A child of the digital age

The New York Times has published a fascinating story about the successes and tribulations of Uber, the digital taxi company.  To me, the really interesting part is the portrayal of the founder and CEO, Travis Kalanick.  I don't want to overstate this, but Mr. Kalanick embodies some characteristics of the "digital generation" that are problematic.  Specifically, while his digital skills are unquestionable, his interpersonal skills might need some work.

The story starts with a hint of the problem:

Mr. Kalanick, who is brash and aggressive even by the standards of Silicon Valley, created Uber four years ago to blow up the traditional taxi business. In more than 60 cities, from San Francisco to Berlin, it is doing just that. Anyone with a smartphone can use Uber’s software to get a ride. . . .  For that achievement, Uber is valued at $4 billion.

There have been some recent incidents, though, that raise questions about aspects of the company's business model and, in particular, its assertion that its service should not be regulated by traditional hackney licensing boards.  Mr. Kalanick agreed to talk to a reporter about these matters, but apparently he did not fully understand the way a CEO might want to talk to a business reporter.

About a recent accident involving an Uber driver who hit 6-year-old Sofia Liu and injured her mother and brother and has been arrested on suspicion of vehicular manslaughter:

In a testy interview at Uber’s offices here, Mr. Kalanick declined to discuss the accident except in the most general terms.

“We work our butts off to go above and beyond what is expected even by the regulators, including insurance, background checks,” he said. “And so it always comes back to, did Uber do something wrong?”

Whew, what a way not to give a positive impression of a caring company!

Not exacty the right response when the competition is able to deliver another kind of message:

The San Francisco Cab Drivers Association, which is losing drivers to Uber, prominently offered condolences to Sofia’s family on its website.

 “Uber may be the next Amazon, but Amazon doesn’t have the same potential capability to leave a trail of bodies in the street,” Trevor Johnson, a director of the association and a driver himself, wrote in an email. 

When asked about another incident, one in which a driver and a passenger got into a verbal and physical altercation late one night in November:

Mr. Kalanick declined to comment about this episode, and shortly afterward, ended the interview.

But, look, he is comfortable dealing in a digital format with people:

David Krane, who last summer led a $258 million investment in Uber by Google Ventures, was full of admiration for Mr. Kalanick and what he called his “superpowers,” including his attention to detail. 

“I know very few chief executives that on New Year’s Day would answer 100 customer service inquiries in public,” Mr. Krane said.

I think the head of the cab association has a good point.  When a company in the digital arena arrives on the streets or in people's homes or businesses to deliver goods or services, it enters into different kinds of business risks.  It would be a good idea to train the CEO of such a company in the basics of person-to-person communication.  I know too many people of the digital age who say, "Well, email and texting are a more efficient way to communicate."  Let's remember that empathy is the most powerful communications tool, one that most often has to be displayed in person.

Surviving Workplace Wellness

One of the fastest growing sectors in health care comprises the firms that promise that wellness programs will make your employees healthier, will save you (as an employer) money, and will help bend the curve for health care costs in general.  The folks who have undertaken this line of work--and the employers that are complicit with them--are skewered in a new book by Al Lewis and Vik Khanna called Surviving Workplace Wellness, currently available on Kindle.

Vik provides a good summary on his blog:

The biggest delusion in Obamacare is the idea that clinically based workplace wellness programs will save either money or lives. They are, in fact, a big government, big company-propelled fantasy that the way to spend less money is to spend more.

Al Lewis and I have penned the antidote to workplace wellness programs for employees who should resent having the privacy invaded, their medical care disrupted, and their money taken for the sake of the government and employers exerting even more control over their lives.

Surviving Workplace Wellness stars the State of Nebraska, Penn State University, Health Fitness Corporation, Truven Health Analytics, WellSteps and a roster of other workplace wellness vendors who missed the casting call for Dumb and Dumber.

Al and Vik use a new technique in characterizing these programs: Analytic rigor, based on actual data, actual costs, and actual results.  They pierce the veil of political correctness on this topic, explaining how human resources departments align with vendors and insurers to exploit the understandable hope of all of us that there is a holy grail in the health care world.

Yes, Virginia, many wellness programs are part of the medical-industrial arms race.  Thanks to Al and Vik for making the truth evident to those who are willing to keep an open mind.

How a fish rots

As we wait for the Board of Trustees of the University of Illinois to indicate whether they plan to investigate the various ethical issues surrounding the recent usurpation of the University of Illinois name and reputation, it is illustrative to look at other aspects of financial dealing between high-ranking University officials and private firms.  As state employees, these folks file annual disclosure forms with the Secretary of State, and the information I summarize here is taken directly from those filings.  I don't have time to go through them all, so I will focus here only on one person.

The Dean of the College of Medicine is required by the University's research processes to sign off on financial disclosure forms and manage and mitigate any potential conflicts of interest.  The Dean indicates on his own annual state forms that he is on the board of Novartis, self-styled as "one of the highest-ranked pharmaceutical and healthcare companies by sales in the world." He also receives consultant fees from Forsight Labs and Alcon Labs, a Novartis company.

Let's reflect on the Novartis code of conduct, which includes this thoughtful advice to employees and governing bodies:

Would your family and friends think it was ethical for a Novartis board member who oversees a large portfolio of research at a university, including research related to the areas in which Novartis and its competitors conduct business, to make determinations of whether researchers in that school are infringing on conflict of interest standards?  Would the answer matter if a portion of that person's own research and educational funding or consultant fees or honoraria had come from that company before becoming Dean?  Would you be comfortable reading about that relationship in the media?

Please understand that I am not suggesting that this person has done anything illegal or that he is personally immoral.  Indeed, the facts presented above are those filed by him in the state documents. But what message is sent to other doctors by this affiliation? Does it send a clear signal of high ethical standards, of the need to protect the University's excellent clinical and research programs from possible disrepute?  The salaries paid by the University are set by the Trustees to be sufficient, in and of themselves, to attract world-class people to work in leadership positions.  When deans ultimately step down from their jobs, they are viewed as extremely attractive candidates for health science company boards.  Why not just wait a few years to cash in, when there is no likelihood of sending the wrong signal throughout your faculty?

In Chicago (as elsewhere), follow the money

Curious observers have been asking me why someone at the University of Illinois would knowingly aid and abet an effort to use the University's reputation to support the commercial objectives of a private firm.  I suspect that, when the facts come out, it will be about the money.  But I am just speculating.

Let's imagine the following scenario.  A major manufacturer of medical equipment, which has succeeded in part by recruiting surgeons to be its spokespersons with the public and in medical conferences, finds that its place in the capital market is faltering.  This may be a result of a number of adverse incidents related to the technology.  It may be because the market for its machine has become saturated, and it is facing a harder time entering new market segments.

Analysts on Wall Street are talking:

• Sell-side analysts aren't happy with the lack of revenue guidance offered by Intuitive Surgical (ISRG) after its Q4 earnings report.
• J.P. Morgan says the earnings call was a disappointment, and that the 2014 outlook is murkier than just a week ago.
• Morgan Stanley says its expectations for guidance were muted, but its below consensus 2014 EPS outlook is coming down another 10%.
• BAML says the stock remains Buy rated but investors must brace for another year of negative earnings growth.
• Canaccord says it wouldn't be buyers on weakness.

This would be an opportune time to conduct a direct-to-consumer national marketing campaign, burnished by the reputation of a major academic medical center.  Some people in that center have been participating in financial gain from the company in the form of "compensation from the company for providing education services to other surgeons and patients."  Or, perhaps in other forms.

So the company and those people decide to create an advertisement, loaded with people in white coats, to give the impression of an institutional endorsement of the company's product.

Or maybe I have it totally wrong.  Maybe it is an absolute coincidence that doctors who have been receiving compensation from this company have appeared in the advertisement.  Maybe they posed for another picture, which was used without authorization by the company.  Maybe they are totally innocent dupes.

The University requires its researchers to file financial disclosure forms every year.

Did the doctors referred to in the advertisement file these forms?  Most, as researchers, are required to: Dr. Antonio Gangemi reports on LinkedIn that he and Dr. Pier C. Giulanotti "have started two main research projects aiming to develop guidelines for training and credentialing in robotic surgery." Dr. Enrico Benedetti lists extensive research activities on his UIC home page, as does Dr. Bernard Pygon.

Questions to be answered:  Are these forms a matter of public record? Since they are financial disclosure forms designed to promote unbiased research and encourage public confidence in the accuracy of research endeavors, we'd like to think so.  What do they say?  Is there any review of those forms by University compliance administrators?  For that matter, does the University have compliance administrators who are charged with reviewing the accuracy of such forms?  Is there any reconciliation between the dollars listed on the forms and the state tax filings of those individuals?  After all, the University is a state entity and could require such a reconciliation.

That's a start.  This whole issue could be cleared up by the University's Board of Trustees.  So far, the entirety of their public response is published here:

Supply chain management on MIT SDM webinar

Webinar–Supply Chain and Risk Management:

Making the Right Decisions to Strengthen Operations Performance

MIT SDM Systems Thinking Webinar Series

Ioannis Kyratzoglou, SDM '11
Principal Software Systems Engineer, MITRE Corporation

Date: January 27, 2014
Time: Noon – 1 p.m. EDT
Free and open to all

Register

 

About the Presentation

 

This webinar will discuss the supply chain operations and risk management approaches of large companies. The presenter, Ioannis Kyratzoglou, will:

• Describe company operations and financial performance in the face of supply chain disruptions;
• Propose a systems-based framework and set of principles to help companies analyze and assess controllable and uncontrollable risks; and
• Explain four key principles that companies can use to better manage supply chain risks and prepare for future opportunities.

He will also discuss how leaders can use this systems-based framework to better understand a company's position in the market relative to its competitors. 

 

A question and answer session will follow the presentation.

 

We invite you to join us!

Where is the UI Board of Trustees?

Enrico Benedetti is Head of the Department of Surgery of the University of Illinois Hospital and Health Sciences System. On January 19, 2014, Dr. Benedetti appeared in an advertisement in the New York Times Magazine that purported to represent the endorsement by the University of Illinois of the daVinci surgical system, manufactured by Intuitive Surgical, Inc.  The advertisement, as I have noted, bears a copyright from Intuitive Surgical, Inc. and in, my mind, warrants extreme disciplinary action against the highest ranked clinical and administrative University officials who approved it.

On January 23, 2014, Dr. Bernard Pygon was designated by the University of Illinois Board of Trustees to be Acting Chief Medical Officer of the University of Illinois Hospital and Health Sciences System, Chicago, renewing an initial appointment made on December 1, 2013.  There is no reason to believe that Dr. Pygon is anything less than a highly competent and well respected physician. However, Dr. Pygon also appeared in the advertisement in the New York Times Magazine.

The presence of Dr. Benedetti and Dr. Pygon in the advertisement, given their positions, raises important questions.  Did they participate in the decision to use the image and the reputation of the University in service to a private corporation?  How can this matter be cleared up to protect their reputations, if appropriate, or apply discipline, if appropriate?

Although these are special cases given their positions, the same questions hold for all of the other doctors pictured and identified in this advertisement.

All of this leads to a question of governance.  Where is the Board of Trustees on this matter?  In addition to approving medical staff clinical appointments, the board establishes the overall guidelines for behavior for the entire university system, a system that includes the Hospital and Health Sciences System.  Will they open an investigation of this matter?  When will they issue a statement to the people of the Chicago region telling of their plans, so as to re-establish trust in this major medical system?

A white coat is a sacred trust

As we consider the growing discussion involving the capture of the University of Illinois' reputation to market the wares of a particular medical device manufacturer, we should pause and reflect how, in doing so, the manufacturer also denigrated the standing of clinicians.

As doctors will tell you, the day they are granted their first white coat is a meaningful, indeed sacred, occasion.  It is symbolic of their taking on a lifelong commitment to alleviate human suffering caused by disease.  Other medical professions, too, wear the coat as a symbol of their commitment to the public good.  The public, in turn, views that symbol as emblematic of that sacred trust.  We look up to and respect people wearing the white coats.  We know they have devoted themselves to our well-being and have engaged in extensive training for our good.

When a non-clinician appears in a white coat in an advertisement designed to hawk the wares of medical device company, it is a violation of that sacred trust.  Such was the case in the University of Illinois-daVinci advertisement in the New York Times.  Here's the ad:

As pointed out by one of the commenters in yesterday's blog post:

According to the university web page, one of the 'team' members is the "Media and Administrative Contact."

I confirmed this by viewing the site.

I imagine this non-clinician was put in the advertisement in that garb to enhance the gender mix presented to the public.  This is particularly important given the company's desire to expand the use of its surgical robot into the OB/GYN field, something that has received adverse publicity.  Indeed, some uses of the daVinci robot in this field have been decried by the head of the American Congress of Obstetricians and Gynecologists.

In mentioning this advertising technique, I mean to impose no blame on the person involved.  After all, we don't even know if she knew how this picture would be used by Intuitive Surgical.

Clearly, some senior clinical leader the University of Illinois was responsible for this ad.  The idea that any such person would add to his or her other Code of Conduct violations by permitting a degradation of the sacred trust inherent in the wearing of a white coat--especially in support of a commercial enterprise--is a sad statement about that person's moral code.

Time to fire somebody

Regular readers know that I tend to operate in a no-blame mode, i.e., be hard on the problem and soft on the people.  But when someone has violated the public trust in an institution to support the commercial goals of a private company, they have shown such poor judgment that consideration must be given to terminating their employment.

Today's example is the following advertisement, which appeared in the New York Times Magazine this past weekend.

So far so good: A hospital is bragging about a technology it has in place to serve its customers.  This happens all the time.  While we might question the efficacy of an advertisement for the University of Illinois in attracting customers from across the United States, that is less a question of ethics than one of business judgement.

But, now let's look at the bottom part of the ad:

Perhaps you have trouble seeing the small print, but the tag line is that the copyright on this advertisement is held by Intuitive Surgical, Inc., the manufacturer of the daVinci robot.  Just above that we have a disclosure that "some surgeons who appear in this ad have received compensation from the company for providing educational services to other surgeons and patients."

Wait a second.  Whose ad is this?  If it is an ad paid for by the University of Illinois, why doesn't the University hold the copyright?  If the ad is paid for by Intuitive Surgical, Inc., how can the University allow its name to be used for commercial purposes?

According to its website, "The University of Illinois is the state's best and most comprehensive public university."  Hmm, a public university, presumably supported by tax revenues.  The University has a Code of Conduct, which provides, in part:

Those acting on behalf of the University have a general duty to conduct themselves in a manner that will maintain and strengthen the public's trust and confidence in the integrity of the University and take no actions incompatible with their obligations to the University.

With regard to professional conduct, those acting on behalf of the University should practice:

• Integrity by maintaining an ongoing dedication to honesty and responsibility;
• Trustworthiness by acting in a reliable and dependable manner;
• Evenhandedness by treating others with impartiality;
• Respect by treating others with civility and decency;
• Stewardship by exercising custodial responsibility for University property and resources;
• Compliance by following State and Federal laws and regulations and University policies related to their duties and responsibilities.

Let's consider how this Code has been violated by this advertisement:

1)  The University has allowed its reputation to be used in a nationally distributed advertisement produced and owned by a private party, in benefit to that party's commercial objectives.  This is not consistent with "exercising custodial responsibility for University property and resources."

2)  The information presented under the University's imprimatur is not "reliable and dependable" and therefore undermines the trustworthiness of the institution.  I refer especially to the assertion:  "See facts and clinical data at www.davincisurgery.com/facts."  This website does not contain the results of objective peer-reviewed, case-controlled data comparing robotic surgery to manual laparoscopic surgery--the expected research standard for academic medical centers.  Instead, the site leads to a document that asserts: "Over the past decade, hundreds of studies have been published on the use of the daVinci Surgical system demonstrating improved surgical outcomes when compared to open surgery."  Imagine the disciplinary action that would follow if a professor in the university had attempted to publish such self-serving information in support of his or her scientific hypotheses and label it as "facts."

3)  The inclusion of a surgery technician and nurses in the photograph raises concern about the idea of "treating others with civility and decency."  What was the process by which those people were invited to participate in the ad?  While it might be based on affection and respect for them as part of the surgical team, were they given a choice? Were they inserted in the picture to give an impression of greater gender and ethnic diversity?  If some of the participants in the photograph have received compensation for their commercial activities, were these staff members treated equally?

4)  On the compensation issue, there is no disclosure as to which surgeons have been compensated by Intuitive Surgical, Inc., the nature of the work they did to receive that money, and the amount of money involved.  Again, the issue of trustworthiness arises.

So, who should be fired for these violations?   Simple: I would choose the highest-rank administrator and clinician who gave permission for this advertisement to be published.

Too much or just right?

I need your help in evaluating this story.  Is this what I should hope for when I advocate for patient-driven care, or is this an example of over-use in a hospital?  I'm really not sure, and I'd welcome your thoughts.

The story is of a 10-year-old boy who has a fever.  He is taken to the local urgent care center at 9:00am.  The family is told that the center cannot disburse medication and that, in any event, since the child's temperature is 102 degrees, he should be taken to the emergency room of a hospital in the neighboring community.

The family arrives at the ED in the late morning.  During the many hours of diagnosis and waiting, a "child life specialist" appears.  These caregivers are apparently common in pediatric centers.  I read from the hospital's website later that these staff members:

[P]rovide emotional support for children and families. They cover the inpatient service, operating room and Pediatric Emergency Department. Child Life is active in preparation and procedural support for children undergoing testing and procedures as well as providing support to children and their families. 

At some point, the specialist asks the child if he would like to watch a movie. He says yes and is presented with a five-page listing of videos from which he can pick.  He chooses one to watch on the television screen.

Meanwhile, he is also loaned an iPad, on which he can play games.

When it comes time for a nurse to insert an IV port, the child life specialist shields the child's eyes from the procedure with a book, while he continues to watch the movie and the iPad.  Here's the scene.

Eventually, at 3:00pm, the boy is discharged with a diagnosis of a fever of unknown origin and instructions to take medication to reduce the fever.

The parents, while greatly appreciative of the demeanor and expertise of the staff, were stunned at level of costs that would be required to deliver this kind of care.  They were perplexed as to why their son needed it.

What do you think?

Give this book to your college senior in January . . .

. . . so s/he won't move back home in June!

I am pleased to announce the publication of our new book, "How to Negotiate Your First Job."  My wife, Farzana Mohamed, and I wrote it to help college graduates plan for their first important negotiation--the terms and conditions of their employment.

In advising many college students, we have found that new entrants to the job market are remarkably unlikely to negotiate the terms of their first job.  Whether fearful of losing an offer, or just unsure what to say or do, this is understandable.  In the book we set forth sound negotiation principles, but we explain them in plain terms and give many examples of how to conduct a negotiation that will get a better deal for the job seeker--but will also leave the employer feeling even more satisfied that they have hired this young person.

In one chapter, too, we address the well documented fact that women do worse in job negotiations than men; and we offer some suggested remedies to that phenomenon.

If you have a college-aged person in your family, or know of a person just entering the work force, please consider purchasing this book as a gift.

We are also happy to hold workshops for students at colleges and universities based on the principles and stories from the book.  If you know of any schools that might be interested, please let us know at advice [at] negotiateyourjob [dot] com.

Here's the link on Amazon for both the paper version and Kindle.  Other eBook formats (Nook and the rest) will be available soon.

Boston area folks can find the book at Brookline Booksmith, Wellesley Books, New England Mobile Bookfair (Newton), Back Pages Books (Waltham), and Harvard Bookstore (Cambridge).

Hang 'em out to dry! Wait, "them" is us!

I can already predict the result.  The New York Times publishes a story about the rise in specialists' incomes, much of which is based on procedures they carry out.  Outrage follows, and health care public policy experts say, "You see, the solution is to move away from fee-for-service medicine and towards capitated, or global, payments."

Sure, that's one answer, but not one that will solve this problem.

You see, even under a capitated system of care, someone has to decide how to pay the various kinds of doctors within a health care system for their work.  That internal transfer pricing is what matters most, not some global payment that the provider organization collects per month per patient. To calculate the physicians' compensation, most organizations use a fee schedule based in some way on the Medicare fee schedule.  What's the basis for that fee schedule?  The Times explains:

Medicare’s valuation of physicians’ services is based on a complex algorithm that is intended to take into account the time and skill required to perform a medical task, with an adjustment made for a specialty’s malpractice rates. 

Buried in the back of The Times story, we find the real problem:

But renegotiating payments involves a highly contentious process that plays out behind closed doors at the American Medical Association’s Relative Value Scale Update Committee, which consists of doctors representing 26 medical disciplines who advise Medicare. In dermatology trade journals, Dr. Coldiron, who has served on the committee, describes it like this: “Everybody sits around a table and tries to strip money away from another specialty.” It’s like “26 sharks in a tank with nothing to eat but each other.”

Primary care doctors — who make up only 12 percent of physicians in practice — say they have little clout, with at most five representatives on the panel. “That committee keeps the perverse incentives in place,” said Brian Crownover, a family physician from Boise, Idaho.

This is not news. The Wall Street Journal described this in detail in 2010. 

Three times a year, 29 doctors gather around a table in a hotel meeting room. Their job is an unusual one: divvying up billions of Medicare dollars.

The group, convened by the American Medical Association, has no official government standing. Members are mostly selected by medical-specialty trade groups. Anyone who attends its meetings must sign a confidentiality agreement.

Yet the influence of the secretive panel, known as the Relative Value Scale Update Committee, is enormous.

I gave an update in 2012, citing an excellent article by Brian Klepper, who quoted Tom Scully, CMS administrator for President Bush:

One of the biggest mistakes we made … is that we took the RUC… and gave it to the AMA. …It’s very, very politicized. I’ve watched the RUC for years. It’s incredibly political, and it’s just human nature…the specialists that spend more money and have more time have a bigger impact… So it’s really, it’s all about political representation, and the AMA does a good job, given what they are, but they’re a political body of specialty groups, and they’re just not, in my opinion, objective enough.

 

The Obama administration remains complicit in this approach.  I reiterate a solution:

I would like to make a simple proposal to President Obama, Secretary of HHS Kathleen Sebelius, and CMS administrator Marilyn Tavenner.  Keep the RUC but insist that all of its meetings and deliberations be made public.  That is within the immediate power of the Executive branch, requiring no judicial review.  This is an administration that has prided itself on transparency.  Surely they can insist that one their key advisory panels, one that will help determine the success or failure of health reform, should perform its functions in the open.  Let’s shine some sunshine on the process and logic used.  If the RUC’s methodology is sound, we will all learn from that.  If it is flawed, the public outcry will make it change its ways.  

 

Meanwhile, for those who insist on promoting global payments, let remind you of a point I made on this topic three years ago:

Now, though, let me let you in on a little secret with regard to capitated care. Underneath the global budget, there is still a fee-for-service arrangement establishing the transfer prices among the providers in a network. That GI specialist will still get paid for each colonoscopy. The big thing to work out in this system is the allocation of any surplus or deficit in the annual budget among the various specialists.

Unless that allocation is skewed heavily towards primary care doctors, decisions about the level of care given will not change. But, if the allocation is skewed too heavily towards the PCPs, there is no real income signal for the specialists, leading to a danger that they will not feel invested in the end result. Unless the system is accompanied by intensive, real-time reporting, along with clear penalties for excessive care, it will not work.

Did I say penalties? You bet. Without those, there is no enforcement of the global budget. But with those, global budgets are likely to raises hackles and resentment among specialists. I predict that the biggest issue facing physician groups in the coming years is the perceived interference by the global payment risk unit in the clinical decisions made by specialists.

CIR conference today: How to Provide Cost Conscious Care

There's a conference sponsored today by CIR (The Committee of interns and Residents) in New York City--bringing together medical educators and health economists to teach new doctors how to provide more cost effective care:

With health care spending soon to consume 20 percent of the GDP, this conference is meant to empower physicians-in-training to develop and execute high-value care projects in their hospitals and health systems, and equip medical practitioners with competencies to meet the challenges of a dynamic and rapidly changing healthcare delivery system.

You can join the conference live here. Here's the schedule:

9:30 AM Choosing Wisely, the Future of Professionalism

10:20 AM the Cost of Care Team gives an overview and gets us motivated

11:45 AM High Value Prescribing: GOTMeds?

1:15 PM How to Operationalize Value

2:15 PM Developing Specific Projects

There are other ways you can share your ideas, ask questions and participate. You can join the conversation by following on twitter at #QIIQ #teachingvalue #meded.

CIR has arranged quite a line-up of speakers:

• Daniel Wolfson, MHSA, Executive Vice President of the American Board of Internal Medicine Foundation. Previously, Mr. Wolfson served for nearly two decades as the founding president and CEO of the Alliance of Community Health Plans (formerly The HMO Group), the nation’s leading association of not-for-profit and provider-sponsored health plans. During his tenure, Mr. Wolfson earned national recognition for spearheading the development of the Health Plan Employer Data and Information Set (HEDIS™), convening the RxHealthValue coalition to provide independent information on the pharmaceutical industry, and co-sponsoring with the American College of Physicians the journal Effective Clinical Practice.
• Neel Shah, MD, MPP , Founder and Executive Director, Costs of Care and a Harvard-affiliated ob/gyn who delivers babies, provides primary care and performs surgery. His writing, research, and medical practice have focused on deflating medical bills by helping caregivers make high value clinical decisions.
• Vineet Arora, MD, MAPP, Director of Education, Costs of Care, Director of GME Clinical Learning Environment Innovation. Dr. Arora is an expert at using novel methods, such as video vignettes and social media to promote clinician awareness and behavior change. In 2012, she was selected as HealthLeaders Magazine’s one of 20 people who make healthcare better.
• Christopher Moriates, MD, Associate Director of Education, Costs of Care. During residency training he co-designed and implemented a successful cost awareness curriculum for Internal Medicine residents, which has been highlighted in multiple publications including the New England Journal of Medicine. He also actively participates on the American College of Physicians’ (ACP) national High-Value, Cost-Conscious Care Curriculum committee.

A benefit of political gridlock? It won't last.

A Washington, DC colleague reported to me this week that spending on lobbying in the nation's capital has declined considerably.  Why?  With current gridlock in Congress, legislation that is viewed as harmful by corporate, labor, or other interests is exceptionally unlikely to pass.  So why spend money fighting something you don't really have to worry about?

I've looked for documentation of this pattern and found this article from the Huffington Post in October.  Excerpt:

More than two-thirds of last year’s top 100 lobbying entities spent less on federal-level lobbying activity during this year’s third quarter than they did the year before, according to a Center for Public Integrity of analysis of new congressional disclosure reports and Center for Responsive Politics data.

There were exceptions to the rule:

Pharmaceutical behemoths, gun advocates and corporate agriculture interests are notable outliers.
 
The big political issue before the current Congress will not be new legislation.  It will be "extenders," reauthorizations of government programs and policies that expire absent renewal legislation.  This article in Forbes gives some examples from the tax code. An excerpt:

In all, 55 provisions of the Internal Revenue Code died an unceremonious death as the possum dropped last night, but understand – this is nothing new. The Code is about as permanent as a Kardashian marriage, with provisions routinely being written for a finite period, expiring, and then either proactively or retroactively being extended. It’s the worst business model imaginable – particularly because many of these short-term provisions were written specifically as business incentives, yet there tenuous nature makes it impossible for businesses to plan for them – but it’s a model that Congress has maddeningly embraced.

So, why doesn't Congress just make things permanent? Obviously, if businesses, labor unions and others need to get laws extended, they will be much more likely to contribute to political campaigns.  It would be electoral suicide, in terms of fund-raising, if provisions were permanent!  So, look for an uptick in lobbying expenses.

Violence prevention on WIHI

Madge Kaplan writes: 

The next WIHI broadcast — Violence Prevention and Community Health — will take place on Thursday, January 16, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:

• Gilbert Salinas, MPA, Director of Patient and Community Relations, Rancho los Amigos National Rehabilitation Center, Kaiser Safety Net Fellow, Institute for Healthcare Improvement
• Thea James, MD, Emergency Medicine, Boston Medical Center; Director, Violence Intervention Advocacy Program
• Rachel A. Davis, Managing Director, Prevention Institute
• Kaile Shilling, Coalition Director, Violence Prevention Coalition (Los Angeles)

We’ve just come through a holiday season that’s bittersweet for some — including families that have lost a loved one because of gun violence. Some incidents garner headlines more than others, due to the sheer magnitude of what’s transpired, the ages of the victims, the incredible shock to an otherwise quiet day in a quiet neighborhood, and the tragic consequences. For those in the trenches of working to reduce gun violence day to day — more often in communities and in health care systems all too familiar with gun-related deaths and injuries — every event stands out and has a story behind it.

How can health care organizations, the very ones that often receive the victims through the doors of their EDs, be more effective partners and leaders further upstream? How can gun violence prevention become part of emerging strategies to encompass and focus on better population health? The January 16, 2014, WIHI: Violence Prevention and Community Health is going to highlight some exemplar thinking and initiatives now gaining traction, that everyone can learn from.

Rachel Davis and Kaile Shilling each have their finger on the pulse of multiple efforts and coalitions that are right now taking a comprehensive preventive, public, and population health approach to reducing violence of all sorts. Dr. Thea James is responsible for close to a decade’s worth of pioneering work at Boston Medical Center that’s spread nationally, to help youth adopt better responses to high-risk situations, and to help medical staff deliver “trauma-informed care.” Gilbert Salinas, currently a Kaiser Permanente Safety Net Fellow at IHI, has garnered national attention for his work in Los Angeles, and with former Surgeon General David Satcher on a seminal 2001 “Report on Youth Violence.” Gilbert will also discuss a hospital-based intervention program he’s helped nurture, known as “Caught in the Crossfire.”

WIHI host Madge Kaplan knows preventing and reducing gun violence is a huge topic. But the January 16 panelists will offer a lot of great, actionable ideas, and you can help make this show concrete and inspiring as well by sharing your work and experiences. Please tune in!

These bonds are a sure thing!

Note:  I am not offering investment advice.  I am not qualified or registered to do so.

The Boston Globe's Robert Weisman offers a summary of a presentation made by Partners Healthcare System at the annual J.P. Morgan Healthcare Conference.  This is an audience of investment people who are trying to keep up with trends in the health care industry and who advise clients on whether or not they should buy bonds. Weisman notes, "The Partners presentation in San Francisco came days after the massive hospital and doctors system disclosed it will sell $425 million worth of bonds to finance new construction and other expansion initiatives."

As you would expect, the PHS made optimistic projections about its future, and I have to agree:  There is little on the horizon that would interfere with Partners' ability to service its debt.

First of all, the company was able to persuade the governor and legislature that it should not be subject to rate regulation and that it should be allowed to keep all the excess revenues it has received over the years. Indeed, the revenue advantage that PHS has in its current contracts, relative to other provider organizations, is guaranteed by the new legislation.

Secondly, even though the Health Policy Commission has raised doubts about the wisdom of PHS acquiring new provider organizations, like South Shore Hospital and Harbor Medical Associates, it does not really matter if the formal merger takes place.

As I have noted:

We need to understand that South Shore has been a vassal of Partners for years, with extremely close clinical relationships and referral patterns. The Patriot Ledger reported: 

"Sarah Darcy, spokeswoman for South Shore Hospital, said the two hospitals have worked together since 2004 on providing a wide range of medical and surgical care. Among them are the Dana-Farber/Brigham and Women’s Cancer Center, the Breast Care Center, and a Harvard Medical School-affiliated surgical residency program at South Shore Hospital."

Merger or not, those relationships will persist.  The doctors trust one another.  Patients and families are used to the referral patterns that have been established. Such relationships are not torn asunder by a failure to create a larger corporation with a common bottom line.

Thirdly, the likelihood that a competing force will arise in the region is small, in that there are a multitude of obstacles standing in the way.  Even if mergers occur that create a "book-end" to Partners, it will be years before that entity will be an effective competitor, given the many cultural and logistical challenges.  And, if it becomes an effective competitor, the state is highly likely to move into a duopoly situation, protecting the revenue streams of both entities.

Finally, for those who think and hope that transparency and tiered markets and consumer-driven health care will dramatically change market share, look at this insightful comment I received on my blog yesterday:

My impression is that health care leaders in the state government are afraid of hurting the golden goose called Partners (as was said by others an important part of the local economy), so they have deliberately limited how big a price incentive that insurers could give to lower priced hospitals in tiered and limited networks to prevent to large a loss of market share too quickly.

But the reverse has happened.

Over the last few years state healthcare leaders have gradually allowed the financial incentives to increase with little noticeable effect on market share - in fact the market share of the highest cost hospitals like those of Partners and Childrens has increased at the same time as tiered and limited networks were introduced. 

Whom do I call to get some of those bonds?

What happens when the profession speaks up

I never wish any one bad luck, like losing a job.  But in this case, I am happy to see it happening because it is an indication that there is hope in the battle against the medical arms race when people in the medical profession stand up for what is right.

The story is from Bloomberg about the maker of the daVinci surgical robot:

Intuitive Surgical, Inc: Layoffs total 7% of sales organization
 
Jan 13 2014 4:01:21

ISRG laid off 7% of its sales force recently; more details are expected this week. Layoffs were focused in GYN, where growth has slowed.

Bravo to James T. Breeden, president of the American Congress of Obstetricians and Gynecologists, who last year said:

At a time when there is a demand for more fiscal responsibility and transparency in health care, the use of expensive medical technology should be questioned when less-costly alternatives provide equal or better patient outcomes. 

A study of over 264,000 hysterectomy patients in 441 hospitals . . . found that robotics added an average of $2,000 per procedure without any demonstrable benefit.  

Aggressive direct-to-consumer marketing of the latest medical technologies may mislead the public into believing that they are the best choice. Our patients deserve and need factual information about all of their treatment options, including costs, so that they can make truly informed health care decisions. Patients should be advised that robotic hysterectomy is best used for unusual and complex clinical conditions in which improved outcomes over standard minimally invasive approaches have been demonstrated. 

Back to the future

I always look forward to giving a talk in Jim Conway's and Ron Goodspeed's physician leadership course at the Harvard School of Public Health, and today's class was no exception. The students--leaders from around the country--are interesting and attentive.  Moreover, Jim and Ron set up the framework for the class in a way that is always engaging.

But today, I was taken aback by their introductory remarks to my class session, which was a review of the turn-around I led at Beth Israel Deaconess Medical Center in 2002 (using a case study prepared by Harvard Business School.)  The turn-around was necessary because of a failed merger within an ineffective corporate superstructure, the CareGroup system.  Truly, I have considered this "old news," but the instructors' remarks put the experience in a current context.  Harkening back to the mid-1990s, they noted that today's environment in health care is remarkably similar: a rush to mergers and acquisitions; financial pressures on hospitals; and big changes in the relationships between doctors and hospitals.

The class discussion stimulated my thinking abut the current scene.  While Partners Healthcare System will likely remain dominant for years to come in the Eastern Massachusetts market, it is interesting to observe other players and see how they plan to deal with the remainder of the market.  Merger fever seems to be the answer.  Let's take a gander:

Is it possible to be Switzerland?

Mt. Auburn Hospital in Cambridge is a high quality facility that has had excellent administrative and clinical leadership for many years.  Following a successful capital campaign supported by loyal constituents, it was able to upgrade and expand its buildings and equipment several years ago.  The focus on quality and safety has been exemplary, with outstanding results.  A long-standing, close relationship with its major physician organization has enabled the organization to do well under risk contracts.  On that front, too, MAH was an beneficiary of Blue Cross Blue Shield's "Alternative Quality Contract" in the early days, when BCBS padded first-year global payment budgets to entice hospitals and doctors to sign on.  Although MAH is part of CareGroup, its has been more like Switzerland.  While its doctors sometimes send higher acuity patients to affiliate BIDMC, they often choose PHS' Massachusetts General Hospital as a referral site.

This latter independence of spirit and practice is now up for grabs.  There have been thoughts recently that it is time for a formal merger of MAH with BIDMC.  These thoughts appear to be driven by expected financial pressures on MAH.  Some people apparently think that a merger would help alleviate the capital issues associated with renewal and replacement of physical plant and facilities. Creating a common bottom line between the two organizations, merging electronic medical records, and sharing in risk contracts would be the goal.  The expectation would be dramatically reduced tertiary "leakage" to the PHS system.

Beyond the normal administrative issues surrounding all mergers, this kind of shift in clinical practices could be viewed as problematic by MAH physicians.  Further, to the extent BIDMC must meet its own capital needs and those of its other new acquisitions, the process by which MAH could rely on access to capital could raise concerns among the loyal MAH community.

Is it possible in a world of ACOs for Mt. Auburn to remain as Switzerland, with relationships among a number of Boston area tertiary hospitals?  That's the underlying question for its administrative and clinical leadership and governing body.

How's the view up there?

New England Baptist Hospital, another CareGroup subsidiary, is nationally recognized for its prowess in orthopaedics.  Like MAH, it has also intensely focused on quality and safety issues and has an exemplary record in that regard.  On top of Parker Hill, separated by some distance from the hospitals in the Longwood area, NEBH has long suffered from lack of easy access to non-orthopaedic specialists who can be crucial to the care of complex patients (those with diabetes, heart disease, cancer, and the like.)  Other orthopaedic hospitals, like the Hospital for Special Surgery in New York, deal with this problem by adjacency to, or physical connection with, a general hospital (NY Presbyterian in the case of the HSS.)

Given the private practice model in place at NEBH, a full-scale merger with BIDMC is not likely.  But a real estate deal might be in the cards.  Sell that property at the top of Parker Hill--one of the best views in Boston--and use the proceeds to build a new pavilion on Longwood Avenue, connected to BIDMC. Integrate the electronic medical records systems and share the adjacent clinical specialists and tertiary facilities as needed.

Three's company?

There's talk all over town about a possible merger of BIDMC, Lahey Clinic, and Atrius Health (the state's largest multi-specialty practice.)  Such a merger is viewed by many as the ultimate book-end to the Partners System.

Gene Lindsey and I negotiated the first major affiliation between Atrius and BIDMC back in 2009, which resulted in a shift in tertiary and emergency care for thousands of patients from Brigham and Women's Hospital to BIDMC.  This partnership also produced the first generation of interoperability between our EHR systems.  Since then, the relationship has grown stronger and provides a foundation for more detailed talks.

There is a long-standing historical connection between BIDMC and Lahey based on Lahey's affiliation with the New England Deaconess Hospital years ago.  But, in recent years, the two organizations have been operating mainly in parallel--neither allies nor competitors.

A three-way merger here is a sophisticated and difficult negotiation. Assuming it makes sense on clinical and financial terms--something worth detailed and rigorous study--there are the following issues:

Leadership:  Only one of the current CEOs has operational experience in running a health care system.  Are the other two prepared to step aside, substantively, if not in title?

Governance:  Three very different kinds of boards are in place in the three entities.  What would be the desirable--and politically acceptable--form of the new governing body?  What would be the mix of lay versus clinical members?  What percentage of the board would come from each entity, or from outside all three?

Clinical direction:  Would this be a tertiary-care centric ACO, viewing the community doctors as referral sources?  Or would this be a primary-care centric ACO, viewing the hospitals as service organizations to the community doctors.

EMR:  What system would be put in place for interoperability of electronic medical records?  The "easy" path--buy an Epic system, the one used by Atrius--is fraught with high costs and loss of control to the vendor.  Is there an alternative that would work "well enough" and avoid the risk of an entirely new system?

Possible splintering within Atrius:  Atrius is a confederation of several multi-specialty practice groups.  While Harvard Vanguard is the largest, the others all have a role in governance.  Another large member, Reliant Medical Group, focuses on Central Massachusetts and relies on St. Vincent's Hospital as a tertiary referral center.  Whether Reliant or other parts of the alliance, will they agree enough on the world of the future to welcome a common bottom line with Lahey and BIDMC?

Thinking back to our class at HSPH today, I'm thinking there will lots of good case studies for Jim and Ron to present ten years from now.  It's too soon, though, to know whether the cases will be success stories or failures.

Lean is where you make it happen

I've been meaning to write about this for several months--ever since attending GBMP’s Northeast Shingo Prize Conference this past fall. Short version:  You never know where you will see a superb example of process improvement. Read more for the details below.

The Center for Comparative Medicine at Massachusetts General Hospital has a mission of providing "the highest quality laboratory animal husbandry and veterinary services to MGH investigators and to ensure that all research animals at MGH are maintained and used in accordance with pertinent laws, regulations and accreditation standards."  This is one of over 80 core facilities at Partners HealthCare System which are in place "to bring state-of-the-art instrumentation, methodologies and expertise crucial to the promotion of research on our campuses and beyond."

More specifically, the CCM works to:

(1) provide reliable, affordable, and responsive laboratory animal care and research services to MGH investigators in pursuit of scientific knowledge and medical breakthroughs for patients and their families;
(2) avoid or minimize pain and distress in animals under our care;
(3) maintain a fulfilling, respectful, and safe workplace for our employees.

The CCM has extensive facilities, including ventilated and static cages and racks, autoclaves, tunnel washers, rack washers, bedding dispensers, automatic watering (Edstrom), biosafety cabinets, cage changing stations.  Services offered include procurement, husbandry, training, technical, import/export, quarantine, pathology, breeding, veterinary consulting, and customized research services to the MGH research community.

Hardly a place to find adherents to the Lean process improvement philosophy?  No way.  Meet Gerard Cronin, the "Kaizen Promotion Manager" at the CCM. As noted in this article by Bruce Hamilton:

CCM has been on its Lean journey for 8 years, and has adapted Lean tools and methods in novel ways to service their 5000 customers as efficiently as possible with a staff of 130 employees.

The results are stupendous, as seen in the accompanying summary.

Further:

As a pioneer in Lean management in Biomedical Research, CCM conducts Lean Tours, trainings and seminars to help accelerate the healthcare industry in the development of new therapies against disease.  

At the Shingo conference's "Lean Lounge," many of us were drawn in by a kooky display of dangerous animals and props. Gerry and his able partner Julieanne Brandolini showed us the innovative pedagogical tools they use in their instructional sessions.  They have created a "Lean Starter Kit" and other kits that teach people the standard work that should be in place in various circumstances.

Many conference attendees dropped by the display and stayed on for some time to learn from the good-natured presentations offered by Gerry and Julieanne. As Bruce noted in the article, "The theme of CCM’s 2013 Lean Lounge booth was 'if we can do it, anybody can.'"

True enough, but the leadership has to be in place to make it happen.  This was one shining example of such leadership.

Bankruptcy does not require a Chapter 11 filing

Almost three years ago, I wrote:

Academic medical centers face all of the problems of two stressed industries -- academia and medicine. The future will belong to the efficient. Hospitals that are driven by their senior faculty and hopeful junior faculty to expand buildings and research facilities, that invest in high-cost but unproven clinical equipment, that do not engage in front-line driven process improvement, that fight transparency of clinical outcomes -- and that plan to depend on private and government reimbursements, government grants, and philanthropy to pay for all this -- will not do well. Those that limit capital investment in inflexible fixed assets, that focus on higher quality and reducing waste, that endorse transparency, that invest in the science of health care delivery as much as basic science, and that develop and implement treatment modes that take care to the patient rather than requiring physical visits by patients, will do well. 

Bob Herman over at Becker's Hospital Review publishes a periodic report about hospital bankruptcies.  Some places have not filed under Chapter 11 but are already functionally bankrupt, in term of persistent decapitalization of their underlying assets.  Others face major challenges.

Look at this story from the Worcester Telegram:

UMass Memorial released figures Wednesday showing that if not for a one-time gain of $108 million from the sale of certain lab operations, the system would have ended its fiscal year in negative territory, partly driven by shrinking revenue from patients and soaring expenses for salaries and supplies.

Chief Executive Dr. Eric W. Dickson, who warned in October that UMass Memorial would post the operating loss, attributed the results to an effort to focus less on "rescue" care and more on keeping people healthy.

"You've got this huge transition occurring, which in the end is good for the community, good for the businesses in the region, and where health care needs to go to truly make it about health care, but when you're taking a $2.24 billion business that has all the infrastructure, all the buildings, all the people set up in that old model and you move it to the new, there's going to be a significant operating loss," Dr. Dickson said. 

The financial results reflect a system with significant financial challenges. Operating surpluses as high as $83 million in 2009 have dropped each year for the past five years. Expenses for salaries and supplies have steadily grown.  

Moody's Investors Service last month downgraded its rating on $299 million in UMass Memorial debt to one step above junk status, citing a drop in patients, a largely unionized work force, a large number of patients on the government's Medicaid insurance plan for the poor, and growing expenses.

Boston Blue Button Innovation Challenge

There will be a hackathon next weekend called the Boston Blue Button Innovation Challenge, run by  Tufts MedStart, a group at MIT called Hacking Medicine, the Office of the National Coordinator for Health IT, and White House Innovation Fellows.  You can get more information here.  As noted:

Blue Button is an international movement to engage patients in their health through access to their health data in both human and machine-readable formats. 

The event will focus on use cases that take advantage of patient clinical data liberated through Blue Button + Direct, a technology available in all Meaningful Use certified technology starting winter 2014. The event will open with patients and providers sharing their highest priority Blue Button use cases which will guide development over the weekend and judging criteria. Example ideas may include but are not limited to:

• Co-designed applications that can improve communication between the health care provider and the patient. (ie. care plans and notes that both the patient and physician can contribute to)
• Simplifying medical jargon, content, and diagnoses for patients. (ie. consumer friendly definitions of clinical terms)
• Clinical health information visualizations. (ie. interactive lab results)
• Population trend analysis. (ie. seasonal, location specific tracking of symptoms at an aggregate level)
• Patient record matching to clinical trials.

 Here's the schedule.

MIT SDM presents: Tele-Health and PTSD in the Military

Architecting a Future Tele-Health Care System to Treat PTSD in the US Military

MIT SDM Systems Thinking Webinar Series

Andrea Ippolito, SDM '11
Ph.D. student, MIT Engineering Systems Division

Date: January 13, 2014
Time: Noon – 1 p.m. EDT
Free and open to all

Register

About the Presentation

This webinar will offer insight into how the US military can provide high-quality, cost-effective, timely access to health care for soldiers and their families — specifically those with post-traumatic stress disorders who may not have easy access to bricks and mortar facilities.

Andrea Ippolito will report on findings and recommendations by an MIT team that researched how technology can help reach those at risk. In this discussion, she will:

• Define the term "tele-health" and explain how technology can be used to treat behavioral disorders at a distance;
• Explain the overall systems-based approach the team used to evaluate the current state of tele-behavioral health within the military;
• Detail the specific enterprise lenses of strategy, policy, organization, services, processes, infrastructure, and knowledge used to examine psychological heath-care services; and
• Share the architecture recommendations proposed to deliver improved tele-behavioral health services to soldiers and their families in the future.

A question and answer session will follow the presentation.

We invite you to join us!