Monday, July 21, 2014

Coaching through failure

I hope you enjoy my latest submission at the athenahealth Health Leadership Forum.

And please be sure to read Jim Conway's commentary on that site.

Thanks.

Barry opines on the AG-Partners deal

Barry Carol often offers thoughtful comments on this blog about health care issues in general and about Massachusetts in particular (even thought he lives out of state.)  He has chosen to comment to the Trial Court about the proposed settlement between the Attorney General and Partners Healthcare System.  He, like others, submitted comments in time for the July 21 deadline.  We all later learned that the AG had asked for a postponement, so that the case will not be heard until after the September gubernatorial primary in which she is a participant.

I've previously posted excerpts from Professor Alan Sager's comments, as well as my own.  I'm sure there are many more that will be submitted in objection to this deal.  If you have filed comments, please send them to me at goalplayleadership [at] gmail [dot] com, and I'll do my best to publish excerpts.  Thanks!

Here's Barry's filing:

I would like to offer a comment on the Attorney General – Partners Health System proposed agreement.

First, I think the proposed deal does not do enough to mitigate the significant price premium paid to the Partners Health System facilities compared to competing hospital systems for similar work and comparable outcomes. These price premiums are paid because of PHS’ dominant local and regional market power. The resulting higher healthcare costs and health insurance premiums make it more difficult for Massachusetts employers to raise wages as much as they might otherwise.

To mitigate this problem, I think there needs to be full price transparency from all providers and all payers. Confidentiality agreements that currently preclude disclosure of actual contract reimbursement rates need to be eliminated so both patients and referring primary care doctors can more easily determine the cost of care before services are rendered and compare prices charged by all providers in the market. We want as much care as possible to be delivered by the most cost-effective high quality providers and we need full price transparency to facilitate this.

I also think insurers should be able to contract with either Massachusetts General Hospital or Brigham & Women’s instead of having to either accept both hospitals in their network or neither.

To the extent that patients like to go to higher cost hospitals that offer better amenities even if they don’t affect medical outcomes, insurers need to be able to charge insured members enough more to go to those facilities to get their attention. Tiered insurance networks should be encouraged.

Healthcare in Massachusetts is the most expensive in the country, I believe. Since the 2006 reforms signed by then Governor Mitt Romney were largely a model for developing the Affordable Care Act, healthcare developments in Massachusetts are closely followed at the federal level. I think the proposed deal with PHS shortchanges the people of Massachusetts and is way too favorable for PHS.

A letter to the Trial Court

Here are my comments to the Court on the proposed settlement offered by the Attorney General and Partners Healthcare System.  (I include them here even though the AG has recently asked for a delay in the court proceeding until after the primary election in September.)  I've previously posted excerpts from Professor Alan Sager's comments.  I'm sure there are many more that will be submitted in objection to this deal.  If you have filed comments, please send them to me at goalplayleadership [at] gmail [dot] com, and I'll do my best to publish excerpts.  Thanks!

Re: Comments on the Proposed Final Judgment in Massachusetts v. Partners Healthcare System, Inc., South Shore Health and Educational Corp., and Hallmark Health Corp., Civ. No. 14-2033 (BLS).

I offer these comments in this proceeding as a citizen of the Commonwealth.  For the benefit of the Court, I first include a short summary of my professional background with regard to matters of market power in general and the state’s health care system in specific.  I then turn to the substance of my arguments.

Following receipt of degrees from MIT in 1974, including a bachelor of science degree in economics, I have had almost forty years of experience in service in public agencies and non-profit institutions.  In many of these positions, I have had to deal with and rule on matters related to market power and make determinations about how to best serve the public interest.  For example, when I was Chairman of the Department of Public Utilities (1983-1987), I issued rulings concerning the manner in which competition should be introduced and encouraged in the electric power industry, the natural gas industry, the telecommunications industry, and the transportation common carrier industry.  Before holding that position, I participated as an expert witness (from 1981 to 1983) before several public utility commissions across America and offered advice to those bodies on how to deal with the extraordinary market and pricing power of the Bell Operating Companies—before those companies were divested from AT&T as a result of a Consent Decree before the US District Court for the District of Columbia in United States v. AT&T. Following my service at the MA DPU, I served as the arbitrator under the Telecommunications Act of 1996 to determine the pricing regime and other aspects of introducing competition into the local exchange market in Massachusetts.  I have published numerous articles on the issues surrounding regulation of public utilities and telecommunications companies, and particularly on the transition from regulated markets to competitive markets.

Since 2006, I have served as a member of the Board of Directors of ISO-New England, the non-profit corporation charged with overseeing and regulating the wholesale electric power market in the region.  Among other responsibilities, the Board is charged with ensuring that market participants do not engage in abuse of market power in the purchase and sale of electric power.

My experience in the health care marketplace of Massachusetts began when I was Executive Dean for Administration of Harvard Medical School (1998-2002).  This was followed by service as Chief Executive officer of Beth Israel Deaconess Medical Center (2002-2011).  In the latter capacity, I had the opportunity to view the dominant provider group, Partners Healthcare System (PHS), exercise substantial and growing market power.  Since leaving BIDMC, I have remained active in the health care field and have been invited by numerous audiences domestically and abroad to speak on health care matters.  I have continued to observe and write about this field and have documented the ongoing market power of PHS and the deleterious effect the exercise of such market power has on the public interest.

Turning to the instant case, the Attorney General offers the Court her interpretation of the appropriate standard of review for the proposed final judgment.  I excerpt a section of her filing:

Judicial review of consent judgments is primarily focused on legality and considerations of procedural fairness. Courts properly review consent judgments to ensure several core requirements are met. First, a court should ensure that they are not ordering conduct that contravenes the law. Second, a court should ensure that any terms that the court might one day have to enforce are reasonably clear. Third, a court should ensure that the consent judgment relates to a genuine dispute by virtue of having some reasonable relationship to the claims asserted.

As in any case in which the Attorney General seeks injunctive relief, the court must consider the public interest. But the public interest inquiry is a narrow one: the inquiry is not "what the district court believes might have been the optimal settlement" the court's duty is to determine "whether the settlement is within the reaches of the public interest."  [Cites omitted.]

It is not my place, nor do I have legal expertise, to suggest a different standard of review.  Instead, I respectfully offer my opinion and advice to the Court as to how it might interpret that standard of review—as a general matter and with specific regard to the case at hand.  I believe that the Attorney General has the burden of demonstrating that such a standard has been met.  In summary, it is my recommendation that the Court rule that she has not done so.  If the Court agrees, the remedies—as I understand them—are to deny the motion altogether or to return it to the parties with instructions to renegotiate an improved settlement.

In applying the Attorney General’s advice that the proposed settlement must be within “the reaches of the public interest,” we must demand that the result achieved is no worse than the status quo and preferably better than the status quo.  In that regard, we have the benefit of the Attorney General’s own work products over the years.  She has concluded that the disparity in rates charged by PHS is not the result of a higher level of quality offered by that organization, but that it is a result solely of the exercise of market power.  She has also concluded that such price disparities are, in themselves, a source of ever-rising health care costs for the citizens of Massachusetts.  In other words, the mere existence of those disparities makes things worse for the consumers of the Commonwealth.

At a minimum, then, we would hope that a settlement with PHS would act firmly and decisively to reduce those disparities—and quickly enough to make a difference.  It is not enough to have the hope that the proposed settlement would achieve this result:  The end must be measurable and enforceable.

At heart, instead, the proposed settlement offers a wish and a prayer towards this result.  Yes, the rates for PHS would be limited to the rate of inflation.  Theoretically, other hospitals and physician groups might then “catch up” if their own rate increases exceeded those of PHS.  However, other providers have not been able to receive rate increases above that of PHS.  There is nothing in the settlement that empowers them to do so, and, indeed, the settlement cannot force insurers to do what they have never done before.

Further, even if providers could get such preferential treatment, the base upon which rate increases would be granted compared to the already substantially higher rates garnered by PHS forecloses the possibility of narrowing the gap by any appreciable amount within any reasonable time frame. By allowing the disparity of rates to continue, the Attorney General offers a result that is worse than the status quo.  That disparity permits PHS to accumulate additional revenues disproportionate to the value it provides to society, extracting ever-increasing funds from the public, and giving it the resources to engage in further expansion, magnifying its market power.  The Attorney General ignores her own conclusion from her past analyses, turning a blind eye to the fact that it cannot be in the public interest to permit a dominant provider to become still more dominant.

If the Court concludes that the public interest standard must result in a reasonable probability that the result will be better than the status quo, the proposed settlement obviously fails for the same reasons.  But the problem is compounded in that the proposed settlement gives explicit permission for PHS to acquire new hospitals and new physicians, expanding its geographic reach and its dominance.

As others will point out, conduct remedies of the sort contained in the proposed settlement are clearly inferior to blocking an anticompetitive merger.  Such conduct measures are typically unsuccessful, in part because antitrust enforcers and courts lack the expertise and institutional capability to adequately regulate firms with market power. In part, too, there are inevitable disputes before the courts as to whether the merger proponent has complied with such measures.  It is for these reasons that federal enforcement agencies and courts have rejected these types of conduct remedies in hospital mergers and other cases.

When faced with similar issues in this or other sectors, the federal government has ordered divestiture of key productive assets, or it has declined to permit mergers. I recognize that the Court may not have the authority to order such a result in this case, but it certainly does have the authority to conclude that the proposals and conduct remedies included in this proposed settlement do not meet the public interest. I respectfully suggest that Court reach such a conclusion.

Sincerely,

Paul F. Levy

Sunday, July 20, 2014

Professor Sager offers lessons in market power

Boston University Professor Alan Sager has filed comments with the Trial Court about the proposed settlement between the Attorney General and Partners Healthcare System.  They are cogent and powerful.  (I include them here even though the AG has recently asked for a delay in the court proceeding until after the primary election in September.)  If you have filed comments, please send them to me at goalplayleadership [at] gmail [dot] com.  Thanks!  Some excerpts from Alan's:

I’m concerned that the agreement is not in the public interest.

First, since 1993, Partners has claimed that its various mergers and affiliations (which, for convenience, I’ll call “combinations”) sought to save money, and that they would save money or have saved money. But Partners has adduced no credible evidence to support those claims. Therefore, no one should believe Partners’ assertions that still more combinations will save money.

Second, Partners has claimed that its combinations would improve quality of care. But it has provided neither credible evidence of past improvements in quality attributable to its combinations nor plausible arguments that its combinations are essential to future improvements in quality.


Third, Partners has generally argued that its various combinations would be good for the public. I contest this assertion and have long argued, with colleagues, that these combinations were designed mainly to benefit Partners by boosting the prices it is paid for care and thereby increasing its revenues, and thereby liberating it to spend and grow without fear of price competition.

The original Partners combination, with successive accretions, help to explain why the cost of Massachusetts hospital care specifically and Massachusetts health care generally has continued to rise. By reducing competition, Partners’ combinations have helped to deepen the financial anarchy that allows health costs to rise. When anarchy prevails, the strong hospitals profit, and insurance premiums rise.

Addressing the AG, he says:

You have negotiated and publicly trumpeted a set of apparent constraints on Partners’ behavior. But you offer no convincing evidence that these constraints on behavior are likely to be practical, effective, or even enforceable. Have they been tried elsewhere? Did they work? How often? Without this evidence, it is likely that the constraints you have negotiated will actually enable Partners to garner substantial revenue increases. Right now, the constraints look like feeble regulatory Lilliputians, unable to restrain Partners’ Gulliver.

Instead of providing evidence that the negotiated constraints on Partners’ behavior are likely to work, you have focused on the procedural superiority of negotiating settlements over going to trial. You thereby trumpet form over substance—negotiating a deal with Partners instead of providing evidence that those constraints are likely to be enforceable and effective in restraining growth either in the prices paid to Partners’ hospitals and doctors, or in the total revenue they garner.

Despite the absence of evidence to support Partners’ claims that its consolidations save money and improve quality, and despite the absence of evidence to support the enforceability and efficacy of your negotiated remedy that allows substantial new consolidations, you assert that your negotiated settlement will be financially and clinically beneficial to the people who need or pay for health care in the Commonwealth. Sadly, this assertion is not credible.

Attorney-General Coakley, I don’t doubt for a second that you mean well. I believe that you hope to get the best deal from Partners that you can, given its great political influence. But I think the time has come to recognize that your negotiated agreement is not in the public interest, and to instead confront Partners in court by suing to divide it into two halves.

Saturday, July 19, 2014

Let's give credit, not throw brickbats

A recent story in the Washington Post makes a common error that causes the casual reader to reach an inappropriate conclusion.  Here's the background.  The Agency for Healthcare Research and Quality offers to help hospitals conduct periodic surveys of their staff on the topic of patient safety culture.  As designed by AHRQ, the survey assessment tools are designed to help hospitals:
  • Raise staff awareness about patient safety.
  • Diagnose and assess the current status of patient safety culture.
  • Identify strengths and areas for patient safety culture improvement.
  • Examine trends in patient safety culture change over time.
  • Evaluate the cultural impact of patient safety initiatives and interventions.
  • Conduct internal and external comparisons.
Hospitals are not required to conduct the surveys.  According to the Post, "About 650 of the country’s roughly 5,000 hospitals took part this year."  Staff who participate in the surveys are promised that their responses will be held confidential.

As the result of  a petition by the National Nurses United to the National Labor Relations Board, the results of the 2012 survey at MedStar Washington Hospital Center were released for public view.  The hospital then decided to also release the 2014 survey results.

Here's the mistake made by the Post in its story:  It compares the Washington Hospital Center results with the national average and concludes that WHC has "low marks." Notwithstanding the language on the AHRQ site about external comparisons, this is a mistake because such results across multiple hospitals cannot be assumed to be comparable.  Indeed, it is well known that some hospitals with higher grades in the survey achieve those results because there is a lack of awareness of the depth of patient safety issues in their institutions: People therefore have false confidence that they are doing well.  Likewise, some hospitals that have excellent safety programs get lower grades because the people in those hospitals have done enough work in the field to believe that they need to do even better to reach the standard to which they hold themselves accountable.  (Indeed, I have found that the one of the best way to judge the commitment of a hospital to quality and safety improvements is to ask people how it's going and have them respond, "OK, but we have so much to learn!"  Such modesty is a good marker for those serious about process improvement.)

So, a hospital-to-hospital or a hospital-to-national-average comparison is not the point.  Rather, the key set of statistics is how a hospital compares to itself over time, and how staff participation in the survey changes over time.  It is on that front that WHC has actually done quite well.  As noted in the story:

In a letter sent to all employees, John Sullivan, the hospital’s president, said the hospital was posting survey results from 2012 and 2014 on its internal communication system. He said he was encouraged that overall hospital results showed improvement and that staff participation increased 24 percent over the two years.

“This is a big step,” he wrote. “Research shows that organizations that regularly share this kind of information with associates make greater gains and improve safety — and that is certainly our goal.”

Also:

The survey is one tool that hospital officials say they use to measure the safety of hospital care. In another key area, the hospital has made dramatic improvements in lowering its rate of central-line infections, according to Arthur St. André, the hospital’s director of quality and safety. Officials are also encouraged that clinicians are self-reporting more incidents, including near-misses, using a new electronic system installed more than a year ago that allows individuals to report anonymously, he said.

Mr. Sullivan, though, was not claiming victory:

He noted that more than half of respondents said the hospital needs to do better in two critical areas — teamwork across units, and reporting errors without fear of punishment.
 
As we encourage more transparency of clinical outcomes in hospitals, let's remember the message I set forth many years ago:

There are often misconceptions as people talk about "transparency" in the health-care field. They say the main societal value is to provide information so patients can make decisions about which hospital to visit for a given diagnosis or treatment. As for hospitals, people believe the main strategic value of transparency is to create a competitive advantage vis-à-vis other hospitals in the same city or region. Both these impressions are misguided.

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.


On this front, WHC deserves credit for its commitment to improving quality and safety for its patients and its honesty in traveling the road ahead.  I hope that, in the future, the Post will ask outside experts to comment on these kinds of stories, rather than relying solely on those internal to the hospital.

Evaluating retail based clinics

I think the rise of "minute clinics" and other convenient care centers in retail areas is a good idea, providing access to people in convenient settings.  But it is appropriate to review the actual clinical performance of such centers to make sure they add value to the healthcare system and patients and don't simply grab their share of the 19% of GDP.

Here's a thoughtful commentary on the topic by Budd Shenkin, as he reviews a recent study on the matter.  Here's a teaser:

Retail Based Clinics (RBCs) are one of the most recent American organizational innovations. Ready access to acute care, especially during evenings and weekends, has long been neglected by our health care system. Large pharmacy companies have taken advantage of their access to capital and their high visibility in communities to establish RBCs on their premises to fill that access gap. While they appear to have become financially successful, serious questions surround RBCs. Do they further fragment an already fragmented system? Do they provide high-quality care? Do they succumb to the temptation to drive further profits by prescribing too many medicines to be bought at the parent company's store where they are located?

Friday, July 18, 2014

Let's give them points for staying on message

I need to apologize to my readers, especially those from outside of Massachusetts, for what might appear to be excessive attention to the issues surrounding Partners Healthcare System.  I truly don't want to write so much on these topics, but I do so because what is happening here is a type of morality play that has relevance to many other parts of the United States (and even some other countries.)  At one level, this is a classic issue of economic and political power: At what point do the perils of market concentration offset the potential benefits from a corpoation's consolidation and growth?  Recent changes to federal health care law appear to encourage market concentration, but for a purpose--to garner economies of scale to reduce costs, to create a larger risk pool to reduce costs, and to enable more coherent management of patient care across the spectrum of services to reduce costs.  It is when those purposes are corrupted that there is a conflict between public policy and corporate arrogance and greed.

In the case of Partners Healthcare System, arrogance and greed predominate as corporate characteristics.  I want to make clear here that I distinguish between corporate characteristics and the purpose, hopes, desires, and commitment of the vast majority of those working in the organization.  I know hundreds of doctors, nurses, and administrators in PHS--and I am personal friends with dozens--and I would not hesitate in any way to say that they are among the most devoted people in the world, living their lives to alleviate human suffering caused by disease.

I believe that there were many good instincts when PHS was created, but in my view the company began to lose its way when founder Richard Nesson, one of the great humanitarians and visionaries in the Boston medical community, died in 1998.  Leadership really matters, and with Nesson's death, the business aspects of corporate strategy rose in prominance relative to the humantiarian purposes that could have been achieved.

Again, this was not a matter of bad people doing bad things.  It was a matter of good people neglecting to do good things.  I could relate many stories of troubling management choices made by PHS leaders over the years, but I fear that doing so would leave the impression that I am attacking them personally, so we'll leave those stories for some time far in the future.

Now, though, I am again forced to respond to a recent letter to the editor submitted to the New York Times by the corporation's CEO.  As a public relations item, it is masterfully written, consistently "on message," but it is deceptive and misleading.

Here it is in its entirety:

The Risks of Hospital Mergers” (editorial, July 7) notes the leadership of Partners HealthCare in supporting the Affordable Care Act by improving care and controlling costs.

Partners’ founding institutions, Massachusetts General and Brigham and Women’s Hospitals, have for centuries offered hope and lifesaving care; one in six of our patients is brought to us from another hospital. Our doctors, nurses, care teams, researchers and educators are among the very best, recognized nationally for their commitment to excellence year after year.

Partners has been a leader over the last 20 years in innovation and science, continually improving care for patients everywhere. Today we are building on our past, tapping into our vast expertise across our system to deliver the highest quality, coordinated and accessible care to bend the cost curve of medical expense.

We have made the commitment to cap our prices and restrict our physician and hospital growth. As a result, we will become the most regulated health care provider in Massachusetts, if not the country. 

Patients choose where they wish to receive their care. They, along with others, will hold us accountable for the quality and cost of the care we deliver. 

Have you been taken in?  Are you a believer?  Beyond the obvious exaggeration that "patients choose where they wish to receive their care" where there is a dominant, closed provider organization, does it matter to you that there is no evidence to support the assertion of highest quality and coordinated care?  Remember Gene Lindsey's words:

If the motivation of Partners over the last twenty years has been to use its market power to really integrate care and lower the cost of care, they have failed monumentally. The care within Partners is no more integrated, and certainly much more costly than in any other healthcare system in the state, the nation, on this planet, and therefore presumably anywhere in the universe. Partners offers spectacular care in specific areas at a high cost. Partners’ performance on some of the metrics of care that is routine in the community arguably falls short from being unequivocally “the best,” although its price never reflects that reality.

Does it matter to you that the price caps permit prices to rise, in contrast to the promises made that mergers would reduce prices?

When the current CEO took over Partners in 2009, I rather unabashedly suggested some agenda items for his term of office.  He was not pleased with this "help," of course, but let's look at them today and see if Massachusetts might have been better off if there had been real attention paid to those items:*

If there is any organization in the state that has the potential to demonstrate the potential for an integrated health care delivery system, it is PHS. But, it will come as no surprise to participants in that system that this has not yet happened. The long-standing rivalry between the two flagship hospitals has meant that rationalization of tertiary and quaternary clinical service between the Brigham and the MGH has often been deferred. Previous Partners CEOs have focused their efforts on integration of back-office and other business aspects of the system, leaving clinical integration essentially untouched. Gary will face an interesting and important choice as to how and if he will address this unachieved potential benefit to the region. If the Partners system first sets an internal example, it might then be possible to achieve a broader rationalization of care in cooperation with the other academic medical centers (BIDMC, Boston Medical Center, and Tufts). We all need to garner these economies to control costs in the over-served Boston marketplace.

The Partners hospitals are full of well intentioned, dedicated people. But there has not been a corporate public commitment to reduction of harm and to transparency of clinical outcomes that could help build broad public confidence in the quality and safety of patient care -- and with this a confidence that we are also attempting to control costs. I would love it if Gary were in the position of challenging me and the other hospital leaders in this arena, rather than vice versa. Ironically, some of the world experts in these matters are faculty members in his hospitals. The Partners system should be a world leader in the science of health care delivery, along with the fields in which it already holds prominence.

The promise remains unmet.

---
* I also made some suggestions with regard to dealing effectively with the threat presented by the Service Employees International Union.  That has a particular irony today, in that the previous Vice President and Political Director of SEIU 1199 is now Martha Coakley's campaign manager!

Thursday, July 17, 2014

Lower prices, not higher prices

The Health Policy Commission has submitted comments to the Trial Court for its consideration of the proposed settlement between the Attorney General and Partners Healthcare System.  It is a comprehensive filing that points out many of the flaws in the proposed settlement.  But there is one pithy paragraph that gets to the heart of the matter:


This point is reminiscent of one I made a few days ago:

In summary, where [the AG] goes wrong is . . . in assuming that market dominance will lead to price reductions to the consumer.  Indeed, she expressly anticipates that Partners' rates will not go down and instead builds in increases.  This result is inconsistent with the federal goals of health care policy, which can only be met if competition is forced upon the marketplace.  Price reductions to consumers must be our goal.  The only way to achieve that is to use the method that has been employed against other market dominant firms in other industries: Divestiture or dismemberment of key strategic assets to permit a contestable market to emerge.  Here, that must mean a split between MGH and Brigham and Women's hospitals.

Gubernatorial candidates: It's time to stand up and be counted

As the July 21 deadline approaches for public comments on the Attorney General-Partners deal, it will be interesting to see if her opponents in the Democratic gubernatorial primary file comments with the Court.  Ditto for candidates from other parties.

The last public comment I have seen from Steve Grossman was this:

“This deal apparently represents a common-sense solution that will continue to deliver quality care to residents of the South Shore as well as control health care costs for consumers and employers."

Don Berwick said this:

“It essentially makes permanent Partners’ already unacceptably high costs without requiring the reduction in prices that is needed, tying the state to a fundamentally flawed pricing structure for the future. The reforms the state needs are much more fundamental.”

According to that same news report, other candidates have opined as follows:

Evan Falchuk, an independent candidate, blasted the agreement.

“Monopolistic deals like this are a huge part of what makes health care so expensive in Massachusetts, and it’s time for them to stop. Partners has already amassed enormous market power, which has translated into spiraling health care premiums for everyone. This deal does nothing to change that, and in fact allows Partners to close on a massive acquisition that will further strengthen its market dominance.”

Republican Charlie Baker, a former chief executive of Harvard Pilgrim Health Care, called the agreement a good start and added that, to truly lower costs, “Massachusetts must insist on full price transparency from all providers for all services from all payers.”

Here's the notice from the Court and the submission address, should anyone need it:


By the way, will the Attorney General post all comments received on her website, along with her response?

Add Beyond Heroes to your library

I'm catching up on some great books people have been sending me.  Here's one by Kim Barnas, Beyond Heroes, which has the prosaic subtitle, A Lean Management System for Healthcare.

Oh no, you say, another Lean hospital book?

Well, yes.  But a good one.

For one thing it is readable, full of engaging stories.  For another, it presents insights and clear guidance to doctors, nurses, and hospital administrators as to how to achieve improvements in clinical and logistical work flows.

It does not oversell what the Lean philosophy can do for health care.  It is simply practical and helpful.

I could not imagine conducting a Lean training program without adding it to the curriculum.

Whether you need an introduction to the concept or are seeking to refine your approach to Lean, this is a valuable book. 

Wednesday, July 16, 2014

Stubborn facts create nightmares

Wow, authors Al Lewis and Vik Khana (of Surviving Workplace Wellness fame) pull no punches with regard to some recent program announcements and analyses in this field.  You can read the whole story here, but the concluding paragraph--dripping with irony, sarcasm, and accusation--sums it up:

We are convinced that these obvious fallacies did not accidentally get overlooked.  Indeed, we have previously coined the term ”the wellness ignorati” to describe industry defenders whose strategy is to deliberately ignore facts. This is not an accusation but rather a compliment.  It is a brilliant strategy . . . based on the accurate assumption that most human resources executives aren’t trained to critically analyze biostatistics while most benefits consultants choose not to.  Indeed, ignoring facts is the only strategy that can keep this industry alive, because . . . facts are the wellness industry’s worst nightmare.

Tuesday, July 15, 2014

You count!

Yes, we know it's not legally effective.

Yes, we know it will be described by the Coakley campaign and others as simply a political move by the Berwick campaign against the Coakley campaign.

But, gee, it's the first time members of the public are offering their view about the inappropriateness of the deal signed between the Attorney General and Partners Healthcare System.  Look at these examples:


And that view--regardless of legal niceties or political framing--is correct.  It's important for members of the public to stand up and be counted.

Won't you please join in?

Admissions about readmissions

The ever-thoughtful Brad Flansbaum presents a cogent summary of what we have learned and not learned about the causes of readmissions and the cost and benefits of reducing them.  I'll summarize briefly but then turn to the ramifications for a new generation of companies that have been created to capitalize on the current readmissions fad. First, here are some excerpts from Brad's post:

Think of the drunk looking for his lost car keys under the only light post in a parking lot.  As unlikely as he might find the keys, he does use logic in his approach despite his low odds of success.

We use readmits for the same reason.  We have mediocre tools to assess outcomes, but nothing better exists.  We use readmissions because we do not have much else to employ.

If one could equate a hospital stay to a restaurant experience, readmits as part of our composite grade would rank somewhere between arranging the table china and the linen choice.

Yes, as a country, we have improved—readmits have dropped 1-2% in absolute terms the last few years.  However, we do not know precisely why, nor have confidence in what interventions we have implemented to make the strides.  

Preventable readmits do not factor much into our large health care price tag.  It is also hard to claim any positive externalities impacting other aspects of care from whatever practice changes we have adopted, given we cannot reliably identify them.

The readmit metric has a long way to go—both on the knowledge discovery front and how we as practitioners should seek wisdom in a very crude measurement.  I am still amazed at how many non-clinicians find meaning in a measure so few clinicians view as high impact.

Brad also includes a list of what we actually know about readmissions.  I include a few:

1.  Not one intervention has magic bullet status.  Most studies indicate success involves the interplay of many items, often involving people outside the hospital in the community.
2.  Medication reconciliation, patient education, family involvement, and follow-up appointments matter—but not to everyone and we do not know if we should apply them to each patient or use them selectively.
5.  Preventable readmissions remain a mystery as a percent of total readmissions.  Based on my read, the low could be 5% and the high could be as great as 20%.
6.  Most readmissions arise secondary to diagnoses unrelated to the initial one.
9.  Administrative claims data, as used by the readmission measure, correlate poorly with clinical data derived directly from medical records.


Now, let's turn to the world of commerce. I'm going to focus on one company, Dovetail, as an example.  It's not the only one, but it appears to me to be represent the attempt of investors to take advantage of the current policy with regard to financial penalties for above-average readmission rates.  The concept, at heart, is to employ pharmacists to make home visits to patients and monitor medication adherence and adjust drug usage in light of the patient's changing condition. (I'm sure the company would say that other parts of the regime are of importance, too, but my sense is that much is based on the home visit model.)

Is there anything wrong with this?  No, not clinically.  It certainly won't do any harm.  And no, not as a short term business strategy, i.e., marketing to hospitals who seek arrows in their readmissions quiver.  Especially when the hospitals can enter into contracts for such services rather than increasing their own staff count.

It is on this latter point that I suspect the business model is unsustainable.  If we review Brad's conclusions, we can see that there is no proven relationship between medication reconciliation and readmissions reductions.  As I understand it, Dovetail and others offer their service on a fee-for-service basis, i.e., so much per patient or interaction or whatever.   In the absence of rigorous direct correlations between interventions and results, hospitals will eventually make a financial judgment that the cost is not warranted compared to their other alternatives.

So, then we turn to the underlying business model of such companies.  Is their goal to have a long-term sustained business, or to exit by sale to other private equity investors?  If it is the former, the company will need to move to a fee based on risk-sharing, at which point their revenues will be more uncertain.  If it is the latter, the multiple used for the purchase price will be heavily discounted given the uncertainties set forth by Brad.  Why?  If, as Brad suggests, effectiveness cannot be demonstrated, hospitals will stop using the service altogether or will demand that prices be reduced to an unprofitable commodity level.

In short, this is a business model without a future. It offers a short-term fit for a psychological niche while hospital administrators flail for answers to the government's financial penalty program. As a sustainable part of the health care system, it is a nullity.  If it is proven to be an effective approach, hospitals will figure out that employing their own staff is more cost-effective than paying a price that includes an equity return to private businesses. 

Ironically, I'm told that many of the investors in these kinds of firms are actually doctors in hospitals.  Well, if so, that is a fact that speaks for itself.

Monday, July 14, 2014

Sorry, Governor, but you are too late

A clip from the State House News Service:

Patrick Weighs In On Coakley-Partners Accord
Gov. Deval Patrick said he wants “to be convinced” the agreement between Attorney General Martha Coakley and Partners HealthCare will bring costs down. The agreement has been filed in Superior Court and a comment period on the agreement is open until July 21. 

"Well look, I share everybody’s concern about how we get health care costs down,” Patrick told reporters after an unrelated event on Thursday. “And that is the lens through which I’m viewing it, I think it’s the lens through which there will be others who comment on the settlement. On the substance of the settlement, I don’t have any more to add.”

Asked if he supports the agreement, Patrick said, “Like I said, I want to be convinced that it doesn’t add to health care costs. We’ve done a lot of really good work, together with Partners by the way, in bringing costs down, and I want to be convinced that this doesn’t push us in the opposite direction. I think it’s going to take a little bit more analysis before I have a point of view on that.” –G. Dumcius/SHNS

Dear Governor:

The AG's agreement with Partners does not "get health care costs down." It allows those costs to rise.

"We've done a lot of really good work, together with Partners . . . in bringing costs down." No, Partners has not brought costs down. The rate increases it has been given, for example by Blue Cross Blue Shield, have been above the statewide average.

And I say this respectfully, but your opinion on the issue does not matter.  This is solely in the hands of the Attorney General, who even argues that the judge in the case has little or no authority to rule on its merits.  Here's a portion of her brief:

Judicial review of consent judgments is primarily focused on legality and considerations of procedural fairness. Courts properly review consent judgments to ensure several core requirements are met. First, a court should ensure that they are not ordering conduct that contravenes the law. Second, a court should ensure that any terms that the court might one day have to enforce are reasonably clear. Third, a court should ensure that the consent judgment relates to a genuine dispute by virtue of having some reasonable relationship to the claims asserted.

As in any case in which the Attorney General seeks injunctive relief, the court must consider the public interest. But the public interest inquiry is a narrow one: the inquiry is not "what the district court believes might have been the optimal settlement" the court's duty is to determine "whether the settlement is within the reaches of the public interest."  [Cites omitted.]

Stop trying so hard!

After several years of chemotherapy, my late friend Monique Doyle Spencer's veins had deteriorated to the point that it was very hard for nurses to insert IV lines.  The most painful moments for her would occur when someone would try multiple times to insert a line.  She noticed that, if they didn't succeed the first or second time, the process would just get worse and worse as they tried harder and harder.  The psychology of the moment was that the person would "anchor" into a certain approach, and the nurse's well intentioned efforts would fall to failure as frustration and anxiety grew--for both parties.

I mentioned this story to my colleague Bijan Teja, a second year surgical resident, who has seen the same phenomenon occur with regard to central line insertions by doctors.  He sent the following note:

Please see attached two papers that have shown that the complication rates increase dramatically with more than two failed attempts at central venous line placement. The recommendation is to stop after two or three tries, and usually try a different site, a different operator, or both.

The first paper from the New England Journal of Medicine in 1994 studied 821 patients requiring central venous catheter placement, and found "if only one needle pass was attempted, the failure rate was 1.6 percent, as compared with 10.2 percent for two passes and 43.2 percent for three or more passes." The authors also noted that the rate of complications rose dramatically from 4.3 percent with one pass to 24.0 percent with more than two passes. "The strongest predictor of a complication was a failed catheterization attempt."

Given the increased likelihood of failure and the markedly increased risk of a complication when more than two needle passes were attempted by the same physician, we believe that more than two attempts by the same physician should be discouraged, particularly when catheterization is elective. We found that when one physician failed to place the catheter, the success rate for an attempt by a second physician (whose degree of experience was similar to that of the first) with one or two needle passes was similar to the success rate for the cohort as a whole on the first attempt. The complication rate was also similar.

The second paper from the journal Surgery in 1998 studied 1435 children requiring central venous line placement and found that two or more attempts at placing the catheter was associated with a 5.4 fold increase in complications compared to insertion on the first attempt.  For those of you attending physicians who are ready to jump to the conclusion that success was a matter of experience, please note that that the paper concludes: "We found no increase in complications associated when catheters were placed by interns or residents."

These studies and Monique's experience demonstrate again that the expertise and good intentions of doctors and nurses can fall to our immutable cognitive and psychological characteristics.  I hope clinicians can learn that it is no sign of weakness to say to a colleague, "Would you mind taking over? I'm stuck here and need a short break."

Sunday, July 13, 2014

The rule of rescue

Way back in 2008, I summarized a talk given by Brent James and included a comment he made:

Much of the US system is based on the rapid response aspects of health care. In contrast to other countries, where the emphasis is on primary care, we spend a lot on treating those problems. We provide better access to specialists and to technology, and we do not ration these services as they do elsewhere. Accordingly, the US mortality rate for heart attack and trauma, for example, is well below Europe. But the impact on overall mortality of our progress in these secondary care arenas is overwhelmed by the impact of a strong primary care emphasis in other countries.

James cites "the rule of rescue" as a reason for this. This is defined as "the imperative people feel to rescue identifiable individuals facing suffering or death." Our health care delivery system is skewed in this direction.

Ironically, other countries are now finding an increased demand for rescue care and so are seeing large financial pressures emerge in that segment of their own systems.


I thought this was a great insight by Brent, but I could never find the source document. Now, thanks to reader Mark Braunstein, we have it, a journal called Law, Medicine & Health Care, Volume 14, Number 3-4 (1986).  Here's the link from someone's class materials at McGill.

The author, Albert Jonsen, is Emeritus Professor of Ethics in Medicine at the University of Washington, School of Medicine, and the article is called, "Bentham in a Box: Technology Assessment and Health Care Allocation." Describing how funds and other resources are allocated, with reference to Jeremy Bentham, the founding father of utilitarianism, he notes:

We reach a conclusion contrary to the utilitarian principle: We benefit a few at cost to many.

This occurs only when technology assessment becomes specific and explicit. The barrier will not rise up if we let these life-and-death decisions slip by, politely unnoticed, in a general rationing or allocation policy.  But if we work at explicit evaluations of single technologies, the barrier is bound to appear.

I call this barrier the rule of rescue.  Our moral response to the imminence of death demands that we rescue the doomed. We throw a rope to the drowning, rush into burning buildings to snatch the entrapped, dispatch teams to search for the snowbound.  This rescue morality spills over into medical care, where our ropes are our artificial hearts, our rush is the mobile critical care unit, our teams the transplant services.  The imperative to rescue is, undoubtedly, of great moral significance; but the imperative seems to grow into a compulsion, more instinctive than rational.

[When involved in a group that was assessing a life-saving technology,] the evidence appeared to be leading to the logical and reasonable conclusion that the technology was not cost-effective. Before that conclusion could be drawn, however, the rule of rescue threw up an impassable barrier.  The logical conclusion of the assessment faltered and fell, and the technology . . . won the day.

This then is Bentham in a box: the rational effort to evaluate the efficacy and costs, the burdens and benefits, of the panoply of medical technologies--an effort essential to just and fair allocation--encounters the straitened confines set by the rule of rescue. Even the soundest consequentialist argument against that rule seem unable to break out of the box.

Appeals to the quality of life or to the impact of a technology on society or culture carry little weight. As we find ourselves becoming more and more skilled at sorting out the efficacious from the useless and the cost-efficient from the wasteful, we find ourselves, at the same, time, unable to extend our felicific calculus to the very expensive technologies that will rescue the few.

Saturday, July 12, 2014

Good progress, but work remains

Here's a superb article by Helen Haskell on the AHRQ site.  It provides a compelling retrospective of the patient safety movement in the US, from 1981 to the present.

Her conclusion is right on target, in my view:

It should be axiomatic that without safe and effective health care, other reforms have little meaning. Yet despite decades of work by patient safety advocates, both inside and outside the health care system, our systems are still far from safe. The topic preoccupying this patient safety advocate is that in the rush toward inclusiveness, population health, and integrated care, the vital unfinished business of safety may be pushed to the margins.

Friday, July 11, 2014

Leading? Hardly.

Well, we could scarcely expect him to say something else, but the CEO of Partners Healthcare System really went out on a limb when he told the Boston Globe:

“The formation of Partners has been a great thing. Care has gotten so much better.”

Well, no, it has not.  Here's a more accurate description from Dr. Eugene Lindsey, the former head of the state's largest multi-specialty group, which has referred patients to Partners for two decades:

If the motivation of Partners over the last twenty years has been to use its market power to really integrate care and lower the cost of care, they have failed monumentally. The care within Partners is no more integrated, and certainly much more costly than in any other healthcare system in the state, the nation, on this planet, and therefore presumably anywhere in the universe. Partners offers spectacular care in specific areas at a high cost.

Partners’ performance on some of the metrics of care that is routine in the community arguably falls short from being unequivocally “the best,” although its price never reflects that reality. What it does succeed at is finance, marketing, government relations and intimidation of other members of the healthcare industry. There has never been a credible analysis that shows that Partners' care significantly exceeds in technical quality, access, patient satisfaction, patient-centeredness, or safety when compared with the other less generously paid academic medical centers in Massachusetts.

Referring to a New York Times editorial, he adds:

Given this reality and the reality that it is the most expensive provider of care in the Massachusetts healthcare market, the Times has made an egregious error to suggest that Partners has been a leader in collaborating to control costs and improve care.

Marc-David offers his thoughts

Marc-David Munk has been writing a blog called "Considering American Healthcare" for a few months.  He has thoughtful observations about many topics, drawn from his experience, particularly in the quality and safety arena.

For example, check out this recent post about the dangers of replacing front-line thinking with corporate mandates. The lede:

It’s a common story to anyone who has been around big healthcare: senior management attempts to respond to a business problem by implementing a series of high level mandates that remove front-line management’s ability to think and make operational decisions. The policies and processes do improve consistency for a period of time, but soon the organization begins to strain under the weight of multiple, often conflicting directives and goals. As the directives increase, a new series of corporate metrics are imposed to confirm that the mandates are followed.  Front-line managers, hamstrung from above and unable to make flexible decisions, either find ways to circumvent the often unreasonable dictates, or watch as performance suffers and customers leave dissatisfied.

Wednesday, July 09, 2014

What Scott and Martha got wrong

In the John Adams 1779 version of the Massachusetts constitution, the Attorney General was appointed by the Governor. In 1855, the document was amended to provide for direct election of the AG by the public, to be the chief lawyer and law enforcement officer of the state.  Beyond judicial review by the courts, the AG is not accountable to any other elected officials. In essence, only the voters can hold the person accountable for his or her legal and policy actions.

The decision by former AG Scott Harshbarger to permit Partners Healthcare System to be created by a merger of MGH and Brigham and Women's Hospital (along with the addition of many community-based doctors and hospitals) has had unfortunate consequences that were predicted by a number of observers.  In one article, for example, Alan Sager, Deborah Socolar, and Peter Hiam noted:

This is largely a formal merger to reduce price competition, one that does little to reduce costly duplication or to increase efficiency.

The merged hospital would have great ability to resist payers' demands for discounts.  

These three people were not just casual observers.  They were experts, deeply seeped in matters related to health care, rate setting, and market power. Scott ignored those views, adopting the rationale that:

The merger of the hospitals reflects the great economic and political pressures on such academic health centers to cut costs in caring for patients and in educating young doctors.

As recently reviewed by the New York Times editorial board:

In retrospect, it looks as if Massachusetts made a serious mistake in 1994 when it let its two most prestigious (and costly) hospitals — Massachusetts General Hospital and Brigham and Women’s Hospital, both affiliated with Harvard — merge into a single system known as Partners HealthCare. Investigations by the state attorney general’s office have documented that the merger gave the hospitals enormous market leverage to drive up health care costs in the Boston area by demanding high reimbursements from insurers that were unrelated to the quality or complexity of care delivered. 

Those investigations by the Attorney General have also been confirmed by a newly created state agency, CHIA:

What surprises me most is the difference between Partners and their next biggest competitor,’’ said Áron Boros, executive director of the Center for Health Information and Analysis, which compiled the report. He said Partners has been able to negotiate high prices with all insurers, unlike other systems. “None of them has the consistent success of Partners in driving prices up,’’ he said.

None of this has been news to the state's insurers, who have been beat up or have acceded to Partners' market dominance over the years, creating a huge disparity in the rates paid compared to other hospitals and doctors in the state.  A senior executive at Blue Cross Blue Shield said at a 2010 public hearing that his company, which has more subscribers than all the other insurers in the state combined, did not "[have] the market power to eliminate disparities in the way doctors and hospitals are paid for their services."

The then-CEO of BCBS came to me and said that the rapidly expanding utilization of services for patients in the Partners system, compounded by the higher rates being paid to that system, was "murdering" Blue Cross' bottom line.

Back then, too, the Attorney General found that these disparities had led to and would lead to greater market concentration by this dominant provider. Such concentration would, she concluded, cause a continuing impetus for higher rates of medical cost inflation.

In 2007, also, in one of the oddest conversations I had as CEO of Beth Israel Deaconess Medical Center, the CEO of one of the Partners hospitals urged me to stop complaining about the disparities.  He suggested that we should just be content with PHS getting high rates and thereby establishing a ceiling under which we could operate at lower rates. He asserted that we would do worse if PHS were not there jacking up its own prices.  (I now regret not reporting this conversation to the AG and DOJ as a veiled attempt at price-fixing.)

But let's turn to the current circumstances, in which Martha Coakley, the AG who did all those studies documenting PHS market power and rate disparities and their adverse impact of overall health care costs in the state, has signed a deal that, in the words of the New York Times editorial:

[W]ould let Partners acquire two more community hospitals in addition to South Shore, in exchange for temporary restrictions on raising its prices and on further expansion. There would be limits, for example, on the number of community physicians it could add to its networks over the next five years and cost increases would be held to the rate of general inflation, which is typically less than medical inflation, for 10 years.

This could be a dubious bargain. Such short-term restrictions have been abandoned as a tactic by the Federal Trade Commission because, an agency official said last month, they are “an inferior substitute” for letting market competition among separately owned providers determine prices and quality. Large-scale mergers almost always lead to higher prices, reputable research shows.

For several weeks, I have been making the point that the deal simply would lock in or exacerbate existing rate disparities, permit Partners to grow, and ignores the very substance of the AG's own studies.

But I have now received some useful comments from around the country that have pointed out that I was wrong to emphasize these points. After all, current federal policy is driving industry consolidation--to deal with taking more risk from insurers, to provide more comprehensive care management across the spectrum of care, and to control costs. In light of this policy direction, what's wrong with Martha's deal?

A thoughtful colleague, Budd Shenkin, explains what's wrong:

As to your graphs, they assume continuity. That should not be the case.  The past has been marked by a lack of competition and a lack of regulation; hence, price inflation as well as cost inflation.  Policy now needs to emphasize price reduction via the introduction of competition, since regulation is really so hard.  So, the New York Times is on the right track when they suggest functional divestiture. You need to be more emphatic on the need to introduce competition.  The price figures are compelling--see here.

Alan Sager, looking at my charts, put it another way in a note to me:

If other hospitals were able to obtain price rises one and one-half times or two times as great as Partners, they would be leveling themselves up to a very high set of prices. Because total spending on Massachusetts hospitals is so high overall, leveling up to Partners' prices is expensive. In one simple comparison, assuming the dollar results of a 2% annual rise for Partners and 4% for all others, Partners’ share of the statewide health budget does drop from 29%  to 25.5%, but statewide spending on hospitals is up by over $7.6B—by more than one-third. 

In summary, where Martha goes wrong is precisely where Scott went wrong, in assuming that market dominance will lead to price reductions to the consumer.  Indeed, she expressly anticipates that Partners' rates will not go down and instead builds in increases.  This result is inconsistent with the federal goals of health care policy, which can only be met if competition is forced upon the marketplace.  Price reductions to consumers must be our goal.  The only way to achieve that is to use the method that has been employed against other market dominant firms in other industries: Divestiture or dismemberment of key strategic assets to permit a contestable market to emerge.  Here, that must mean a split between MGH and Brigham and Women's hospitals, with each being permitted to keep their associated physician groups and community hospital feeders.

Such a solution would not interrupt the goal of care management.  Just ask anyone at the two hospitals: MGH and BWH remain clinically distinct institutions, even after 20 years of being part of the same system.  (Here's where The Times is wrong on that point when they say, "The Affordable Care Act has incentives that encourage hospitals and doctors to integrate their operations and collaborate to control costs and improve care, and Partners has been a leader in doing that." As we've seen, costs have not gone down, and in terms of safety and quality, there is no quantitative support for the premise that PHS does better than others in the region or nationally.)

With a break-up of PHS, we can imagine a contestable health care market in Massachusetts--Brigham, MGH, BIDMC, Lahey, Steward, Tufts, Tenet--but only if one other condition is imposed.  That must be complete interoperability of electronic medical records. Absent this ability to send personal data from one hospital to another, consumers will not have the freedom to leave one network to search out higher quality and lower cost in another.

Unless these two critical components are adopted, Martha will join Scott in creating the state's largest unregulated monopoly.  Unfortunately, as she is leaving the AG's office, there will be no way to hold her accountable for what will be one of the largest public policy mistakes in the history of the Commonwealth.

Unfair, unjust, and ineffective

An article from the Western Journal of Emergency Medicine (Western J Emerg Med. 2014;15(2):137-141) offers a frightening example of blatantly systemic problems in a hospital that lead to a patient's death, which is then blamed on an emergency physician, who then faces a loss of licensure.  It is a truly awful case, on so many levels.

As Howard Ovens, Director of the Schwartz/Reisman Emergency Centre at Toronto's Mt. Sinai Hospital, notes: 

Besides the slack and cowardly administration, the expert opinions were flawed, and the process was unfair and probably would not have withstood a court challenge (EP was repeatedly not represented when judgments were made about him).  Finally, every principle of the patient safety movement with regard to not blaming individuals for system problems has been violated.

The abstract:
 
We report the case of a 32-year-old male recently diagnosed with type 2 diabetes treated at an urban university emergency department (ED) crowded to 250% over capacity. His initial symptoms of shortness of breath and feeling ill for several days were evaluated with chest radiograph, electrocardiogram (EKG), and laboratory studies, which suggested mild diabetic ketoacidosis. His medical care in the ED was conducted in a crowded hallway. After correction of his metabolic abnormalities he felt improved and was discharged with arrangements made for outpatient follow-up. Two days later he returned in cardiac arrest, and resuscitation efforts failed. The autopsy was significant for multiple acute and chronic pulmonary emboli but no coronary artery disease. The hospital settled the case for $1 million and allocated major responsibility to the treating emergency physician (EP). As a result the state medical board named the EP in a disciplinary action, claiming negligence because the EKG had not been personally interpreted by that physician. A formal hearing was conducted with the EP's medical license placed in jeopardy. This case illustrates the risk to EPs who treat patients in crowded hallways, where it is difficult to provide the highest level of care. This case also demonstrates the failure of hospital administration to accept responsibility and provide resources to the ED to ensure patient safety.

Tuesday, July 08, 2014

This doesn't apply to us, we are different

A brilliant reminder from Terry Fairbanks (National Center for Human Factors in Healthcare at MedStar Health), offered as a comment on one of my previous blog posts:

When I was preparing a piece on how the healthcare industry could learn from aviation with respect to safety, I called an internationally regarded expert in human factors engineering and aviation safety. I asked him what similarities and differences he saw between aviation and healthcare safety. He said: "Overwhelmingly the biggest similarity is that when the aviation safety revolution started out in the 1970s and we tried to bring safety engineering methods from other industries into aviation, aviation said, 'This doesn't apply to us, we are different.'"

Empathy requires inquiry as much as imagination

I just read a remarkable quote from Leslie Jamison, in her book of essays called The Empathy Exams (Garywolf Press, 2014).  Jamison has taken the role of a standardized patient in medical school training sessions.  One of the SP's tasks is to grade the students on item 31, "Voiced empathy for my situation/problem." She came to realize some important things about empathy.  An excerpt:

Empathy isn't just remembering to say that must be really hard--it's figuring our how to bring difficulty into the light so it can be seen at all.  Empathy isn't just listening, it's asking the questions whose answers need to be listened to. Empathy requires inquiry as much as imagination. Empathy requires knowing you know nothing. Empathy means acknowledging a horizon of context that extends perpetually beyond what you can see.

Empathy comes from the Greek empatheia--em (into) and pathos (feeling)--a penetration, a kind of travel.  It suggests you enter another person's pain as you'd enter another country, through immigration and customs, border crossing by way of query.

Monday, July 07, 2014

A death spiral in Worcester?

"What would you do if you were Eric Dickson?" I asked a knowledgeable colleague about the CEO of the financially troubled U. Mass Memorial Health Care. 

"I'd get another job," he replied. "That place is in a death spiral."

Dr. Dickson, by all accounts, is a thoughtful, honest, and effective leader, with a terrific sense of what it takes to improve hospital work and clinical processes.  So, if my colleague's remarks are accurate, the seeds of that destruction were planted before his arrival.  I have heard for over 15 years about poor operational decisions and labor strife in Worcester.  Those factors left a terrible legacy.  If we go back to 2012, when the previous CEO announced his resignation, the Telegram and Gazette noted:

The system posted a $27.9 million surplus in the fiscal year that ended in June 2011, but that was down 67 percent from 2010.

In February, UMass Memorial announced it wanted to close a $50 million gap in its $2.5 billion budget and would lay off 150 workers and sell two businesses employing an additional 750 people. UMass Memorial blamed its budget cutting on lower numbers of patients, more free care for patients unable to pay and pressure from employers and insurers to restrain medical costs. 


During [the CEO's] tenure, the health system completed a number of construction projects, including the Lakeside Wing expansion to the University campus, which added a new emergency department and other facilities to the busy hospital. UMass Memorial added medical facilities in Milford and Southboro, opened new doctors’ offices in the region, added medical staff and developed centers focused on heart and vascular, musculoskeletal, diabetes and cancer care. 

It was bad timing to invest in new buildings. But that was just the least of the problems.  As reported in the Worcester Business Journal this past April:

UMass Memorial announced it was facing an operating loss of $57 million at the end of its fiscal year last fall; the system was operating in the red as of the first quarter of 2014, according to Dickson's blog.

To stop the bleeding, UMMHC executives have conducted a series of layoffs, eliminating at least 357 positions across the system by the end of March. Layoffs were rumored to have continued into the beginning of April, but UMMHC has not confirmed additional cuts.

Meanwhile, the system has agreed to sell Palmer-based Wing Memorial Hospital and Medical Centers to Baystate Health of Springfield, curtailing UMMHC's reach into the western half of the state, and it had already sold its home-based health and outreach laboratory businesses in 2012 to focus on core services.

Dr. Dickson is boldly fighting back--displaying admirable honesty--neither claiming victory nor giving up hope.  On one of his recent blog posts, he said:

Over the past week, you may have seen articles about our current financial performance . As the articles suggest, the patient (us) has been stabilized, but it is not out of the woods yet.

One article, in the Boston Business Journal, lays out the up's and down's:

“We will continue to see some re-sizing,” said Sergio Melgar, who joined UMassMemorial in January as its new chief financial officer. During an interview with the Boston Business Journal, Melgar said any future moves will depend on the strength of the system’s revenue in the months ahead.

“If revenue volume drops ... We will learn to live within the means of the revenue coming in,” Melgar said.

During the first six months of the fiscal year, UMassMemorial’s inpatient volume declined by about 8 percent, while lower-cost outpatient services were up about 2 percent. Melgar said the six-month performance included a steep drop — between 10 percent and 15 percent — in patient volume in the first quarter that was later offset by a strong rebound in care in the following three months.
Melgar said UMassMemorial’s strong patient volume in April marked its first year-over-year gain for a given month since 2012, adding that the momentum also appears to have carried over into May. “We will be up year-over-year,” he said.

Well, I don't know how to put this more gently, but I predict the upward bump will go away and the long-term pattern of reduced revenue will remain. As noted, the system has sold off important feeder community hospitals as well as some ancillary service lines.  But beyond that, its ranking as a high-cost tier of tertiary center means that patients are being referred to the lower cost St. Vincent Hospital just a few minutes away. 


As noted by the Telegram and Gazette in April:

UMass Memorial Medical Center has been in a competitive battle for patients with cross-town rival St. Vincent Hospital, a Tenet Healthcare Corp. 300-bed hospital that a number of insurance plans present to patients as a lower-cost place for care.

Between 2008 and 2012, inpatient discharges jumped 8 percent at St. Vincent but inched up only 0.9 percent at UMass Memorial Medical Center, according to data from the state Center for Health Information and Analysis. 


By all accounts, St. Vincent's continues to burst at the seams with business. Reliant Medical Group, for example, serves about 200,000 people as the largest multi-specialty practice in the Worcester region.  Over 80% of its patients are on a capitated payment regime, and so the cost of tertiary services is a key factor in deciding whether to send patients to U. Mass or St. Vincent.

If it turns out U Mass cannot recover, what happens?  Well, in Arizona, a similar situation arose with regard to the state-owned hospital, and here was the result, according to the Republic:

The Arizona Board of Regents and University of Arizona Health Network endorsed the framework of a deal that would allow Banner Health to pursue an acquisition of the Tucson-based health system and its two hospitals.

Banner Health, UA Health Network and the University of Arizona still must finalize details of that pact, which is expected to have broad implications for Arizona's health care, the UA's medical school campuses in Phoenix and Tucson and medical research statewide.

Banner and UA Health Network boards on Thursday approved a "principles of agreement" draft that spells out Banner's intent to invest nearly $1 billion to acquire UA Health Network and affiliate with the University of Arizona. The document does not list a purchase price, and details may change. Officials expect to wrap up negotiations this fall, possibly by September. 

Who could rescue U Mass Memorial?  Would the state have the nerve to invite Partners Healthcare System to continue its westward expansion?

Sunday, July 06, 2014

Arithmetic

An editorial in the New York Times prompts me to take a moment to present some arithmetic to that editorial board, our Attorney General, the Boston Globe, and the businesses and individuals who will pay for health care in Massachusetts under the terms of the recently announced deal between the AG and Partners Healthcare System. The deal allows PHS to have rate increases "only" equal to the rate of inflation for ten years.  The Times mistakenly characterizes this provision by stating that the agreement "would at least slow the increases in Partners’ prices." Well, maybe so and maybe not, but it is not the absolute level of the PHS rate increases that matters:  It is the wide disparity between its rates and that of other providers.

Some of us have argued that this agreement is a nullity because it will cement in the current rate disparity for years to come.  This, combined with other features of the agreement, virtually guarantees PHS a continued revenue windfall for years to come.

To illustrate, let's take the case of 1% annual inflation.  Assume that PHS rates are currently 20% above its competitors. (That is conservative in many cases.  For example, it reportedly receives over 40% more than Massachusetts Eye and Ear Infirmary to carry out the exact same procedures.)  Let's present a chart showing what happens to the rate differential against other doctors and hospitals under three cases: They all get a 1% increase (red), 2% increase (gray), or a 3% increase (yellow).

Here's the chart:


Let's now assume inflation is 2% for the ten years, and the other hospitals and doctors get raises of 2% (red), 3% (gray) or 4% (yellow).  Here's that chart:


Hmm, in the best of cases, where the percentage rate increase granted to others is two or three times that received by Partners, the catch-up takes 10 years.

But recall that insurance companies have no requirement to give others more than they have given Partners.  In fact, their pattern has been to give less. (Also, please recall that all hospitals are subject to legislation that keeps rate increases below the rate of GDP growth in the state.)

Check my numbers.  Use your own assumptions if you don't like mine.

BU professor of health care Alan Sager said it exactly right:

"The harm to the public will accrue more slowly under this deal, but the harm will occur."

Did the early patients know they were guinea pigs?

While we're on the topic of marketing robotic surgery, let's note a new article in JAMA Surgery that tells of the real human cost of the rapid infusion of this technology.  From the abstract: 

Importance  Surgical innovations disseminate in the absence of coordinated systems to ensure their safe integration into clinical practice, potentially exposing patients to increased risk for medical error.

Objective  To investigate associations of patient safety with the diffusion of minimally invasive radical prostatectomy (MIRP) resulting from the development of the da Vinci robot.

 Conclusions and Relevance  During its initial national diffusion, MIRP was associated with diminished perioperative patient safety. To promote safety and protect patients, the processes by which surgical innovations disseminate into clinical practice require refinement.

A related news release from UC San Diego, where the authors reside, noted:

Researchers at the University of California, San Diego School of Medicine have found that the risk of patient harm increased two-fold in 2006 – the peak year that teaching hospitals nationwide embraced the pursuit of minimally invasive robotic surgery for prostate cancer.

“This study looked at the stages of innovation and how the rapid adoption of a new surgical technology—in this case, a surgical robotic system—can lead to adverse events for patients,” said Kellogg Parsons, MD, MHS, surgical oncologist, UC San Diego Health System and first author of the paper. “There is a real need for standardized training programs, rules governing surgeon competence and credentialing, and guidelines for hospital privileging when novel technologies reach the operating rooms of teaching and community hospitals.” 

“A responsibility of deploying a surgical technology should include the responsibility to monitor it as it diffuses throughout the real world to ensure safety,” said David C. Chang, PhD, MPH, MBA, director of Outcomes Research at UC San Diego School of Medicine and the paper’s senior author.  “Surveillance of surgical safety should be ongoing, much like the Centers for Disease Control monitor changes in trends of infectious diseases across the country.”

 “One potential intervention would be the development of standardized training and credentialing programs, much like the aviation industry requires of flight crews inexperienced with new types of aircraft,” said Parsons, who is also an associate professor of surgery at UC San Diego School of Medicine. “An independent, continuously updated tracking system for the adoption of new surgical technology is also essential. Prior estimates of robotic prostatectomy uptake, provided exclusively by the robot manufacturer, substantially overestimated the speed with which it was adopted by the surgical community.”