Shifting retiree health benefits

In a post below, I discuss the possibility that the new health care law many entice many employers to drop their company-provided health insurance plans and send their staff over to one of the new health insurance exchanges or Medicaid. Such a strategy, I noted, depends on a firm reaching a conclusion that having company-sponsored health insurance is not important to attract and retain workers.

But there is a group of people who are served by company-provided insurance whose competitive employment choices are no longer of any concern to the firm: Retirees.

Post-employment health benefits are an expensive drag for many companies. Even if the full provision of health insurance ends upon Medicare eligibility, there is the cost of covering retirees during an intervening period. This could easily be 10 years or more, since people can often retire in their mid-50s.

Hewitt Associates seems to be on top of this trend. The company conducted a survey last year of 245 U.S. companies that offer medical benefits to 1.3 million retirees and their families and "learned that six out of ten employers intend to evaluate their long-term retiree medical benefits strategy in the near future, and nearly half of these companies have already begun the evaluation process."

Look at this finding:

While the second option seems more drastic, the first option is intriguing because it still allows a company to gain financial stability with regard to the retiree health care costs. You set an annual amount that you are prepared to spend per person and let the former employees go shopping. Nothing says you have to increase that amount each year, or, if you do increase it, nothing says that you have to do so at the rate of inflation of health care costs. This could remove a huge liability from the balance sheet of many corporations and transfer the risk of future cost increases to the former employees.

Mystery Photo 6

   We are switching to a different part of the World for this Mystery Photo. There are not too many clues here so if you are not familiar with this landmark, you may not be able to guess it. On the other hand, it does have some characteristics to its architecture that may help you place it in the world. Please feel free to enter any guesses, because this is a hard one, I think. Comments are anonymous as far as I am concerned. But if you make a guess, I will answer it personally, if you desire.

My email: renraeretire@gmail.com

A counterbalance focused on quality

Ascension Health, the largest chain of Catholic hospitals, has joined forces with Oak Hill Capital Partners, a private equity firm, "to form Ascension Health Care Network (AHCN), a joint venture that will provide an alternative funding source for the acquisition of Catholic hospitals and other healthcare provider entities. AHCN will offer these entities access to financial, operational and clinical resources."

Ascension Health is renowned for its quality and safety programs and also its commitment to the efficient and profitable operation of the hospitals in its non-profit network. Further, Ascension operates under a distributed leadership model, designed to ensure a strong local presence in all communities that are served by the national system.

The announcement is short on details as to how the business arrangement between a non-profit chain and a private equity firm will work. But this move seems to be a direct challenge to other private equity firms with little or no hospital experience. Ascension seems to be saying to hospitals in distress: "Before you sell out to someone with no track record and no demonstrated commitment to the long run, call us."

Gentlemen, start your engines . . . .

Come on in any time!

Winchester Hospital, a 229-bed facility just north of Boston, has announced that it has eliminated defined visiting hours, effective immediately. With some exceptions -- operating rooms and for clinical reasons including infection concerns for the patient or visitor, safety, clinical care and interventions, or if the patient needs rest -- people visiting patients can do so whenever they wish. "We recognize the value of emotional support during the healing process," said Kathy Schuler, vice president of patient care services and chief nursing officer at Winchester Hospital. "We hope this new policy will benefit all patients."

This is good stuff and a nice contrast to the story below. It would be interesting to know whether the initiative was driven by the staff or whether it came out of consultation with a formal patient advisory council. At BIDMC, it was the latter, as described here, after our ICU Patient and Family Advisory Council suggested to the MDs and RNs that it would help accommodate family members who work late and allow loved ones to visit at their convenience, rather than at ours.

No way to run a hospital

A friend reports on her recent experience in a New York City hospital, where her husband was undergoing a hernia repair.

They were about as un-user friendly as one could be. They called 5 times to tell him to come in between yesterday and today, all the time seeming to change the information. They gave him the wrong pick-up info to give me, so when I came up the K elevators to an empty reception area, I only figured it out by barging into the patient bay area where there was a lone nurse at the station. She told me to go back down and come up the A elevators. When I did, I couldn't find the recovery area (no signs) and had to ask somebody at the blood bank window, who pointed me to the right doors -- which were locked. You couldn't open them by pushing on the door release button and nobody answered the intercom.

So I called Sam on his cell phone, and he gave me to a nurse who couldn't seem to understand the problem: "The door is locked, can you please have some one let us in?" (There was another woman there trying to pick someone up by then.) "We're very busy right now." So we got in because some staff person opened the door with a card key and let us in, too. (He probably shouldn't have: How did he know who we were?). I felt badly for the other woman because she was old with a cane. The nurses couldn't seem to focus on talking to her, whereas they were suddenly wanting to help me.

And the elevators barely work and were crowded as hell. If we had put Sam in a wheelchair like they suggested, I think we would still be there. Of course he was walking slowly, having just had his abdomen repaired, so I basically had to body-check the elevator doors (and they were brutal) to get him in.

ObamaCare Shift

A colleague pointed this out to me recently, and I think he has it right: While more people will have health insurance as a result of the federal health care reform act, a side effect will be to reduce the number of people insured through the employer-based insurance plans that have characterized the US health care system. These people will either be insured as individuals through the state exchanges that are to be established or, if eligible, through Medicaid. There are three aspects of economic hydraulics that are likely to lead to this result.

First, the penalty to be assessed against employers for not offering coverage -- $2000 per year -- is dramatically below the cost of providing insurance. If you are an employer and can save, say, $5,000 by paying $2,000, why wouldn’t you do that? And the $2000 is not even indexed to inflation, while the annual charge for an employer-sponsored plan is likely to go up over time. Hence the differential will grow every year.

In the past, the provision of a health care benefit was viewed as competitive factor in hiring and retaining a firm's work force. But for the vast majority of businesses, that may be a less important factor than saving a few thousand dollars per employee and being able to offer a portion of those savings in higher wages and/or improving the profitability of the firm. Sure, some businesses might still want to attract workers by having their own semi-customized insurance benefit, but the power of that is likely to diminish over time.

A second factor is that the so-called “Cadillac” tax will make employer-sponsored health care even more expensive if you have a plan with generous benefits. Health coverage in excess of $10,200 for individual plans and $27,500 for family plans will be hit with a 40 percent excise tax on the amount in excess of the floor. The tax is indexed for inflation plus 1 percent.

Finally, to help avoid the excise tax, employers are going to “dumb down” plan designs by raising deductibles and co-pays. As they do so, the substantive difference between their own plans and the ones that will be offered through state exchanges or Medicaid will diminish. Even if you have a residual concern that your workers may want an employer-based plan, their desire might be diminished as you make your plan less attractive, so you lose little in competitiveness by referring them to the non-employer based plans.

There are those who believe that there was an ideological basis for this construct, that the Administration and a majority of Congress wanted people to move away from employer-based health insurance as part of an eventual movement to a federally chartered single-payer regime. Others say that it is just a natural extension of a bill that created important protections -- benefit mandates, a floor for medical loss ratios, guaranteed issue, restrictions on medical underwriting -- all of which act to increase the cost of insurance products.

Whatever the reason, we should expect that the world of employer-based health insurance that was created in the 1940s in the United States will rather rapidly move away from that system to one in which government-controlled insurance exchanges and direct government pay (Medicare and Medicaid) will rule. On the latter point, I have have now heard a couple of people estimate that the percentage of the US population covered by government payers can be expected to rise from the current mid-30s% to about 50% over the coming five years or so, abetted by the factors mentioned above but also by expanded income eligibility for Medicaid.

Snake oil, still available

While many in the health care industry are betting their strategic plan on some combination of accountable care organizations, limited networks, and global payments, there is clearly a segment that is going the other way. These are hospitals that seem to be betting on the discretionary, luxury market for care, and especially cancer care.

These hospitals advertise to a national audience in media of general circulation. I saw a few recently in an airline magazine.

What is striking about some is the modern equivalent of snake oil that they are peddling. Preying on the fear of cancer, their verbiage and offer of amenities overshadows the fact that their proposed combination of therapies has no proven efficacy greater than that found in oncology centers in communities throughout the world.

Here’s one. I am NOT making this up.

Built in Accordance with Nature

Built to Outsmart Cancer

Vastu, the ancient Indian science of architecture and building, works in accordance with the natural laws of the universe – Earth, Water, Air, Fire, and Space. A building designed to Vastu standards ensures that these elements exists harmoniously, which in turn balances the energy of the building itself. A Vastu designed building, therefore, positively affects the overall well-being of all who enter.

…[W]e are able to provide what no other cancer center in the world can offer – a healing atmosphere for any and all ailments while enhancing the spiritual, emotional, and mental aspects of the human being.

(After more of this, we find a list of services offered. Like a midrange restaurant that is trying to make its menu appear to be haute cuisine, they use capital letters on normal words to give the appearance of something special. I am especially taken with “Clinical Lab with Pathology”!)

Medical Oncology • Hematology • Radiation Oncology (Including the World’s Most Advanced Robotic Radio Surgery, The CyberKnife™ • Surgical Oncology • State-of-the-Art Imaging & Radiology, Including PET/CT, CT, MRI, Digital Mammography & Nuclear Medicine • Dedicated breast center with Genetic Counseling • Clinical Lab with Pathology • Mind & Body Medicine • Naturopathy • Skin Cancer and Dermatology Center • Clinical Research

We can laugh at this, but it feels obscene when there remain millions of people without access to health care. It also feels obscene when there is so much work to be done on reducing waste and improving the quality and safety of care in clinical settings.

This is not a revolution in North Africa

I have discussed the futility and absurdity of not permitting staff in hospitals to have access to social media like Facebook, but let us now consider the cruelty of not permitting patients and families to have access to it on the public wireless network that is made available to them. Such is apparently the case in this pediatric setting: "[T]he hospital network has decided I can’t get on Facebook anymore." Earth to hospital administrators: This is not a revolutionary setting in North Africa.

Orthogonal, towards MIT

Walking along the Charles River on the Cambridge side late this afternoon, I glanced southeast towards Boston across the river and was blinded by the glare of sunlight reflecting off the ice. How can the setting sun attack from the southeast?!

The riddle is solved when you see that the stainless steel roof structure and/or windows at 111 Huntington Avenue had caught the rays of the setting sun from the southwest (see shadow on the buoy in the river) and reflected them at a right angle towards MIT.

Rick Gilfillan on WIHI

The Newest Innovator on the Block: Center for Medicare and Medicaid Innovation
Thursday, February 24, 2011, 2:00 PM – 3:00 PM Eastern Time

Guest:
Rick Gilfillan, MD, Acting Director, Center for Medicare and Medicaid Innovation

Health reform in the US has a lot of moving parts, and sometimes it’s difficult to sort out the political ups and downs from the on-the-ground changes and challenges facing those in the trenches, seeking to make health care delivery safer, more patient-centered, better coordinated, and cost effective. As WIHI tries to keep its eye on the ball of innovation and new designs so badly needed to pave the way, it’s a sincere pleasure to welcome to the program the man behind the country’s first-ever government center dedicated solely to figuring out what works...and what could be spread widely.

Dr. Rick Gilfillan, the Acting Director of the Innovation Center at CMS, has a track record of thinking outside the box. He helped design a bundled payment system – coupled with a guarantee of quality care – for the Geisinger Health System in Pennsylvania, long before others were willing to take the notion seriously. Now Dr. Gilfillan is working hard with his staff in Washington to roll out opportunities for others to tell him, and to tell the country, about other payment models that are needed for health care. What’s the accountable care organization (ACO) model that’s good for patients as well as the bottom line? Where are providers walking the talk of the Patient-Centered Medical Home and reinventing primary care?

Join WIHI host Madge Kaplan to get the latest from Dr. Gilfillan about the Innovation Center’s plans, priorities, and programs that will enable health care providers to test new ways of delivering care and sharing the learning more broadly. There will be plenty of time for your questions and comments and we look forward to your participation!

To enroll, please click here.

Expand and acquire to prepare for the IPO

Today's story that Cerberus Capital Management has offered to buy the financially troubled Jackson Health System in Florida is consistent with an own-it-flip-it approach to investment in hospitals. Part of the business strategy is to create an organization with a larger revenue stream for when it comes time for the initial public offering in a few years. This simply creates a greater sales multiple when the IPO occurs. As we have seen in other sectors in the economy, this phenomenon is remarkably independent of the actual sustainability of the business as an operating entity in the long run. Capital markets flock to size during an IPO.

This is the same strategy being employed by Vanguard Health Systems in buying the financially troubled Detroit Medical Center. Each deal is likely to be highly leveraged, and as long as the cash flow from Jackson/DMC is positive for a few years, the strategy has the potential to yield an excellent return to the investors in the private equity fund.

By the way, you wonder why the newspaper doesn't check its own recent story on Cerberus to make sure it gets its fact right. Today's story says:

Cerberus . . . spent $895 million to buy the Caritas hospitals, including St. Elizabeth’s Medical Center in Brighton and Carney Hospital in Dorchester. As part of the deal, Cerberus agreed to assume $260 million in pension liabilities for workers and pledged to spend $400 million on new emergency rooms and surgery wards.

The one from two weeks ago, however, reports:

Cerberus paid $495 million for the Caritas system, a sum that funded its pensions and retired most of its outstanding debt. It also committed to pumping another $400 million in capital improvements into the system over the next four years, although de la Torre acknowledges that those funds may come from hospital revenues in coming years, rather than from Cerberus itself.

The dummies' guide to The Joint Commission

I received an email advertisement, and it left me saddened. It is for a book entitled The Joint Commission Survey Coordinator's Handbook. This was the text of the email:

Packed with expert advice, best practices, and sample tools and tracers, this book saves you from having to research and manage Joint Commission accreditation activities on your own.

Now in its 12th edition, this fully updated book by Laure L. Dudley, RN, MS, interprets The Joint Commission’s standards in practical, straightforward language that removes the guesswork for you. Discover what has changed in the past year, what you need to know about the standards, and what you need to do to comply.

So, I figured that this was the dummies' guide to the Joint Commission's standards. I was saddened to think that those standards are so abstruse that there is a need to translate them into "practical, straightforward language."

Then, I clicked on the book's image in the email and was taken to the real advertisement. Upon further review, I figured out that the book is not the dummies' guide only for hospital folk who are about to be surveyed by the Joint Commission. It is as much a guide for the surveyors themselves! The ad includes the following in addition to the text above:

Benefits:

• Find answers to all of your Joint Commission questions in one resource
• Remove the guesswork and hunting for the latest Joint Commission changes
• Gain confidence in your role as survey coordinator
• Become an effective communicator with staff and leadership

What’s new:

• Joint Commission Standards and CMS: Much has changed in the Joint Commission standards following the organization’s deemed status application. Find out how this affects survey preparation as The Joint Commission aligns closer to the CMS Conditions of Participation.
• The clarification process: One of the most nerve-wracking components of a Joint Commission survey is clarifying requirements for improvement. Find tips and suggestions for getting the most out of your clarification process.
• Insider perspective: This year the Handbook is written by a former Joint Commission employee and contains guest commentary by several other former staff, offering readers a distinct insider’s perspective.
• Updated Life Safety Code® for the non-engineer: Written by safety expert Brad Keyes, CHSP, discover how the Life Safety Code® is accessible to survey coordinators and other non-engineers.

I don't know if the book is an officially authorized publication of The Joint Commission. That point is blurred a bit, as there is an endorsement in the advertisement from someone putting herself forward as a surveyor. If it is authorized, it should say so. If it is not, it does not seem appropriate for a JC employee or contractor to endorse a publication by a third party.

Beyond this point, though, what does it say about hospital accreditation standards if there is a need for them to be translated or interpreted in this manner? What does it say about the training of surveyors if they need CliffNotes to do their job confidently?

Maybe this is just a clever company trying to make money from both hospital safety and quality folks and from JC surveyors. On the other hand, it is the 12th edition, so the book seems to have some staying power. And the author is a former executive director of The Joint Commission.

For years, I have been proclaiming the importance and value of JC surveys, having great appreciation for the dedication and expertise of the surveyors who visited our hospital, and noting:

I have often said that, if the Joint Commission did not exist, we would want to invent it. An objective outside review of this sort is extremely helpful to a hospital as it strives to provide better and better care to the public.

Each time I said that, though, observers from other hospitals would skeptically respond by saying that the accreditation standards are often recondite at best, but also sometimes in conflict with good clinical practice. Some of that is inevitable, and I am confident the JC is involved in its own process improvement efforts on those fronts. But, wouldn't it be nice if the 12th edition of this book were the last because it just wasn't needed any more?

"Revolution" in Wisconsin!

   
 I have purposely avoided writing about politics on this blog. I never wanted to stir up the comment and flaming rages that occur on some websites. But I think on this issue, I must. Hit the button Read More to see my opinion.

     Our fine state of Wisconsin has made national news for the last week. In case you have not been keeping up -- we have a new Republican governor and our state legislature has changed after the last election so that it has a majority of Republicans, similar to what happened in other states and at the federal level. The Republicans were elected to change the way government is being conducted, to try to cut spending and balance the budget without raising taxes. Our fair state like many in the nation now has a deficit, ours amounting to 3.6 billion dollars predicted for this current year of 2011. With all due respect, our previous Democratic Governor Doyle spent us into a 1.9 billion dollar deficit by enacting programs that were funded in some degree by the Federal Stimulus Package, but that will end in July. It is a fact that that same Governor also used very creative accounting and also actually stole from various protected funds to finance the state operating budget. He had arranged to spend almost 6 months worth of the 2011 spending on certain programs in the year 2010, so that there is now a deficit to fund those programs. He stole 200 million from the Doctors' Patient Compensation Fund and used it for operating expenses. That "steal" has now been found to be illegal by our state Judicial, so it needs to be paid back. He also stole money from the Department of Transportation and various other places in order to "balance his budget." All these changes, plus the economic times, and the absence of stimulus money as of July all contribute to a state that is basicly "broke." Our new Governor and the new Republican legislators were elected to change all this. Tough work must be done to cut spending and things need to change.

     Wisconsin also has been losing businesses for the last couple decades. Businesses are moving out of the state partly because of taxation levels, but some efforts have been made to improve taxes for business. Previously our state was number 5 and number 9 as the most taxed state in the union, but now we are at number 14. A little better. But the business climate is still very hostile mostly because we have complete penetration of labor unions in the state and we are not a Right to Work state. As I understand that, it means that unions that get into a business or workplace can require that all workers in the business are labor union members. This gives the unions huge collective bargaining abilities and makes it very difficult for businesses to control costs or even negotiate changes in benefits, employment contracts, etc. These "hostile to business" conditions have led to a loss of manufacturing and loss of many other businesses from the state. Therefore we lose jobs, and we lose tax revenue. This has also contributed strongly to our poor economic status. Our former Democratic Governor tried to remedy some of this by trying to negotiate with the Teachers' Union, WEAC for example but that Union specifically would not budge and would not come to the negotiation table through two years of attempts by Governor Doyle. The example of the Teachers' Union is the first to come to the attention of the nation. Teachers have very good benefits: retirement benefits that continue for life and are put away with very minimal contribution of the employee. Teachers' health care is funded with very small contributions from the teachers. This is the setting for our new Governor Walker's first major step to balance the budget. A bill now stands before the State of Wisconsin Senate to have more of a contribution to retirement by teachers and to ask them to increase the percentage of their health care that they pay from 1/2% to I believe 3 or 4%. But most biting to the Teachers' Union, the bill would limit considerably the rights to collective bargaining. This bill would also limit all other government workers to the same collective bargaining restrictions except for emergency workers: ie police and firefighters. I believe this is Scott Walker's first attempt to cut some of the power of the state's labor unions and to move us toward becoming a Right to Work state. In summery this is the steps leading up to these remarkable protests in the state capitol.

    Now several things have happened. First there has been a huge outpouring of protestation by mostly the Teachers' Union, but I think other public workers have joined the protest to some degree. Tens of thousands of mostly teachers have stormed the State Capitol building and have occupied its public areas and hallways, shouting, beating drums and carrying placards. They are basicly camping out inside the capitol. Teachers have left their schools from all over the state to join this protest. Some schools were forced to close because they had no teachers and some announced that they would close last Thursday and Friday. Other schools attempted to open but so many teachers "called in sick" that they did not have enough staffing to accept children. Parents were dropping off their children at the school in the morning on their way to their own jobs and were met by the principal and secretary and told that their children could not be left there because there was no staffing. What were these parents to do now? They had no knowledge of this in advance and now needed to return home and could not go to work. Work places then found themselves without enough staff as well. The Milwaukee Public School system announced that they would stay open. Administration encouraged their teachers to come to work. In the central city being open is especially important because many inner city children, perhaps as many as 50 or 60% in some schools depend on the school for breakfast and lunch, and even for health care, not only learning. The administrators told this to WEAC callers when they phoned to encouragre union members to not got to work at their schools the next day. WEAC's answer was that it did not matter; teachers should still not go to work. The protest and "killing the bill" would be more important in the long run. Some teachers regarded this whole protest movement as a "teachable moment" and even took their classes to the protest. Can you believe it? Since in order to save their job back at their own schools, these teachers who had called in sick needed notes from their doctors, so low and behold here were at least two doctors who worked for a state clinic signing sick excuses. To me this is lying, unethical and unprofessional. The media announced that this action would be investigated. Notably there were no doctors there signing excuses on Monday. Of course, that might be because many schools were out due to it being President's Day.

     Then the 14 Democratic Senators left town. The Republicans have 19 members. But to vote on budgetary issues, a quorum is needed. One more Senator is required to achieve a quorum. So all 14 Democratic Senators have been moving from hotel/motel to hotel/motel in Illinois running away. They have been moving so that no one can find out where they are. They are relatively safe however, because Wisconsin State Patrol can not go into another state to get them. Apparently they are going to hang out as long as need be. This basicly paralyzes the government when it comes to enacting financial bills. March 4 is some sort of deadline to provide payment for some services. So we may be in a bigger mess.

     The Assembly Democrats came to the assembly but were stalling for time and came to work with orange T shirts under their suit coats and began a shouting spree to disrupt the proceedings. They complained that they were not waited for before the Assembly started their proceedings. They accused the Assembly Republicans of starting proceedings without waiting for them. Well, there were news bytes on the media that stated the Assembly was meeting and would take up the same Budgetary Bill. So the Democrats knew; they were just trying to disrupt proceedings. Their yelling amounted to complaints about starting without them. The Assembly can pass the bill because they have a quorum without the Democrats.

     Many other states are in similar trouble for many of the same reasons. So if this Bill succeeds in being passed, the same bills will be introduced in many other states. There will be moves also to make other states Right to Work states. This then becomes a national issue. Also President OBama and the National Democratic Committee regard Wisconsin as a pivotal state in the next Presidential election. For all these reasons people are being transported to Madison to protest from many other states and are being sent in by the Democratic party as well. Our friend, Jesse Jackson was here last week beating the drum. Hence the persistance of this problem. It has become a national issue. The Tea Party sent busloads of counter protestors last week and probably will continue to do that.

     I can see why the public employees do not want to give up their health care and retirement benefits at the previous rate of payment. That is only human. And of course, the collective bargaining part is of concern to some. But I agree that we have to cut spending, balance the budget without raising taxes, and we do need to reduce union choke holds on businesses. Therefore I am in favor of Governor Walker's bill. But what I am most angry about is the lack of ethics being demonstrated by the opponents of this bill. The protestors taking off school, the doctors writing them excuses, the Senators running out of the state, and the Assemblymen just disrupting proceedings without any contructive attempt to provide another answer.

     Then I had a confrontation with a woman that I swim with in water aerobics. She is a sweet older woman but she demonstrated she is living in La-La-Land. She thinks that we are in this deep economic do-do only because Governor Walker is spending all kinds of money. (He wants to give 140 million in tax cuts to small business in the state.) She equates this with rich businesses and thinks that within 6 weeks of him taking office he has run up the 3.6 billion dollar deficit. She thinks that the budget was perfecting balanced and everything was hunky dorry before he took office. These are the people that really make me made. So many people are living in La La Land and voting to spend and spend and spend. Our forefathers that established this country had the correct idea. Only taxpayers should be able to vote on financial issues, not those that don't pay tax. And I would add a requirement. Voters should need to pass a test of multiple questions in order to be able to vote. They should have certain knowledge before they are allowed to shape our future.

     OK, I feel better! Do you feel better?


   

Shared decision making

Along the lines of the video below, please read this article from the Health Affairs Blog by Jessie Gruman about shared decision making. The key excerpt is below, to which I would only add an equally important point demonstrated in the Dave-Danny case: Knowledge and information go both ways in a truly participatory process, not just from provider to patient.

It is important to have (and to promote) a step-by-step process to present us and our families with evidence that helps us understand the trade-offs of health decisions and to thus prepare for productive discussions with our physicians. And it is important to know that most individuals and physicians who go through this formal process find it feasible and satisfying.

But it is the values that this model embodies that justify the focus, energy and investments in it. Those values are that:

…Information and evidence about tests and treatments is a critical component of many health care decisions.

…Patients and caregivers can understand evidence and can use it to help them weigh their options.

…Providers can discuss available evidence – what is known, where it is lacking and what it means – with patients.

…Patients are explicitly invited to participate in the decisions about their care (even if that participation consists of delegating decision-making to a caregiver or physician).

…The opinions and preferences of patients – informed by their understanding of the evidence –shape and determine the tests they take and the treatment they undergo.

Dave and Danny on the big screen

Regular readers may recall that I wrote about a grand rounds presentation by Dr. Danny Sands and e-Patient Dave deBronkart. It was an impressive and moving exposition about the power of patient involvement in the delivery of health care.

Dave and Danny did a reprise of this session at the IHI Annual Forum in December, and IHI has generously made it available for public viewing. I offer it here for you. It is about an hour long, but well worth your time. (You can play it in the background while you catch up on the long weekend's emails today!)

Danny and Dave are now both active in the Society for Participatory Medicine, spreading the word and publishing research in support of "a cooperative model of health care that encourages and expects active involvement by all connected parties (patients, caregivers, healthcare professionals, etc.) as integral to the full continuum of care."

If you cannot see the video, click here.

IHI Forum 2010 Session A1: How Patient-Provider Engagement Can Transform Healthcare from e-Patient Dave deBronkart on Vimeo.

Mystery Photo 5: Peterhof, Russia

Mystery Photo 5 -- Peterhof, Russia (Petrodvorets)

    
    The Mystery Photo 5 was of a classical European Palace Complex built by Peter the Great across the Bay of Finland from Saint Petersburg, Russia. Several of the buildings are built right on the Bay of Finland. Over time both Peter the Great, his wife Catherine and then succeeding royalty spent time here at Peterhof.

      These two photos (above and below) show the Monplaisir Palace. This is the first Palace that Peter the Great originally built on these grounds. Later after the Grand Palace and other dining palaces, etc were built, this Palace was used primarily by his wife Catherine who modified and added to it. It was also later used by Katherine the Great after her husband, Peter III was deposed.

     Following are several photos from inside the Monplaisir Palace. It has lots of wood, mostly oak, gorgeous chandeliers and a very large collection of 17th century antique furniture, much of it from the private collection of Peter the Great.

        Peter the Great reigned for 42 years over Russia, from the time he was 11 years old. Born in 1672, as he grew into majority, he became more and more influenced by European ideals. He traveled several times to European capitols and attempted to forge alliances that would help him and his own country. He also fought wars with the Turkish Empire and with the Swedish Empire. These did not always work out for Peter but in the 18th Century he was eventually named Emperor of the Russian Empire though he himself disavowed this title of Emperor. His European influence comes out in the construction of Peterhof. The word means Peter's Court, and shows some of the German influence in the area as well. Later the name was Russianized to Petrodvorets. Peter was married twice. His second wife was Catherine who was eventually named Empress, Catherine (not Katherine the Great, who was the wife of Czar Peter III later in the 18th century).  Her influence is also strong at Petrodvorets. Some buildings were modified or added to at her behest. Peter died at age 57 after ruling for 42 years. But Peterhof was utilized and slightly modified by later royalty all the way up to Nicholas II and the Russian Revolution in 1917. The buildings and grounds were highly damaged by the Germans in World War II but they were among the first to be restored after the Great War. Thanks to Russian Army engineers and 1000 volunteers the buildings and grounds were restored to their original beauty by 1947.

     The following three photos show the lovely gardens and some of the fountains that are scattered around the grounds.

Below is the Aviary. 

     Peterhof has been called the "Russian Verseilles." However, I have been at Verseilles also in my lifetime and I agree with those who say that this pronouncement actually might be an insult to Petrohof. The grounds and gardens are certainlyextremely beautiful, and I think more picturesque than Verseilles. Peterhof is also very well known for its magic with water. There is an extensive fountain system throughout the parks surrounded by statuary, terraces, and patios with marvelous stonework. This system serves as the showcase for the beautiful palaces and buildings at Peterhof. We took the hydrofoil across the Bay of Finland which lands right on the property. This manner of entrance allows the visitor to amble up the broad entrance avenue beside a long reflecting pool and approach the Grand Palace from a gorgeous perspective. One enters the main fountain courtyard and from there can amble in various directions to view the several other small palaces on the grounds. 

Below is the Grand Palace and its front terrace and fountain display.

     The above photo is taken from the front terrace of the Grand Palace, looking out over the fountain display, and down the long reflecting pool right to the Bay of Finland which is how we arrived when we came by Hydrofoil from Saint Petersburg. This was certainly a lovely place to visit.

2 kidneys versus 100,000 lives

This story about a kidney transplant mix-up in California is bound to get lots of coverage. It is these extraordinary cases that get public attention. I am sure it will lead to a whole new set of national rules designed to keep such a thing from happening.

Of course, such rules already exist, and it was likely a lapse in them that led to this result.

Nonetheless, we will "bolt on" a new set of requirements that, in themselves, will likely create the possibility for yet a new form of error to occur.

This kind of coverage and response is a spin-off from the "rule of rescue" that dominates decisions about medical treatment. We find the one-off, extreme case and devote excessive energy to solving it. In the meantime, we let go untreated the fact that tens of thousands of people are killed and maimed in hospitals every year.

Those numbers are constantly disputed by the profession. To this day, many doctors do not believe the Institute of Medicine's studies that documented the number of unnecessary deaths per year.

And you never hear anyone talking about this 2010 report by the Office of the Inspector General, which concluded:

An estimated 1.5 percent of Medicare beneficiaries experienced an event that contributed to their deaths, which projects to 15,000 patients in a single month.

As the IOM notes, “Between the health care we have and the care we could have lies not just a gap, but a chasm.”

There is an underlying belief on the part of policy makers and public and private payers that the focus on quality is best addressed through payment reform. Let me state as clearly as I possibly can: That is wrong. It is a classic example of the old expression: "When you have a hammer, everything looks like a nail." Changes in payment rate structures, penalties for "never events," and the like can cause some changes to occur. Their main political advantage is that they give the impression of action, and their major financial advantage is a shift in risk from government and private payers to health care providers.

But these are gross tools and will have unintended consequences. More importantly, they do not get to the heart of the problem, the manner in which work is organized in the highly complex environment of hospitals and physician practices. This is an environment in which ineffective work-arounds -- instead of front-line driven process redesign -- are the usual answer to obstacles in patient care.

They do not address the unmet education needs of doctors-in-training, training that is a throw-back to a cottage industry in which each person is expected to be an artist, relying on his or her creativity, intuition, and experience when taking care of a patient. The resulting lack of standardization -- the high degree of practice variation -- creates an environment that is inimical to process improvement based on scientific methods.

They do not address the documented advantages of engaging patients in the design and delivery of care, nor the power that such engagement brings to both doctors and patients.

Add to this the sociology of dehumanization in medical schools documented by Linda Pololi, and you have a stewpot of well-intentioned people destined to kill and maim others.

It is up to the medical profession, not the politicians or the insurance companies, to change this. First, though, they have to be willing to acknowledge that problems exist, that the current level of harm is not a statistically irreducible amount. The need to put aside the usual responses -- "the data are wrong" -- "our patients are sicker" -- "our care is the best in the country" -- and have the intellectual modesty to recognize that the real work has just begun.

To the extent the medical profession continues to abdicate responsibility, the more will step in politicians, regulators, and payers to do it for them. If you are a doctor and already feeling a lack of control over your professional life and your relationship with your patients, just wait.

I have previously quoted experts on this field, but the most cogent imperative remains the one provided by Ethel Merman:

Now what kind of an attitude is that, 'these things happen?' They only happen because this whole country is just full of people who, when these things happen, they just say 'these things happen,' and that's why they happen! We gotta have control of what happens to us."

The infrastructure chronicles -- Volume 3.5

Back to our occasional series about infrastructure. This one is about a part of infrastructure that, oddly, often tends to be invisible: Signage.

Designing effective signs is important. After all, if there is a need for the sign in the first place -- for safety, convenience, or efficiency -- why not post one that solves the problem? But, we often see the opposite, a sign that actually makes things worse. It is at that moment that a sign becomes invisible.

In a previous post, I presented the dangers of sign congestion in a hospital. In another, I presented an example of one from the Postal Service that provides guidance that is unhelpful because it requires a person to detect the difference between 12 ounces and 13 ounces in a letter s/he is about to mail.

Here's one that demonstrates simple clutter and a bureaucratic point of view. It is posted on the "Fare Array Hut," a small structure at many MBTA transit stops that is not designated as a "Fare Array Hut." So, to start with, you might look at the sign and say, "Where's the Fare Array Hut?"

Then, you wonder, "Do I have to validate my card in the manner set forth?" The answer is no. It does make it easier to enter the train in one of the back doors, but you can also validate upon entering through the front door.

And then, you see things on the poster that simply have no relevance for you, like "Ensure all revenue is properly collected and recorded."

By the way, it turns out I am not the first person to notice this problem. After writing this post, curiously searching Google for the term "Fare Array Hut," I came upon this post by another blogger, who nicely describes the situation.

Catholic Hospital vs Secular Hospital -- What a change!

     Below is part of the mission statement of a large local hospital that I wish to speak about below:

"At (LOCAL LARGE HOSPITAL) we value the diversity of our patients, employees, physicians and visitors. We recognize the importance of intentional activities, projects and initiatives to help make our environment one that cares for and nurtures the health and personal development of every individual. The diversity of each of these individuals, makes CSM the successful organization it is today. Our success and growth are dependent upon our:



Creating an environment of continuous learning about diversity and inclusion


Community involvement


Creating new and innovative ways to serve others


Our patients and staff deserve an inclusive environment in which they can move towards optimum health and development without unnecessary barriers to their success. We are made stronger by the diversity of knowledge, experiences and perspectives we each bring to this environment."

     Recently my hospital at which I practiced for 34 years before I retired, merged with a large Catholic Hospital in Milwaukee. For some years the two hospitals, though joined, maintained their own separate campuses. Then this combined hospital conglomer decided to build a large brand new hospital building on the site of the Catholic Campus, using some of the old buildings but adding a huge new building. They then closed the secular campus and slowly moved all operations to the new hospital.
 

     I had been attending Grand Rounds Medical Education meetings once a week even after I retired. There was a month or 6 week hiatus in the Grand Rounds after the move, and then the meetings were again reved up.
     There was just one major problem which continues to be an admitted problem. No space was allowed in the new hospital for medical education. That is there is no auditorium or any large room with audeo visual capabilities which will seat more than 35 people comfortably. Our old hospital had a beautiful stadium seating auditorium with an audio visual room in the back, a small stage/riser across the front and a vestibule and cloakroom at the back. This room was not only used for staff medical doctor meetings at least once or twice a week, but the nurses used it, and it was sometimes used for patient meetings as well, also sometimes opened up to the community to give educational or leadership meetings. So the idea that the brand new up to date, hottest of latest technology hospital would not allow space for larger meetings and education was inconceivable to me. I was told that space had been allowed on the top floor but in decisions to cut costs and redesign, the space was taken for some other purpose. There is now a move to put a space in the medical office building on the site, but there is no allotment for audiovisual technology so that would have to be paid for by the doctors. Incredible!
     The meeting I attended on Tuesday was one of the bimonthly medical ethics meetings. Now I have attended many of these back at the old hospital. They are led by a PhD in ethics and examine various ethical dilemmas in medicine. You can imagine that such occasions arise in the life and death business of medical care. In past ethics meetings, there was not usually any significant consideration of Catholic canon or the ethical decisions being made in a Catholic Hospital. Well, now the whole hospital is really a Catholic Hospital. The topic was "Maternal and Fetal Medical Ethical Conflicts." Our ethics PhD presented a case from Phoenex, AZ which made national newspapers. A 23 year old woman had pulmonary hypertension, a disease which can cause heart failure and has imperfect treatments. She was given birth control and told not to get pregnant, but she did get pregnant and presented at about 7 weeks. It was recommended to her in the doctor's office that she should have the pregnancy terminated. She refused. Then she returned at 11 weeks of pregnancy in heart failure and in cardiogenic shock (the heart was no longer able to pump strongly enough to maintain the blood pressure and blood flow). In other words, she was sick unto death. She was going to die probably within a day or two if the pregnancy wasn't terminated. Finally at this Catholic Hospital in AZ, after an ethics consult and much discussion, it was decided to cause the fetus to be delivered. It was felt that the mother could be returned to at least the level of function that she had before the pregnancy in a few days without the added burden of the pregnancy on her heart. The Director of Medical Care at the hospital, a nun, after much deliberation did approve the pregnancy termination to proceed. After all the baby was going to die either way: of course, if the mother died, or if the pregnancy was terminated. The baby was not large enough to survive on its own even with ventilators and all the treatments available to premature infants. This was just too premature. Everything proceeded as planned, and the mother improved and was discharged from the hospital. About a year later, apparently the local archbishop somehow got word of this and a huge bruhaha occurred within the local archdiocese. Bad things happened to that Catholic Hospital. It's Catholic status was removed, which means the hospital loses its non profict status and there are all sorts of financial and social implications. The nun who still was Director of Medical Care was excommunicated and had to resign her job so that the ramifications did not extend to her Catholic Order. This information made it to the national news media, and many obstetricians around the country began to feel that they would not be able to practice at all in Catholic Hospitals around the country. These types of issues are always possible in a busy obstetrical hospital.
     Our ethics doctor began to go into the ethics of this whole case. He then brought out the Catholic issue of abortion, even to save the mother's life and how the Holy Canon is against this. He then tried to frame the case in a different ethical way in which under these circumstances a decision not to stop the pregnancy and save the mother's life would be classed as irrational. He really had to jump through some ethical hoops to try to get around the Catholic Canon. This type of lengthy discussion would have never taken place at the secular hospital where I was on the staff. One of my retired colleagues raised his hand and commented that the problem didn't seem to be ethical, but rather was only in question because of the religion at the hospital: Catholicism and its Canon. The ethicist had nothing to offer in response to that comment. I just found the whole lengthy and convoluted discussion to be so entirely different to the types of discussions that were held at these conferences at the previous hospital campus. What a change! I have since spoken with another OB on the staff at the nice new hospital. She cites an example just in the last 9 months of her practice at this new hospital, where she was set to stop a pregnancy also to save a mother's life, though the mother's life was not as immediately threatened as the Phoenix case. This OB said that the religious director of the hospital had found out about her surgical plans and was outside the OR telling her that she could not proceed with the surgery. The mother was already anesthetized. They had to get an ethics committee to come into the hospital and lots of discussion went back and forth, but finally she was able to proceed with her operation. It sounds to me that issues like this in lesser degree are more common than we think.

     I ask you to read again the above mission statement of the hospital with its paragraph about inclusivity and diversity. Do these types of case decisions sound like inclusivity and diversity? Can current medical care of the mother and the fetus mix with Catholocism? What do you think?

It all comes back to cost and choice

Those watching the implementation of national health care reform are advised, again, to keep an eye on Massachusetts, which began many of the same programs several years ago. As will be evident eventually at the national level, after you provide universal access to health care by creating a more broad-based insurance program, you then need to focus on two areas: cost and choice. (Remember that President Obama tried to present the case that access, lower costs, and choice were mutually consistent public policy goals. 'Taint so. Eventually, you have to deal with the other two to have a sustainable solution.)

Governor Deval Patrick today offered his legislative proposals in this arena. The key elements are control over provider rates; encouragement for capitation and bundled payment regimes; creation of integrated delivery systems; and transparency of prices and medical outcomes.

I was especially intrigued with the rate-setting aspect of his plan. For some time, I have been suggesting that a return to administrative rate-setting for rates paid to hospitals and doctors was inevitable in a state in which market power had for so long dominated the methodology for establishing those rates. This has been mightily opposed by most industry observers. My point was that rate-setting already existed, but it was in the hands of unaccountable insurance companies.

So the Governor now proposes rate-setting, admittedly through the back door, but substantively so in any event. How will it work? We will not appear to regulate rates paid to providers, except that an insurance company's premiums will not be approved unless the underlying rates paid to providers meet certain conditions. Here's the relevant excerpt from the press release:

This legislation clarifies the [Insurance] Commissioner’s authority to reject premium increases where the underlying provider rates are excessive. Specifically, the Commissioner may disapprove rates that contain provider increases inconsistent with the following criteria:

• The rate of increase in the state’s Gross Domestic Product;
• The rate of increase in total medical expenses in the region as reported by the Division of Health Care Finance and Policy;
• A provider’s rate of reimbursement with a carrier, especially in relation to the carrier’s statewide average relative price;
• Whether the carrier and a contracting provider are transitioning from a fee-for-service contract to an alternative payment contract.

So, whether you call it six of one or half a dozen of another, we are back to rate-setting.

On the choice front, the Governor adopts the religious dogma of pricing discussed here earlier, stating that "the existing fee-for-service payment system is outdated in the medical field." He apparently understands that doing so is inconsistent with consumer choice and thus he "encourages the formation of integrated care organizations (commonly referred to as Accountable Care Organizations or 'ACOs')". As discussed in the last two paragraphs of this post, insurers and providers better tread carefully here. Unless consumers are confident of getting the same or better quality of care from the restricted network serving them, there will be extreme negative feedback in the future. Transparency of outcomes will definitely help, but the power of habit and reputation is long-lasting.

So congratulations to the Governor for taking steps that are consistent with the state's policy of universal access. The key to legislative adoption of these proposals, unfortunately, is likely to be an attempt to minimize discussion of what they would mean for individuals and families, and for doctors and hospitals. Otherwise, they will be viewed as bitter medicine, even if they are in the service of an overall policy objective -- universal access -- that is clearly the right direction.