me to?
3. If I am uncomfortable with a staff member or communication with you as I undergo my care, how do you want me to handle that?

As for questions to ask my representative(s), well I did try with Senator Hatch but am still trying to parse out what on earth his response (letter) said. I'm not sure if I need to learn double talk and how to decipher boiler plate response-speak or educate myself more to the political context of question asked and "where in all this is my answer?" I'll get there, and I'll admit the journey is keeping my interest. Would love input on what 3 questions would provoke moving things in the direction of advocating for patient-driven care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement. (I envision a letter writing campaign.) I don't think the law is going to solve any of this either but if I'm going to stay engaged with my representatives I want to be a provocateur via good questions and enroll others to do same.

"...changes are seldom if ever brought about by government fiat, whether legislative or regulatory." Agreed! And, as people are forced to interact with their own mindset (beliefs) there are instances of changing their mind! That is why I love this debate, it seems to be provoking change.

At the heart of it..."changing the shameful situation of millions of uninsured Americans."

To keep productively focused I only refer to the legislation as The Affordable Care Act. I find the the label "Obamacare" intentionally divisive. I don't care who came up with it, I want universal access to health insurance and removal of rules about pre-existing conditions and lifetime coverage limits.

That you for this rich post Paul. Lots to chew I'm taking small bites.

Ben said...

Thank you for the thoughtful reflection on where we focus our attention in health care. Your premise, that one cannot “ bolt on a communitarian solution to a health care system that is inherently impersonal and inhumane and expect that the resulting framework will have humanitarian characteristics” is exactly right. Indeed, acting as though you can “get there from here” results in frustration and dead-ends.

That said, I think that it is not a matter of choosing broad ‘communitarian’ (read ‘policy’) level VS working at the individual patient level, BOTH are essential. Moreover, focusing on one to the exclusion of the other ensures failure of both. It is iterative. Currently, initiatives growing out of such values as prevention and wellness are in direct conflict with payment rules, resulting in many rural hospitals, for example, having to choose between providing wellness, prevention and primary care services (which are what are mostly needed) and making sure they have enough “heads in the beds” and reimbursable outpatient procedures (see Medicare conditions of participation) to stay solvent (because if they don’t, access to ANY care is threatened).

Ultimately, it is all about the patient (or, perhaps more accurately, the person). But for the patient/person to be effectively served, attention must be paid both to the individual patient experience and to the broader value/policy context within which that experience takes place. It is necessary and appropriate for individuals to choose where they want to put their energy but it is essential that both perspectives be aware and take responsibility for the effects (positive and negative) that their actions have on the other. The vision—which indeed seems a long way off—is that those perspectives (patient centered care and a policy framework that reinforces prevention and wellness) be aligned.

Richard said...

You have clearly articulated that real change, real transformation of health care, is driven by leaders leading their organizations differently.

The leaders that you mention are examples of leaders looking in the mirror and recognizing, “if it is to be it is up to me”. They are actively leading their hospitals and health care systems by being personally accountable and are ready to take the risks associated with being self empowered.

They are not waiting around for permission; they lead with clarity, vision, respect and trust. Thanks for the post Paul!

Barry Carol said...

Paul –

Assuming a hospital CEO wants to do the right thing, here are the issues that I’m interested in your perspective on how to address:

First, how to you get the support of the Board, especially if its historical focus was to grow revenue, profit and market share and, at the minimum, to sustain the enterprise?

Second, how do you get buy-in from doctors many of whom perceive the CEO, even if he’s an MD himself, as a “suit” who is mainly interested in protecting his own job, placating his Board and earning his bonus which is mainly driven by growing revenue, profit and market share?

Third, how do you stand up to rainmaker doctors, especially surgeons, who sometimes don’t want to hear about the need to follow checklists, take a timeout before a surgical procedure starts, or even to be reminded to wash his hands regularly? The fear is that if too many of these docs get ticked off, they will take their well insured patients elsewhere which could have a significant adverse financial impact on the hospital.

Perhaps the second and third issues could be mitigated if the doctors who practice at the hospital are hospital employees rather than independent contractors with admitting and practice privileges. Presumably the hiring criteria would have to include ensuring that the doctors on the team are comfortable working within a collegial and collaborative culture which is, as I understand it, the way it works at Mayo Clinic and Kaiser.

David J. States said...

Progress toward the Triple Aim can be achieved by focusing on activities that advance at least two aims. For example, the health of the population can be improved and health care costs reduced through public health measures such as reducing smoking, although not one where hospitals are necessarily the lead organizations. An area where hospitals do need to provide leadership is price transparency, and this will both improve the patient experience and reduce health care costs. The financial burdens of health care are not trivial, even for patients with insurance, and we owe it to our patients to make cost information accessible and understandable.

Paul Levy said...

Stay tuned, Barry, over the coming several days and weeks.

C Johnston said...


Thanks for the response. Doing the right thing is always important. Your post alludes to the idea, though, that this should be a preferred approach to health care reform, since you "do not believe in global change, though, nor do [you] expect it to arrive or even be helped much by government leaders in Washington, London, Amsterdam, or Jerusalem" and that "such changes are seldom if ever brought about by government fiat, whether legislative or regulatory". I read recently that Intermountain Healthcare was losing $1 million per year by vastly improving the quality of their community-acquired pneumonia care due to being able to provide that care in lower-cost settings. It is tremendous and incredible that they do this, perhaps even heroic, but to hope simply that others will follow and in fact rely on this heroism as the primary mechanism of change in the U.S. health care system seems absurd to me. In any business or industry, it will always come down to individuals and individual organizations leading and innovating, not the government doing it for them. There is a role for government, however, in realigning the incentives so that these people who are doing the right thing are not swimming upstream. I'm not a fan of government determining the microscopic components of providing care and paying for it (they have a terrible track record here: I do think they can and should play a role in creating the kind of climate where people and organizations doing the right thing are actually rewarded for it instead of punished.

Paul Levy said...

Thanks. Here's the thing:

Hospitals always have a mix of money-making and money-losing services. There have been many, many times over the years that hospitals have invested in people, plant, and equipment to provide services that lose money. Those are offset by other functions that make money.

If you were to look at the static case, they never would have decided to do the former and would have only focused on the latter. But they made a strategic decision to do both.

Yes, IH and others might lose some revenue from reducing pneumonia treatment, but overall they do quite well. Once you start giving financial incentives to "do the right thing," you risk unintended consequences in that such incentives are inevitably crude and imprecise. I'll discuss that in future posts.