Yes, they blinked

I ran into an insurance company executive the other day who questioned whether I really thought that Blue Cross Blue Shield of MA could have done better in its recently signed contract with Partners Healthcare System here in Massachusetts.  Recall that the state's largest insurer gave away a huge rate increase to the state's dominant health care system  --  a 2-3% increase on a base that is, what, 15 to 20% higher than the rest of the market.   I said, "Whether it is fear of government regulation or a desire to go along to get along, a tremendous opportunity to truly control costs has been squandered."

This person said, "Remember, this was a private negotiation between two parties."  I allowed how I wasn't in the room, and it is easy to criticize, but, as I thought about it later, this statement alone might be indicative of why the insurance company blinked in this case.

A negotiation of this sort is never a private negotiation between two parties.  When two economic behemoths talk, there are a huge number of interested parties in the community.  And, those constituencies had already made their views known, views that could have been leveraged in this discussion.  Here are examples:

The Attorney General had pounded away two years running that a major issue facing the health care system, one that was driving up costs for the entire state, was the large disparity in rates paid to this provider group compared to others in the state.

The Governor had filed a bill to expand the authority of the Insurance Commissioner to review the rates paid by insurers to providers.  (By the way, many current and former state officials feel that the Commissioner already has that power.)

The Inspector General had expressed concerns that PHS would try to rush through a new contract before legislation passed that could limit payment increases.

Members of the legislature were publicly expressing concern about the rate disparity issue.

The insurance company had had noticeable success in marketing a tiered product, requiring higher co-pays from patients visiting the high-priced providers.

Lower cost competing hospital groups were creating ever more integrated alternative clinical networks.

Business groups in the state were clamoring for real cost controls in premium increases.  Given the unemployment situation, with people less likely to leave jobs for new ones, they felt that tiered insurance products could gain greater acceptance than in the past.

This provider group had not paid a promised $40 million to reduce insurance rates and was being derided for that delay.  It had every reason, given the pending legislation, to try to strike a deal before the law changed.  The insurance company, in contrast, had no reason to hurry.  Further, it had the moral upper hand, having forced other, more poorly paid, providers in the state to take dramatically lower rate increases.

In a public hearing about two years ago, this insurance company had said that it did not have the heft to fight the market power of PHS.  It seemed to fail to understand that the world had shifted.  If there was ever a time to go head-to-head, publicly if necessary, this was it.  An opportunity was lost.

Twenty questions for public policy proposals

As I re-read the comments I have received regarding my critique of plans to impose financial penalties for variations in readmission rates, I realized that my correspondents and I were talking past one another.  I was presenting views based on how to design public policy, while they were stressing (understandable) concerns about the quality and cost of medical care.  They were viewing high readmission rates as something that deserved the hammer of a financial penalty, while I was viewing the issue as one of many public policy issues surrounding the health care environment, where unintended consequences of policy intervention are something to be considered.

To help explain how I view these kind of issues, I am going to share a list of twenty questions modified slightly from those Larry Bacow used to share with his students while a professor at MIT (before heading off to be President of Tufts University.)  Even though the list is over twenty years old, and Larry might modify them even more at this point, it is still a remarkably useful framework within which to view a wide range of issues.  Some are not germane to health care, but many are. 

These kinds of questions underlie a lot of the commentary you see from me here on this blog.  Please understand that these questions, although demanding some degree of analytical rigor, are not designed to stymie public policy advances, but to focus public policy interventions in the hope of more effectively solving problems.

1.  In identifying the problem, or proposing the program, what does one hope to change?  Examples:  The overall distribution of income; the income of particular groups; incentives; resources; bargaining power; political power; competitive advantage or opportunities; a condition that afflicts some particular target population; a source of social conflict or friction; some legal, customary, or social arrangement or the legitimacy of certain actions or arrangements; values, tastes and interest; the range of choice available to some group; other.

2.  In identifying that problem, exactly what specific characteristics of the state of the world concern you, and what changes in these specific characteristics is your proposed program intended to achieve?  (Specify characteristics in terms of "final," not intermediate, objectives, e.g., the quality of life of individuals affected by the program.)

"Characteristics" should consist not only of concepts but estimates of the values of these variables.  Identify the data you use in determining these values.

Express the magnitude of the problem in terms of numbers, severity, costs, etc., and indicate the urgency or priority it should have on the agenda of those whose concern it is.

3.  What is there, if anything, about the problem or issue that makes it a matter of public concern rather than something better left to private action or allowed to take care of itself?

4.  What is it that makes the problem hard to analyze or the solution hard to apply?  Examples:  Objectives not clear; instrumental relations not clear; data not available; technological uncertainty; incentives conflict with compensatory objectives; strongly conflicting interest among parties; legal or moral or traditional obstacles; sheer magnitude or cost; jurisdictional confusion; novelty or unfamiliarity of the problem; administrative costs; incentives within administration, including possibly corruption; bad side effects; wasteful side effects; "horizontal" inefficiency; "vertical" inefficiency; political weakness of beneficiaries and advocates; others.

5.  Can you distinguish elements of the problem in terms of:  Market efficiency; administrative efficiency; equity; ethics; justice; information; technology; individual rationality, responsibility or self-control; other.

For example, would the problem disappear if you were satisfied with: The distribution of income (by income size or by particular groups); the working of the market; the equal and effective enforcement of the law; the adequacy of private insurance; the responsiveness of the political system; the elimination of specific handicaps; the goodwill of the parties involved; the state of public information and knowledge; the way existing programs are administered; the conformity of individuals to law or ethical principles; etc.

6.  What are the main changes in behavior that will be induced by the incentives, resources, information, etc., that the proposed program creates?

a.  The intended changes, without which the program serves no purpose;

b.  The undesired changes that nullify the program or elevate its cost;

c.  Changes that are neutral with respect to your purpose but that have to be allowed for or taken care of.

Distinguish the changes in behavior of the intended and unintended beneficiaries from changes in the behavior of administrators and others whose actions matter but who are intermediaries, not beneficiaries.

7.  What is it that defines, bounds or delineates the problem area of the program?  How much leeway is there in defining the problem or in the coverage of the program?  For example:  The "package" of activities involved, e.g., "medicine"; the nature of production, e.g., nuclear energy; the nature of consumption, e.g., alcoholism; the marketing arrangements, e.g., cable television; governmental jurisdiction, e.g., zoning; some connection between revenues and expenditures, e.g., social security or highway programs; the nature of the target population, e.g., the elderly; law, tradition, custom, some moral principles, e.g., adoption; other.

Is there some minimum scope or scale on which the problem has to be tackled to do any good?

8.  a.  Is the problem peculiar to the social and institutional structure of the United States or of the particular area in which it occurs, or is it a universal problem that any society must solve?

b.  How was the problem defined and handled 25 and 50 years ago?

c.  How is the problem defined in other countries or other jurisdictions, and how do they handle it there?

d.  What is new and novel about the problem or its solution?  How do the newness and novelty affect the definition of the problem, the choice of technique for solving it, flexibility or inflexibility in choice of solution, and the precedents that bear on this program or that this program will establish?

9.  Generalization of the problem:  similarities and analogies.

a.  What other problems are like this one, and what are the similarities and differences?

b.  What are the "solutions" of those other problems, and what do they suggest about solutions for this one?

c.  What is the larger problem of which this is only a part?

d.  What are the smaller problems into which this one can be subdivided?

e.  Does your problem fall into some general analytical class of problems, e.g., discrimination, public goods, externalities?

10.  What are the interdependencies between this problem and other problems, this program and other programs?

a.  The solution of which other problems will make this one disappear?

b. What other problems will disappear if this one is solved?

c.  What problems will become solvable by identifiable programs if this one is solved?

d.  What programs should be enlarged or tapered off if this one succeeds?

e.  What small problems does this one subsume?

f.  What big problem is partially ameliorated if this solution works?

g.  What problems get harder if we try this solution here?

h.  What problems are discovered if we solve this one -- i.e., what is it that we ignored that we'd stop ignoring, or begin to treat as a "problem," if this program proves workable?

11.  Is the desired change incremental or systemic?  Is the object: A Constitutional change; a major change in institutions; a shift to a new"equilibrium" that once achieved, will last; a consolidation or standardization of existing programs; an intensification or modification of existing programs; bringing old programs up to date; once-for-all change or change continuous through time; reversible or irreversible change; establishment or disestablishment of precedents?

12.  How do the dimensions of the problem and the effectiveness of the solution vary with the passage of time?  Is the problem getting better or worse over time?  Is the solution getting more effective or more obsolete over time?

13.  What checklist of techniques do you use to determine the optional ways of approaching the problem?  Examples:  Transfer payment in cash; transfer payment in kind; tax or subsidy on the transaction; licenses and prohibitions; contract enforcement; control of prices, rents or wages; insurance; information; publicity; property rights; public provisions; nationalization; provision of legal services; restructuring or a market or profession; provision of some public good or service.

What is, or ought to be, the relation of the technique or instrument to the nature of the problem or the purpose of the program?  (What techniques can be ruled out?)

14.  What assumptions, if any, about the following underlie your analysis:  Cost functions; supply elasticities; consumer preferences; market structure and market response; income elasticities of demand; price elasticities of demand; productivity trends; distribution of income, wealth, and opportunity by income size, by age, by occupation, by residence, by ethnic group; time preference and discount rates; substitutability of inputs and resources; substitution possibilities in consumption; incidence of taxes, benefits, or price changes.

15.  What determines the level of government at which the problem is perceived or the solution is initiated?

a.  Does the problem area coincide with an effective area or jurisdiction?

b.  Is multi-level collaboration or strategy involved?

c.  Is uniformity among states or regions important?

d.  Is it the nature of the problem, the nature of the preferred solution, or what, that determines the level of government or the agency of government?

e.  How much is the current definition of the problem and the current governmental action a product of historical evolution rather than of defensible choice?

16.  Identify the various interested groups that affect and/or are affected by current governmental action on the problem or program.  In what ways does your proposed program (or even your definition of the problem) reflect the need to reconcile conflicts, balance the conflicting interests, combine diverse interests in a "package," avoid drastic shifts of power, observe tradition, and appeal to diverse ends and goals?  Is the problem one that could conceivably be solved with a mix of measures that would leave nobody worse off?  Or does it necessarily detract from the wealth, welfare, power or status of some group?

17.  If you could set research in motion to help you understand this problem and its solution, what research would you initiate?  How long would it take?  Would you wait for it?  Whom would you want to do it?  What would it cost?  Would it involve assembling existing data, generating new data, experiments, regression analysis, case studies, or what?  Could you build the research into the program?  Would it be basic research or applied?  Could you count on getting the results you need?  Exactly how would your proposal be affected by the results?  What process could produce decisive evidence to establish or to falsify the more controversial hypotheses that underlie your analysis or your proposal; and can you identify what results you would take as conclusive?

18.  What mid-course corrections would you envision if your program does not work as planned?  How will you know when and if it is time to make those mid-course corrections?  How will you convince others that the time is ripe and the corrections are the right ones?

19.  a.  Assume that you held the position of one of the actors currently dealing with your problem.  How would you attempt to get your proposed program adopted and implemented?

b.  Identify a specific bet about governmental action in your policy area and the odds at which you would take  a bet that satisfies two further conditions:  (1) you believe that you can win money from your examiners; and (2) you believe your advantage stems essentially from your understanding of causal factors that your examiners might neglect (rather than any specific information you might have.)

20.  If your definition of the problem is correct and if your proposed solution is any good, why hasn't the problem been so defined and a solution applied already?

Electric soccer

Here is a remarkable company called sOccket, started by young women from Harvard, that is trying to light up the world -- literally -- using specially equipped soccer balls.  They generate and store electricity while moving, which can then be tapped for low-voltage LED lamps, water sterilization devices and mini refrigerators.

Did I say unintended consequences?

I raised lots of hackles in my post below about penalizing hospitals for readmissions, generally and in the face of poor data to support such penalties.  Some commentors have said, in essence, "What can be the harm?  We'll move the needle the right way, even if the methodology is not so precise."

Well, here's one example of the kind of harm that can occur when policies are not clearly thought out.  In December, Karen E. Joynt and Ashish K. Jha from Brigham and Women's Hospital published an article in Circulation: Cardiovascular Quality and Outcomes, entitled, "Who Has Higher Readmission Rates for Heart Failure, and Why? Implications for Efforts to Improve Care Using Financial Incentives."  I quote the abstract:

Background—Reducing readmissions for heart failure is an important goal for policymakers. Current national policies financially penalize hospitals with high readmission rates, which may have unintended consequences if these institutions are resource-poor, either financially or clinically.

Methods and Results—We analyzed national claims data for Medicare patients with heart failure discharged from US hospitals in 2006 to 2007.  We used multivariable models to examine hospital characteristics, 30-day all-cause readmission rates, and likelihood of performing in the worst quartile of readmission rates nationally.  Among 905 764 discharges in our sample, patients discharged from public hospitals (27.9%) had higher readmission rates than nonprofit hospitals (25.7%, P<0.001), as did patients discharged from hospitals in counties with low median income (29.4%) compared with counties with high median income (25.7%, P<0.001).  Patients discharged from hospitals without cardiac services (27.2%) had higher readmission rates than those from hospitals with full cardiac services (25.1%, P<0.001); patients discharged from hospitals in the lowest quartile of nurse staffing (28.5%) had higher readmission rates than those from hospitals in the highest quartile (25.4%, P<0.001).  Patients discharged from small hospitals (28.4%) had higher readmission rates than those discharged from large hospitals (25.2%, P<0.001).  These same characteristics identified hospitals that were likely to perform in the worst quartile nationally.

Conclusions—Given that many poor-performing hospitals also have fewer resources, they may suffer disproportionately from financial penalties for high readmission rates.  As we seek to improve care for patients with heart failure, we should ensure that penalties for poor performance do not worsen disparities in quality of care.  (Circ Cardiovasc Qual Outcomes. 2011;4:53-59.)

Clean up your act, Mt. Ida students

Mt. Ida College is a wonderful school that thoughtfully provides hourly shuttle bus service from the local MBTA stop to the college, enabling commuting students to easily get to and from classes.  Unfortunately, after each group of students patiently waits for their bus, sipping coffee, eating pastries and ice cream, they leave behind their detritus on the sidewalk and in the parking lot.  They do so even though there is trash bin right where they wait.

The parking lot is on my route to and from the train station, and so I often get to witness this.  Here a bag from the doughnut store has been dropped within three feet of the trash bin, a typical pattern visible after the bus leaves.

The college offers a large variety of courses of study.  Maybe there should be a required class in environmental studies, or maybe the administration can just send word to the students to be better neighbors.

How regulation adds layers

Secretary of HHS Kathleen Sebelius recently proudly announced that three burdensome regulations in the health care world had been changed.  In an article entitled "Reducing Red Tape to Help Hospitals Improve Care and Reduce Costs," she explained the first change:

[T]oday hospitals must have a single Director of Outpatient Services who manages all of the various outpatient services throughout the hospital. This requirement was created years ago when most of the care given in a hospital was inpatient. Back then, it made sense to have 1 person in charge. But these days, everything from arthroscopic knee surgery to tonsil removal can be done on an outpatient basis. And each of these departments oversees its own services. This has made having 1 director oversee all of these specialty directors an unnecessary administrative burden on hospitals. So as part of the proposed rules, we would do away with this requirement and allow hospitals to decide the best way to oversee and manage these patients.

Directionally, of course, this is very sensible, as are the two other changes discussed in the article. One would also allow Critical Access Hospitals in rural areas to have lab work, radiology services, and other items be done outside of the hospital.  (Who knew that they couldn't?)  The other would free up hospitals to use advanced practice registered nurses and other non-physician providers to their fullest potential.

When I ran a hospital, I became aware of the Conditions of Participation under which hospitals were eligible for federal reimbursement.  These and hundreds of other regulatory standards are immensely detailed and complicated.  It is easy to imagine how they got that way.  There were likely two main categories.  One category consisted of rules that were written because in some hospital, somewhere, something harmful happened to a patient.  This would provoke a rule.

I am guessing, for example, that the 18-inch rule came from such an incident.  What's that rule?  The purpose is to prevent storage or any other obstruction from interfering with the spray of water from a sprinkler head during a fire.  So, when your hospital is surveyed by the Joint Commission or CMS, inspectors go around measuring the top of storage containers to make sure nothing is within 18 inches of the ceiling.

This one has some logic, although it is often applied more stringently that necessary.  For example, some hospitals and inspectors apply it even where there is no chance of obstruction, e.g., when the storage area is against a wall and not in the way of a sprinkler or the spray pattern.  But that is just a minor burden.  Other rules that are not necessary can be quite expensive, or perhaps harmful.

For example, there was the one imposed by the Joint Commission in 2004 that required giving patients an antibiotic within four hours of presentation if they went to an emergency department and were discharged with a diagnosis of pneumonia.  The standard was developed after publication of 2 large retrospective studies showing an association between antibiotic timing and outcomes in patients with pneumonia.   But doctors have explained to me that this approach could also result in overuse of these medicines, in that it was not dependent on growing and identifying cultures within that amount of time, or even sufficient certainty that pneumonia was, in fact, present.  This latter point was documented in a study from the University of Connecticut School of Medicine:

What the researchers found, as reported in the July 2006 issue of the journal Chest, was that there was too much “diagnostic uncertainty” to deliver antibiotics to 22 percent of patients.

Perhaps in response to this kind of analysis, the standard was modified in 2006 to require the finding of a positive chest x-ray or CT scan during the hospitalization to confirm the diagnosis of pneumonia.  It was later modified to extend the 4 hour period to 6 hours.  But in the interim, thousands of patients received antibiotics without sufficient reason -- at a time when we are told that overuse of antibiotics is an important cause of drug resistance in bacteria.

Let's now go to the next category.

I suspect, but cannot prove, that some portion of existing rules were put in place to protect the jobs or economic interests of various constituencies.  It feels like the two mentioned above -- requiring in-house radiology and labs, and limiting the roles of advanced practice nurses -- might have originated in that way.  I imagine, too, that there are howls of complaint from affected special interests when these types of changes are proposed.

So, congratulations to the Secretary for moving in the right direction on these three items.  The fact that there were only three is indicative of how hard it is to change rules once they are put in place.

WIHI on Safety Net Hospital Transformations

Safety Net Hospitals: Untold Stories of Quality Transformation​​
October 20, 2011, 2:00 PM – 3:00 PM Eastern Time

Guests:
Bruce Siegel, MD, MPH, President and Chief Executive Officer, National Association of Public Hospitals and Health Systems (NAPH)

Linda Cumming, PhD, Vice President for Research at the National Association of Public Hospitals and Health Systems (NAPH) and Director of the National Public Health and Hospital Institute (NPHHI), NAPH’s research affiliate

Steven R. Counsell, MD, Chief of Geriatrics and Medical Director for Senior Care, Wishard Health Services, Indianapolis; Professor, Indiana University School of Medicine; Director, Indiana University Geriatrics
 
Caroline M. Jacobs, MPH, MSEd, Chief Patient Safety Officer/Senior Vice President, Patient Safety, Accreditation and Regulatory Services, New York City Health and Hospitals Corporation
 

The usual way safety net hospitals wind up in the news in the US is when – faced with insufficient reimbursements and other reductions in funding – survival is questionable. The story angle becomes one of fiscal woes exacerbating and undermining the efforts of dedicated providers to deliver good care to mostly uninsured and underserved communities.

This situation and the necessity to address it remain quite real. But it often obscures another picture that's emerging in this critical sector of US health care: the ways in which safety net and public hospitals are innovating their way to greater stability. Even with financial constraints, they are improving care for patients, becoming leaders in quality and safety, and acting as mentors to other health care organizations interested in population health. Denver Health, Contra Costa Health Services, Cambridge Health Alliance, and Stony Brook University Medical Center are just some of the names of places with visionary leaders and bold initiatives underway – so much so that they're gaining the attention of national policy leaders in search of new models of care to achieve health reform.

This exciting trend will be further unpacked on the October 20th WIHI. Host and producer Madge Kaplan will welcome Bruce Siegel and Linda Cummings of the National Association of Public Hospitals and Health Systems to the show to describe a comprehensive agenda for change that’s underway to support the ambitions of their members. They'll be joined by Caroline Jacobs of the New York City Health and Hospitals Corporation and Steve Counsell of the Indiana University School of Medicine and Wishard Health Services, each of whom will provide some rich examples of what’s being achieved at their hospitals on the front lines of care

The focus of the October 20^th WIHI is especially timely as all of health care gears up to engage with greater numbers of low-income patients gaining insurance under health care reform. Who better to turn to for decades of experience but public and safety net hospitals? Please join us!

To enroll, please click here.

Modeling readmissions

The current intent to judge hospital performance and modify hospital payments based on relative rates of readmissions is not wise.  Contrary to President Obama's characterization that readmitting a patient to the hospital is equivalent to bringing a car back to the mechanic after a repair, rates of readmissions are based on a number of factors, of which a significant portion are services not provided by the hospitals and environmental conditions not controlled by the hospitals.

But let's put my objections aside and determine how we would model an "appropriate" rate of readmissions.  Well, a new article in JAMA* explores existing models, noting that robust models are needed "to identify which patients would benefit most from care transition interventions, as well as to risk-adjust readmission rates for the purposes of hospital comparison."  The article concludes that the capability for doing these things does not yet exist.

In "Risk Prediction Models for Hospital Readmission," the authors state as their objective:  "To summarize validated readmission risk prediction models, describe their performance, and assess suitability for clinical or administrative use."  Their conclusion, after reviewing two dozen such models, was that "Most current readmission risk prediction models that were designed for either comparative or clinical purposes perform poorly."

For the technically inclined among you, here's more of the abstract:

Fourteen models that relied on retrospective administrative data could be potentially used to risk-adjust readmission rates for hospital comparison; of these, 9 were tested in large US populations and had poor discriminative ability (c statistic range: 0.55-0.65). 

Although most models incorporated variables for medical comorbidity and use of prior medical services, few examined variables associated with overall health and function, illness severity, or social determinants of health. 

So, even if the readmission rate is the right metric to use for comparison purposes, we don't have a model that would accurately compare one hospital to the others.  This suggests that the time is not ripe to use this measure for financial incentives or penalties.  It might give the impression of precision, but it is not, in fact, analytically rigorous enough for regulatory purposes.

---

*2011;306(15):1688-1698. doi: 10.1001/jama.2011.1515

The big lie

There is a wonderful expression in politics, "If you say something often enough, it becomes the truth."  Of course, it doesn't really become the truth.  A lie retold is still a lie.  But, you can succeed in diverting political attention, especially in today's news environment, when reporters are not given enough time and bandwidth to really explore issues.

Take today's New York Times story about Massachusetts health care costs by Abby Goodnough and Kevin Sack.  The thesis is that the introduction of capititated, or global payments, will offset cost increases resulting from universal health care access.  The reporters give credence to the premise, even though there is not empirical support for the conclusion.  Indeed, such support as exists in Massachusetts suggests that the manner in which global payments were introduced resulted in higher, rather than lower, costs.  The story also fails to discuss consumer concerns about such plans, which would limit choice.

But then, the reporters retell the big lie, the one that suggests that concerns about the cost trends of the dominant provider group have been alleviated by a recently signed contract.  Ready?  Here you go:

Under market and political pressure, Partners also agreed to renegotiate its contract with Blue Cross Blue Shield and accept lower reimbursements, which is expected to save $240 million over three years. ... Blue Cross Blue Shield of Massachusetts said payments to Partners would increase at about 2 percent a year rather than the previously anticipated 5 percent to 6 percent.

Let's deconstruct this.  First of all, the PHS contract had one year to run, not three years.  Whatever rate renegotiation they accepted for the last year of the contract, they would have been smoking something to think that they would have received 5 to 6 percent going forward.  Also, as previously mentioned here, the base on which they get their "about 2 percent" increase is substantially above the market.  Other hospitals that were at or below market rates also received rate increases in the "about 2 percent range" -- starting one or two years ago.  Indeed, with other, non-dominant hospitals, BCBS started those negotiations by offering negative or zero change in rates.  Partners, then, didn't give up anything going forward.  It was permitted to keep its huge bolus of embedded, above-market rates.

Oh, and what's this "about 2 percent," anyway?  Remember that it was reported as "between 2 and 3" percent?  This week, it's been rounded down to 2 percent.  At this rate, in a month, they will describe it as "practically zero."

One thing the reporters get right is this:  "The politically powerful hospitals clearly hope to persuade lawmakers that price controls are not needed."

Likewise, the insurance company, it appears.  Whether it is fear of government regulation or a desire to go along to get along, a tremendous opportunity to truly control costs has been squandered.

But you will never see that story.  The big lie persists.  Welcome to the spin cycle.

Congratulations to Peter Pronovost

Peter Pronovost has been elected to the Institute of Medicine.  Bravo!  This is so well deserved.  Here's a summary of his work from Newswise.

A professor of anesthesiology and critical care medicine and surgery at the Johns Hopkins University School of Medicine, Peter J. Pronovost directs the Armstrong Institute for Patient Safety and Quality at Hopkins and is senior vice president for patient safety and quality for Johns Hopkins Medicine, where he has transformed the way hospitals around the world think about bloodstream infections.

Peter Pronovost has brought a scientifically rigorous yet common-sense approach to eliminating medical errors and unnecessary harm, shaping the national conversation about patient safety in the process. His biggest success so far: the much-heralded, cockpit-style, five-step checklist for doctors and nurses designed to prevent central-line associated bloodstream infections (CLABSIs). The simple checklist, coupled with a program that promotes a culture of safety, has transformed the way hospitals think about bloodstream infections, which kill more than 30,000 patients a year and sicken many thousands more. Thanks to Pronovost, these infections are no longer seen as a cost of doing business. They are preventable.

Pronovost and his team have dramatically reduced ICU bloodstream infections throughout the state of Michigan and exported that success to hospitals across the nation and the world. His program is now in place in 47 states, Puerto Rico, the District of Columbia and in many countries throughout the world. As he spreads the message that CLABSIs can be virtually eliminated, he is also using these strategies to prevent other harm, such as surgical-site infections and pneumonias contracted through the use of ventilators.

In 2008, Pronovost was awarded a MacArthur Fellowship, or “genius grant,” from the John D. and Catherine T. MacArthur Foundation for exhibiting exceptional creativity and showing the promise to make important future advances based on a track record of significant accomplishment. That same year, he was also named one of Time magazine’s “100 Most Influential People.”

He is the author of the book, “Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out,” published in 2010. He is also author of more than 200 research articles.

Thought for the day

Clouded visions of purity and virtue

In an op-ed entitled, "The Thing Itself," New York Times columnist David Brooks decries the fact that, in this polarized political environment, "many issues that were once concrete and practical are distorted because they have become symbolic and spiritual."  "Nearly every practical question becomes a values question," he notes, and "to compromise on any front is to court disaster."  "There are rewards for those who fight over symbols, few who see the thing itself."  And, then, with regard to one specific program that had become a policy disaster, he explained that "its champions ignored basic practical considerations.  They were befogged by their own visions of purity and virtue."

I think this is a good appraisal of the current state of the body politic, and I am struck by how often it applies in the health care arena.  Let's face it, the issues are pretty straightforward -- providing access to health care; shifting our focus from a system based on the high-end "rule of rescue" to one based on a thorough system of primary care, prevention, and early detection; paying special attention to the management of care of the 15% of the population who account for 85% of the costs; reducing the amount of preventable harm in clinical settings; and introducing techniques of process improvement that have been proven to work in so many other sectors.  Those, to use Brooks' terms, are "the thing itself."  But then we surround them with ideology and a lack of analytical rigor in policy-making, and we end up with a stalemate, lack of progress, or, maybe worse, unintended consequences.  Let me give three examples:

Class-less

The Community Living Assistance Services (CLASS) Act, inserted into the health care reform legislation, was intended to be a voluntary program open to all working Americans. It would have provided a basic lifetime benefit of a least $50 a day in the event of illness or disability, to be used to pay for even non-medical needs, such as making a house wheelchair-accessible or hiring a home caregiver to assist with basic tasks.

As noted in the Washington Post, "The program was to be entirely self-financed with the premiums participants paid. Obama officials said that presented them with a problem: If they designed a benefits package generous enough to meet the law’s requirements, they would have had to set premiums so high that few healthy people would enroll. And without a large share of healthy people in the pool, the CLASS plan would have become even more expensive, forcing the government to raise premiums even higher, to the point of the program’s collapse."

All of this was obvious to many observers when the bill was being considered, and so it is no surprise that the administration had to conclude that the program was infeasible.  But look at this response:

“I’m very disappointed,” said Connie Garner, who helped draft the CLASS Act while on the staff of the late senator Edward M. Kennedy (D-Mass.).  “CLASS is a critical backstop, giving working families a tool to protect themselves from being one illness or injury away from poverty,” said Garner, who directs a group called Advance CLASS Inc. “The president promised to implement this program. We expect him to keep that promise.”

De-capitated

As discussed here many times, the concept of capitated, or global, payments as a replacement for fee-for-service pricing has interesting pro's and con's.  As to the key question of whether it will produce better outcomes at lower costs, though, it does not have much empirical support.

Where this is empirical support, I have found two categories of interest.  The first is those companies, like Commonwealth Care Alliance, who have taken on the care of small populations of dual eligible patients, those on both Medicare and Medicaid.  They have figured out how to manage those patients on a budget much more efficiently compared to those patients who, in essence, navigate their own way through the health care system.  This is good, although the situation with which they are compared is scarcely a paragon of anything.

The second is those systems, like Geisinger, that own both an insurance company and a provider network and are therefore able to optimize costs and transfer prices internal to their financial bottom line, and who are dominant providers in their market area.

But these kinds of example are few and far between and are not representative of the health care system.  Accordingly, there seem to be two main groups who support capitation.   One group does it for business purposes related to a corporate goal of shifting risk.  The other group adopts the rhetoric that all doctors want to do is order expensive tests and procedures to make more money.  Here's one summary from an advocacy group:

Under the global payment structure, docs are paid a set amount of money for each patient they care for, rather than for each procedure or test they provide. So, the providers have incentive to increase efficiency and better coordinate care between nurses, primary care physicians (PCPs) and specialists. 

And more of their "analysis:" 

The current fee-for-service system rewards the quantity of care over quality. You have to go to a doctor’s office or a hospital to be seen and to be tested. Each one of those visits is charged separately. There’s no incentive to do it any other way because the visits and the tests are how the doctor and the hospital make their money.

Global payments support more nurses, community health workers and cost-effective help, like online consultations or home visits. Public health must be integral to this structure as well.

When wishful thinking and rhetoric take over in a policy debate, unintended consequences arise.  This same group, for example, expressed surprised concerns "about narrowing patients’ choices for medical care," something that is inherent in the limited networks you need to make capitated payment regimes work.  Should we be relieved to know that this group "will watch to make sure residents get the care they need?

Re-admitting -- "Never" again

In the absence of a analytical support that might diagnose a particular problem in a rigorous fashion, regulatory agencies will do what regulatory agencies do:  Accept the rhetoric of their political leaders and use the hammer in their hand and see everything as a nail.

I have addressed this problem with regard to so-called never events:

In the face of slow progress, there is little doubt why the regulatory hammer is employed. But it is a crude tool. Its effectiveness as a deterrent is minimal because it does not address the structural issues underlying the problem. It emphasizes a particular outcome rather than a process that will achieve it. It penalizes people when it is too late to make a difference. Finally, it serves mainly to create resentment among those who are targets for improvement. Such is often the nature of regulation, no matter how well intended.

The target de jour is readmissions.  The Boston Globe notes:  "President Obama and members of Congress have cited high numbers of hospital readmissions as a main driver of soaring health care costs, as well as being bad for patients."  The Wall Street Journal explains that at a town-hall meeting the President  compared readmitting a patient to the hospital to bringing a car back to the mechanic -- as inapt a comparison as one could imagine.  He asserts, "And too often we’re not seeing the best practices in some of these hospitals to prevent people from being readmitted. That costs a lot of money."

This leads to the following policy prescriptions:

Starting in 2013, those with the highest rates could be docked Medicare payments. The health and human services department has pledged $500 million to help hospitals partner with community-based organizations that help patients make the transition from a hospital bed to their home.

Wow, this feels like foreign policy.  There, we pound the table and assertively define the enemy to show that we are manly and powerful leaders -- before we are accused of weakness by the other party.  We impose sanctions and supply armaments to the opposing forces, and we find ourselves in a quagmire.  In health care, we grab on to one of many interrelated clinical issues and define it to be a "main driver" and both penalize providers and throw money at the problem.  As in foreign policy decisions, I predict many unintended consequences.

The Jubilee Project explores diabetes

Here is a video by the Jubilee Project's Eric Lu highlighting the voices of diabetic patients and their struggles and dreams.  As always, every view generates a contribution for a worthy charity.

If you cannot see the video, click here.

Don't wake up late if you plan to shower

A Perfect Stay.  I can't think of another thing to say.

How bare should the bare essentials be?

An article by Jessica Zigmund in Modern Healthcare (October 10), entitled “The Bare Essentials,” presents an interesting conundrum for the federal government as it defines what should be covered by the health insurance programs that will be offered by state exchanges under the Patient Protection and Affordable Care Act.

The short version of the controversy is that an advisory panel from the Institute of Medicine has made recommendations concerning what clinical conditions should be covered.  But the National Association of Public Hospitals and Health Systems would like to see “critical enabling services,” such as language interpretation, transportation, and case-management included as well.

The balancing job for the Department of Health and Human Services is to create insurance plans that are reasonably expansive in terms of coverage, but not so much so that they cannot be offered at affordable prices.  The law requires insurance plans to cover at least ten general categories of health services: ambulatory services, emergency care, hospitalization, laboratory services, maternity and newborn care, mental health and substance abuse programs, pediatric services, including oral and vision, prescription drugs, preventive and wellness services and chronic disease management, and rehabilitative and habilitative services and devices. The coverage must also be similar to those provided by typical employers.  Over 68 million people will be likely to procure insurance under these standards.

The IOM committee viewed its role as reviewing evidence-supported medical conditions.  NAPH took a broader view.  Of course, there are cost implications here, with interest groups on both sides.  As noted in the article, “If the rule is very robust, it could make plans too expensive and not meet the law’s goal of coverage and access for all.  But if it’s too bare-boned . . . then the package could be viewed as depriving millions of people of the coverage they need.”

I have great sympathy for the points raised by NAPH.  For language interpretation, for example, it is not appropriate to rely on a family member or friend to be the go-between in a discussion between a patient and a doctor.  Indeed, it can raise grave cultural difficulties:  Imagine an English-speaking teenage son translating for a Southeast Asian woman and her gynecologist.  Neither can you expect family members to maintain clinical dispassion in an emergency room setting.  Good communications is not just a convenience:  It can be a matter of life and death.

The issue is whether the insurance plans should cover such expenses when they are essential to the treatment of the categories of illness envisioned by the law.  They are not always covered by private insurance plans now.  The hospitals absorb those expenses when they are not covered.  Perhaps it is a good time to make them an accepted and expected portion of the insurance products.

It looks like we might have to wait a while for the answer, though.  The article notes that, in typical Washington fashion, “There has been talk that a final rule might be pushed back until after the 2012 elections because of the political implications attached to it.”

What happens in Atlantic City . . . gets reported here

I just returned from giving a keynote address at the Annual Institute of the New Jersey and Metropolitan Philadelphia Chapters of the Healthcare Financial Management Association.  Regular readers of this blog will not be surprised at the themes I covered (transparency, front-line driven process improvement, the virtuous cycle between reducing harm and financial efficiency), and I need not elaborate on them here.

Instead, I want to talk about the huge variety of vendors and other companies exhibiting at the meeting.  If one were cynical, one could walk away understanding how health care and related expenses constitute 16 percent of the nation’s GDP.  But, if you look beyond that, you will see many firms that are involved in offering services designed to reduce the cost of health care and make it more effective.  Let me mention two I happened to visit.  (I have no financial interest in either.)

The first was a company called Avery Telehealth, based in Scottsdale, Arizona.   This firm is offering a readmissions avoidance program for it clients, promising a 30% reduction in readmission rates for congestive heart failure, acute myocardial infarction, and the like.  I was impressed with the no-nonsense approach employed.  It is heavy on personal involvement from care transition social workers, daily contacts from call center nurses, and using telecommunications to connect residence-based equipment to monitor patients' daily status and vital signs.

In a different category, JBH Advisory Group from New York City offers hospitals help in refining their food and nutrition services programs.  The company views these services from a retail/restaurant operations perspective rather than an institutional health care framework.  JBH consultants have assisted in over 1000 hospitals in the last 18 months, realizing a reduction in total food and nutrition services costs from 13 to 30 percent, averaging 26%.

This is just a very small sample, but I was pleased by a lot of what I saw.  On a humorous note, I include a picture of the give-aways of one bank at the trade show.  They clearly did not expect many doctors to attend this meeting, as the use of fat-and-happy-MD stress balls in the hands of finance folks might be misconstrued!

Going along to get along

The relative quiet since the state's largest insurer gave away a huge rate increase to the state's dominant health care system  --  a 2-3% increase on a base that is, what, 15 to 20% higher than the rest of the market -- is indicative of something here in Massachusetts.  After all, if there was ever a time for that insurer to challenge the market power of the provider group, this was it, with other hospitals and physicians waiting in the wings to serve the public at a lower cost and employers looking for lower priced products.

Year's ago, the CEO of this provider group said to a then-balking CEO of this insurance company, "This is what good health care costs."  The latter conceded, and the pattern was established.  The current team seems to feel the same way, even in the face of evidence from other parts of the region that such costs are not necessary to deliver high quality care.

Or maybe this was a case of going along to get along, slipping a story by a body politic and media that has lost the will or interest to focus on another large, implicit tax increase on the people and businesses of the state.

How I made the call

Here's my ruling on the soccer play described in the post below.  Thanks to all for your opinions.  This business of refereeing a football game is very challenging.  Things happen quickly and unpredictably.  I often find it useful to replay the tough calls and share them with others, as here, as part of learning to be better at this.  After 17 years or so of being a licensed referee, it still bothers me when a child is hurt, even if I think my call was correct.

Going back to the match, I allowed the goal, as a clean charge with the goalie not in possession.  The red coach differed, saying I had an obligation to protect the goalie.  The white coach saw it the way I did.  No surprises on either side there!

Here's what my referee colleagues said when I presented the case to them:

John:  Agree with your call. No real obligation to protect the keeper in the Laws of the Game. Sounds like a 50-50 ball misjudged by the keeper.

Jeff:  It might depend, for me, on the extent of the 'collision, goalie knocked down'. Part of playing fairly in going up to head a ball is to be able to come down and not knock over an opponent - a player is responsible for his momentum - body, cleats, whatever. When that opponent is the keeper, refs might apply even stricter judgement to what is a fair jump. That said, at U12 D1 a level of physical play is of course expected and needs to be accepted. So I guess for me it would depend on the extent of the contact against the keeper after the header (which I of course can't judge).

Bill:  Agree with John, assuming that white player was jumping more or less straight up. D-1 (division 1) almost requires you to allow it.

Tom: Seems like another classic case of “you had to be there to see it.”  You were the one there, so I would tend to go with your call.  Some things I might’ve considered:  I think we do have to consider that the keeper can be more vulnerable than the average player.  However, sometimes  keepers endanger themselves as “part of the job.”  What was the angle and speed of the white player when he went up to head the ball?  Did he launch himself at it and perhaps into the keeper? Or did he go up fairly vertically, in which case perhaps the keeper’s momentum carried him underneath the descending white attacker?  Sometimes, attacking players might say after a foul “but, ref, I got the ball.”  In which case the answer is that “yes, but you had to go through the other guy and foul him to get to it.”

From your description, the keeper does not have possession, therefore I would be influenced by the speed, trajectory, and control of the white attacker’s leap to head the ball and win a 50-50 situation.

BTW, players are sometimes “hurt” in games when their pride takes a hit. Maybe that was part of the play in your game? 

My reply:  Thanks, Tom. Yes, I was close and had a good angle, and I saw it as a fairly vertical jump, with the keeper going forward under him.  In fact, I remember, in that split second, being impressed with the fact that it was a remarkably clean approach to the header. (There was a big height differential between the two players.)

You make the call

It was Columbus Day weekend here, creating a holiday opportunity for many youth soccer (football) tournaments.  I was referee of a half dozen games on Sunday and Monday in Natick, a neighboring town.

Even though these are children's games, the level of play is excellent, and the games often present challenging calls for the referee.  Here's the situation I faced in one of the games.  You decide the call, and later today, I will post my decision, along with commentary from some of my colleagues.

It is a Under-12, top division, boys match, hard driving and physical but quite clean.

A high bouncing ball approaches red's goal.  The red goalkeeper comes out to get it, but it starts to bounce over him.  As it is in the air over his head, a white player, having jumped up, cleanly heads it into the goal.  The two collide and both are knocked down.  The goalie is hurt by the collision and has to leave the field.

Your call.  Allow the goal?  Or, call a dangerous play against the white attacker and not allow the goal?

Do you need any other facts to help decide the matter?

Dear NY Times, let us interpret the news

It used to be that you could count on the New York Times to separate clearly news stories from analysis or commentary, but the newspaper now regularly blurs the distinction.  Let me give an example from today's paper, in a front right story entitled (in the paper edition), "Median Incomes Shrank Further After Recession". 

By the way, that I might agree with the opinions put forth is not the point.  The point is that a news story is supposed to be news, not opinion.  Let the readers draw their own conclusions.

Here's the lede:

In a grim sign of the enduring nature of the economic slump, household income declined more in the two years after the recession ended than it did during the recession itself, new research has found. 

The use of the term "grim" is problematic, as it is the writer's characterization.  The sentence would have be accurate and properly sparse without it.  But that is minor compared to this conclusion, two paragraphs further along:

The finding helps explain why Americans’ attitudes toward the economy, the country’s direction and its political leaders have continued to sour even as the economy has been growing. Unhappiness and anger have come to dominate the political scene, including the early stages of the 2012 presidential campaign.

Where does this come from?  There is no evidence presented in the story that there is a connection between the two.  Maybe, for example, people's attitudes towards their political leaders result from those leaders behaving like incompetent boobs (my opinion).  But there is not even support included in the story for the proposition that these are "Americans’ attitudes" or that they have "continued to sour," i.e., grown in scale.  Again, I am not saying the conclusion is wrong:  I am saying that, in a news story, the reporter is supposed to provide factual support for the statements.

The rest of the story, after the page turn, is an excellent summary of economic research on the income issue, by this reporter who presents this kind of material well.

In previous decades, the Times would have separated the news story -- "median incomes shrank" -- from an accompanying news analysis story  -- "grim figures explain public malaise."  By combining the two aspects into one story, the newspaper falls into the entertainment trap of certain television networks.  Maybe that is its intent.