To turn or not to turn

A colleague informs me that 98% of people who are reading a story on the New York Times on-line version do not "turn the page" when the story jumps to a second page.  If that is the case, it presents a crystal clear rationale for redesigning the website, taking advantage of the flexibility one has in graphic design to make it more likely that people will read more of the high quality content that The Times offers.

Let's do a little crowdsourcing here.  How would you design the web version of the newspaper to encourage and enable subscribers to read more of these stories?

My simple answer, although I don't know if it is technically possible, is to have the story automatically expand as it senses your cursor reaching the last paragraph on the first page.

Thanks to John and Kathy

How like John Halamka to share with the world his and his wife's experience with breast cancer.  John believes that knowledge is power, and shared knowledge even more so.  Tune in on his blog every Thursday for an update.

Better than printing money

John McDonough, one of the health care experts in Massachusetts, writes on his blog about the three-year renewal of the state's Medicaid waiver.  John presents a history of the waiver and notes that it provides the "green glue," i.e., the infusion of federal cash, that makes possible the health care reform process approved by this state several years ago.

The details are impressive. $26.7 billion over three years, a $5.69 billion increase over the prior waiver, and bringing $13.3 billion federal dollars to the state; $120 million for safety net hospitals such as Boston Medical Center (BMC) and Cambridge Health Alliance (CHA); a pilot project to improve pediatric asthma care; a first-in-the-nation express renewal process for MassHealth, the state's Medicaid program; enhanced early intervention services for Autism Spectrum Disorders, and more.

There are many similarities between the Massachusetts health care access legislation and the federal plan passed by Congress  -- individual mandate, guaranteed issue of insurance, an insurance exchange with minimum coverage standards, and subsidized insurance plans for lower income people.  The big difference is that a substantial part of the costs of the state plan are covered by this Medicaid waiver, offsetting appropriations that would otherwise be needed from the state treasury.  The federal government, in contrast, has no higher level of government to provide funding for its program. It was well known when the federal bill passed that the financial projections showing zero budget impacts were wrong, ignoring, for example, the annual multi-billion dollar override of the SGR adjustment for physician salaries.  Since the legislation really did not provide comprehensive ways to address those cost increases, they will remain a political battle in coming years.

Heavyweight development

Boy, did I underestimate the capital capacity of the Partners Healthcare System when I wrote a post suggesting that plans by Brigham and Women's Hospital to spend roughly $500 million for new clinical and research space would be problematic.  I said:

I write it as a citizen watching the unfolding of a business plan that seems to me to be building in future health care cost increases for our region, or worse, potentially weakening one of the country’s great hospitals.

I underestimated by a factor of two, for now the hospital has filed a notice of intent with the Boston Redevelopment Authority to develop 360,000 square feet of research and wet laboratory space and 355 to 455 parking spots.

I am not current with construction costs in the highly congested Longwood area of Boston, but I believe it reasonable to assume at least $1000 per square foot for lab space.  Underground parking spots, requiring slurry wall construction in these high water table soil conditions, come in at $80,000 each if not more.  So, the total price tag, assuming room for 400 cars, not counting demolition and clearance costs of the existing structure, is about $400 million.

This takes your breath away.  A billion dollar construction program, in the face of the end of the federal stimulus program for NIH research and likely flat funding going forward.  The capital accumulated must therefore derive mainly from margins made on the clinical business.  If anything gives the lie to the idea that the recently signed contract with Blue Cross Blue Shield was not overly generous, you have it here.

That white stuff is not baby powder

People in the UK who use public baby-changing units might want to use those baby wipes on the changing surface, as well as on the baby.  This story in The Telegraph reports:

More than nine in 10 baby-changing units in the North West have tested positive for traces of cocaine. The tests, carried out by using specialist wipes, found that 92 per cent of the 100-plus units examined carried traces of the class A substance. They included facilities based in public toilets in shopping centres, hospitals, police stations, courts and churches.

Police stations? Courts? Churches?

I know that talcum powder is not longer recommended for babies, but isn't this going a bit too far?

Short memories

When the health care reform bill was pending, and the Congressional Budget Office was asked to opine on its financial impact, one of the "givens" in the cost equation was the annual sustainable growth rate (SGR) formula included in the 1997 Balanced Budget Act.  The was a provision that would reduce physician Medicare rate schedules each year.  The SGR adjustment was to save hundreds of millions of dollars during the ten-year analysis period used by the CBO.  It was included in the calculation because it was a sure thing prescribed by law.

The problem is that, since 2003, Congress has postponed the rate reduction.  Each year, thousands of doctors from around the country, directly and through their trade associations, lobby hard -- and they are successful.

The SGR formula works this way:   If spending due to increased use of services by Medicare patients rises faster than the nation’s gross domestic product, Medicare must compensate by cutting reimbursement rates for physicians enough to bring spending back in line with GDP growth.  This year, the SGR adjustment would hit doctors with a 27.4 percent pay cut for their Medicare patients in January unless Congress steps in.  As noted in this Washington Post article:

Postponing the cuts . . . would cost $21 billion for a one-year delay and $38.6 billion for two years. Fully repealing the formula would add nearly $300 billion to the deficit, according to the Congressional Budget Office.

Rest assured, the cuts will be postponed again, kicking the can further down the road.

But this year, the whole thing is mixed up with the controversy about extending the payroll tax cut.  Here is an explanation from Politico that should make the whole thing clear:

After a very long Monday, House Republican leaders announced last night they would not hold an up-or-down vote on the Senate’s two-month payroll tax cut and SGR patch. Instead the House plans to take a series of mostly show votes today, including one on the motion to reject the Senate's version and instruct conferees, and another on a "majority resolution" that restates the House Republicans' priorities when it comes to a two-year "doc fix" and other parts of the year-end package. Little is certain, and GOP leaders were careful not to overpromise on the slate of votes today. Majority Leader Eric Cantor (R-Va.) said the endgame is to appoint a conference committee "so we can actually work the differences out." He added: "We can resolve this situation and the people of this country can get what they deserve — certainty on tax policy and health care policy going forward." Minority Leader Nancy Pelosi said she would not appoint members to a conference.

Legislative battles

As financial pressures impinge the health care system, the various players sometimes seek legislation to protect their interests.  I have heard of two such situations in Massachusetts, and I offer them for your consideration and your comments.

The first involves emergency ambulance service.  Earlier this year, several of the major insurers in the state stopped reimbursing out-of-network ambulance providers, and instead started to send the checks to patients who used those ambulances. Those ambulance companies now have to try to collect from people for payments, and they are losing hundreds of thousands of dollars.

(This only relates to emergency calls, not routine transfers. For routine transfers, ambulance providers already agreed to be reimbursed at agreed-upon rates with insurers and municipalities.)

I can understand why the insurers want to use lower cost ambulance services, but I have trouble imagining a more cruel thing than approaching a patient or a patient's family after an emergency situation (which perhaps led to long-lasting disability or death) to collect funds that the insurers have sent to the family.  It is also inherently inefficient and adds costs if the ambulance companies have to try collect funds from hundreds of individual patients rather than the few insurance companies.

Rep. Jim Cantwell of Marshfield has filed a bill to force insurers to pay EMS providers, and it has a cost-control provision that would give ultimate rate-setting power to local selectmen.  The Fire Chiefs Association, Massachusetts Municipal Association and Massachusetts Hospital Association support this bill.  This sounds like one that, in legislative parlance, "ought to pass."

Then there is a proposal that comes out of the growth of tiered networks, in which insurers charge higher co-pays or otherwise limit coverage to patients who choose higher cost providers.  Well, it turns out that some of those high-cost providers are seeking legislation that would require insurers to include them in the low-cost tier of the network.  The two fields at play are pediatrics and cancer care.  The providers' argument is that they offer essential services not available at other providers, or that they offer similar services but at higher quality.

Given the current absence of current and publicly available quality and outcome data, it is hard to make a persuasive argument for this exemption from the tiering system.  If I were a legislator, I would want to see the numbers and be assured that the stated services are indeed not available from other lower-cost providers or that they are not the same quality. And, yes, if then persuaded that these are essential and of higher quality and are being allocated away from poorer people because of the pricing regime, legislation might be warranted.  But the burden of proof should lie with the providers requesting such an exemption.  Also, since things change over time, the process for such exemptions should rest with a regulatory agency rather than having specific providers' names being written into the law.

I welcome your thoughts on both of these matters and wonder, also, if people are seeing similar issues arise in their states.

It moved into my path!

For those who think texting while driving is dangerous, let's consider how many people hit regular mailboxes while driving!  The USPS is clearly a public safety hazard.

Really, the most significant?

Medscape Today has an article featuring "The Most Significant Medical Advances and Events in 2011."  The list includes things like some FDA drug warnings; the fact that the Supreme Court will review the health care reform law; some finding about cellular phone use and brain activity; withdrawal of propoxyphene from the market; and new listings of top hospitals.

To which I say, "Bah, humbug!"  Most of the things mentioned have had and will have little or no impact on you, me, our relatives and friends as we seek to get care or avoid care.

What are the most significant advances and events?  They are the ones that have occurred by communities, patients, and clinicians in their home towns or their home regions that demonstrate the potential for real improvement in clinical care.  These are the ones that save lives now.  These are the ones that empower patients to be true partners with their caregivers and vice versa.  These are the ones that have nothing to do whatsoever with government mandates, accreditation actions, and the like.

These are the ones that occur because, by strategy or opportunism, well intentioned and thoughtful people modestly work together to reorganize the work in hospitals and other settings.

Examples from this blog are:

1 -- A patient named Christian who persuaded a nurse to allow him to administer his own dialysis, and who then trained others, transforming care in a Swedish hospital.

2 -- Peter Pronovost and colleagues document that reducing central line infection rates in Michigan also lowered costs.

3 -- Glen Cove hospital achieves 1223 patient days without a central line infection.

4 -- The one million people of Saskatchewan allocate $5 million per year of government funds to establish and maintain a Health Quality Council, an independent agency that measures and reports on quality of care in Saskatchewan, promotes improvement, and engages its partners in building a better health system.

5 -- The University of Michigan Health System demonstrates the power of adopting a Lean process improvement philosophy and generously shares its experience with the world.

6 -- Jeroen Bosch Hospital in the Netherlands celebrates the opening of a new building by enthusiastically endorsing transparency of clinical outcomes.

7 -- Aided by the Vermont Oxford network, thousand of neonatologists create state consortia to to set statewide targets and objectives, compare best practices, and understand the variability in clinical practices across and within institutions. 

8 -- The SCAD ladies band together and influence the direction of medical research.

9 -- The Sepsis Alliance presses for greater awareness of this deathly clinical syndrome.

10 -- The Manukau District Health Board in New Zealand propounds the following philosophy: 

 

What we need to do if something goes wrong is pull back from the instinct to place blame and instead think more deeply about the contributing factors. We need to think about how the system got us to where we are and where the faults in it lie.

Synthetic Biology Explained

This is a short, clear, and fascinating video about the basics of genetic manipulation and, by extension, the use of engineering principles to create new organisms.  As the squib says:

From selective breeding to genetic modification, our understanding of biology is now merging with the principles of engineering to bring us synthetic biology.  Written, animated and directed by James Hutson, Bridge8.

Well worth the six minutes it takes to watch.  If you cannot see the video, click here.

The latest from the Jubilee Project

Eric Lu and his friends from the Jubilee Project are back with this funny skit, supported by students from Harvard Medical School.  As always, every time someone views the video, a contribution is made to a worthy cause.  Look for a cameo appearance in this one by Dr. Nancy Oriol, HMS Dean for Students.

If you cannot see the video, click here.

What they say versus what they do

I thought it might be instructive to compare the various wordles below, showing the strategic priorities of the hospitals, with what the CEOs say are their priorities.  So, I took this chart of top issues hospital CEOs say they face from a while back and made a wordle out of it.  I rounded off the percentages and repeated the word in the wordle application one time for each ten percentage points (e.g., MD/hospital relations at 25% became 3).  Here's what you get:

Now, compare that with any of the ones below.  Here's Emeline's, representing a number of academic medical centers, to remind you:

Hmm, seems like there is not much correspondence between corporate missions and how leaders spend their time.

Baltimore time is Pepsi time

Andrea Walker from the Baltimore Sun reports:

PepsiCo has signed a deal that allows employees and dependents across the nation to get certain surgeries at Johns Hopkins Hospital — a cutting-edge arrangement that could grow in popularity as companies look to provide better health care and contain costs.

The world's second-largest soda company will pay for workers and their dependents — about 250,000 people — to travel to Baltimore for cardiac or complex joint surgeries, such as correcting problems in a previous knee replacement. PepsiCo will also cover the deductible and coinsurance for the procedures.

It's a free country, so PepsiCo can do as they like, but I wonder what the basis is for choosing Hopkins instead of another hospital.  Is it that it can demonstrate superior outcomes compared to other hospitals around the country?  No it cannot, but there are no published figures that would enable that kind of comparison.

So, the answer has to be that PepsiCo negotiated a really good price for these services:

Hopkins in turn will charge Pepsi a set rate for the surgery, rather than separate fees for physician charges, preoperative testing and other related services. The arrangement was announced last week.

As this is mainly incremental business for Hopkins, I am willing to bet that the price offered is substantially below that charged to local residents going to the hospital, whether covered by Medicare or private insurers.  In a large, fixed-cost institution like Hopkins, as long as you don't have to add new physical facilities and expensive equipment, you can price just high enough to cover your short-term marginal costs and come out ahead.

But I wonder if PepsiCo considered other institutions or conducted a taste test?  That would have provided a real challenge.

The wordle from the Hub academic medical centers

And the final one in our series of wordles, this one based on the mission statements of the Boston academic medical centers (BIDMC, Brigham and Women's Hospital, MGH, Tufts Medical Center, St. Elizabeth's Hospital, Boston Medical Center, Children's Hospital, Mass Eye and Ear Infirmary, Dana Farber Cancer Institute, and Joslin Diabetes Center.)

Dr. Shaw offers Canadian hospital and health system wordles

And one more post continuing our theme of visual representations of hospital mission statements, we have these submissions by Dr. Susan Shaw, in Saskatoon, Saskatchewan.  She writes:

I wondered if things might be different in Canada.  We don't really have Academic Medical Centers in the same manner as the US system.  But I picked some of our largest teaching hospitals or networks that partner with Canada's largest medical schools.   

I also made a second wordle using all the mission statements of our Saskatchewan health regions for a comparison.

Joe Colucci sends the wordle for nonprofit hospitals

Continuing our theme of  visual compilations of mission statements from hospitals.  Joe Colucci, Research Associate at the Health Policy Program of the New America Foundation, compiled a wordle from the mission statements of about 50 nonprofit hospital systems across the country.  He notes that if  you zoom in on the image, there's quite a lot of detail -- small words that only recur a few times.

Here's the wordle for academic medical centers

Responding to my post below, a Facebook friend, Emeline Aviki created -- faster than you can say "AMC"! -- this wordle based on the missions statements from seven leading US academic medical centers.

She notes: "The most concerning words that are missing from this image are 'sustainability' and 'efficiency.'"

In a comment to my original post, Bruce Ramshaw offered a perceptive thought before he even had a chance to view Emeline's work product:

Many are learning the words and including them in their mission statements: patient-centered, world class, team-based care, value, quality improvement, etc. etc. But unfortunately, other than individuals leading extraordinary efforts (like Peter Pronovost and others), the academic medical center leadership and overall organizational design continues to persist in an increasingly outdated mindset, and in an organizational hierarchy with vertical department silos that actually prevents implementation of the improvements described by the words in their mission statements.

What would this look like for academic medical centers?

A colleague in the arts sent along the following:

"An analysis of the mission statements of leading US art museums yields some surprising results," By András Szántó. From Art Basel Miami Beach daily edition; Published online: 01 December 2011.

The graphic above shows most frequently used words in 60 museum mission statements. The bigger the word, the more often it appears.

Quick. What do the following terms have in common? Beauty. Values. Discussion. Contemplation. The answer: none of them figures prominently among the institutional imperatives of US art museums—at least in light of their mission statements.

In fact, if you scanned 60 mission statements of prominent museums that exhibit contemporary art, you would find that each of the words above appears exactly once. Other words found missing from 59 of 60 mission statements: advocate, progressive, ambitious, ethical, intelligence, strategic, video.

If we were do the same for the nation's academic medical centers, what words would predominate?  Which would be missing?

Please provide your answers in the comments below.

Wellness Challenge at the Gaylord Palms

#IHI You may recall my post below about staff recruitment, orientation, and engagement programs at the Gaylord Palms in Kissimmee, Florida.  Here's another I liked a lot, which could be easily replicated by any employer.  The goal is to promote employee health and wellness, but not in a heavy-handed way.  Consistent with the leadership philosophy of the Gaylord Palms, they made it fun.

The prize is $1,000.  You take your "bingo card" (above) and have each box in the bottom half certified when you carry out the measure, e.g., physical exam, blood drive, flue shot, etc.  If you complete 10 of the 16 squares, you are entered to win in the drawing for the grand prize.  If you complete 12, you get two chances to win; 14, three; and 16, four.

I think this is a painless and enjoyable way to promote employee health.  I am also willing to bet that participation in the program reduces the company's health care bill by well more than the cost of this incentive program.

We, robots

First we have robots that you take home after going to the hospital, and now we have robots before you leave the hospital to go home.  An excerpt:

[Brian] Jack and his colleague Timothy Bickmore of Northeastern University have enlisted “Louise,” an avatar, or virtual discharge advocate. She appears on a computer-like screen that is rolled up to patients’ hospital beds to walk them through the discharge process. 

Louise can spend 40 minutes or more with every departing patient. She is never distracted and can create well-targeted discharge summaries using information about each patient. Louise can communicate using synthetic speech and through a touch-screen display. And patients actually like her, says Clancy, “some . . . better than real, live nurses.” 
 
Oh, come on. Let's take some of the energy that went into this kind of programming and direct it to adopting Lean process improvement so that real, live nurses or case managers have the time and energy to carry out these functions.

Meanwhile, recall this scene from I, Robot.

Sonny (a robot): What does this action signify?
[winks]
Sonny: As you walked in the room, when you looked at the other human. What does it mean?
[winks]
Detective Del Spooner: It's a sign of trust. It's a human thing. You wouldn't understand.