Senator Kerry informs and learns

US Senator John Kerry joined a BIDMC event last night in Florida to provide an update to members of our community on recent events in Washington regarding the progress of a national health care bill. We were impressed with the extent of the Senator's knowledge on the subject and his commitment to thoughtful legislation, and we were grateful for the time he spent with us.

There was also time for John to meet several of our supporters and doctors. Here, he is briefed by Maine businessman Bobby Monks and BIDMC doctor Dr. Steven Freedman,who have been working together to develop a new patient empowerment and involvement model called "Trust".

Humorous note: Dr. Mark Zeidel, our chief of medicine, jokingly describes Trust as a template for patient-doctor interactions that would enable a husband to offer his wife a full, complete, and detailed summary of his visit with a doctor -- as opposed to the stereotypical summation:

She, "What happened and what did he say?"
He, "It was fine."

Railing against the tide

Several months ago, I wrote about the futility of banning social media in a hospital. I argued that it was counterproductive and a waste of resources. This point of view has been supported in other forums.

Now, I learn that the University of Iowa Hospitals and Clinics organization is banning Facebook and other such applications as "inappropriate for the health care workplace."

I shared this article with e-Patient Dave, who replied, "The instant killer question on this issue, from the people I talk to, is 'So, what do they do about people doing it on their phones?'"

Indeed.

May I have the envelope, please?

In a post below, I listed several of the questions posed by the MA Division of Health Care Finance & Policy in preparation for the first of annual public hearings concerning health care provider and insurer costs trends. There were also others posed by the Attorney General. The answers to these questions have now been submitted by various parties. The answers are publicly available. You can open the envelope and see them here.

I haven't had time to review all the submissions yet, but the point I made a couple of weeks ago about federal and state underpayment for Medicare and Medicaid services, and the resulting impact this has on commercial insurance rates, is well documented in several of these filings. If I have a chance in the next few days, I'll pull out pertinent excerpts on this and other topics so you don't have to dig through dozens of pages.

Magnets help pancreatitis pain

Please watch this fascinating story on YouTube about a patient with chronic pancreatitis, who found relief in a procedure developed by BIDMC doctors Steven Freedman and Alvaro Pascual-Leone. I wrote about this earlier here, but watching this patient talk about it provides another dimension to the story.

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

Me, here and there

I really enjoy sharing what we have learned about enhancing quality and safety, transparency, and process improvement with health care providers and insurers around the country. But sometimes you just can't arrange to be there in person.

Today, I was invited to talk with board members and senior staff at HealthSpring, a large Medicare Advantage organization serving several states in the South and Midwest. I couldn't get there, so I joined by phone. Here's a picture of "me" presenting to the group.

Pioneer speaks about MA health reform

The Pioneer Institute is a public policy research center in Massachusetts. On the political spectrum, most people would call it conservative, or a least free-market oriented. In my opinion, regardless of your particular position along that spectrum, the institute's work is worth reading.

Last month, it issued a paper about the Massachusetts health care reform experiment that serves as a report card on a number of factors, with particular focus on the question of the equity and sustainability of the financing of the health care insurance access system put in place by Chapter 58 of the Acts of 2006.

For those interested in the possible applicability of the Massachusetts model to the national scene, authors Amy M. Lischko and Kristin Manzolillo say:

It is undeniably premature to enact a reasoned national-level solution based on Massachusetts’ or other state experiments. . . .

[We give Massachusetts'] health care reform financing an overall grade of “C” based on the following findings:

Metric 1: Is the funding for healthcare distributed equitably across various funding sources? The data indicate good performance in this area in the early phases of reform; however, without more recent data available, there is only a moderate level of certainty that this has been sustained. Grade: B.

Metric 2: How have per capita health care expenditures changed for the newly insured and the health safety net? Reform’s sustainability relies upon a continuing decrease in the use of the Health Safety Net Trust Fund (HSNTF) as more individuals gain access to insurance. With funding going towards both the HSNTF and Commonwealth Care, along with increased per capita spending on the newly insured, it remains unclear if this model is sustainable. Grade: C

Metric 3: Has the reform altered relative health care cost trends?There is no evidence to suggest that the reform has changed the general health care cost growth trend that was estimated based on 2004 data; however, it is inappropriate to rely on older data for evaluation of this metric. Grade: Incomplete.

Metric 4: Are premiums going up and if so for whom? The reform has to date succeeded at reducing the rate of increase for people purchasing in the nongroup market, but costs in Massachusetts still exceed national averages. Furthermore, the recent cost increases experienced by small groups need to be understood and quickly addressed if the reform is to be sustainable. Grade: C

Metric 5: Are residents able to afford coverage, or do they seek exemptions to the individual mandate? Based on the available data, the initial number of individuals deemed unable to afford coverage is minimal. However, with rising health care costs, the sustainability of this area of reform is questionable. Grade: B

Metric 6: How do Massachusetts’ medical bankruptcy rates compare to those in other states? While Massachusetts residents reported a decrease in the difficulty of paying medical bills since 2006, one in five adults indicated that they were paying off medical bills over time in 2008. When looking at adults earning more than 300% of the federal poverty level, over one in four are still carrying medical debt. Grade: C

AHCJ to JC: Please be less obscure

The Association of Health Care Journalists offers advice to the Joint Commission about transparency and clarity.

These are the good old days

Interesting point of view from our CIO, John Halamka, in this Business Week article.

Quietly in service

Mark Krivopal, Medical Director of one of our hospitalist groups, sent me this note:

Dr. Kwan Kew Lai is one of our hospitalists and has been with us for a few years. Besides being an excellent physician with a previous training in infectious disease, she is also an avid marathon runner and, more importantly, constantly does philanthropic work. She's been all over Africa helping people with AIDS. She's been to New Orleans after Katrina. Now she is back from Haiti.

In your blog you talk about some other members of the BIDMC and Boston medical community providing relief in Haiti. I wanted you to be aware of Kwan Kew as well. She does these things without the fanfare or really even telling anyone. I feel incredibly privileged to know and work with her.

Here's her blog.

Argentina candy invasion

As my loyal readers know, I am an infrastructure junkie. But I also take some pleasure in noting the country of origin of products I see in grocery stores, but especially in public places like restaurants and hotels. For example, how does New Zealand butter make it to the tables of fancy restaurants in London, when the UK has a powerful dairy sector?

Several months ago, I expressed wonder at the fact that a hotel in Boston could find it commercially reasonable to import bottles of water from the other side of the globe to serve to people attending conferences. As a trained economist, I marveled at this application of the theory of comparative advantage.

Yesterday, another example emerged at another hotel. Sitting in front of me on a conference table were these sucking candies. Look closely and you will see that they are from Córdoba, Argentina, a distance of over 5000 miles. How can this be financially sensible with a surfeit of hard candy manufacturers in the United States?

Now, I know that the peso has been falling in value relative to the dollar, making exports to the US more attractive. But this is a broader story than commerce with the US. From this article, we see that this company exports its candy to 110 countries. From humble origins -- an Italian immigrant in 1924 engaging his children in making caramel at the family bakery -- the company has become a world presence.

The capitalist system has its inequities and demands regulation in many respects, but the "invisible hand" of Adam Smith is truly a wonder to behold. These kind of examples explain why it is impossible for economies with centralized control to replicate the scope, scale, and diversity of the product and service offerings that emerge from free economic systems.

A doctor's visit

This note came from a doctor newly arrived in Boston. As you know, MDs can be the harshest critics of care, so it was heartening to receive this.

This letter is to convey my deep appreciation for the outstanding care I received at BIDMC several days ago when I was emergently taken to the Emergency Department for acute abdominal pain, then to the Intensive Care Unit. In a quick series of roller-coaster like events, I developed a bacteremic shock and a liver dysfunction which were very promptly managed, and I was discharged feeling much better in less than a week.

Several remarkable individuals- doctors, nurses and other health care staff were involved in my care. I have never been in a hospital for anything other than minor things; this was my first time at the receiving end of serious care, a valuable lesson that made me reflect what it is that they do that makes a difference between a frightening experience and one that I can look back and learn from, as a physician myself.

First, they explained and reassured. I think the doctors and nurses deserve a lot of credit for keeping me and my family informed regularly of what was going on, in a transparent and objective, yet reassuring manner. This allowed me to be a participant witness of the rapidly unfolding events without panicking. For a frightened patient, uncertainty about the illness is often worse than the illness itself. Reassuring words from a confident physician can make a huge difference, and instill that essential ingredient of recovery, namely hope.

Second, they were empathic and respectful. All those involved in my care evinced the four key elements of empathy (engage, educate, empathize and empower); examples were the nurse who empowered me to titrate my own oxygen use based on my looking at the O2 saturations (but of course without letting down her own guard), and my physicians who listened to my own interpretations of the illness before stating his or her own, backed by good evidence, of course. And the use of good humor made this patient feel special (as one nurse put it, “I was the best patient in ICU because I talked, sat up and provided ample urine output!”)

Third, they provided effective and efficient care which was proactive, and not reactive. My journey from walking into the ED to receiving expert assessments was within minutes. Not a single procedure was delayed, and not a single intervention left out in efforts to make the illness more comfortable to bear. I would especially commend the nurses who, as the key coordinators of care (the “quarterbacks” of the care team as one of my colleagues puts it) were always on top of what was happening and communicated effectively with me and the family all the way through.

We don't spend more

Many in the United States bemoan the fact that we spend such a large share of our GDP on health care. We argue that we could do it better and for less, and we point to other industrialized countries as proof. But we overlook the fact that those countries spend more on improving the social determinants of public health. It appears that the combined total of these two categories may be relatively constant across countries.

The Blue Ridge Academic Health Group has published a report entitled, The Role of Academic Health Centers in Addressing the Social Determinants of Health. (Go to this site and look for Report 14.) It contains a startling set of statistics.

Country -- % of GDP on Social Programs/% of GDP on Sick Care/Total % GDP
United States -- 2.3%/16%/18.3%
Canada -- 5.8%/10%/15.8%
Netherlands -- 9.6%/9%/19.6%
Sweden -- 11.6%/9%/20.6%

The report summarizes the situation as follow:

Our current health care system is costly and ineffective to an increasing degree each year because it has too limited a focus – sick care delivery – and pays inadequate attention to health promotion. Moreover, the health promotion programs that are in place rarely focus on social determinants of health such as jobs, housing, education, etc. Instead, the focus largely remains on the health problems and concerns of individuals, rather than on the problems endemic to a population.... That’s why the Blue Ridge Group believes that the U.S. health care delivery system, as currently constructed and funded, is the not the optimal foundation – even with more direct financial investment and dramatic changes in incentives and regulations – to improve the health status of Americans and thereby achieve greater societal happiness and progress. Similarly, we are concerned that current health reform activities are focused too narrowly on insurance reform without setting in play genuine reforms that also reflect the factors relating to social determinants of health.

Thanks to my friend and colleague Dr. Fred Sanfilippo, Executive Vice President for Health Affairs at Emory University, and Chairman of Emory Healthcare, for leading me to this report.

Moore's code

Although Massachusetts is a relatively small state, it has the sixth largest (by acreage) state park system in the country. One example is Moore State Park in Paxton. Here are two details from a winter walk.

It is up to us, not the US

A conversation with a reporter yesterday helped me clarify my thoughts about federal health care legislation. In my view, the most effective role of the federal government would be to provide national standards by which the health insurance companies operate (e.g., with regard to pre-existing conditions, rescission, and lifetime limits), require the existence of insurance exchanges, and establish the conditions under which universal access to insurance is made possible. Other items I would suggest for federal legislation are summarized below.

I am hoping the US government will not attempt to control the costs of health care by making legislative decisions with regard to clinical matters. Not because we should abandon cost control; but because federal efforts in this sphere are likely to be crude and not clinically appropriate. You just have to look at the process by which the USDA food pyramid is influenced by food product lobbyists to imagine how the government would attempt to regulate the design and provision of care among medical specialties, equipment and supply manufacturers, and pharmaceutical companies.

As should be evident to readers of this blog, I think it is possible for the participants in the health care system to accomplish major changes in the rate of medical cost inflation. Two articles have this theme. One is by Business Week's Catherine Arnst. The other is by Lucien Leape, Don Berwick, and others in Quality and Safety in Health Care. Both are worth reading, and they overlap in recommending several areas -- reducing infections and other preventable harm; empowering patients and families to participate in their care; and disclosing and apologizing for mistakes.

Beyond these articles, there is a remarkable consensus on these items, and yet hospitals and doctors often fail to implement them. Even hospitals that house some of the most accomplished authors in these fields often do not follow the advice of those colleagues when it comes to making improvements in the delivery of patient care.

It is not unusual for industries facing structural change to be slow to move. Why? Because the leaders of those industries were promoted based on their success in the past financial, political, and social environment. They were hired for their ability to maintain the status quo, rather than for their ability to make change. Eventually, though, societal forces make themselves felt. If an industry does not adapt, the government will step in. The medical profession has to decide whether it wants to take charge of this process or abdicate to Congress the right to act in its stead.

More on Atrius and BIDMC

Several weeks ago, I wrote about a new clinical partnership between Atrius Health and BIDMC. Today's Boston Globe has a story by Liz Kowalcyzk that provides more context for this relationship.

The article mentions the integration of our electronic medical records. John Halamka describes this in more detail on his blog:

By working with Epic and Atrius, we enabled a "Magic Button" inside Epic that automatically matches the patient and logs into BIDMC web-based viewers, so that all Atrius clinicians have one click access to the BIDMC records of Atrius patients.

No additional password required. Nothing. The entire BIDMC medical record appears. Now, computers are just tools, but it helps to have this kind of interoperability when your goal is greater coordination of care.

The infrastructure chronicles -- Volume 3

Back to our occasional series on infrastructure. For this post, I will be digging back into the telecommunications portion of my career, to a period when tin cans and string dominated the industry.* Well, maybe not quite so far back, as that, but far enough that I came up empty when I did Google searches on some of the terms below. But let's get to the point.

Have you wondered how companies can offer you free teleconferencing service? Most of us are used to paying for this service, but there are a bunch of firms that offer it for no fee, and will even create customized numbers for you and offer other add-ons. How do they do it and make any money?

The answer goes back to the monopoly days of the Bell System, when AT&T and its subsidiaries dominated. But even then, there were a number of small local telephone companies, often serving rural areas. The policy at the time was to share the revenues of the Bell System with those companies to help subsidize local telephone service in otherwise isolated communities. The mechanism for doing this was called the Separations and Settlement Process.

Once a year (think "sweeps week" on television), the traffic coming into and out of these small companies was measured and provided the basis for the number of dollars that company would receive as a gift from the overall revenues of the Bell System. It worked for everybody. Ma Bell didn't care, as it was awash in revenue anyway; and it didn't want to incur the high per subscriber costs inherent in serving rural areas. The local telco's likewise welcomed the income, which enabled them to keep down the cost of basic telephone service while providing hefty profits for the owners of those companies.

The system was often manipulated. The subscribers in Smalltown were told by the local telco when the measurement period was occurring. They were urged to make as many calls as possible during that week, knowing that doing so would pay dividends for the rest of the year.

Fast forward now to the end of the AT&T monopoly, the introduction of long distance competitors like MCI and Sprint, cellular service, cable TV, and other technological advances. Consider the Telecommunications Act of 1996, which served to open up the very switches owned by the big regional telephone companies (like Verizon) and the little ones, too, to anybody who wanted access to those computer racks.

Through this all, Congress preserved the policy goal of subsidizing local exchange service, especially for rural areas. Over time, new versions of the Settlements process emerged. It still pays for those local telco's (now called local exchange companies, or LECs) to have traffic, in that they are paid extra money from the national pool of telecommunications revenues based on minutes of use emerging from and ending in their central offices.

Now, you are starting to get the idea. A teleconference company mounts its switch on the rack of a carefully chosen LEC, maybe somewhere in the middle of Iowa. The teleconference company's very existence provides extra traffic for that LEC, generating extra Settlements revenue, part of which is shared with the teleconference company. The company does not need to charge you a fee for a teleconference, because the entire United States is already paying for it.

What is the difference between the service and technology behind the free teleconferencing service and the one you pay for? Nada.

Why would you ever want to pay for this service? Beats me. You and everyone else already are, in your regular local and long distance telephone rates.

How long will this deal last? When was the last time Congress took away a subsidy?

Now you can understand why I love health care. Having been weaned off the world of telecommunications subsidies, I craved a field in which the subsidies are even more rampant and impossible to untangle.

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* I worked as a telecommunications regulatory consultant for a while, and I was also Chairman of the MA Department of Public Utilities, which regulates common carriers in the state.

A back-handed way to make policy

One of the arcane steps in government regulation of health care is the Physician Payment Rule. This is the manner in which CMS, the Medicare agency, annually allocates payment dollars among the various specialty services. The PPR effectively makes policy.

The construct for all of this is a zero-sum game. When CMS wants to raise fees for some specialties (e.g., primary care doctors), it is required to reduce the fees for others.

The American College of Cardiology notes that the most recent version of the PPR contains such a drastic reduction in payment rates for office-based cardiology diagnostic tests that many community cardiologists are considering joining a cardiology service in a hospital.* So what's wrong with that? Well, once those MDs start providing the same services in a hospital, it means fewer services will be available close to people's homes in the community. Further, the rate the hospitals can charge for exactly those same diagnostic tests is higher than the private doctors could charge.

So the overall cost to society of health care actually goes up, notwithstanding what is supposed to be a zero-sum impact. Patients are inconvenienced, too.

As you know, I have advocated for an increase in payments to PCPs, so they can spend more time with patients and get out of their triage role. But it is short-sighted to require that, in the short-run, the sum of physician payments from Medicare not change. Perhaps the President and Congress can add this item to their health care summit discussions.

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*ACC also charges that the CMS data and methodology are flawed. I don't comment on that.

Dr. Cocchi goes to Haiti

This is a story about and by Michael N. Cocchi, MD, a fellow in Critical Care Medicine in our Department of Emergency Medicine. He joined a group of doctors and nurses recently in a medical relief mission to Haiti. It was his first time on such a mission. When I heard some of his stories, I asked if he would be willing to share them with us.

The photo of his patient Yvonne and the circumstances surrounding it are described in the video.

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

Easier than voting for tax increases

Just a thought as federal and state policymakers make speeches about putting a lid on the rates charged by private insurers. One of the best kept secrets of health care reimbursement rates is that the federal and state payers, Medicare and Medicaid, do not pay rates that are fully compensatory. This means that private insurers pick up the subsidy for the public plans and include those costs in their rates so that hospitals and doctors can be kept whole.

So . . . the fastest way to hold down insurance rate increases would be for the federal and state governments to pay their fair share. Of course, then someone would have to increase taxes. This takes political courage and a commitment not to hide the full costs of government programs. How much better to use the insurance companies as tax collectors instead.

The Bucket Brigade

These are pictures from the founding meeting of The Bucket Brigade on January 9. This new charitable organization is the brainchild of Monique Doyle Spencer (seen above) after meeting Samuel Kuacliet (below). It is further described in a Boston Globe story today by Adrian Walker.

Samuel's village in southern Sudan was attacked in 1987 when he was tending the cows, and at age 6 he and his family walked 1000 miles to Ethiopia to escape. A number of the refugees were eaten by lions along the way, or starved, or otherwise perished. After the war between Eritrea and Ethiopa erupted, they returned to Sudan. During this rainy season walk, a number of refugees were eaten by crocodiles, or starved, or otherwise perished. They were forced to leave Sudan again in 1992, this time to Kenya.

In 2001, Samuel managed to immigrate to the USA. Seventeen years later, he returned to his village in Sudan and saw his mother again. During that intervening period, he did not know whether she was alive or dead.

He brought back money and goods for his community. When Monique heard this story, she decided to start a charity to provide direct assistance to this village, called Yirol. As noted on the website:

We’ve adopted one village. We’re a group of volunteers, so the overhead will be minimal. Each year, our volunteer will go home and, working with the villagers, assess the highest needs.

That’s when we spring into action, wiring funds directly to merchants and our volunteer. We monitor every penny and encourage new ideas to help the people of the village develop self-reliant ways to survive.

I was honored to be asked to serve as a founding member of this board. I hope you will find the story compelling and contribute funds to serve this small corner of the world.