Remembering our veterans: Not just a Monday holiday

A health care blogging break in honor of our veterans.  For a history of Veterans Day, see here.  I always liked that it is one holiday that does not get moved to the closest Monday:

Veterans Day continues to be observed on November 11, regardless of what day of the week on which it falls. The restoration of the observance of Veterans Day to November 11 not only preserves the historical significance of the date, but helps focus attention on the important purpose of Veterans Day: A celebration to honor America's veterans for their patriotism, love of country, and willingness to serve and sacrifice for the common good.

A murmuration of starlings

This is an absolutely astounding video, filmed in Ireland.

If you cannot see the video, click here.

Murmuration from Sophie Windsor Clive on Vimeo.

Coletta at MITSS

Carey Goldberg over at CommonHealth reported on a speech by Sandra Coletta, head of Rhode Island's Kent Hospital at this year's annual dinner of MITSS.  I won't steal her thunder, but will simply say that this is about the values demonstrated by a leader of a hospital when she acknowledged its systemic errors in the death of a patient.

Back in September, 2008, I related some stories of this type, where other leaders likewise took responsibility.  I am sorry that it remains newsworthy that a hospital leader would act in this way, but it is still unusual enough to warrant attention.

The SCAD ladies set an example

John Novack, from Inspire.com, a place that organizes online patient communities around various diseases and conditions, sent me this link to a great online report entitled, "The SCAD Ladies Stand Up: Stories of Patient Empowerment."

From the introduction: 

The “SCAD Ladies” story is an extraordinary one: women with a rare heart disease self-organized online and began studying their disorder. This patient initiated effort led to physicians at the Mayo Clinic launching new research to learn more about spontaneous coronary artery dissection (SCAD).

The first essay is by Sharonne Hayes, a Mayo doctor, who notes:

Enter “patient-initiated” research. Still in its infancy, this may prove to be the new “gold standard” for the study of uncommon medical conditions.

It stands to reason that the people most highly motivated to support or to even initiate investigations of a rare condition are those personally affected and their close relatives. Our experience with the “SCAD ladies”, Katherine Leon and Laura Haywood-Cory and their online “heart sisters”, provides an example of successful patient-driven, social networking–enabled research. Our pilot and ongoing studies demonstrate that if a large organized group of patients self-identify and present themselves to researchers as study participants, a major barrier to rare disease research can be eliminated.

Delivering a patient-prioritized research agenda to potential investigators, as was done by the SCAD group, also may serve as an incentive for busy clinician-investigators and help convince them to commit to a new line of research or to this unfamiliar study methodology. Many organized patient advocacy groups have developed research agendas. However, the highly engaged and committed women who prompted the SCAD study, linked only via the Internet, demonstrated levels of sophistication and specificity in their patient-initiated research questions that were on par with those developed by formally organized groups. They had clearly done their research, and as a result, allowed this researcher to more clearly visualize the potential of success.

Check out the other essays from patients, which follow in the report.  They are well worth reading.

We will spend many years dying

Here is an excellent post by Janice Lynch Schuster on Disruptive Women in Health Care.  The occasion was Steve Jobs' death, but she draws broader lessons.

Here's the one that struck home most to me:

For many years now, I’ve written on this subject with Dr. Joanne Lynn, a geriatrician and hospice physician. In our book, Handbook for Mortals: Guidance for People Facing Serious Illness, we talk about the living with/dying of conundrum. Americans like to talk about “the dying” as if they were a different sort of person, in contrast to the rest of us, whom Joanne characterizes as the “temporarily immortal.” Once someone has been labeled as dying, we expect him or her to go about the business of doing just that: taking to bed, saying farewells, making peace with God, signing up for hospice, giving up daily routines and purpose. We think of the dying as a distinct group, with different interests, and an entirely different role to play in this life.

The fact is, for Boomers like Jobs, we will spend many years dying of something. Nearly 80 million of us are aging together, and along the way, we will accumulate illnesses of old age: heart disease, cancer, and Alzheimer’s. Thanks to modern medicine and public health, we will live for a long time with what have become chronic conditions. Where these diseases once killed swiftly and uniformly, they are now chronic conditions with which we live—and from which we die.

Bravo to Brent James

Dr. Brent James last week was awarded Columbia Business School’s W. Edwards Deming Center for Quality, Productivity and Competitiveness. As described in the press release:

The Deming Cup grew from the center’s drive to highlight the achievements of business practitioners who adhere to and promote excellence in operations – the Deming Center’s area of focus. This award is given annually to an individual who has made outstanding contributions in the area of operations and has established a culture of continuous improvement within their respective organization.

Dr. James was recognized for his pioneering work in applying quality improvement techniques that were originally developed by W. Edwards Deming and others, in order to help create and implement a “system” model at Intermountain, in which physicians study process and outcomes data to determine the types of care that are most effective.

Imagine that, improving clinical care is consistent with efficiency in the health care system.  This has to be another lie, just like that stuff about Pronovost saving lives and reducing costs by reducing the rate of central line associated bloodstream infections.  Or assertions by that trio of fraud, Spear, Toussaint, and Kaplan.

This stuff can't be true.  If it were everybody would be doing it.  Right?

Back on January 15, 2009, I published a post entitled "What does it take?", in which I expressed frustration with the slow pace of process improvement in hospitals.  What followed in the comments was a virtual seminar by some of the country's leaders in the field.  They are still worth checking out.  Brent offered his point of view:

Paul, you have put your finger on what I regard as THE core task of the present generation of the healing professions. It is very clear that we are in the midst of a transition. The term of art that is usually used to describe the present state – and which Don Berwick so eloquently explained (at least, at the level that an individual physician would experience it) – is “the craft of medicine.” It’s the idea that every physician (or nurse, or technician, or administrator, etc.) is a personal expert, relying primarily on their personal commitment to excellence. In a very real sense, every physician occupies his/her own universe, with its own reality, truths, physical constants. As a physician I might say to a colleague, “What works for you, works for you. What works for me, works for me. Let’s both stay focused on the patient – our core fiduciary commitment to put the patient first in all things – and that will guarantee the best possible results.”

David Eddy said it most eloquently: This core assumption of the craft of medicine is scientifically untenable.

As a direct result of some solid research around this fact, the healing professions are in the midst of a major sea-change, a once-in-a-century shift: We’re moving from “medicine practiced as individual heroism” to “medicine as a team sport.” The kinds of tools you’re talking about make perfect sense in a team setting, but almost no sense within the craft of medicine.

Don is right in calling it culture change. However, we are well past the tipping point. There is strong evidence that the professions have committed to a new course and are actively moving. It’s the difference between 5% of the profession “getting it” (where we are now), and moving to a point where it is standard, accepted, background business essentially all of the time.

The key change concept was perhaps best expressed by Winston Churchill: “People like to change; they just don’t like to be changed.”

I am also deeply impressed by Roger’s classic text on change: Diffusion of Innovation. He describes bottom-up change, by sharing results (both data and word of mouth) from initial thought leaders (his “early adopters”). That has worked very well for us, and makes the change fun – rather than something that a bunch of external “know nothings” are trying to do to you. 

You only have three seconds

In my continuing occasional series about entrepreneurs, I present this gentleman, a shoeshine guy at the corner of Sixth Avenue and 47th Street in New York City.  Street vendors often engage in hawking to attract business, but this fellow is a master.  As people walk by, he turns from the current customer's job, makes eye contract, and offers a pithy phrase that is meant to draw business.

"When are you going to do something about those shoes?

"Don't you love her?  What about those shoes?"

"Are you selfish?  Think of those shoes."

When I remarked on how effectively he segmented the market, (i.e., how well he seemed to understand what would work with different folks) he said, "You only have three seconds to make a connection."

It worked on me.  As I walked by, all he did was to shake his head from side to side and say, mournfully, "Those shoes . . . ."

Entitlement or naïveté?

I make it a practice of saying, "Yes," to any student or young professional person who wants career advice.  This serves two purposes.  One is to provide (hopefully) helpful assistance to someone starting his or her career.  The other is for me to be rejuvenated by the energy and idealism of the next generation of community leaders.

This week, a person who is involved in health care consulting at one of the big firms sought advice about how to move from that environment to a job "somewhere in the provider-payer space."  (By the way, I hate the term "space" when it is used in this manner, but I have learned to expect it from consultants and venture capitalists.)

The person thought that the ideal job would be to join the internal strategic planning group in a large academic medical center.

I advised against this.  I pointed out that such groups are often marginalized in AMCs.  They tend not to be respected by the doctors and nurses, because they are viewed as not understanding the obligations, work flows, and other issues associated with delivering clinical care.

I suggested, instead, that this person seek a "line" job in a hospital, helping to run an ambulatory clinic or some other operational role.  "Learn what it is like," I said, "to organize how care is delivered, dealing with nervous patients, stressed out nurses, and doctors with strongly held views.  Over time, you will demonstrate good work and initiative and how make changes.  Based on that, you may be asked to participate in task forces that help set the strategic direction for the hospital.  By then, too, you will be known and respected by clinicians and therefore less likely to be marginalized."

The response was firm and immediate: "No, I don't want to do that.  My salary would take a cut, plus I want to be involved at a higher level in the institution."

I was struck by this.  Just a short time out of MBA school, followed by a stint as a consultant, this person was confident s/he would provide value in the corporate planning function of the most complicated type of business in the world.  Whatever happened to the idea of starting low, learning what life is like on the front lines, demonstrating ability, and working one's way up the ladder?

Instead of being rejuvenated by the energy and idealism of someone in the next generation, I felt like I was facing an overabundance of entitlement.  Perhaps, though, I took it the wrong way.  Maybe it was just naïveté.

Texas-sized shoot-out

It has been some time since I reported on the Parkland Memorial Hospital saga.  A new article about things in Dallas draws us back to events in Texas.

Here's the title: "Ask the Editor: DMN Managing Editor George Rodrigue responds to accusations from UT Southwestern's Dr. Daniel K. Podolsky".  Here's the link.  Here's the lede:

Our Sunday story on patient safety indicators among Texas’ larger hospitals drew a rather heated response from Dr. Daniel K. Podolsky, president of UT Southwestern Medical Center. His University Hospital-St. Paul finished rather badly in the standings, and Dr. Podolsky accused us of cooking the books. His theories are incorrect – we played it straight, and we included all the necessary caveats about the limitations of our data – but maybe, if you care about journalism or health care, you’ll find our dialogue to be an interesting debate. As usual in these cases, we’ve printed Dr. Podolsky’s full comments below, along with our response.

I am sure that public relations consultants across the country are viewing this as a case study in media relations.

South Carolina on WIHI

Organizing for Health: A Story from South Carolina
November 3, 2011, 2:00 PM – 3:00 PM Eastern Time

Guests:
Rick Foster, MD, Senior Vice President of Quality and Patient Safety, South Carolina Hospital Association

Kate B. Hilton, Director, Organizing for Health; Principal in Practice for Leading Change at the Hauser Center for Nonprofit Organizations at Harvard University

Landis Landon, President, Immaculate Merchant Services; Resident, Columbia, South Carolina

In August of this year, a very different sort of town hall meeting was held in Columbia, South Carolina. About 90 people who shared the zip code 29203 sat down to talk about the health issues they faced. The list was long: lack of dental care, colon cancer, breast cancer, diabetes, heart disease, stroke, mental illness, low birth weight babies, and more. Any one of these issues is worthy of attention; indeed, in most parts of the US, you can find initiatives trying to either prevent or reduce the burden of specific diseases that affect specific individuals. But what if the approach was more comprehensive and more widespread – and, most importantly, engineered by the community itself? What if hundreds of people from across the community –representing neighborhoods and businesses and insurance companies and local hospitals and municipal offices and professional schools – all decided to band together to turn things around?

That’s what the people decided in Columbia, South Carolina, and WIHI is pleased to welcome to the program some of the key leaders behind the effort – Rick Foster, Kate Hilton, and Landis Landon – to describe their groundbreaking mobilization.

Some of the concepts and goals underpinning the Healthy South Carolina campaign are quite familiar, such as expanding the role of primary care and helping everyone become more physically active. What sets this initiative apart is the strategy. It starts with training some 300 leaders by the end of this year (2011). They’ll play several roles, but will focus in part on fanning out across Columbia, SC, to work directly with residents on creating pathways and programs to better health. There will also be a major emphasis on improving everyone’s health literacy and communication skills. And every part of the community’s health care delivery system is pledging, along with insurers, to engage in serious discussions about how to improve access to primary care, reduce reliance on emergency departments for non-urgent problems, and reduce costs.

Yes, it’s just the beginning stages and yes, it’s just one community. And no one knows whether this multi-year effort will succeed. Still, at a time when new models of better health, better health care, at reduced per capita costs, are badly needed, Healthy South Carolina is an initiative to root for, learn from, and watch. WIHI Host Madge Kaplan hopes you’ll join her and her guests on Nov 3. Invite someone from your community to tune in with you!  

To enroll, please click here.

l'equip petit

Of all the football (i.e., soccer) videos I have seen, this is the most inspiring.  It captures the beauty of the game through the eyes of the young players from a team in Spain.  It provides intense validation for those of us who coach youth teams.

If you can't see the video, click here.


l'equip petit from el cangrejo on Vimeo.

Blog roll revisions and invitation

Attentive readers will note two changes in my list of blog links (to the right.)  First, I have moved blogs related to Lean process improvement into the "Transparency" category.  The two are so interrelated that it made sense to combine them.  If you write a blog about Lean, I would be happy to consider it for inclusion.  Just offer it in a comment below.  Also, if you are part of a hospital association, hospital, or other organization that is strongly committed to transparency and have a website or a blog about that, please let me know in a comment below.

Second, I have updated several other blogs to indicate a "dormant" status.  These are blogs that have been officially closed by their writer or are otherwise inactive but have a wealth of information and interesting points of view that still deserve reading.  An example is Mike Sevilla's Dr. Anonymous.  (Mike is now over at Family Medicine Rocks, where he offers a slightly different perspective on things.)  Another is Lester Leung's Apollo, MD, which gave us a travelogue in his journey from pre-med to the beginning of residency.

Ohio steps backward on transparency

After expressing enthusiastic support for many quality initiatives by hospitals in Ohio, I must report with disappointment an action by their trade association to dismantle the state's hospital transparency website.  This article summarizes:

The Ohio Hospital Association (OHA) is backing a piece of recently introduced legislation that would free hospitals from the requirement to report performance data such as measures of heart and surgical care, infection rates and patient satisfaction.

The reason?  Alleged duplication of effort with the CMS Hospital Compare website.  According to an OHA spokesperson:

The time and effort spent on reporting the data to the state as well as the federal government reduces the resources Ohio hospitals can devote to patient care.

To which I reply, "Bull twaddle!" (This is a family blog, or I would use stronger terms.)

First, let's acknowledge that the data presented in the the CMS site is old, very old.  It accomplishes little or nothing with regard to transparency.  As I have noted:

While you cannot manage what you do not measure, trying to manage with data that are a year or two or more older is like trying to drive viewing the road through a rearview mirror. The principles of Lean process improvement and other such systems suggest that real time "visual cues" of how the organization is doing are essential. Why? Because that kind of data is indicative of the state of the organization right now, not what existed months or years ago.

Second, let's be real about the amount of time this state-run site "takes away" from delivering patient care.  This data would be collected regularly by hospitals, as part of delivering patient care, even if there were no federal or state reporting requirements.  It is not an incremental responsibility.

Next, the Ohio Department of Health says:  “It was an unfunded mandate for ODH to collect the information and make it public."

To which, I can only repeat the above, "Bull twaddle!"

Since when does a state agency get to complain about unfunded mandates from the legislature that supervises it?  (You only get to complain about unfunded mandates if a higher level of government imposes a cost on a lower level of government.)  The staff of the agency get funded every day they work there.  This is a matter of priorities.  In any event, this is a gross overstatement of the amount of effort needed for this task.

I am willing to bet that a graduate student or health care club at OSU, Case Western, or one of the other fine schools in Ohio would gladly set up and maintain a voluntary website for the Ohio hospitals.  Each hospital could enter through a password-protected portal to enter real-time data about the metrics that are of value in pursuing important quality and safety goals.  At virtually no cost.  It would take seconds, not even minutes or hours, to enter it once a month or once a quarter.  As I have noted:

Such data are collected in hospitals on a current basis. If their main purpose is to support process improvement, they do not need external validation or auditing to be made transparent in real time.

Come on, Ohio.  Don't step backward.

AMCs: Off target and lacking a sense of urgency

As noted in a previous post, I was impressed negatively by a Mt. Sinai hospital paid op-ed that extolled the virtues of academic medical centers while making no reference to the role that such centers could play in improving the quality of care delivered in America.  While acknowledging the attributes of AMCs, I said:

But these statements fail to tell the story of how academic medicine, in many institutions, is failing the American public.

It does not, for example, explain why many AMCs have been slow to adopt proven tools of process improvement to reduce harm to patients and improve efficiency. 

It does not explain the  persistent lack of transparency in many such institutions with regard to clinical outcomes, notwithstanding the documented value of such transparency in improving quality and safety. 

It does not explain why the medical schools that own or are affiliated with many AMCs have failed to train their students in how to use the scientific method to improve the delivery of care.

It does not explain the huge variation in practice among residents and attending physicians, giving lie to the concept of evidence-based medicine.  

It does not explain the reluctance of many AMCs to engage patients and families in the design and delivery of care.

A friend referred me to a summary of TEDMED talk by Daniel Kraft, which reinforced these points:   

Notably Daniel spoke about how when he finished his training at Massachusetts General Hospital 15 years ago the hospital still functioned, from an delivery standpoint, in about the same way as it does today, with specialty silos, defined training hierarchy, etc.

I am guessing that Daniel's talk was mainly on how to leverage new technologies in the health delivery system, but his observation applies more generally, too.

Ironically, one of those Mt. Sinai op-eds (John Morrison and David Muller, "Science and Medicine in the Service of Society," September 10, 2010) made related points:

Historically, medical schools emerged within universities primarily to educate physicians, yet Master’s and Ph.D. programs centered at medical schools now produce the vast majority of the scientists trained in biological arenas relevant to medicine.

All too often, these programs simply co-exist, isolated by different curricula and cultures. If we are to maximize our capacity to impact clinical practice through scientific discovery, we need to produce leaders in biomedicine and health care who see themselves as members of large, interactive teams committed to clinically relevant breakthrough science.

Meanwhile, Michael Nielson in the Wall Street Journal notes that networked science uses "online tools as cognitive tools to amplify our collective intelligence. The tools are a way of connecting the right people to the right problems at the right time, activating what would otherwise be latent expertise."

He notes, though, that this is not rewarded in the field:

Even if you personally think it would be far better for science as a whole if you carefully curated and shared your data online, that is time away from your "real" work of writing papers. Except in a few fields, sharing data is not something your peers will give you credit for doing.

How interesting that people in academic medicine are able to see the need for a more integrated, cooperative, and collaborative approach to medical training, research, and work flows when it applies to the advance of basic science and technology, but they have yet to modify the structure of their academic centers to allow such behavior to thrive.  And, beyond that, they remain blind to the idea of applying those same concepts to the actual delivery of care.  Were they to do so, we could be saving thousands of lives right now, well before the next great cures to disease are developed.

Example:  At a recent meeting of medical academic leaders, the president of one center proudly reported over the growth in faculty, in enrollment, in buildings, and so on at his institution.  Someone asked him about systematic quality improvement.  He cited improvements on Press-Ganey results, acting as though this was the surrogate for quality improvement.

Off track and too slow, folks.  Too slow.  As we have seen, if you don't start to define the important clinical improvement issues and make progress, the government will do it for you and do it wrong.

Recall what Captain Sullenberger said, ""I wish we were less patient. We are choosing every day we go to work how many lives should be lost in this country."

"We have islands of excellence in a sea of systemic failures. We need to teach all practitioners the science of safety."

A green car!

Heavy wet snow combines with leaf-laden trees to offer an opportunity for a new paint job -- and more -- for my little Honda civic hybrid!

Danielle will find your lost pet

I have written about a number of new businesses on this blog, in health care and beyond, but none has caught my attention as much as Compassionate Pet Services.  Owned and operated by Danielle Robertson, the company helps pet owners recover their lost animals.

Danielle notes:

Losing a pet is a very stressful and even traumatic experience.  A well organized search plan provides the best chance to bring your pet home safely.  Unfortunately, most people do not know how to effectively search for a lost pet, and the advice that you receive from well-meaning people and the information that you find on the internet may be inaccurate or just overwhelming. 

Compassionate Pet Services is here to provide the services, information, and resources that you need to help find your lost pet.  I am a certified Missing Animal Response Technician and have been helping people find their lost pets since 2009. 

I never knew there was such a thing as a Missing Animal Response Technician, but Danielle actually has extensive training in wildlife management and then special training in this field of finding lost pets.  To learn more, you can check out her blog, Lost Pet Research and Recovery, and for dramatic and moving stories of recoveries, Lost Cats Found.

Here's a sample: 

Many of you may have heard about the tornado that tore through Springfield, MA, and  surrounding towns on June 1, 2011.   One man, Michael Roescher, was home with his step-daughter and their seven cats when the tornado leveled their house.  Initially he was convinced that none of the cats had survived, but then he miraculously found their goldfish still alive in the rubble.  With renewed hope and the help of many friends and strangers, Roescher persisted in his search, and he was able to find all seven cats over the course of five days and none were seriously injured.

Best of luck to Danielle in her venture, and good luck to all of you searching for your lost pets.

Addressing health care at Jewish Family & Children's Service

Charlie Baker and I shared a podium today at the annual meeting of the Board of Advocates of the Jewish Family & Children's Service.  JFCS provides a multitude of services to the community, and does so very well, and we both felt honored to be invited.  We were led in a panel discussion by Sy Friedland, former CEO of JFCS, on the topic of "What's going to happen in health care, no matter what happens in Washington?"  (You see Sy and Charlie in this photo.)

Before attempting a run for Governor in 2010, Charlie was CEO of Harvard Pilgrim Health Care, a highly respected health insurance company in the state.  In previous lives, he served both as Secretary for Administration and Finance and as Secretary of Health and Human Service for the Commonwealth.  As you might expect, he has lots of thoughtful things to say about the health care system.

I remember, during the campaign, that Charlie explained the major items of his health care platform to be increasing payments to primary care doctors and other cognitive specialists, with the purpose of giving them the chance to spend more time with patients and thereby avoiding as many referrals to higher paid specialists; pursuing broad-based transparency of cost and quality to offset unsupported reputations of certain hospital and physician groups that were thereby able to exercise undue market power; and to create coordinated medical management programs for the 120,000 dual eligible people in the state.  These are folks who are "old enough for Medicare, but sick and poor enough for Medicaid."

As Charlie noted today, dual eligible people constitute 20% of Medicare subscribers, but account for 40% of Medicare spending.  Likewise, they account for 15% of Medicaid enrollees, by 30% of Medicaid costs.  Based on relatively small pilot programs in the state, covering about 15,000 to 20,000 people, coordinated management of these patients results in service delivery at 30% lower cost than the two uncoordinated programs.  (My keen readers will quickly note that these contracts are annual fixed fee payments based on patient risk characteristics -- the one clear example that capitation can work in selected environments.)

Charlie's remarks were timely during the gubernatorial campaign, and they were more so today, in the Governor Deval Patrick has announced that he wants to create just such a program.  Charlie graciously complimented the Governor on his intentions in this regard.

That still leaves his other two items to be implemented.  Both remain excellent ideas.

Dump your old drugs safely this Saturday

This Saturday is "National Prescription Drug Take-Back Day."  This is a program originated by the U.S. Drug Enforcement Administration to fight drug abuse by adults and teenagers in the United States.  Studies show that people who abuse these types of drugs get them by raiding the medicine cabinets of their friends and family members.  To keep unused or unwanted prescription drugs out of the hands of drug abusers, on Saturday, between 10 a.m. and 2 p.m., people can safely throw away their unused prescription drugs at designated collection sites around the country.

I see a further value in that this offers a safe disposal regime for return of unused antibiotics.  If you throw unused antibiotics down the toilet, they can end up entering the ecosystem, where they can help create disease resistant bacteria or, even thought less likely, harm fish and wildlife.  In this program, they will be properly destroyed.

Also, of course, expired drugs may be ineffective or even harmful.  For example, taking expired tetracycline (an antibiotic) can cause serious kidney problems.

You can find a local collection site on this webpage.

Hospital Pumpkins

As we approach Halloween, there's been a lot of pumpkin traffic on my blog this week, linking back to this site about a pumpkin carving contest at my former hospital.  Here it is.  Some great images (one at left)!

Rational economic creatures?

I heard a wonderful talk by Abhijit Banerjee, economics professor at MIT, about his and Esther Duflo's new book entitled, Poor Economics.  Here is a short summary, accompanying this video interview of the authors.

Why do the poor remain poor despite a million different strategies to counter poverty? Well, perhaps because policies that deal with poverty alleviation are often based on cultural and literary stereotypes of how the poor are "lazy or enterprising, noble or thievish, angry or passive, helpless or self-sufficient." And therefore we often rely on over simplistic policies with readymade formulae - "Free markets for the poor," "Make human rights substantial," "Give more money to the poorest." A new book, Poor Economics, tries to make one key point - let’s stop staring at data and theories, and understand instead the coherent story of how really poor people live their lives.

The authors present several examples of policy and programmatic interventions that have failed because policy-makers do not take the time to understand how things work on the ground in these poor communities.

I am struck by the similarity to many proposed interventions in health care.  In the last several days, I have discussed this with regard to penalties for failure to meet certain metrics regarding patient readmissions to hospitals.  But it is a broader issue.  For example, a move to capitated rates of pay is viewed by some as the sine qua non of health care policy.  I have noted that there is little empirical support for this approach, even if it might have a sound economic rationale.

But does it have a sound economic rationale?

Still feeling the after-effects of a morning at MIT, where I first learned the term over four decades ago, I propose we conduct a gedanken experiment.  That is, let's consider a hypothesis for the purpose of thinking through its consequences.

I put forth the following thought experiment.  Advocates of capitated, or global, payments argue that the current system of fee-for-service medicine leads to overuse, in that doctors and hospitals have a financial incentive to conducts tests and procedures to generate revenue.  The economic underpinning of a global payment system is that hospitals and doctors are rational economic creatures.  Setting a per-patient budget, it is argued, will cause the hospitals and doctors to work within that revenue envelope to deliver care more efficiently.  They are at risk for any over-spending and they get to keep the surplus if they beat the budget.

But, answer me this.  Let's say, we have a system where, say, 25% of the patients are on a global budget and the remainder are on a fee-for-service payment plan.  

If the economic theory is correct, that the hospital and doctors are rational economic creatures, shouldn't we notice a difference within the same provider network in how the global patients are treated from how the FFS patients are treated?

Let's turn away from the thought experiment briefly to review real data.  I pose a question for my readers:  Has such a difference been documented in those systems that have this mixed payment regime?  I think not.  But if you have counter examples, please provide cites to support your answer.

But now, pretend you are running that hospital and physicians network.  As suggested above, you believe that professional ethics should not allow your system to treat people differently based on the kind of insurance plan that covers them.  So, you instruct everyone to think about all patients as though they are covered by the global fee.  You do this even though you suffer revenue losses from the FFS patients, who, by the way, remain the majority of your patients.

If we do this, haven't we just disproven the hypothesis that doctors and hospitals are rational economic creatures?

So, which is it?  Are they rational economic creatures, willing to treat identical patients differently based on pricing?  Or, are they not rational economic creatures -- treating all patients alike -- in which case the theoretical basis for global payments appears to be problematic?