Good diagnosis, Zeke. Why no cure?

I really like it when I agree with Zeke Emanuel and never more so than with his recent column in the New York Times about proton beam machines.  You will recall that I addressed this topic several months ago.

He notes:

If you want to know what is wrong with American health care today, exhibit A might be the two new proton beam treatment facilities the Mayo Clinic has begun building, one in Minnesota, the other in Arizona, at a cost of more than $180 million dollars each. They are part of a medical arms race for proton beam machines, which could cost taxpayers billions of dollars for a treatment that, in many cases, appears to be no better than cheaper alternatives.

To generate sufficient revenue, proton beam facilities need to treat patients with other types of cancer. Consequently, they have been promoted for patients with lung, esophageal, breast, head and neck cancers. But the biggest target by far has been prostate cancer, diagnosed in nearly a quarter of a million men each year.

There is no convincing evidence that proton beam therapy is as good as — much less better than — cheaper types of radiation for any one of these cancers. 

And here's the upshot: 

With Medicare reimbursement so generous, and patients and doctors eager for the latest technology, building new machines is sane, profitable business for hospitals like Mayo.

But it is crazy medicine and unsustainable public policy. 

If the United States is ever going to control our health care costs, we have to demand better evidence of effectiveness, and stop handing out taxpayer dollars with no questions asked. 

So why doesn't the administration, which runs and controls Medicare, change this?  Didn't you work in the White House, Zeke?  Can you tell us why?

BioInnovations Conference at MIT

A note from Lamees Hamada, a graduate student at the Sloan School:

The MIT Sloan Healthcare Club is holding its annual BioInnovations Conference, Driving Innovation & Entrepreneurship in a New Era, on February 24th. The conference will feature keynote speakers, Chris Viehbacher (CEO of Sanofi), Phillip Sharp (Nobel Laureate and Co-founder of Biogen and Alnylam Pharmaceuticals Inc.), and George Scangos (CEO of Biogen Idec). Panels will focus on paradigm-shifting trends: personalized medicine that creates more value, new business models that sustain innovation, healthcare financing that nurtures entrepreneurship, and emerging market healthcare that tackles global challenges. The conference will conclude with a networking reception, the BioInnovations Poster Session, which will feature student research from MIT and other universities. Early bird tickets are on sale through January 30th. Please visit the conference website for further information.

The harp delivers and soothes

One of the most satisfying decisions I made during my tenure as CEO of our hospital was to introduce harp playing.  This happened in an unplanned way.  I was walking near the building and ran into a family friend, Nancy Kleinman, and asked what she was doing.  She mentioned that she was spending a lot of time playing the harp, and I invited her to play in our public spaces.  She was willing to volunteer, but I insisted on her being paid because I felt that this would be an important service, one that should be offered on a professional basis.  Of course, no insurance company would cover this kind of service, so I paid for her personally for several months.  Later a generous donor stepped forward to fund the program on a ongoing basis, and an additional musician was added to expand the program.

Beyond public spaces, the harpists were also asked to play in individual patient rooms.  Here is an example.

Here is a more recent one, offered at Boston University's Marsh Chapel recently:

Kindness

One of our dear Marsh Chapel members is in hospital.  We visited her on Wednesday at Beth Israel Deaconess.  She heals, hour by hour.  How grateful we are for the skill and care of doctors and nurses there.  The best wisdom of the reason, the finest attention to efficient detail, the steady combat, as in every hospital, against infection—these we again prized, this Christmastide.

After conversation and prayer, the elevator brought us again to the first floor.  As the door opened, something…A wondrous note, an audible epiphany, a gratuitous kindness…the sonorous notes of a harp.  To the gifts of medicine, there were added the gifts of music.  Deep, resonant, lovely.  Something else.  Something transcendent.  A gratuitous kindness, calling us up and calling us out.  How fitting that harp note.  A gift not strictly necessary, but utterly meaningful.

Walking away, one heard something, something deeply about being human or becoming fully human.  We will not reach our height, become who we are, only by rationality and efficiency, as crucial, as saving as they are.  To become who we are we shall need a turn to grace, that chord of depth and height and breadth and love, resounding from the nimble fingers of someone making a gift of gratuitous kindness. 

-The Rev. Dr. Robert Allen Hill, Dean of Marsh Chapel

Tracking adverse events

A recent report from the Office of Inspector General at the US Department of Health and Human Services finds, unsurprisingly, that hospital incident reporting systems do not capture most patient harm.  A summary of major points:

All 189 sampled hospitals had incident reporting systems to capture events, and administrators we interviewed rely heavily on these systems to identify problems.

Hospital staff did not report 86 percent of events to incident reporting systems, partly because of staff misperceptions about what constitutes patient harm.

Nurses most often reported events, typically identified through the regular course of care; 28 of the 40 reported events led to investigations and 5 led to policy changes.

Hospital accreditors reported that in evaluating hospital safety practices, they focus on how event information is used rather than how it is collected.

And here are the recommendations:

AHRQ and CMS should collaborate to create a list of potentially reportable events and provide technical assistance to hospitals in using the list.

CMS should provide guidance to accreditors regarding surveyor assessment of hospital efforts to track and analyze events and should scrutinize survey processes when approving accreditation programs.

Sorry, but to me this is all somewhat "ho-hum."  Virtually all adverse event reporting systems are "bolt-on" additions to hospital clinical information systems.  They do not result from a thorough analysis of how work is done on the floors and units of hospitals.  They are not designed by the people who actually have to report such events.  They are certainly not designed to capture near-misses, which occur 100 to 1000 time more often than actual adverse events, but which are a huge source of information about systemic problems.  Filling them out is often considered "extra work" by busy clinicians, not as part of a process of continuous, front-line driven process improvement.  Thus the recommendations offered in the report will not, I predict, make a significant difference in the future.

What are also unsurprising are the findings in this article by Downey et al, covering the period 1998 to 2007:

As the patient safety movement enters its second decade, an emerging body of research is finding that safety for hospitalized patients has likely not improved significantly over the past several years. This study, which used the AHRQ Patient Safety Indicators (PSIs) to analyze safety events in 69 million hospitalizations over a 10-year period, also finds no clear evidence of improved safety. Of the 20 PSIs analyzed, 7 increased in incidence over the time period studied, 7 decreased, and 6 did not change. While PSIs are best used for screening purposes and not for direct comparisons between hospitals, they have been used to track system-level rates of safety problems over time. The results of this study and other recent literature provide continued urgency for the safety movement to strive to improve the safety of the entire health care system.

What's going on? Answer:  We hear of great work done in quality and safety improvement by hospitals on the leading edge.  And that work is often impressive.  But those reports distract us from the fact that most hospitals still do not have in place clinical, administrative, and governance leaders who seriously and consistently put process improvement at the top of their strategic objectives.  As I have mentioned, I am often approached at my speeches by nurse managers and young doctors who say, "How can I get my CEO/Chiefs/Board to support these kind of activities?"

I have urged here my (former) colleagues in academic medical centers to take the lead in these matters. Many, too, have urged the country's medical schools to incorporate the science of health care delivery improvement into their curricula. Thus far, the pace is way too slow. Let's hearken back to Captain Sullenberger's imperative:

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

Front page ads hiding as news stories at the New York Times

The New York Times has now fully blurred its news reporting roles and its and its reporters' commercial forays into book publishing.

Some time ago, I raised this issue with regard to an advertisement for a Times book presented as an article about Bernard Madoff.

Now, we see it again.  A front page story by Times reporter Jodi Kantor about Michelle Obama contains this paragraph:

But interviews with more than 30 current and former aides, as well as some of the first couple’s closest friends, conducted for “The Obamas,” a new book, show that she has been an unrecognized force in her husband’s administration and that her story has been one first of struggle, then turnaround and greater fulfillment.

 

And, at the end of the article, we have this tag line:

This article was adapted from “The Obamas,” by Jodi Kantor, which will be published Tuesday by Little, Brown & Company.

Indeed, the whole article is just a teaser for the book, for it can scarcely be considered front page news.  Since when does a reporter get to publish a self-referential story based on his or her book?  Since when does a newspaper permit this kind of commercial use of a front page story, whether for its own profitability or that of its reporters?

Physicians study leadership at HSPH

Each year, I am delighted when Jim Conway invites me to be a guest lecturer in a class on Physician Leadership at the Harvard School of Public Health.  The attendees are senior doctors from institutions around the world who come to Boston several times over two years for four-day weekends of classes.  Jim, as many of you know, served from 1995-2005 as Executive Vice President and Chief Operating Officer of the Dana-Farber Cancer Institute.  After leaving that position, he was senior vice president and senior fellow at the Institute for Healthcare Improvement.  During my tenure as CEO of BIDMC, he was a true mentor to me in learning about the process of quality and safety improvement.  He also played a key role in helping our hospitals' boards learn how to exercise strong governance over clinical matters.  To the extent we were successful as an institution in reducing preventable harm, he was a major contributor.

Jim is accompanied in this teaching course by Ron Goodspeed, former President of the Southcoast Hospitals Group.  Another committed practitioner of process improvement, Ron was highly regarded throughout the state.  For example, in 2006 he was named President of the Board of Directors of the Massachusetts Coalition for the Prevention of Medical Errors. As noted by Paula Griswold, president of the coalition, he was selected because his "credentials, experience and dedication to quality patient care [were] invaluable as the coalition worked to educate the health care industry about best practices in preventing medical errors." 

The topic of the day was the case study written at Harvard Business School about my arrival as CEO of Beth Israel Deaconess Medical Center in 2002 and actions thereafter.  As is my practice, I warned class participants that I would take pictures of those who asked really good questions or made particularly insightful remarks.  There were many and I don't have space here for them all, so I can only offer prominence to a few. I am especially pleased, though, to include Dr. Holmes (above), who was born at the Beth Israel Hospital and who confirmed again my assertion that all of the babies born in that hospital and the successor BIDMC are above average!

Why such a short reply?

A physician friend with whom I have been corresponding wrote, after I sent a short reply to an email:

You have perfected the CEO art of short, succinct emails.  All CEO's I know can do this.  I can't.  Do they teach that art in CEO school?

My reply: 

It is a post-graduate course.

So, here's my philosophy on email, from the work environment, which tends to run over into personal stuff.  I never wanted to be the bottleneck in something that was going on.  I always figured that a quickly delivered short, responsive note was better than a delayed expansive one.

Also, when you get 500+ notes a day, it is important to answer each one as you read it.  If you hold it to think about, and then read it again, and then respond, you have doubled your intake folder and used up a lot of time.  This is a fundamental rule of time management: Whether a paper or electronic letter, or a phone message, deal with it the first time you read/hear it.  (Unless it is something that really requires a lot of research or thought.)

Also, email has now changed.  Its past virtue was that it was asynchronous.  No one expected you to reply right away.  Now, everyone has a PDA, and there is an expectation that you will be in touch all the time and responsive immediately.  If you don't give an answer, the person sends you another note 15 minutes later, asking if you got the first one.  Again, you have now doubled your inbox.

(This is one reason I rather publicly threw away my Blackberry when I was a CEO:   I wanted people to understand that I was not always available.)

Unfortunately, this has now carried over into personal emails, too.  If I didn't answer relatively quickly, you  would wonder if you offended me, or if I perceived you as unthoughtful, or whatever.  So, I tend to reply quickly and concisely.

Finally, as friends, we have lots going on back and forth during the day.  Just as would be the case if we were together, some responses during the course of the day would be short and some long.

Steve Spear's MIT webinar on January 9

Here's another great webinar being offered next week by the MIT System Design Management crew:

Creative Experimentation: Developing a Skill Critical for Managing Complex Operating Systems

MIT SDM Systems Thinking Webinar Series

Steven J. Spear

Senior Lecturer, MIT Sloan School of Management; Senior Lecturer, MIT Engineering Systems Division; Senior Fellow, Institute for Healthcare Improvement; and author, The High Velocity Edge

Date: January 9, 2012

Time: Noon - 1 p.m.

Open to all

Register

A broad-based capacity for experimentation is critical for organizations to succeed because the systems in which people are embedded are increasingly complex and fast. For instance, medical treatment used to be accomplished by "going to the doctor," a sole practitioner supported by a handful of other professionals, who mastered a body of scientific knowledge through steady practice. Now, thanks to the tremendous advances in medical science and technology, diagnosis and treatment span myriad disciplines and countless professionals. Doctors have to be masters in their own fields and masters in coordinating care delivery tailored to individual patients' needs. Experience can no longer be steadily accumulated over time. Rather, teams must experiment off-line so they are prepared for the variety of situations they'll face in real time. The same challenge of having to build knowledge in particular disciplines and learn quickly how to pull the pieces together into coherent eff! orts is characteristic of manufacturing design and production, services, information technology, and more.

Steven J. Spear's webinar will illustrate this migration from simple and stable to complex and fast, with examples of how organizations have learned to succeed by cultivating a capacity for high-speed, broad-based experimentation. A question and answer session will allow listeners to speculate about what would be involved in developing such a capability in their own organizations.

Rapid response teams and end-of-life care

How well are end-of-life issues dealt with in emergency situations in hospitals, i.e., when rapid response teams are called in?  Researchers in Australia, Canada, and Sweden asked that question and studied the treatment of several hundred patients over the course of a month.  Nearly one-third of patients seen by a rapid response team ultimately had limitations placed on their care (such as do-not-resuscitate orders).  This is suboptimal compared to making those plans earlier, during less stressful times.  Here is the formal conclusion published in Critical Care Medicine:

Issues around end-of-life care and limitations of medical therapy arose in approximately one-third of calls, suggesting a mismatch between patient needs for end-of-life care and resources at participating hospitals. These calls frequently occur in elderly medical patients and out of hours. Many such patients do not return home, and half die in hospital. There is a need for improved advanced care planning in our hospitals.

Tired is bad. A tired organization is worse.

If stating the obvious were a sign of success, we would have to give The Joint Commission an A+.  It issues Sentinel Event Alerts, ostensibly designed to to emphasize pressing safety issues and provide guidelines for organizations on how to address them.  The December 14, 2011 topic:  "When caregivers are tired, they are more likely to make mistakes."

First of all, this is not a sentinel event.  As noted in the paper itself, it is a long-standing and well documented problem.  Characterizing it as something new when it is not quickly loses readership and attention.

The paper goes on to make some helpful suggestions about hand-offs, fatigue management, and the like.  There is nothing wrong with the ideas.  It is just that they do not get to the root problem -- a task-oriented environment in which well intentioned people work beyond their limits.  In other words, the suggestions are window-dressing to the real issue, the need to re-design how work is done in hospitals.

I guess it doesn't do any harm to issue such papers, and it might do a little good.  But, wouldn't it be great if The JC became an effective leader in transforming health care, rather than restating the obvious?  It still doesn't offer open access to its Leading Practice Library, a compendium of best practices from those hospitals it has surveyed.  And the agency has made virtually no progress with regard to reducing the rate of wrong-site surgeries.

I think they are tired in Oakbrook Terrace, Illinois.

Or perhaps I am being unkind.  After all, the main task facing The JC is ensuring that the CMS Conditions of Participation are met.  This is an incredibly detailed list of standards covering all aspects of hospital operations. 

Let me give you an example.  One part of the COP is the Life Safety Code Certification.  Part of that certification is guided by this portion of regulations in the Federal Register.  The summary is simple:

The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community.

But then, the surveyors' manual relating to these regulations goes into excruciating detail.  Such detail is required, after all, when the regulations say things like this about hand cleansing dispensers: 

(9) Notwithstanding any provisions of the 2000 edition of the Life Safety Code to the contrary, a hospital may install alcohol-based hand rub dispensers in its facility if:

(i) Use of alcohol-based hand rub dispensers does not conflict with any State or local codes that prohibit or otherwise restrict the placement of alcohol-based hand rub dispensers in health care facilities;

(ii) The dispensers are installed in a manner that minimizes leaks and spills that could lead to falls;

(iii) The dispensers are installed in a manner that adequately protects against inappropriate access;

(iv) The dispensers are installed in accordance with chapter 18.3.2.7 or chapter 19.3.2.7 of the 2000 edition of the Life Safety Code, as amended by NFPA Temporary Interim Amendment 00-1(101), issued by the Standards Council of the National Fire Protection Association on April 15, 2004. The Director of the Office of the Federal Register has approved NFPA Temporary Interim Amendment 00-1(101) for incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. A copy of the amendment is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD and at the Office of the Federal Register, 800 North Capitol Street NW., Suite 700, Washington, DC. Copies may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02269; and

(v) The dispensers are maintained in accordance with dispenser manufacturer guidelines.

So, to be fair, who at The JC would have the energy and time to focus on the big picture?

Swirling down the drain, ever faster

Some months ago, I wrote about the deterioration of the Boston area transit system, linking to an article I published in Commonwealth Magazine.  We are now witnessing the sequelae of the syndrome I presented there.  The Boston Globe reports that the MBTA is seeking major fare increases and service cuts:

The MBTA would raise subway fares by up to 70 cents and dramatically cull bus routes, eliminate ferries, and end weekend commuter rail trains under a plan unveiled yesterday to help erase a projected $161 million deficit.

To be fair, this is not just about Boston.  The New York Times recently published an article entitled "The Recession Squeeze on Buses and Trains", documenting similar problems in lots of places.  About Boston, the Times noted:  "[R]idership is up, but so is debt; last year, virtually every dollar paid by riders went to debt service."

It is a mistake, though, to link these problems with the recession. There are long-lived structural issues at play.

A friend has helped me review the MBTA’s most recently reported statistics (for 2010) to the National Transit Database.  These numbers demonstrate that fares collected per boarding (column 1) generally do not cover even the direct vehicle operations plus maintenance costs per boarding (column 2).  Those costs, by the way, exclude the amounts needed to maintain fixed infrastructure and cover general and administrative categories.

Commuter Rail		$5.68		$7.41
Demand Response		$1.67		$28.51
Boat		$4.43		$5.23
Rapid Transit		$1.10		$1.33
Light Rail		$1.06		$1.45
Motorbus		$0.72		$2.75
Trolleybus		$0.69		$4.14
SYSTEM TOTAL		$1.30		$2.42

Now, these are average costs, and it is harder to estimate the marginal costs of an additional trip; but there is every reason to believe that those marginal costs exceed the marginal revenues received per trip.  In other words, an increase in ridership may actually cause the system's net income to fall.  This is a terrible vicious cycle for a transit system.

What if they had had to pay?

A true story, with changes made to protect privacy.  A 89-year-old man with dementia, a heart condition, and other serious medical conditions fell in his Arizona apartment and broke his hip.  His children, wanting the best possible care, arranged for him to be air-lifted to New York.  There, the orthopaedic surgeon advised them that the chance of their father surviving hip surgery was very low, but he would do as the family wished.  The man's three children could not agree.  Two would have avoided the surgery, but a third felt very strongly that everything that could be done for the father should be done.  The other siblings, out of guilt and respect for the third, acceded.  The surgery took place, and the father spent three days in the ICU before his heart gave out.

Here's the terrible and hard-hearted question I pose:  If the costs of this procedure and hospitalization had not been covered by Medicare, would the man's children have proceeded along the chosen path?  I am guessing not.  I don't know the total bill incurred, but it was certainly in the range of tens of thousands of dollars.

In the US, we don't have a good societal process for making these decisions.  In the United Kingdom, though, they do, as reported by Bob Wachter in a recent blog post.  Here are some excerpts:

[D]uring my six months on sabbatical in London, when I asked British physicians or hospital administrators who have spent time in the US about their main impression of our healthcare system, I nearly always heard some version of, “You people don’t know how to say no to anything.”

In the UK, they have built an organization that makes these tough decisions: the National Institute for Health and Clinical Excellence (NICE). I was lucky enough to spend several hours with its leaders last week in the organization’s London headquarters. NICE is awesome, not just for what it does, but for what its existence says about the maturity of the British political system when it comes to healthcare.

I asked Sir Michael [Sir Michael Rawlins, NICE's founding chairman] what it was about the culture of the British people and the NHS that allowed NICE to function, when America has such problems saying, and accepting, a forthright “no.”

“The man on the street gets it,” he replied. “They know that there is a finite amount of money. And politicians get it as well — they know that someone is going to have to make these tough decisions, and they’d rather it be us than them.”

Imagine that.

Bob concludes:

Decisions over setting limits are invariably wrenching, but our failure to create a transparent way to make these decisions just means that rationing occurs implicitly  and haphazardly.

Ultimately, silly season will end, our society will come to grips with the need to choose, and we will begin looking for a method of making these thorny decisions. When that day comes, it’s nice to know that we have a model to learn from.

Blog takes on CNN. Wins.

It isn't often that I scoop a major network, but my story about the use of UV light as a disinfectant at Cooley-Dickenson Hospital in Northhampton, MA beat CNN's story by a month.  But they do have some neat video.

Efficiency matters even in a high fixed cost industry

I have so much respect for the people at the Dartmouth Institute for Health Policy and Clinical Practice and the excellent work done there that I hate to quibble with their work.  But I fear that Stephen S. Rauh, Eric B. Wadsworth, William B. Weeks,  and James N. Weinstein have overstated an argument, and their view needs correction.

The problem is in a Perspective article in the New England Journal of Medicine, "The Savings Illusion — Why Clinical Quality Improvement Fails to Deliver Bottom-Line Results".  (Aside, thank you, NEJM, for allowing public access to articles of broad public interest.  When will others, like JAMA?) Here is the argument in a nutshell:

[The] management and organization [of the typical health care setting] create a rigid cost structure that is relatively insensitive to small changes in patient volume, resource use, or the severity of patients' health conditions. This fixed-cost dilemma leaves most health care costs insensitive to changes in volume and utilization, so clinical quality improvements typically create additional capacity rather than bottom-line savings. An examination of the different cost layers highlights the distinction between variable costs, such as supplies and medications, where reduced use produces true savings, and fixed costs, such as facilities and ancillary services, where the costs persist despite reduced use.

Because of the rigid cost structures, incremental reductions in resource use are unlikely to generate cost savings for either a health care setting or the health care system. The most meaningful way to achieve savings is to focus on overall reductions in utilization rates for health care services and to eliminate the associated unnecessary capacity.

The mistake the authors make is in presenting a static and incomplete view of cost savings and the financial interests of an individual firm, and also a narrow view of the societal advantages that are produced when an industry leader accomplishes cost reductions.  Indeed, by their logic, no firm in any industry characterized by high fixed costs would ever invest in efficiency programs and measures.

Two years ago, I gave an example from my former hospital's ICUs.  Our staff had accomplished a marvelous reduction in the rate of ventilator associated pneumonia.  We admittedly reduced clinical revenues for that "book of business" as a result.  If we had focused on that financial outcome, though, and chosen not to carry out the VAP reduction program, we would have been too limited in our view.  By reducing lengths of stay, we were able to avoid a huge bolus of new fixed costs:  The clinical capacity we created solved a growing congestion problem and enabled us to avoid the new fixed costs of an expanded ICU, along with the essentially fixed-cost staff, equipment, and supplies that would have been required for that addition.  Every firm faces capital constraints, and alleviating those constraints is as important a financial focus as what might be a short-term reduction in income.  

By the way, on the societal front, we could and did see more patients who would have otherwise gone to higher cost competitors.  That is also a common result in many industries.

We don't know how to make a decision

Twenty years ago, I went to Prague as part of US AID advisory group to help the Czech government make some decisions about wastewater planning.  I had just come off a stint as executive director of the state's water resource authority, and someone figured that I might have expertise that would come in handy.  As I am not an engineer, I had my doubts, but I thought I wouldn't do any harm.  Plus I had always wanted to visit Prague.

I had been told that there was a major dispute among the planners and engineers in the city.  They agreed that there was a need for a new sewage treatment plant, but there was a disagreement as to whether the new plant should be built at the site of the existing facility on Cisarsky Island in the Vltava River (left) or at a new location in the suburbs.

I did what any self-respecting consultant would do and asked every person I met for his or her opinion.  To my surprise, everyone agreed that a new treatment plant in the suburbs would be the way to go.

So, I asked my host the obvious question:  "I was told that there was a difference of opinion on this matter, but I see that you have a consensus."  His reply, "Yes, we have a consensus, but we don't know how to make a decision."  You see, after 40 years of heavy-handed Communist rule by the USSR, the newly freed nation had not developed the decision-making capability required of an independent country.

 

From there, I went to Bratislava, on the Slovak side of the country, to conduct a seminar for municipal officials about financing infrastructure facilities.  I introduced the concept of using revenue bonds to finance power plants and the like, with the cost of debt being paid by the users of the facilities.  For the past several decades, such facilities had been financed by the Soviets, and the underlying costs had been hidden from consumers, built into an arcane revenue model of the central government.

"If consumers have to pay for the full costs of the power plants, the price of electricity will be inappropriately high," was the first reaction from a person in the group.  I explained that there are two ways to recover such costs, from the taxpayers or the ratepayers.  I asked, "Wouldn't it be better for consumers to have a proper price signal as to the value of the electricity they use?"

I might as well have been an alien from outer space.  People either shook their heads, "No," or I received blank stares.  The premises of capitalism were utterly foreign to this group.

Let me draw some parallels with health care.  "We don't know how to make a decision" might apply to the millions of patients in the world who are treated like serfs in the health care system.  Health care professionals often prescribe and order, without helping their patients become full partners in the treatment planning and decision-making process.  People like e-Patient Dave and others are trying to conduct their own Velvet Revolution to remedy this kind of attitude.

The parallel on the cost side is equally apt.  We have no idea, as health care consumers, what it costs to treat us.  Those costs are hidden in a dense fabric of insurance inclusions and exclusions, charge masters, contract allowances, co-pays, and the like.  The current interest in establishing global payments as a substitute for fee-for-service pricing is an ineffective way of solving this problem.  It mainly shifts risk from insurers to providers, leaving the providers as gatekeepers and middlemen in care decisions.  As a solution to the problem of uninformed consumers, it is lacking.

Other parts of the economy thrive with relatively efficient fee-for-service pricing because those sectors are characterized by transparent presentations of choice, quality, and prices.  There is a need for a radical disintermediation of insurance companies in health care to allow a similar direct connection between consumers of health care and their providers.  With that in place, we would all learn "how to make a decision."

If the business model of the future is accountable care organizations that provide a full range of medical management services in their catchment areas, the value of stand-alone insurance companies diminishes.  Instead, each ACO could offer a combination of insurance and care to its subscribers.  Interestingly, if you consider those systems in the US that are viewed as most successful, several already have that model.

A new blog

Some time ago, I acquired the url for "notrunningahospital" in case there was confusion about the name of this blog.  That way I could refer people over here if they ended up at the wrong place.

But then I realized that a blog address is a terrible thing to waste and wondered if I could do something useful with the other one.  Here's what I came up with:  I have been gradually copying posts related to transparency and Lean process improvement from this blog to the other serve as an archive and resource to people in hospitals who might want to review the experience at Beth Israel Deaconess Medical Center and other hospitals and apply lessons to their own institutions.

What you see documented on that blog is a consistent and decided institutional commitment to transformational change at BIDMC and several other places.  It takes a long time and with constant reinforcement from the top folks to fight inertia and entropy and build sustained momentum for this kind of change.  Personal involvement and interest of the CEO and clinical leaders is essential.

I hope you find the new site to be a useful resource.  (You can also continue to search "Lean" and "transparency" on this blog and find many posts on those topics, but the search engine is not always comprehensive, so you might find the other site to be a more useful place to review those posts.)

I also continue to search for success stories in these arenas from around the world.  If you have some to share, please let me know.

Dhaya helps with the transitive property

I want to help you end the year with some warm laughter, and the best vehicle I can find is this wonderful story by my friend Dhaya Lakshminarayanan about teaching mathematics to her mother -- and about the American dream.  It appeared on Snap Judgment in August.

If you cannot see the video, click here.

Verizon: "Your session is now closed. Thank you, have a nice day."

I again break my holiday blogging break because I can't wait till the New Year to share this story with you.Verizon sent an email offering a special rate on a new two-year contract for the FIOS internet, telephone and television service to which I subscribe, and I wanted to know how it compared with my existing rate. Here's the actual chat transcript after I clicked on the icon above.  I couldn't make this up:

A Verizon Service Representative will be with you shortly. Thank you.

Agent Stephen has joined.

Stephen : Chat ID for this session is 12281146501.

Stephen: Hello. Thank you for choosing Verizon and visiting our Verizon chat service. How can I help you place your order?

You(21:01:30): I am looking at the $104.99 2-year contract. What am I paying now?

Stephen(21:02:30): let me send you a link to check your bill.

Stephen(21:02:40): https://www22.verizon.com/ForYourHome/BillView/MyBillNew.aspx?

Stephen(21:02:50): Please click on the above link to check your bill after logging into your online account.

You(21:03:47): I don't recall my user name or password, and when I clicked on the link to retrieve them, nothing happened.

Stephen(21:04:22): Do you have a paper bill whch you can look?

You(21:05:35): No, I don't. The site responded, and I asked for both. The next screen is blank, so far. Stay tuned!

Stephen(21:06:35): Let me provide you with the number to call and get this infromation, as online being into the sales department, we don't have the internal access to look into your account.

Stephen(21:06:50): Please contact our Consumer Solutions Center directly at: (800) VERIZON or (800) 837-4966, 24 hours a day, 7 days a week.

You(21:07:27): I called the number before i tried this live chat, and it said no one is on duty at this hour -- even though it claims to be available 24x7.

Stephen(21:08:37): I understand. In that case, I recommend that you try back later or come back online during the business hours. So that the online account specialists are available during that time.

You(21:09:47): So 24x7 doesn't actually mean 24x7?

Stephen(21:10:27): It should be 24 X 7, because most of our customers do get it available 24 X 7.

Stephen(21:11:22): Do you have any other questions for me today?

You(21:11:35): I guess I am special! As I went through the menu on the phone, it asked whether i wanted to talk about FIOS internet, Phone, or TV. I have all 3. I picked internet and then got that message. Would I do better picking some other choice?

Stephen(21:12:05): Let me send you a link to contact Verizon via email about it, and get it resolved within 24 hours.

Stephen(21:12:25): http://www22.verizon.com/content/ContactUs

Stephen(21:12:31): Please click on the above link to contact Verizon via email.

You(21:12:50): About what, my initial question about the 2-year contract, or how to talk to a representative?

You(21:13:38): Meanwhile, the online request for my user id and password stopped functioning.

Stephen(21:14:04): I am sorry, but per your first statement, you just asked question about your existing bill. Could you please be more specific on your initial question that you are trying to ask?

You(21:14:51): I am trying to compare the offer you have on your website, for a two-year contract, with what I am currently paying.

Stephen(21:15:21): Which Verizon services do you currently have?

You(21:15:35): FIOS internet, phone, and TV.

Stephen(21:16:15): You can go for our Verizon FiOS Triple play with FiOS Prime HD 15/5Mbps Internet FiOS Digital Voice Unlimited calling for $104.99 a month with two years price guarantee.

Stephen(21:16:30): If you are out of the contract or under the last 60 days of the contract, then you'll get $300 Visa reward card.

You(21:17:21): I understand that offer. What I do not know is what I am currently paying, so I can compare the offer with my current rates. I don't even know if i have a current contract.

Stephen(21:17:51): Like I said, you need to login into your online account to see your bill, or check your paper bill.

Stephen(21:17:56): Can I assist you with anything else from my end?

You(21:19:09): And, I keep telling you that your website which is supposed to help me get online by restoring my user id and password is not working. And your 24x7 phone line is also not working, telling me to call back during business hours.

You(21:19:50): Is this some kind of cruel joke? I am interested in the product you are offering, and you are making it impossible for me to evaluate it.

The chat application is experiencing connectivity trouble. Your chat will be re-assigned to another agent and will be given high priority. We apologize and Thank you for your patience. (21:20:41)

Agent Valentina has joined. (21:20:41)

Your session is now closed.

Thank you, have a nice day.

---

A Verizon Service Representative will be with you shortly. Thank you.

Agent Jacob has joined. (21:23:03)

Jacob : Chat ID for this session is 12281147492. (21:23:03)

Jacob(21:23:03): Hello. Thank you for choosing Verizon and visiting our Verizon chat service. How can I help you place your order?

You(21:23:23): I was just chatting with Stephen when I got this message:

You(21:23:38): The chat application is experiencing connectivity trouble. Your chat will be re-assigned to another agent and will be given high priority. We apologize and Thank you for your patience. (21:20:41)
Agent Valentina has joined. (21:20:41)
Your session is now closed.
Thank you, have a nice day.

Jacob(21:24:38): I sincerely apologize for all the inconvenience caused to you. How may I assist you today?

You(21:26:12): I am interested in the $104.99 two-year contract. I would like to compare it, though, to my current FIOS charge for TV, internet, and telephone service. I do not recall my user name and password, and your website does not function to restore those to me. I tried calling the 24x7 800 number for customer service, but it was not available.

Jacob(21:26:32): Let me assist you here.

You(21:26:40): My simple question is whether you can tell me what I am currently paying, so i can compare your offer with my current charges.

Jacob(21:26:45): Could you please let me know, if you have UserID and Password for Verizon service account?

You(21:27:14): Did you see my note above? "I do not recall my user name and password, and your website does not function to restore those to me"

Jacob(21:28:09): I do apologize for that. Let me assist you with the link to check the plans and price for the service.

Jacob(21:28:19): https://www22.verizon.com/ForyourHome/Registration/Reg/OrLogin.aspx
Please click on the above link and enter your Home phone number.

You(21:29:10): That site says: "Enter your Verizon home phone number if only adding a bundle or new Internet or TV service. You will not be able to see or modify existing services."

Jacob(21:30:10): Yes, you would need to register online for the UserID and Password.

Jacob(21:30:21): Could you please let me know, if you do not have Home phone service?

You(21:30:32): I have home phone service.

Jacob(21:31:02): Great! Please enter the Home Phone number and you would be able to view the service.

You(21:32:26): I have done that, but no, I cannot view the service. It asks me to select a plan I might be interested in. It does not show me my existing plan or charges.

Jacob(21:33:01): Yes, you would be able to select the Triple bundle at $104.99/month, you would need to select Prime HD TV plan, Internet plan with speeds up to 15/5 Mbps and Unlimited calling plan.

Jacob(21:33:11): About the Existing service, you would need UserID and Password.

You(21:33:55): I am trying to compare that offer to what I am currently paying. As I explained to you already, I do not know my user id or password.

Jacob(21:35:15): Yes, I do understand your concern and as you do not have UserID and Password, it would not be possible to check the existing service.

Jacob(21:35:30): You would be able to view the new plans and price listed on the Build Bundle page, that you can opt for.

You(21:36:20): Is this some kind of cruel joke? I am interested in the product you are offering, and you are making it impossible for me to evaluate it.

Jacob(21:37:50): Let me assist you with the link to retieve your UserID and Password.

You(21:38:21): I have already explained to you that that link does not work.

You(21:39:27): Perhaps, instead, you could send me the link to RCN or Comcast . . .

Jacob(21:40:32): I sincerely apologize here for the inconvenience caused to you.

Jacob(21:40:53): I would recommend you to try the link and let me know, if you are able to retrieve your userID and Password.

You(21:41:57): Jacob, I already tried that. I am sure none of this is your fault, but this has been an extremely frustrating interchange. Perhaps we should just call it a night.

Jacob(21:42:52): https://signin.verizon.com/sso/ForgotUserIDPassword

Jacob(21:43:12): Please try to proceed with this link and check, if you can retrieve your userID and Password.

You(21:45:25): The link doesn't even load now. Last time, it loaded and did not work to deliver the Id and password. I think you should move on to help the next customer.

Jacob(21:46:50): In this case, I would recommend you to call our Local Verizon Office and get the UserID and Password for Verizon service account.

You(21:47:16): What is the number for the local office?

Jacob(21:47:51): You may please call The Local Verizon Office at 1-800-837-4966 between 8:00 AM and 6:00 PM EST from Monday to Friday. I assure you the best assistance.

You(21:49:24): Oh yes, that is the number that promises service 24x7...

You(21:49:34): Good night.

Early terms news arrives late in MA

(Yes, I know I was going to take a holiday break, but is it my fault if an engaging radio story caused me to backslide?)

WBUR, NPR, and Kaiser Health News have teamed up to produce radio and "print" health care related stories, and the reporting partnership brings together some excellent capabilities.  I especially like the open source aspect of the stories.  They even include this note: "All original KHN material – articles, graphics and videos – can be used for free, if you credit us and link to us."  (Er, note to The Joint Commission!)

Here's the story by Martha Bebinger about recent efforts by Massachusetts hospitals to avoid early term Caeserian section births.  (If you prefer, you can listen to the radio version.) Here's the lede:

There are lots of reasons why an expectant mother and her doctor might choose to deliver the baby before its due date: the health of mom or baby, the doctor's schedule, the demands of work, or even to hit or avoid a specific birthday. But if that perfect day falls before the 39th week of pregnancy, and there’s no medical reason for an early delivery, many hospitals in Massachusetts are saying no, you have to wait.

She goes on to explain that pre-39-week deliveries result in more complications for the babies:

"Early-term infants have higher rates of respiratory distress. There are also issues with feeding," says Dr. Lauren Smith, medical director at the state Department of Public Health. "The most recent evidence shows that babies born before 39 weeks may also have developmental issues, so when you add up the increased risks and you weigh that against a situation when it’s purely elective, then you really can’t justify it."

What is sad about this story is that while it is considered news among the medical community here in Massachusetts, it is "olds" elsewhere in the country.

A decade ago, the folks at Utah's Intermountain Health instituted a protocol to reduce the number of early term C-sections.  Within just a few months, they were seeing major results.  Brent James and Lucy Savitz provided a description in Health Affairs:

[I]n 2001 the Intermountain pregnancy, labor, and delivery leadership dyad focused on the induction of early labor as a target for improvement. They created a shared baseline that identified when elective induction is medically appropriate and deployed it across the entire Intermountain system, which performs more than 32,000 deliveries each year. When an expectant mother arrived at the hospital for an elective induction, nurses completed an electronic check sheet that summarized appropriateness criteria. If the patient met the criteria, the induction proceeded; if not, the nurses informed the attending obstetrician that they could not proceed without approval from the chair of the obstetrics department or from a perinatalogist—a specialist in high-risk pregnancies.
 

Elective inductions that did not meet strong indications for clinical appropriateness fell from 28 percent to less than 2 percent of all inductions. The length of time women collectively spent in labor fell by roughly thirty-one days per year. As a result, Intermountain is now able to deliver about 1,500 additional newborns each year without any additional beds or nurses. The new protocol reduced the rates of unplanned surgical delivery (cesarean section) and the attendant higher costs. Intermountain’s overall rate of deliveries by cesarean section is now 21 percent, while the national rate is approaching 34 percent. The protocol also reduced admission rates to our newborn intensive care units, reducing their costs as well.

We estimate that the Intermountain elective induction protocol reduces health care costs in Utah by about $50 million per year. If applied nationally, it would lower health care delivery costs by about $3.5 billion annually.

(A more technical description is offered in this article in Obstetrics and Gynecology by Oshiro, et al.)

What other innovations in the delivery of health care have yet to arrive in Massachusetts?  The state's academic medical centers are tops at scientific research but often lag with regard to adopting process improvement and applying the scientific method in care delivery.  In so doing, they cause harm to patients and permit waste and extra cost to persist in the state.  I hope Martha and her team have a chance to focus on that question.

Happy holidays!

With this view of winterberry in the field behind my house -- on a sunny, warm and decidely not winter-like day in Boston -- I leave you for a blogging break through the New Year.  Thanks for your loyal readership, and best wishes for a lovely holiday season for you, you families, and your friends.  Let's also give thanks to our colleagues in the health professions, the most well intentioned people in the world, who devote their lives to alleviating human suffering caused by disease.

Stay tuned.  Lots more to come in 2012!