Blogging break here for the next week or so.
Live and learn
Every now and then, I like to clean out my old folders on Gmail. Yes, I know there is unlimited memory, but I am a reverse pack-rat.
So, I went in and deleted the contents of my "sent mail" file. Little did I realize that this also deleted the copy of every email I have ever sent in all of the individual folders that I had created. So, now hundred of things I had carefully saved for business and personal purposes are gone. There is no way to reverse the action.
At first I was bothered, but then I realized that most of those messages actually don't matter at all. So, a new Kubler-Ross paradigm arises: Shock, dismay, freedom, happiness.
So, I went in and deleted the contents of my "sent mail" file. Little did I realize that this also deleted the copy of every email I have ever sent in all of the individual folders that I had created. So, now hundred of things I had carefully saved for business and personal purposes are gone. There is no way to reverse the action.
At first I was bothered, but then I realized that most of those messages actually don't matter at all. So, a new Kubler-Ross paradigm arises: Shock, dismay, freedom, happiness.
Wine takes the lead on the city streets
It's times like these that I wish the Center for Short-Lived Phenomena were still around. They used to study interesting geological and astrophysical events, but they also would explore questions like, "Why are there so many dead squirrels on the street this year?" (Answer, the weather was excellent for acorn production, and boy and girl squirrels created lots of pups, who then got squashed crossing the streets.)
What prompts this wish on my part? A noticeable bulge in the number of single-serving Sutter Home wine bottles on the streets of my fair city. Recall my Mike-Dukakis-inspired compulsion to pick up trash when I take my walks around the neighborhood. In the past, nips prevailed, especially vodka servings, especially near the collegiate neighborhood transit station.
Now, though, it is wine. Cabernet Sauvignon is the apparent favorite, followed by Pinot Grigio, with Chardonnay a distant third. Were the CS-LP here, they could tell us whether this is a seasonal tilt in preferences, or a longer-term subtle refinement of the local student body's alcohol tastes.
In any event, it remains disturbing to think of (1) automobile drivers drinking these bottles clean and then (2) driving under the influence while tossing them on the roadside as trash.
What prompts this wish on my part? A noticeable bulge in the number of single-serving Sutter Home wine bottles on the streets of my fair city. Recall my Mike-Dukakis-inspired compulsion to pick up trash when I take my walks around the neighborhood. In the past, nips prevailed, especially vodka servings, especially near the collegiate neighborhood transit station.
In any event, it remains disturbing to think of (1) automobile drivers drinking these bottles clean and then (2) driving under the influence while tossing them on the roadside as trash.
Good stuff happening in the countryside
There is a tendency for those of us associated with urban and suburban medical centers to forget the many dedicated people serving the public in rural areas, often where there are high poverty levels. One such group are the folks at the Appalachian Regional Healthcare System (serving northwest North Carolina and northeast Tennessee) who run the Appalachian Healthcare Project. Here is a description:
Appalachian Healthcare Project is a collaborative effort of the medical community to provide healthcare for the low income, uninsured residents in Watauga and Avery Counties. The project enrolls persons who meet program guidelines and coordinates healthcare on their behalf. The coordination of healthcare includes assigning patients to a primary care provider, managing referrals to specialists, and obtaining medications for the patients. The medical care providers donate much needed care to those who qualify.
In 2011, the AHP assisted more than 500 patients with prescriptions, valued at approximately $1.8 million. Currently, 33 primary care providers and 60 specialty care providers participate in AHP. Community outreach activities included three sessions of Boone’s Biggest Winner weight loss program and 17 community health fairs and screenings, 38 CPR classes for the community and 12 health promotion events.
ARHS also runs a Farmworker Health Program, which "provides access to quality, affordable, community-based, culturally appropriate, and comprehensive healthcare services for migrant and seasonal farmworkers and their families in Watauga, Avery, and Caldwell counties."
The system's Facebook page gives a great update on these and other activities. This all reminds us that those delivering care locally, with a good understanding of community needs, are a vital part of the country's health care system.
Appalachian Healthcare Project is a collaborative effort of the medical community to provide healthcare for the low income, uninsured residents in Watauga and Avery Counties. The project enrolls persons who meet program guidelines and coordinates healthcare on their behalf. The coordination of healthcare includes assigning patients to a primary care provider, managing referrals to specialists, and obtaining medications for the patients. The medical care providers donate much needed care to those who qualify.
In 2011, the AHP assisted more than 500 patients with prescriptions, valued at approximately $1.8 million. Currently, 33 primary care providers and 60 specialty care providers participate in AHP. Community outreach activities included three sessions of Boone’s Biggest Winner weight loss program and 17 community health fairs and screenings, 38 CPR classes for the community and 12 health promotion events.
ARHS also runs a Farmworker Health Program, which "provides access to quality, affordable, community-based, culturally appropriate, and comprehensive healthcare services for migrant and seasonal farmworkers and their families in Watauga, Avery, and Caldwell counties."
The system's Facebook page gives a great update on these and other activities. This all reminds us that those delivering care locally, with a good understanding of community needs, are a vital part of the country's health care system.
Scholarships for IHI National Forum
Dale Ann Micalizzi, Founder/Director of Justin's HOPE at the Task Force for Global Health, sends along this reminder about scholarships for attendance at this year's IHI National Forum. For information, click here.
Here is the description:
Justin’s HOPE Project and IHI are extremely proud to announce the Justin Micalizzi Memorial IHI Scholarship in loving memory of Justin A. Micalizzi who died at the age of 11 due to a medical error. Learning from this devastating loss ― and making a difference that will improve pediatric health care ― has become a quest for Justin’s family. Justin's HOPE project will award scholarships to health caregivers who are committed to pediatric patient safety and providing a safe health care environment for their patients and families.
The Justin Micalizzi Memorial IHI Scholarship will cover the cost of the General Conference fees for IHI’s 24th National Forum on Quality Improvement in Health Care December 9-12, 2012, in Orlando, Florida. In addition, the scholarship will provide a $1,500 reimbursement to be used toward travel, lodging, or other Forum expenditures (including fees for Learning Labs or Minicourses).
The Justin Micalizzi Memorial IHI Scholarship will cover the cost of the General Conference fees for IHI’s 24th National Forum on Quality Improvement in Health Care December 9-12, 2012, in Orlando, Florida. In addition, the scholarship will provide a $1,500 reimbursement to be used toward travel, lodging, or other Forum expenditures (including fees for Learning Labs or Minicourses).
Wendy honors Bruce and others
My husband, Bruce, loved to take care of his family. When we received the news that he had cancer, he immediately determined that we should strive for normalcy. It was his desire for normalcy, as elusive as it seemed to us at that moment, that set his family down a path of carrying on, doing well, and enjoying life. It served us well through his illness and beyond, and I am sure will continue to do so.
It is my great hope that cancer patients and family members – or anyone dealing with a devastating diagnosis – will be able to avail themselves of this document free of charge, and that it somehow helps. To that end, I am offering it as a free download, under a Creative Commons license.
She also hopes that it might stimulate some people to philanthropy:
I also hope that our experience might inspire readers who are so moved to make contributions to Dr. Rebecca Miksad's medical research fund for her study of liver cancer and cholangocarcinoma, the form of cancer that affected Bruce. Dr. Miksad must be one of the most talented, intelligent, dedicated and compassionate physicians that I shall ever know. To make a donation to BIDMC's CureLiverCancers team, please click here.
#2, now. Is their advice still good?
The Johns Hopkins Hospital has ranked #1 among America's Best Hospitals in US. News & World Report for 21 consecutive years 1991-2011. You simply won't find a more knowledgeable and trustworthy source of the medical information you require.
Hmm, this year it was not ranked #1. Some other place was, complete with a Duck Boat parade.
Oh, but wait, the hospital says something different on its website advertisement:
Year after year, The Johns Hopkins Hospital ranks among America's Best Hospitals in US. News & World Report. You simply won't find a more knowledgeable and trustworthy source of the medical information you require.
Hmm, a copy editor's dilemma!
Mandar does not mandate
An excerpt:
Empower's objective is to nourish the innovation culture by empowering staff to play a role in innovation. The objective is also to leverage the passion of each employee and to play any role that the employee chooses to play in this innovation set up. So, for example, innovation starts with an idea, but once the idea is conceived, there are many other roles that one needs to play. One needs to learn how to sell the idea, how to build a story. One needs to learn to build networks and circles of trust where you get good feedback to develop that idea into something else. Finally, one needs to authentically connect with people who can help bring that idea to a proof of concept. This is a very social process. Not everyone in an organization needs to be the person with the idea. You can play other supporting roles -- just like in a movie there is an actor and there are supporting actor roles. That's what Empower facilitates -- it helps you understand what role you want to play. It all begins with a state of mind in which you decide you want to play a role. This necessitates looking inward so that you can support not just yourself but people around you as well.
I think the home-grown spread aspect of Empower is a fascinating feature:
The uniqueness of Empower is that it's a grassroots initiative. Employees organize these workshops for one another at the workplace -- that's the first step. It's not mandated, but it's peer-to-peer inspired. The first step is an introduction to Empower, which is held over a lunch session. During the introduction, we discuss the innovation theory and the various roles that one can play. We also introduce some breathing and meditation exercises. The staff then chooses the second step. Someone may say, "Yes, I like the introduction session and I want to invest my time in learning more about the innovation theory as well as mind management." And the third step is, if people want to learn how to facilitate the Introduction class, they are trained and then they run the Introduction sessions at their workplace.
Brown versus Warren: A pre-Labor Day view
It is always dangerous to prognosticate election results before Labor Day, but I am going to offer an opinion based on observation of one set of clues only: The design of lawn signs.
Look at these two. First, the incumbent's, Scott Brown:
Next, the challenger's, Elizabeth Warren:
Those of you not from Massachusetts may have been led to believe that this is a liberal state. Not so. While it is often portrayed as a highly Democratic state, look at this party enrollment:
The Republicans always come out and vote, the Democrats more sporadically. So, the race is about getting the Democrats to vote and grabbing those unaffiliated voters. Who are these people? Well, in great measure, they are like most of the rest of the country, concerned about the same things.
But the dirty secret is that--like the rest of the county--they are less concerned about the issues than they are about the characteristics of the person running. They want to trust and like their Senator. And it is here that the Warren campaign has been faltering. She/they seem to think that her substantive record and experience on issues will bring out the vote. Her answers on policy issues are thoughtful and in full paragraphs, but they come across as dispassionate and intellectual. They have failed, so far, to convey in a visceral way who she is and why we should like her. Her lawn sign offers nothing to offset this.
What the Brown campaign understands is that this election is about personality. "He's for us" on his lawn sign has double power. "He cares about us" is part of it, but subliminally, "He's one of us" is the underlying message. Scott always refers to Elizabeth as "Professor Warren." He is appearing to be respectful, but he is really reminding the electorate that she is an untrustworthy Cambridge Harvard intellectual, while he is a normal person.
The lawn signs tell us all this. Gee, I can even text Scott a message. I bet he is likely to answer.
(Please note that this blog post is not about my personal vote or my preference in the race. It is simply an analysis of what I see and hear.)
Look at these two. First, the incumbent's, Scott Brown:
Next, the challenger's, Elizabeth Warren:
Those of you not from Massachusetts may have been led to believe that this is a liberal state. Not so. While it is often portrayed as a highly Democratic state, look at this party enrollment:
 |
| Source: http://en.wikipedia.org/wiki/Politics_of_Massachusetts |
But the dirty secret is that--like the rest of the county--they are less concerned about the issues than they are about the characteristics of the person running. They want to trust and like their Senator. And it is here that the Warren campaign has been faltering. She/they seem to think that her substantive record and experience on issues will bring out the vote. Her answers on policy issues are thoughtful and in full paragraphs, but they come across as dispassionate and intellectual. They have failed, so far, to convey in a visceral way who she is and why we should like her. Her lawn sign offers nothing to offset this.
What the Brown campaign understands is that this election is about personality. "He's for us" on his lawn sign has double power. "He cares about us" is part of it, but subliminally, "He's one of us" is the underlying message. Scott always refers to Elizabeth as "Professor Warren." He is appearing to be respectful, but he is really reminding the electorate that she is an untrustworthy Cambridge Harvard intellectual, while he is a normal person.
The lawn signs tell us all this. Gee, I can even text Scott a message. I bet he is likely to answer.
(Please note that this blog post is not about my personal vote or my preference in the race. It is simply an analysis of what I see and hear.)
Not enough time for lupus
That systemic lupus erythematosus affects a relatively small percentage of the population does not change the fact that this is a troublesome life-changing disease of uncertain origin and unclear treatment. Thus, we find that physicians and nurses involved with this problem are extremely dedicated to their patients. Together, they try to establish a partnership that will help ameliorate symptoms and maintain normal life patterns.
A book is coming out this fall that should be helpful in that regard. The author is Dr. Donald Thomas, Jr., and the book title will be The Lupus Encyclopedia (Johns Hopkins University Press). This should be a definitive work that will be of great value to patients and caregivers.
The foreword to the book is being written by Dr. George Tsokos, Chief of Rheumatology at Beth Israel Deaconess Medical Center, himself a world expert on the subject. I reprint with permission some excerpts of the current draft of his introduction (which might change somewhat in the final printing), as they are indicative of the passion displayed by those involved in this disease. The biological aspects are stunning, and time will tell what can be done about those, but note especially the final paragraph. There, George decries the current medical care system, which itself contributes to the suffering. That aspect of the disease is within our control and deserves as much attention as the scientific aspects.
Like Dr. Thomas, as a senior in medical school I was assigned to participate in the care of a 24-year old young lady with fevers, chest pain, swollen joints and blood swollen legs. Systemic lupus erythematosus loomed first in the differential diagnosis, and the tests confirmed the presence of anti-nuclear antibodies, anemia, low platelet and lymphocyte counts, which helped seal the diagnosis. Her face is still vivid in my memory, and her anxious and inquisitive eyes ask me every day, "Will you ever find a cure for me? I am engaged to be married and I want to live." We gave her prednisone in buckets like it was done those days, and we probably added to her lupus symptoms a bunch of dreadful problems caused by the drug. Decades later, we can diagnose patients with the disease faster, we can treat them more effectively, minimize drug-related side effects, take better and prompt care of infections and other frequent conditions linked to lupus and promise an almost normal and lengthy life, but we cannot answer positively the proverbial, “Are we there yet?”
How do you solve a problem like lupus? Even if you scan through the pages of the book you hold in your hands you will realize that you are up for a crash course in medicine, not sparing obstetrics, gynecology and neurology. How do you grasp a disease that wants the doctor to command every field in medicine and how naively we expect our fatigued, achy, feverish and disillusioned patient to handle it? Breathing hurts, the joints yell, the skin blemishes and the kidneys silently go in to oblivion. Every organ becomes involved to pour away the well-being and the life of the young ladies.
Lupus is a demanding partner in the life of the patient, and you will soon learn that prompt diagnosis, perfect close care by specialists, tight control of medications and their side effects and abiding, tenacious efforts to control comorbidity (infections, cardiovascular disease and cancer) make all the difference in the world. Doctors are continuously pressed to shorten their encounter with the patients while the documentation component looms continuously larger. This could be fine in the wisdom of the regulators should the doctors be dealing with simple self-limited, one-dimensional diseases. But obviously, the Procrustean (one fits all) approach is damning to patients with lupus and their doctors. The doctors have little time to go over the many dimensions of the disease that each patient brings to each office visit and no time to educate them properly.
Dr. Thomas and all of us who care deeply about the patients know very well that it is the patients who take charge of their disease who fare the best. They come to the office quite prepared, and it is our duty to educate them further. They bring knowledge acquired from the internet (usually unfiltered and non-critical) and the doctor is pressed to transfer scientific knowledge to properly fill the gap. It is incumbent upon the healers to translate the medical information to the patients so that they can maximize the earned benefit. In these encounters lots is lost in the translation that compromises the welfare of the patient.
A book is coming out this fall that should be helpful in that regard. The author is Dr. Donald Thomas, Jr., and the book title will be The Lupus Encyclopedia (Johns Hopkins University Press). This should be a definitive work that will be of great value to patients and caregivers.
The foreword to the book is being written by Dr. George Tsokos, Chief of Rheumatology at Beth Israel Deaconess Medical Center, himself a world expert on the subject. I reprint with permission some excerpts of the current draft of his introduction (which might change somewhat in the final printing), as they are indicative of the passion displayed by those involved in this disease. The biological aspects are stunning, and time will tell what can be done about those, but note especially the final paragraph. There, George decries the current medical care system, which itself contributes to the suffering. That aspect of the disease is within our control and deserves as much attention as the scientific aspects.
Like Dr. Thomas, as a senior in medical school I was assigned to participate in the care of a 24-year old young lady with fevers, chest pain, swollen joints and blood swollen legs. Systemic lupus erythematosus loomed first in the differential diagnosis, and the tests confirmed the presence of anti-nuclear antibodies, anemia, low platelet and lymphocyte counts, which helped seal the diagnosis. Her face is still vivid in my memory, and her anxious and inquisitive eyes ask me every day, "Will you ever find a cure for me? I am engaged to be married and I want to live." We gave her prednisone in buckets like it was done those days, and we probably added to her lupus symptoms a bunch of dreadful problems caused by the drug. Decades later, we can diagnose patients with the disease faster, we can treat them more effectively, minimize drug-related side effects, take better and prompt care of infections and other frequent conditions linked to lupus and promise an almost normal and lengthy life, but we cannot answer positively the proverbial, “Are we there yet?”
How do you solve a problem like lupus? Even if you scan through the pages of the book you hold in your hands you will realize that you are up for a crash course in medicine, not sparing obstetrics, gynecology and neurology. How do you grasp a disease that wants the doctor to command every field in medicine and how naively we expect our fatigued, achy, feverish and disillusioned patient to handle it? Breathing hurts, the joints yell, the skin blemishes and the kidneys silently go in to oblivion. Every organ becomes involved to pour away the well-being and the life of the young ladies.
Lupus is a demanding partner in the life of the patient, and you will soon learn that prompt diagnosis, perfect close care by specialists, tight control of medications and their side effects and abiding, tenacious efforts to control comorbidity (infections, cardiovascular disease and cancer) make all the difference in the world. Doctors are continuously pressed to shorten their encounter with the patients while the documentation component looms continuously larger. This could be fine in the wisdom of the regulators should the doctors be dealing with simple self-limited, one-dimensional diseases. But obviously, the Procrustean (one fits all) approach is damning to patients with lupus and their doctors. The doctors have little time to go over the many dimensions of the disease that each patient brings to each office visit and no time to educate them properly.
Dr. Thomas and all of us who care deeply about the patients know very well that it is the patients who take charge of their disease who fare the best. They come to the office quite prepared, and it is our duty to educate them further. They bring knowledge acquired from the internet (usually unfiltered and non-critical) and the doctor is pressed to transfer scientific knowledge to properly fill the gap. It is incumbent upon the healers to translate the medical information to the patients so that they can maximize the earned benefit. In these encounters lots is lost in the translation that compromises the welfare of the patient.
The pace of justice
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| This is not Mike |
He arrived in the court serving South Boston and said to the court official, "I guess I have been on the lam longer than Whitey Bulger!"
The official laughed and said, "Get out of here. Case dismissed."
Well, duh! A wish and a hope is not a policy.
Folks who are urging the adoption of risk-based provider contracts seem to forget the basics: To take on risk, you have understand the degree of risk you are taking on and how to manage it, and you need to have a balance sheet strong enough to take on that risk. Kaiser Health News reports:
Few hospitals interested in becoming accountable care organizations are ready to take on financial risk, according to a survey released Friday from The Commonwealth Fund.
“We’re really still at the very beginning of the adoption curve of the ACO model,” says lead author Anne-Marie Audet, who researches health system quality and efficiency at Commonwealth. “The challenge is that hospitals are still not ready to assume financial risk.”
There are already 154 ACOs serving nearly 2.4 million Medicare beneficiaries, and dozens more ACOs are involved in partnerships with private insurers. But so far, the majority of ACOs are pursuing models that allow them to share in any savings they achieve without losing money if they fail to cut costs. In other words, there’s a lot of carrot but not much stick.
But only one in five hospitals pursuing an ACO model reported that they were using
We are not there yet, and the future is uncertain, notwithstanding Ms. Audet's optimism. Why is it that we expect things to change? What is it in the future of hospital finances that will make them more interested in taking on risk in the future? Do we expect their financial capacity for losses to grow? Do we expect that there will be truly integrated care across the spectrum of care, including community-based facilities like nursing homes and rehabilitation hospitals?
This is a policy direction based on a wish and a hope, not a rigorous assessment of its likelihood of success.
Few hospitals interested in becoming accountable care organizations are ready to take on financial risk, according to a survey released Friday from The Commonwealth Fund.
“We’re really still at the very beginning of the adoption curve of the ACO model,” says lead author Anne-Marie Audet, who researches health system quality and efficiency at Commonwealth. “The challenge is that hospitals are still not ready to assume financial risk.”
There are already 154 ACOs serving nearly 2.4 million Medicare beneficiaries, and dozens more ACOs are involved in partnerships with private insurers. But so far, the majority of ACOs are pursuing models that allow them to share in any savings they achieve without losing money if they fail to cut costs. In other words, there’s a lot of carrot but not much stick.
But only one in five hospitals pursuing an ACO model reported that they were using
We are not there yet, and the future is uncertain, notwithstanding Ms. Audet's optimism. Why is it that we expect things to change? What is it in the future of hospital finances that will make them more interested in taking on risk in the future? Do we expect their financial capacity for losses to grow? Do we expect that there will be truly integrated care across the spectrum of care, including community-based facilities like nursing homes and rehabilitation hospitals?
This is a policy direction based on a wish and a hope, not a rigorous assessment of its likelihood of success.
Follow True North to St. Louis
This month, The Mayo Clinic Proceedings has published a section (free and open to the public) dedicated to ACO (accountable care organization) commentaries written by leaders from large health systems across the country, including Ballard, Ascension, Partners, Atlantic, and Methodist Le Bonheur. There is one to which I would like to draw your attention. It is by Robert Porter and Amanda Tosto, from SSM Health Care St Louis, entitled, "The SSM Health Care Approach to Achieving 'True North': Improving Health Care Quality While Reducing Costs."
My regular readers will not be surprised to see that what I like about this article is the emphasis on process improvement, patient-centeredness, and transparency shown by the authors, irrespective of the regulatory or institutional framework offered by the federal government. You or I might not agree with everything set out, but we have to admire the thoughtfulness and commitment demonstrated. Here are some pertinent excerpts:
SSM Health Care St Louis thoroughly investigated the opportunity to participate in the Medicare Shared Savings Program (MSSP) as an ACO and weighed components of the application to determine if this program was in the best interest of the organization and, ultimately, the people in the communities that we serve.
SSM Health Care St Louis has determined that its path forward is to respond to the fundamental factors driving the health care industry in the context of the overall US economy, rather than conform to the requirements set forth by the MSSP. We have designed a deliberate path, True North, which synchronizes the economics of its transformation with the operational changes necessary to accomplish that transformation. SSM Health Care St Louis recognizes that transformation and change must occur, whether or not the political environment is conducive to the current efforts of the Centers for Medicare and Medicaid Services to establish a reformed health care system within the regulations outlined in the Patient Protection and Affordable Care Act.
Like many health care organizations, SSMSL has determined that the future of its mission, and of health care in this country, depends on creating a system capable of delivering dramatically greater value and eliminating the rampant behavioral, clinical, and administrative waste within the current system. Value is defined as achieving high-quality outcomes with the greatest efficiency/least cost over time and across the continuum. Achieving this requires a major philosophical, cultural, and operational shift from a focus on volume and the treatment of sick patients to a focus on the active engagement of individuals, with the support of health care resources, to manage their health.
The key elements in SSMSL’s version of True North are:
● Assembling the elements of the health care system around the patient as an integrated team.
● Aligning the incentives of all parties, including and especially the individual, around optimizing health and minimizing waste. This includes, ultimately, placing financial risk with those best equipped to manage that risk, the person and her/his physician and care team.
● Developing comprehensive tools to support information-managed care across time and across the continuum including:
OE Predictive modeling of health risk in the population being supported; OE Clinical decision support to ensure that health care professionals have the information and resources needed to make fully informed, evidence-based decisions OE Disease registries that provide real-time information regarding the interventions needed to optimize management of patients’ care and the level of their compliance with their individual health management plan;
● Statistical tools to study and understand variation in order to address unjustified variation and test improvements in care delivery processes;
● Business intelligence systems to extract and report real-time information to support performance management;
● A culture of transparency and clinician-led accountability to drive the organization toward the goal of superior value.
● Assembling the elements of the health care system around the patient as an integrated team.
● Aligning the incentives of all parties, including and especially the individual, around optimizing health and minimizing waste. This includes, ultimately, placing financial risk with those best equipped to manage that risk, the person and her/his physician and care team.
● Developing comprehensive tools to support information-managed care across time and across the continuum including:
OE Predictive modeling of health risk in the population being supported; OE Clinical decision support to ensure that health care professionals have the information and resources needed to make fully informed, evidence-based decisions OE Disease registries that provide real-time information regarding the interventions needed to optimize management of patients’ care and the level of their compliance with their individual health management plan;
● Statistical tools to study and understand variation in order to address unjustified variation and test improvements in care delivery processes;
● Business intelligence systems to extract and report real-time information to support performance management;
● A culture of transparency and clinician-led accountability to drive the organization toward the goal of superior value.
Can't get them to (re-)admit a mistake
The federal government’s Centers for Medicare and Medicaid Services (CMS) last week announced reimbursement penalties for more than 2,000 hospitals — including a number in Massachusetts – because of the facilities’ 30-day readmission rates. “No hospital community is doing more to address readmissions than Massachusetts,” said MHA President & CEO Lynn Nicholas. “Our hospitals are committed to providing safe, high-quality patient care, and are national leaders in voluntary, public reporting of patient quality and safety information. MHA supports the concept of working collaboratively with others to improve the readmission rate and recognizes that financial incentives can play a constructive role. But it must be recognized that hospitals do not control most of the factors that affect readmissions. Hospitals can perform their roles with all due diligence and yet may not see a significant impact on the readmission rate. So programs that are designed to address the readmission rates should take that reality into consideration.”
MHA believes that CMS has failed to comply with the requirements of the ACA to not count readmissions that are for conditions unrelated to the initial hospital admission, or for readmissions that are part of a scheduled medically appropriate care regimen such as chemotherapy.
Hospitals across the state are currently participating in numerous projects to address and reduce hospital readmissions, in particular the STate Action on Avoidable Readmissions (STAAR) initiative. Participating hospitals have formed cross-continuum teams and submitted baseline 30-day readmission rates, and are now busy determining how to improve the patient's transition from hospital to post-acute settings. In addition, in 2010 the MHA Board of Trustees unanimously endorsed an association-wide initiative to move beyond public reporting and transparency to make measurable, concrete improvements in hospitals' performance, with a particular focus on readmissions.
Medicine and Football
Watch this heartwarming story from the BBC. Back in March, a brilliant young footballer had a heart seizure on the pitch and one of the country's leading cardiac surgeons happened to be in the crowd AND the security guards were smart enough to let him on the pitch to direct emergency treatment. And that's just the beginning of the story! (BTW, an NHS triumph!)
If you cannot see the video, click here.
If you cannot see the video, click here.
Maria's story
When you are dealing with an illness, it is important to remember that every patient is an individual and everyone should get the best possible treatment. I think the most important message of my story is to never accept one doctor’s opinion – get a second and third if necessary. Treatment guidelines are useful but may not be appropriate for everyone. Every case is different.
My headaches began after an ordinary bout with the flu. My primary care physician ordered an MRI to determine the exact cause. Since I had had a head trauma about 20 years ago in the same location of the headaches, he suspected a cerebral aneurysm. Instead, he found a ping-pong ball sized tumor in the middle of my brain. Other than the headaches, I had been experiencing light and noise sensitivity and my normal sleep patterns changed. During the MRI, I began feeling confused and felt a weakness on my left side as well as problems with my eye. I was admitted to the hospital, and the following day the doctors performed a stereotactic brain surgery needle biopsy. My diagnosis was confirmed – Glioblastoma Multiforme.
My doctors told me that surgical resection was not an option and they offered me conservative treatment and experimental protocols with an estimated survival rate of two years. This was not good enough. I needed a second opinion. Unfortunately, after speaking with another doctor, the consensus was the same – a resection was not an option.
With the help of some friends, I was referred to another neurosurgeon at Columbia Presbyterian [Dr. Jeffrey Bruce], who had developed the surgical technique of removing a tumor in the pineal region, the same area mine was located in. After reviewing my MRI and various other test results, and taking into consideration my young age and otherwise healthy condition, he decided to remove the tumor. The pathological analyses of the tumor showed a lower grade tumor (Anaplastic Glial-neuronal) than was originally diagnosed by the needle biopsy. After 6 hours in surgery, I had a relatively easy recovery – I could even talk and walk the following day and by the 10th day, I had no symptoms at all. As a precaution, I received a 7-week proton therapy.
Now, I feel healthy and strong and have no remaining after-effects of the tumor. My follow up MRIs show no new growth. My long-term prognosis is good! Because my brain tumor was removed, my quality of life is better. Because my brain tumor was removed, my chance for long-term survival has increased significantly. With God’s help, I will now live to see my young sons grow up.
Let's do the numbers
The answer is that they cannot, if we think about running the business on a long-term basis. What makes it work is extracting cash and the exit strategy, the heart and soul of private equity.
As Warren Buffett might say, let's keep this simple. A for-profit hospital system has the following disadvantages vis-a-vis a non-profit hospital system: (1) Its finances are a mixture of equity and taxable debt, both of which are more expensive than the nontaxable debt of a non-profit; (2) it pays taxes--federal and state income tax, property tax, and sales tax--on which the non-profit is exempt; and (3) it is an unattractive vehicle for charitable donations, compared to the tax-advantages offered donors of non-profits.
These are hefty financial advantages for non-profits, which nonetheless are fortunate if they are able to earn an operating margin of 3%. Admittedly, that's 3% of revenues, not a 3% return on capital.
An equity investor in a for-profit doesn't care about margin, strictly speaking, but rather is focused on the rate of return of his or her investment. But let's stick with the operating margin just for a moment, and let's just accept that a 3% margin would not generate the kind of equity return demanded by the market place: You pick the hurdle rate: 15%, 20%, 25%, more? It doesn't matter. A three percent margin just doesn't get you there.
Given the extra costs inherent for a for-profit firm, how can it do better than the 3% margin of the non-profit hospital? How can it offset the relative disadvantages by decreasing its costs or increasing its revenues sufficiently? Creswell and Abelson suggest that part of the answer for HCA has been to "upcode" its patients, collecting more money for the same services. They note that individual doctors receive great pressure to contribute to the hospital's income statement by offering unnecessary, high contribution services. They also suggest that HCA intentionally sends away lower paying patients. Finally, they hint that there might be some operating efficiencies employed by the for-profits that are not used by non-profits.
I do not judge those assertions (although I note that these are very thorough reporters), but I say to you that even this mix of actions would not produce such a substantially different margin as to satisfy private equity investors. Those investors are satisfied by two financial techniques employed by private equity firms in all kinds of industries.
First, use the cash flow of the firm to produce interim equity returns. Focus on EBITDA (earnings before interest, taxes, and depreciation). Employ a capital structure with a very high percentage of debt (i.e., leverage up). Minimize capital investments by not fully funding depreciation. Sell off unnecessary assets. These include things like the pathology laboratory, where you discontinue running your own laboratory. Call Quest and sell them the business, agreeing to pay them laboratory fees. Also, monetize the real estate value of your buildings, perhaps with sale-lease backs or outright sales. Meanwhile, purchase physician practices that will produce referral volumes, offering above-market prices. Pay your debt service costs, but extract as much cash as possible.
Your goal is to show steady growth in EBITDA. Think about it this way: The top line (revenue) is actually more important than your bottom line (net income after interest, taxes, and depreciation). You will do anything to add revenue (even, in the case of Vanguard Health Systems, buying the distressed Detroit Medical Center).*
But wait, some of those tactics produce cash in the short run but add operating costs in the long run. Some actually lose money. What good is that?
The answer comes from the second financial technique: Avoid the long run by flipping the business in an IPO (or to another private equity firm in a secondary buyout). The capital markets are awash in cash right now, money seeking opportunities. There is always a greater fool. You pick your timing, and you go to market with a success story--a record of top line growth, of EBITDA returns in the teens, a prominent public presence. Here's the secret part. You don't actually need to generate that much cash in your IPO to produce a great return for the equity investors. Remember, you have been extracting cash all along for them. Plus, you are highly leveraged. A small increment on the sale prices relative to your purchase price gives you a nice hit on the equity return.
How best to characterize this whole situation? Please review this thoughtful summary by private equity experts at Day Pitney: "It is kind of like the gold rush in years past."
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* I am mainly talking about the US market here. For-profit hospitals in non-US locations can do very well indeed on a bottom-line basis. They play in countries with national health insurance. People who can afford private insurance or who are provided it by their employers (or international visitors) go to them for unregulated private-pay service, especially in the high-end, high-compensation specialties. Those specialties might have long waiting times at the nationalized hospitals, or they might not be offered at all, or they might be viewed as substandard. Those hospitals, too, often have a dominant geographical advantage in that market segment.
Interestingly, though, the unregulated nature of such hospitals can mean that the actual quality of care is undocumented, as they can be exempt from governmental reporting requirements. Thus, such hospitals can have an unjustified reputational advantage, offering the appearance of higher quality without ever proving it. They could also engage with impunity in the kind of practice cited in another Abelson and Creswell New York Times article, Hospital Chain Inquiry Cited Unnecessary Cardiac Work.
The Jubilee Project takes off
Last week, Eddie, Jason and Eric left their jobs (White House and Consulting) and school (Harvard Medical School) to pursue their dreams and work on the Jubilee Project full time making videos for a good cause.
To kick things off, we're currently on a road trip across the country to move to LA. Along the way somewhere in Indiana, we wanted to have some fun. This video is a thank you to all of you for making this possible.
We've launched a fundraiser to produce a film to end AIDS. Please support us by donating to our fundraiser.
If you cannot see the video, click here.
Windham offers a lot of hot air
My post below about the staff's response to a safety problem in a local theater got a lot of attention. (By the way, the theater director called and reported that the cause was fixed: The loose seats had gotten "ungaffed" from the others in the row.) But the story also prompted a note from Melissa Mattison, one of my favorite doctors, who reported on a even more poor staff response to a huge safety hazard at Windham Mountain Adventure Park.
See a recent feature about what happened to my daughter in NY last weekend. My seven year old daughter jumped onto "The Big Air Bag" and the bag wasn't positioned correctly. It was too far out from the platform. Her fall was broken by the bag - thank goodness! But instead of staying on the bag, she was thrown off the bag and on the ground. Thankfully she doesn't appear seriously injured but she landed on her head in a mud puddle, came up bleeding (cut mouth/gum), scraped up and down her arm and leg and covered in mud.
Here's the video of the event:
Melissa continues:
Here is a link to a Yelp review I did to also ‘get the word out’. Yelp can be a powerful way to affect change in the commercial world, but until staff at facilities adopt a different stance towards safety it seems it will take time to truly change things.
Here's the pertinent part of the Yelp review:
Here's where it gets even worse. The staff operating this ride did NOT stop the ride. They would have let my 5 yr old jump right after if I hadn't stopped her. The staff did not inquire how my 7 yr old was. She picked herself up and we walked together up the hill to the main lodge/bathroom area and NO ONE who worked there asked us a single question or stopped us. I cannot imagine they didn't see this happen. There weren't that many people there, my daughter was crying loudly and was a mess (bleeding, muddy). Another parent there asked me if she was okay, as she was concerned. After we washed out the cuts in the bathroom, the manager of the facility (Alexander) came up and asked us what happened. (I think one of the other parents must have said something to him.) When we told him his response was, "You signed the waiver didn't you?" and then he went on to say, "This has been working fine all summer."
See a recent feature about what happened to my daughter in NY last weekend. My seven year old daughter jumped onto "The Big Air Bag" and the bag wasn't positioned correctly. It was too far out from the platform. Her fall was broken by the bag - thank goodness! But instead of staying on the bag, she was thrown off the bag and on the ground. Thankfully she doesn't appear seriously injured but she landed on her head in a mud puddle, came up bleeding (cut mouth/gum), scraped up and down her arm and leg and covered in mud.
Here's the video of the event:
Melissa continues:
Here is a link to a Yelp review I did to also ‘get the word out’. Yelp can be a powerful way to affect change in the commercial world, but until staff at facilities adopt a different stance towards safety it seems it will take time to truly change things.
Here's the pertinent part of the Yelp review:
Here's where it gets even worse. The staff operating this ride did NOT stop the ride. They would have let my 5 yr old jump right after if I hadn't stopped her. The staff did not inquire how my 7 yr old was. She picked herself up and we walked together up the hill to the main lodge/bathroom area and NO ONE who worked there asked us a single question or stopped us. I cannot imagine they didn't see this happen. There weren't that many people there, my daughter was crying loudly and was a mess (bleeding, muddy). Another parent there asked me if she was okay, as she was concerned. After we washed out the cuts in the bathroom, the manager of the facility (Alexander) came up and asked us what happened. (I think one of the other parents must have said something to him.) When we told him his response was, "You signed the waiver didn't you?" and then he went on to say, "This has been working fine all summer."
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