Convergence

I noticed this interchange on Facebook:

Jane Sarasohn-Kahn, a health economist and management consultant (and blogger) had this in her status bar:

In London meetings all day with UK and US colleagues, arguing about whose health system is worse. It's a draw: it you don't have health insurance or a medical home in the US, then the UK system looks awful great. If you're in the UK and have access/rationing/queueing challenges, the US looks great.

This drew a response from Matthew Holt, of The Health Care Blog fame:

I am prepared to bet you a nickel Jane that every one of your UK colleagues has private health insurance and doesn't have to worry about said rationing, but no poor Brit goes bankrupt because they're in hospital.

A long time ago, I wrote about how the US and European health systems will eventually converge.

The health systems in these countries are owned and financed by the government and are often appropriately cited for the quality of care offered to the public. Indeed, in debates here in the US, they are often called out as examples of what we might strive for in terms of universal coverage and a greater emphasis on primary care than we have.

[In a nationalized health system, the] appropriation by the parliament is a politically derived decision, just as it would be for any appropriation for a program of important national priority, and it therefore competes with other worthy national programs for resources....

In the face of inevitable limitations on the ability of the national hospital system to offer all services demanded by the public, a growing parallel system is emerging, in which private practitioners offer elective therapies and procedures outside of those supported by the national system.

As I note above, I am not saying one is better than the other. Just different. I predict, though, that the systems will start to look more and more alike over time. Pressure in the US for a more nationally-determined approach. Pressure in Europe for more of a private market approach. It shouldn't surprise us to see this convergence. After all, the countries are dealing with the same organisms, both biologically and politically.

A final note from the Facebook back-and-forth:

Neil Versel asks,

What about cost and quality?

Liz Scherer replies,

One word: oy.

Suggesting that -- in all systems -- a concerted focus on quality, safety, transparency, and process improvement would be well worthwhile.

Election Day Thoughts

On the eve of Election Day, here are some thoughts about John Gardner, founder of Common Cause, as remembered in a 40th anniversary speech by Bill Moyers. I hope the very good people who lose in tomorrow's balloting will keep up their fights, whether they are incumbents or challengers. They, especially, deserve our thanks for participating in our election process.

At his most eloquent, when he talked about the ‘rebirth of a nation’, he admitted that the notion might seem “wonderfully optimistic” but he quickly assured his audience that a successful rebirth of our country would involve severe labor pains. "We may howl with pain,” he said, "before we do what needs to be done.”

He also told us, “Don’t pray for the day when we finally solve our problems. Pray for freedom to continue working on the problems that the future will never cease to throw at us.”

I learned from him that the best way to live in the world is to imagine a more confident future and to get up every morning to do what you can to help bring it about. “Don’t let the vast superstructure of civilization mislead you,” he said, “Everything comes back to the talent and energy and sense of purpose of human beings.”

... LBJ appointed John to head H.E.W. on the very next day after announcing that he was sending ground troops to Vietnam. In the Rose Garden the president said to his new cabinet member, “Whatever happens in Vietnam, we’ll not fail to pursue the Great Society.” But two years later John went to the LBJ ranch in Texas to plead for larger appropriations for his programs. The president turned him down and instead cut even more from the budget as it was. Gardener responded with a muted anguish that pained the president. As they were about to get out of the car, LBJ put his arm around him and said, “Don’t worry, John. We’re going to end this damned war and then you’ll have all the money you want for education and health and everything else.”

It was not to be. In an emotional private meeting one year later, Gardner told the president he was resigning: “In an election year you deserve the total support of every cabinet member and a cabinet member who doesn’t think you should run shouldn’t be in the cabinet.” Face to face, he said: “I believe you can no longer pull the country together.”

That’s the kind of man he was. He gave up his position but not his principles. He left the government but not the fight. And he founded Common Cause because he didn't want to sit on the sidelines. "Everybody’s organized but the people," he said. "Now it’s the citizen’s turn.”

Real help in setting up an ACO

I highly recommend this video, which contains the most comprehensive advice for those wanting to set up an Accountable Care Organization. (If you cannot see the video, click here.)

Ostrich-like to the extreme

Seen today while on a bike ride in Sherborn, MA. I don't know how long this person plans to remain this way, but it is an odd way to celebrate Halloween.

Sad News on the Soccer Pitch

A fellow referee, about my age, sent an email entitled "Sad News." Of course, when I saw the subject line, I got worried that my friend might have a serious medical problem. Here's the text:

Don't worry - sad for me, funny for you.

I reffed some games at the grade 5/6 intramural jamboree the other day. While waiting for the horn to signal the kickoff, White team asks me who gets the kickoff. I told girls from each team that whoever guessed closest to my age would get the kickoff (taking off my hat in the interests of full disclosure). After several seconds I asked the Orange player closest to me for her guess. She whispers "67." As I was about to toss the ball to the White team for the kickoff, the closest White player says "72."

I told them both they were lucky I wasn't packing my red cards today.

Best to all,

Jeff

So that's how the rates are set

The Wall Street Journal published a very important article this week. Written by Anna Wilde Mathews and Tom McGinty, it is entitled, "Secrets of the System: Physician Panel Prescribes the Fees Paid by Medicare.

Here's the lede:

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

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

Yet the influence of the secretive panel, known as the Relative Value Scale Update Committee, is enormous. The Centers for Medicare and Medicaid Services, which oversee Medicare, typically follow at least 90% of its recommendations in figuring out how much to pay doctors for their work. Medicare spends over $60 billion a year on doctors and other practitioners. Many private insurers and Medicaid programs also use the federal system in creating their own fee schedules.

By coincidence, one of our doctors had just explained this to me a few days earlier. After reading the article, he jokingly and then seriously commented:

The only thing missing from the description is the cigars. Actually they make it sound more shady than truly exists. The recommendations from this committee are made to Pro-PAC (Prospective Payment Assessment Committee), who then set the Medicare fee structure.

Procedures have always won out over E&M time.

Another doctor friend put it this way: I think that it is the core of much evil.

Why the harsh reaction? Well, it is inherent in this statement: "Procedures have always won out over E&M time." Evaluation and management (E&M) services refer to visits and consultations furnished by physicians. You might want to think about this as "old-fashioned doctoring." The MD talks, listens, probes, and uses his or her cognitive skills to figure out what's wrong with you and what might be done about.

It contrast, procedures are things that are done to you mechanically, like surgery or other invasive techniques.

Both are important to medical care. But which is more important? One can certainly make a case that a primary care doctor's, nephrologist's, or neurologist's E&M can make a significant difference in the course of treatment of a patient. Indeed, those doctors' diagnostic skills can often obviate the risk, cost, and disruption of interventional procedures. This is not to say that people who perform procedures are not also important: Indeed their abilities are essential and determinative in many cases. However, the process described in the article results in greater values being ascribed to the procedures than to the cognitive services. And greater value translates into higher payment rates.

It may be that the committee's skewed membership leads to this result. It might be, too, that there is some historical basis for a payment system of this sort. Whatever the reason, it is clearly time to undo the bias.

The future for health care in the United States will be based in great measure on employing cognitive skills to bring about prevention, chronic disease management, and overuse of the medical system. The payment system should reflect that high value.

Unfortunately, this is viewed as a zero sum game. Under Washington rules, if cognitive specialists are paid more, proceduralists must be paid less so that the presumed overall level of appropriations will be held constant. But that is the static case, one that assumes the same number of procedures will be carried out. In the dynamic case, paying cognitive specialists better so they can spend more time with patients will reduce the need for procedures and thereby reduce overall health care expenditures, even if the proceduralists are not taken down a notch.

Transparency arises in the South

Novant Health is a not-for-profit health care organization serving more than five million residents from Virginia to South Carolina. Their team recently decided to dramatically expand the degree of transparency they provide with regard to clinical outcomes.

Paul Wiles, Novant's President, said to me: "We are delighted that you are willing to let your readers know of our efforts to enhance the field with respect to transparency of clinical information."

If you go to this website and click through the various categories, you will see an honest and open exposition of how they are doing on central line infections, ventilator associated pneumonia, and other important items. They mean it when they say that they are "committed to providing clear, accurate and honest information about the quality of care we offer to all of our patients."

Here's the VAP chart, which is illustrative, too, of the presentation of quite recent data. Why wait two years for national numbers based on administrative data when virtually every hospital collects real-time data on actual clinical outcomes?


Paul continued, "Our latest quarter is now posted. We had some improvements, some the same and unfortunately some declines in our performance. With our results in the public domain we have a real incentive to make our results better."

This view is consistent with what I have said before:

Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

Congratulations to everyone at Novant for making this commitment. Do I detect a movement? Will the Boston hospitals join in?

Kevin's thoughts about online MD ratings

Kevin Pho, MD, has a thoughtful article in USA Today about online ratings of doctors. Here are a few excerpts:

There are some good reasons consumers should be wary of the information they find online about doctors.

Most publicly available information on individual physicians — such as disciplinary actions, the number of malpractice payments, or years of experience — had little correlation with whether they adhered to the recommended medical guidelines. In other words, there's no easy way to research how well a doctor manages conditions such as heart disease or diabetes. That kind of relevant performance data are hidden from the public.

Objective performance data, such as how often doctors appropriately screen patients for cancer, or how many of their patients meet blood pressure or cholesterol targets, are often not revealed. They need to be made publicly available.

Mungerson Lecture

I was honored to present the 2010 Mungerson Lecture at Advocate Illinois Masonic Medical Center today. The lecture is named for Gerald Mungerson, an inspiring leader and a passionate advocate for the health and wellness of the communities he served. This included Boston, where, prior to going to Chicago, he served with distinction as General Director of what is today is part of the Brigham and Women’s Hospital. (You see his son, Andy, and wife, Cynthia, in the accompanying picture.)

As explained to me by Susan Nordstrom Lopez, President, "Each year we select the Mungerson lecturer on the basis of his or her dedication to health care and record in improving a health institution, practice or community. Like Jerry, the Mungerson Lecture balances clinical rigor with the critical need to involve lay people in understanding, supporting and improving health care."

I was asked to expand on a topic covered on this blog, "On Purpose," with a particular emphasis on the role of quality, safety, transparency, process improvement, and patient involvement in the new health care environment. Of course, this was a bit like preaching to the choir, as Advocate Illinois Masonic Medical Center does an excellent job on these fronts. Their commitment to transparency is exemplified in these posters on the various floors of the hospital, where staff, patient, and visitors can see progress on a variety of indicators and metrics.

An unpersuasive approach

It is election season, and both challengers and incumbents need to raise lots of money to compete for our votes. But there is a right way and wrong way to do it.

Several weeks ago, I received a telephone call from an incumbent in the Congress. I prefer not to mention his or her name, or whether s/he was from the House or Senate, or from which party. The person was from another state and had been in a position to influence the level of appropriations received by the National Institutes of Health.

S/he called my office asking for a campaign donation and said, "You have a large amount of NIH-funded grants. I've done a lot for you. I'm in a tough election, and I am hoping you will return the favor by contributing to my campaign." Before this phone call, we had never talked to one another.

I am grateful for the support given to NIH research by many Congresspeople. The intramural and external research carried out under NIH auspices is expanding our knowledge of disease, diagnostics, and therapies. The whole county and the world benefit from the actions of Congress in this arena.

But it just didn't feel right to receive a campaign solicitation in the context delivered by this candidate. The personalization -- "I've done a lot for you" -- suggested that there should be a quid pro quo. This is clearly at variance with the NIH grant application and approval process, which is based on scientific evaluations by peer reviewers.

It also suggested that there was some kind of unwritten contract between this legislator and me, one to which I was an unknowing party. No one likes to be told that they owe someone in this fashion. I found it unpersuasive, and offensive.

Doctors supporting doctors

A couple of years ago, I wrote a post entitled "The Shame of Malpractice Lawsuits," in which I tried to evince some sympathy for how doctors feel when they are sued. I wrote about a friend, saying:

Even though she knew that she had done nothing wrong, my friend's main emotional response to the lawsuit was that she was ashamed. She did not want anyone to know about the case -- whether colleagues in the hospital or social friends. . . . As I talked to other doctors, I learned that this was a common reaction to such lawsuits. Another friend talked of the scars left from a case 20 years ago. He was found not to be at fault, but he could still vividly recall the weeks of shame he felt while the case proceeded.

There was a large response from readers but, in my mind, they sometimes missed the point. The post was simply to express empathy for the suffering felt by doctors who are accused of mistreating their patients.

Today, I learned about an approach being taken and Brigham and Women's Hospital that is meant to help address this in a simple and elegant fashion. There is a group of a dozen BWH doctors who have faced malpractice lawsuits during their career. When they learn that a fellow member of the staff has been served with a lawsuit, they simply write the person a letter saying that s/he should feel welcome to contact any of them to talk about how they feel. The idea is just to let the accused person know that there are others who have gone through the process who are there to help. Of course, they are careful never to talk about the merits of the case or other matters that would jeopardize its legal standing.

I think this is an excellent and thoughtful idea that could easily be copied by others and am pleased to share it for that purpose.

Soccer net bags a turkey vulture

Now really, how can you print a story like this and not include a picture?

The Unseen Sea

A friend from the Bay Area sent a link from NPR containing this video. I found the second half particularly engaging, as the fog laps up against the hills like the ocean against the shore. Here's an excerpt from the link:

Simon Christen lives in Oakland and has been pointing his camera across the bay at San Francisco for the past year, taking time-lapse photos of the city. "About halfway through the project, the fog became the main subject," he writes in an e-mail, "and I tried to find locations to highlight it."

The Unseen Sea from Simon Christen on Vimeo.

Good food

Here's a story on WBUR radio about a friendly competition among health care chefs in the Boston area. It took place at the 90th anniversary celebration of the Massachusetts Health Council last week.

Listen to the show to get the name of the winning chef. I'll provide a hint by saying that you would have to be above a certain age to be eligible for his meals.

Research matters

With all the attention on clinical matters, it is easy to forget that a substantial portion of the role of academic medical centers is related to research. Here at BIDMC, over 1600 people are involved in research. These include principal investigators, other research faculty, fellows, technicians, and students. We have about 400 thousand square feet of research space under management, some owned by us and other leased.

The chart above shows our research activity in dollar terms over time, compared to the trend in NIH funding during the same period. In contrast to the highly competitive aspects of clinical care in the Boston market, there is a good amount of cooperation on the research front. Many projects are multi-institutional in nature.

One such program is the Dana Farber/Harvard Cancer Center, which brings together researchers from Dana Farber Cancer Institute, MGH, Brigham and Women's Hospital, Children's Hospital, BIDMC, Harvard Medical School, and the Harvard School of Public Health. Among other things, this program facilitates the availability of clinical trials of new cancer therapies to patients in the member hospitals.

Of course, we are properly expected to administer these trials in a way totally consistent with all rules and regulations. We recently concluded that we were not doing so with regard to some issues of documentation and reporting. Although there has been no indication that these mistakes had any impact on patients, we temporarily suspended enrollment until we can remedy the problems. As noted in this Boston Globe story by Liz Kowalczyk, we

. . . expect most of the trials to open to new patients within weeks — a half dozen already have — once investigators and support staff have completed additional training on compliance with trial rules and proper documentation of progress and results.

Fortunately, too, during this period, new patients will still have access to trials because of the multi-institutional aspect of the research program.

Hospital officials said about 25 cancer patients a month typically enroll in trials, and most who need access to experimental treatments before a trial reopens would be referred to another Harvard hospital that is part of the cancer center.

It just costs too much

Stuart Altman and I were invited to share the podium as lunchtime speakers today at the New England-Israel Business Council's 2010 Life Sciences Summit. The Summit is designed to foster relationships between the life science industry, research, healthcare and the investment community in New England and their counterparts in Israel.

We had not really coordinated our talks beforehand, but we ended up with similar themes. Stuart starting out by reminiscing about one of his first jobs, when he was warned that if the then-current 7.5% of GDP represented by health care spending increased to 8.0%, a disaster would be befall the country. Of course, it is now over 17%. He explored the trends that have led to this and suggested that the higher prices of US medical services accounts for a significant portion of this result.

He concluded by advocating for a change in the current fee-for-service pricing regime and for implementation of the Accountable Care Organizations envisioned in the recently passed US health care bill. Turning then to specific concerns of the audience, Stuart suggested that there will be pressure to limit the use of drugs that are not cost-effective and that the pharma and device industry will be incented to produce products that enhance quality and improve efficiency.

My talk centered on topics familiar to readers here. I touched on the marketing-driven success of certain products whose clinical efficacy has yet to be found superior, and yet whose costs inflate the overall health care budget. I challenged those firms in the audience to focus on innovation that has the potential to reduce the cost of health care delivery.

Tactical update on SEIU

It's been a while since I have provided an update on SEIU's corporate campaign against BIDMC and on its attempts to organize the health care workers in this city. For those who were away on Labor Day, you might have missed this interview by Bob Oakes on WBUR with the local head of the union. The blog post to which Mr. Oakes refers is this one.

What is striking about the interview is to compare the broad agenda set forth with actual actions by SEIU. Whereas the past several years have been characterized by spending hundreds of thousands of dollars disparaging BIDMC; there has been virtually no activity with regard to the other hospitals mentioned, those in the Partners Healthcare System.

There has been a theory circulating around town that this tactical decision to avoid MGH and Brigham and Women's Hospital might have its origins in the personal relationship between the former head of the SEIU and the Chief Operating Officer of PHS, who served as an Deputy Secretary of Labor under President Clinton. Will SEIU's reluctance to take on the PHS hospitals be put aside now that Mr. Stern has left the SEIU and the COO is leaving Partners?

The secret of quality is love

A friend forwarded this link to a wonderful interview between Bob Wachter and Peter Pronovost, and appended the following note:

Check out the quote below; wow! (Bold mine)

'.......that to some extent Donabedian had it right when he was interviewed on his deathbed and asked what the secret of quality is. He said the secret of quality is love. Because if it's not in your heart and if you don't truly believe that this is the right thing to do, and there's a humbleness that I'm human, we're never going to make progress on infections.'

Man bites dog! Four candidates agree!

Gubernatorial politics in Massachusetts is pretty competitive, so it is something to note when all four candidates agree on something. The Greater Boston Interfaith Organization gave the four competitors such a forum last night. They all agreed that they were in opposition to two pending ballot questions, one which would repeal the state's affordable housing law and one which would roll back the state's sales tax.

Here's their signed statement:

Misdirection?

Is there a subtle, but important bit of misdirection going on in the description of the new role of Caritas Christi as it moves to for-profit status under ownership by Cerberus Capital Management? Such may be evident in this piece by Martha Biebinger on WBUR.

As you read or listen to this story, you might think that the firm is attempting to take on Partners Healthcare System. That is highly unlikely, for several reasons.

First, the Caritas community hospitals are not in areas served by PHS community hospitals. Their targets of opportunity, as I have noted here, are the physician practices and the independent community hospitals in those regions.

Second, the Cerberus system will need access to high level tertiary and quaternary care for those patients who need more advanced treatment than that available in the community. While St. Elizabeth's Hospital can handle some of those patients, it lacks a number of the really high-end clinical services (e.g., solid organ transplant.) It would be too expensive to create these services at St. E's.

What factors will come into play in seeking the affiliation for high acuity cases? Reputation and price. Inclusion of one or both of the two flagship PHS hospitals would have marketing value to the Cerberus accountable care organization. But what to do about the fact that the PHS hospitals and doctors have the highest rates in the region? Answer: Because of its overall financial position, PHS has the ability to shift costs to offer discounts to secure these referrals.

That misdirection may be in the works is prompted by two parts of the story:

First, a quote from the Caritas CEO:

Hospitals that compete with Caritas say that with an infusion of cash the chain could buy up local physician practices and refer all their patients to the nearest Caritas hospital. There is also speculation about which failing hospitals Caritas may buy to expand its network and market power. De la Torre shrugs at the suggestions. “We’re not looking to do it; obviously if a hospital in need is there and it works out, fine. . .

Next, a quote from a PHS official:

“The more competition in the marketplace, it’s better for the patients and better for the consumers, so that has been our general philosophy over the last few years,” says Partners Chief Operating Officer Tom Glynn.

Both of these are so obviously at variance with prior behavior that the only question remaining is whether the quotes have been coordinated.

If so, this hopeful thought by an insurance company executive may be wishful thinking:

“If there’s real competition between two high-quality systems, there’s a better chance of holding down the costs.”

Go back to the chart in Attorney's General's report on payment disparities. You will note that the Caritas hospitals get paid more than their community-based competitors. And, of course, likewise for the PHS doctors and hospitals.

Are we instead witnessing the creation of a new duopoly, where the chance of holding down costs over time is illusory?