Mark Graban, an expert on the use of Lean process improvement in hospitals, has opened up his own process as he prepares revisions of the "Visions of a Lean Hospital" ideal state chapter in his book, Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction.
He notes on his blog:
I’ve shared the first chapter of the book for those who signed up on my book’s site. Now as I’m making revisions, I’d like to get your input and ideas around the final chapter – “A Vision for a Lean Hospital.” I think the chapter has some good ideas, but given my audience here, I’m not going to pretend I have all the answers for hospitals. So I’d like to hear what you think in the comments for this post, or email me. What’s missing? What’s confusing? What’s wrong?
Here's your chance to be a ghost writer!
Thursday, March 31, 2011
How the veterans are winning the war
At a seminar last night at the Center for Public Leadership at Harvard's Kennedy School, one of the students asked a question along the lines of, "How do you know when you have done too much with regard to transparency?" My answer was that the question presupposed the wrong approach to transparency, that it was being driven by the CEO without proper attention to the efficacy and appropriateness of what was being measured and disclosed. Instead, I suggested that it should be driven by the leadership of the organization, but based on metrics that were viewed as useful and appropriate by the clinical staff. In such an instance, transparency serves the function laid out by IHI's Jim Conway, as summarized here in an article discussing the BIDMC experience:
[P]ublic reporting created what management guru Peter Senge calls creative tension, a key in getting an organization to change. Announcing a daring vision — the elimination of patient harm — combined with honestly publicizing the problems, fuels improvement, he said.
I expressed the concern last night that the general recalcitrance of the medical profession about engaging transparency will inevitably lead to fiats about disclosure from government regulatory agencies. The problem with those fiats is that they will be grossly constructed and force hospitals and doctors to focus on the wrong things, in a manner not consistent with widely established principles of process improvement. (See, for example, this approach in Maryland.)
Now comes the Veterans Administration, proving the case with panache! You may recall my complimentary post on the VA back in January. Thomas Burton's article this week in the Wall Street Journal -- "Data Spur Changes in VA Care" -- documents this in more detail. Some excerpts:
Hospitals serving U.S. military veterans are moving fast to improve care after the government opened a trove of performance data—including surgical death rates—to the public.
The information was released at the urging of VA Secretary Eric K. Shinseki. Among other things, it presents hospitals' rates of infection from the use of ventilators and intravenous lines, and of readmissions due to medical complications. The details have been adjusted to account for patients' ages and relative frailty.
"Why would we not want our performance to be public? It's good for VA's leaders and managers, good for our work force, and most importantly, it is good for the veterans we serve," Mr. Shinseki said in an emailed statement.
At VA hospitals in Oklahoma City and Salem, Va., the rate of pneumonia acquired by patients on ventilators was shown last fall to be significantly higher than the national VA average. The Salem hospital says a relatively low number of patients on ventilators skewed its infection rate higher, but staff members at both facilities say the numbers prompted action.
Seeing the data helped, says the Salem hospital's chief of surgery, Gary Collin, because "you can become kind of complacent."
In contrast, notes the article:
This unusually comprehensive sort of consumer information on medical outcomes remains largely hidden from the tens of millions of Americans outside the VA system, including many of those in the federal Medicare system.
And, as I reported last month,
A November 2010 report from the Health and Human Services inspector general concluded that one in seven Medicare patients is harmed by medical care, nearly half of those avoidably.
Conway is right. Senge is right. The veterans have figured out how to start winning the war for patient safety and quality and process improvement. The rest of the profession is in retreat and is letting the wrong people design the battle plan.
[P]ublic reporting created what management guru Peter Senge calls creative tension, a key in getting an organization to change. Announcing a daring vision — the elimination of patient harm — combined with honestly publicizing the problems, fuels improvement, he said.
I expressed the concern last night that the general recalcitrance of the medical profession about engaging transparency will inevitably lead to fiats about disclosure from government regulatory agencies. The problem with those fiats is that they will be grossly constructed and force hospitals and doctors to focus on the wrong things, in a manner not consistent with widely established principles of process improvement. (See, for example, this approach in Maryland.)
Now comes the Veterans Administration, proving the case with panache! You may recall my complimentary post on the VA back in January. Thomas Burton's article this week in the Wall Street Journal -- "Data Spur Changes in VA Care" -- documents this in more detail. Some excerpts:
Hospitals serving U.S. military veterans are moving fast to improve care after the government opened a trove of performance data—including surgical death rates—to the public.
The information was released at the urging of VA Secretary Eric K. Shinseki. Among other things, it presents hospitals' rates of infection from the use of ventilators and intravenous lines, and of readmissions due to medical complications. The details have been adjusted to account for patients' ages and relative frailty.
"Why would we not want our performance to be public? It's good for VA's leaders and managers, good for our work force, and most importantly, it is good for the veterans we serve," Mr. Shinseki said in an emailed statement.
At VA hospitals in Oklahoma City and Salem, Va., the rate of pneumonia acquired by patients on ventilators was shown last fall to be significantly higher than the national VA average. The Salem hospital says a relatively low number of patients on ventilators skewed its infection rate higher, but staff members at both facilities say the numbers prompted action.
Seeing the data helped, says the Salem hospital's chief of surgery, Gary Collin, because "you can become kind of complacent."
In contrast, notes the article:
This unusually comprehensive sort of consumer information on medical outcomes remains largely hidden from the tens of millions of Americans outside the VA system, including many of those in the federal Medicare system.
And, as I reported last month,
A November 2010 report from the Health and Human Services inspector general concluded that one in seven Medicare patients is harmed by medical care, nearly half of those avoidably.
Conway is right. Senge is right. The veterans have figured out how to start winning the war for patient safety and quality and process improvement. The rest of the profession is in retreat and is letting the wrong people design the battle plan.
Wednesday, March 30, 2011
Conversation at the Center for Public Leadership
Many thanks to the Center for Public Leadership at Harvard's Kennedy School for inviting me to meet with the Zukerman and Dubin Fellows tonight. The Zuckerman Fellows are graduate students or professionals from the fields of law, business, or medicine who are pursuing a second degree in health, education, or public policy in order to broaden and deepen their understanding of public sector issues. The Dubin Fellows are master's degree students at the JFK School who have demonstrated strong character, academic excellence, the ability to thrive and lead in the face of adversity, and a commitment to making a transformative impact on the communities they serve.
My topic was about lessons from leadership positions, with a particular focus on engaging front-line staff in process improvement, building constituencies in the complex environment of academic medical centers, and the importance of transparency in both clinical and administrative matters.
I promised to post the pictures of those who asked especially good questions, but everyone did! I don't have room here for all, but I include a few. Special thanks to Laura Burke (bottom right), a resident in Emergency Medicine at BIDMC, for her role in organizing tonight's event.
Mystery Photo 7: This is Mont Saint Michel, Normandy, France
Mont Saint Michel is an islet just off the coast of France, where the Couesnon River flows into the sea. This river has always been touted as the border between Brittany and Normandy. However, the flow of the river has changed from time to time and the Mont is now in Normandy.
In prehistoric times this area was all land. But the scouring of the sea over eons has removed the softer rocks leaving this hunk of granite.The natural shape of the islet served several different peoples as guardian fortresss over the centuries. Following the departure of the Romans in 460 AD, the Mont was held by the Amoricans, a Romano-Breton culture which extended into Britain. But it was conquered by the Franks. 
The origin of the monastery on the peak of the Mont is told in a very colorful legend. Supposedly the Archangel Michael appeared to St. Aubert, bishop of nearby Avranches in 708 AD, telling him to build a church on the islet. St. Aubert ignored him several times until reportedly the Archangel burned a hole in his skull with his finger. The church was built and eventually did become a monastery.
The islet has been connected to the mainland by a bridge of land at low tide which was obliterated at high tide. The bay silted up due to the lack of water motion in and around the Mont and also due to the grazing of sheep on the salt flats. In 1879 the land bridge was built up into a permanent causeway. One could drive out to a parking area to visit the islet. But it was thought that this was not historical and it was felt that the natural water motion in the area should be restored. Therefore a hydraulic dam was built across the River Couesnon and the causeway was obliterated starting in 2009 (after we were there). This project will be completed in 2012. There will now be a foot bridge to the Mont, and shuttles will take people from a parking lot on the mainland to visit the site.
I found Mont Saint Michel to be very quaint. Climbing through the spiralling streets from the sea level to the Monastery at the peak, creates a sense of returning to Medieval times. One can easily picture what life was like here in centuries past. That's one of the attractions to travel: the sense of history and identifying with and learning from what came before.
"Stay tuned!" I have some photos of the Normandy Beaches to show you, maybe in the next posting or two. Viva La France!
Tuesday, March 29, 2011
It's not "nothing" -- Accepting gratitude
A friend and I were discussing the point that effective communication is most likely to occur when the other person feels that you understand his or her situation. This is an underlying premise of negotiation theory: You are more likely to be successful at a negotiation when you understand the other person's underlying interests and when you make it clear to that person that you do. To do otherwise, whether in negotiations or other settings, is likely to lead to speaking at a person, rather than to the person. Not because you mean to, but because the other person will not value what you say, compared to when they think you really "get it."
One of the things I learned in my hospital days was how to accept gratitude. A hospital can be an uncomfortable place for patients and family members. It is a strange physical environment, where people are anxious because of feared or actual medical conditions or forthcoming procedures or tests. In that situation, when you do something kind for someone, the person is truly grateful. It can be as simple as offering directions, or picking up a fallen object, or something much more serious.
When I started working in the hospital, when someone would say "Thank you" to me, I would often answer, "It's nothing," or "No problem." Wrong! I was taught that such an answer devalues the gratitude that the other person is feeling. A more appropriate response is, "It is my pleasure," or "I am so pleased I was able to help." That indicates that you understand their feelings.
Over the years, I trained myself to do this. Lo and behold, once I got rid of the "It's nothing" conversation stopper, people would jump in and continue the conversation even further. I was able to learn so much more about people's fears, expectations, experiences, and hopes and then help translate those into improvements in the clinical environment.
Try it. It's not "nothing."
One of the things I learned in my hospital days was how to accept gratitude. A hospital can be an uncomfortable place for patients and family members. It is a strange physical environment, where people are anxious because of feared or actual medical conditions or forthcoming procedures or tests. In that situation, when you do something kind for someone, the person is truly grateful. It can be as simple as offering directions, or picking up a fallen object, or something much more serious.
When I started working in the hospital, when someone would say "Thank you" to me, I would often answer, "It's nothing," or "No problem." Wrong! I was taught that such an answer devalues the gratitude that the other person is feeling. A more appropriate response is, "It is my pleasure," or "I am so pleased I was able to help." That indicates that you understand their feelings.
Over the years, I trained myself to do this. Lo and behold, once I got rid of the "It's nothing" conversation stopper, people would jump in and continue the conversation even further. I was able to learn so much more about people's fears, expectations, experiences, and hopes and then help translate those into improvements in the clinical environment.
Try it. It's not "nothing."
Monday, March 28, 2011
A mentor hospital
The Institute for Healthcare Improvement gives the following update. How impressive! And how generous of Columbia Regional to offer to share what they have learned. What a shame that The Joint Commission has not followed this lead by making its best practice library available to all.
Mentor Hospital Goes 5 Years Without a VAP
Staff at Columbus Regional Hospital in Columbus, IN, recently celebrated an amazing accomplishment. They have gone five years without a single incidence of a ventilator-associated pneumonia (VAP). These deadly pneumonias used to be considered an unfortunate reality in ICUs. As a participant in IHI's 100,000 Lives and 5 Million Lives Campaigns, the hospital took aim at reducing VAP by implementing the IHI Ventilator Bundle, evidence-based care guidelines that, when reliably applied, can drastically reduce and even eliminate these infections. One of the enduring legacies of the Campaigns is a robust registry of mentor hospitals, facilities that have outstanding track records in improvement in Campaign-related topic areas that have generously agreed to provide support and clinical expertise to hospitals seeking help with their implementation efforts. Columbus Regional has been a mentor hospital since 2006 for the topics of VAP, Rapid Response Systems, the Central Line Bundle, and Heart Failure Core Processes. IHI congratulates Columbus Regional on their tremendous achievements.
Mystery Photo 7
Here is another guessing game! I think this one might be easier than the Wind Palace in Jaipur. Hint, the profile of this place viewed from more of a distance is very well circulated. What is its name?
Sunday, March 27, 2011
Coding, medical billing and the current use of my MD.
I will tell you about my specific coding blunders that I had to use my medical knowledge to fight. I think two of them are very common and should be argued with your doctor if you detect them.
The biggest blunder and hardest to correct when I had my outpatient day surgery on my arm to remove the melanoma and at the same time, do a sentinel node biopsy. Of course, in preparation for my surgery, the anethesia resident came to my day surgery room to review my medical history, and discuss the anesthesia she was going to give me. And she started my IV. Standard practice calls for an intracath in the vein (a plastic sheath threaded into the vein, rather than just a small metal needle) because with an intracath the IV site is more stable and reliable even if the hand is moved around during surgery. But the drawback is that it is more painful to place an intracath into the vein. So the anesthesiologist first infliltrated some lidocaine (xylocaine) with a fine needle as a pain killer around the vein she planned to use for the IV. (As an aside, she couldn't get that IV started; the vein collapsed. So she had to try two different times in other veins and I didn't have the benefit of the pain killer for those veins anyway. But that is beside the point.) When my bill came back after surgery, it listed two drugs that were administered under a class called "self-administered pharmaceutical agents." I had heard about this one before. I was given a Tylenol with codeine pill after the surgery while still in the recovery day surgery room. Apparently Medicare and insurance do not cover oral meds given in these circumstances because they can be taken by the patient without the need for a nurse. So a charge is administered for these meds that is often quite large. I was charged $35.00 for that single pain pill. Medicare tells you that you could get a prescription through your doctor prior to the surgery and then take that pain pill at the day surgery site on your own and avoid that charge. However, it is also a known protocol that the day surgery people will not let you bring any of your own meds with you nor will they let you take them without a direct order that you can take your own meds, from your doctor. By the time you need this order, your doctor is long gone. So this issue is a well-known Catch-22 and you basicly just have to pay the large fee for that single pain pill that they administer. But in my case, along with that charge for the Tylenol with codeine, there was a charge for another self-administered drug, denied by Medicare. First I had to call Medicare to see what the code and denial applied to. Then I had to call the hospital and have someone look at my chart to see what that other self-administered drug I could have been given under that code. I didn't recall anything else. And it couldn't have been self-administered if I was already under the anesthetic. A couple phone calls showed that it was lidocaine. It was that infiltrated lidocaine used to deaden the site where my IV was to be started. Well, I certainly didn't administer that to myself with a needle from a vial of the medication. Clearly the use of this medication had been miscoded, denied by Medicare, and I was being charged about $65.00 for this, when it should have been part of the whole procedure and paid for by my insurance. Now that I had it sorted out from the codes, I had to call back the billing of the hospital, and tell them what needed to be changed so that that charge would be resubmitted and would apparently be paid for. It took about 2 months but it worked.
The other two instances were pre op lab blood tests that were coded as routine. This happened when the surgeon ordered preops for my melanoma surgery and it happened again when my gastroenterologist ordered a pre procedure potassium and metabolic panel before my colonoscopy. In both cases the procedure was being done for diagnostic reasons: melanoma in case of that surgery, and symptoms before the colonosocpy which had to be coded using the number for the symptoms, not as routine. Medicare is very clear that it does not pay for routine tests. It now will pay for a routine screening colonoscopy but apparently will not pay for the labs that your doctor requires you to have before the screening procedure. Mine was being done due to some vague symptoms so those needed to be coded properly so that Medicare would pay also for the pre procedure labs. It took a phone call to the billing for my clinic to find out what the lab was and how it was coded; then a call to Medicare again to affirm that they would not pay for the tests under this code. It was a V code: V76.23. All V codes are routine tests done for some screening reason. That immediately told this MD that they had coded the lab tests as routine and they would not be paid for until we got those codes changed. Now I had to get a message back to my gastroenterologist directly for him or his assistant to change the code and replace it with a code that means "change of bowel habits" the symptom that required the colonoscopy, and then resubmit that to Medicare. That is now in the process of happening and I assume it will take a couple months for this to get straightened out. The total cost to be saved here was $88.00 for the lab test, and $24.00 for drawing the blood for the lab test.
You see! You need an MD to be sure that you are billed properly and receive payment for all the medical items that you are entitled to. Most people would probably just pay the bill. But sometimes these errors add up to several hundred dollars or more. Be forewarned and be alert; examine your EOB carefully and call to ask questions that you don't understand.
Saturday, March 26, 2011
Please nominate for Schwartz Center Award
I am pleased to post this at the request of the Schwartz Center. Please see below and consider people or groups of people who might be worthy recipients of this award:
Nominations Open for Schwartz Center Compassionate Caregiver Award®
New England Caregivers Sought Who Demonstrate Extraordinary Compassion for Patients
Boston, MA (March 22, 2011) – The Schwartz Center for Compassionate Healthcare, a nonprofit organization dedicated to strengthening the patient-caregiver relationship, is seeking nominations for its 2011 Schwartz Center Compassionate Caregiver Award®. For the first time since the program began in 1999, caregivers from all six New England states are eligible.
The winner will receive $5,000 and be honored at the Kenneth B. Schwartz Compassionate Healthcare Dinner on November 17th at the Boston Convention Center. Last year’s event attracted more than 2,000 attendees. Four finalists will also be recognized and receive $1,000 each. Nominations are due April 22, 2011. Information on how to nominate a caregiver for this prestigious award is available on the Schwartz Center’s website.
The center and award are named after Ken Schwartz, a Boston healthcare attorney who died of lung cancer in 1995 and came to believe that medicine is about more than performing tests and surgeries, or administering drugs. As he wrote in an article published in the Boston Globe Magazine, “These functions, as important as they are, are just the beginning. For as skilled and knowledgeable as my caregivers are, what matters most is that they have empathized with me in a way that gives me hope and makes me feel like a human being, not just an illness.”
Nominees must work in a health-related organization or practice, such as a hospital, physician office, outpatient clinic, community health center, visiting nurse or home health agency, nursing home, or hospice organization. Any paid caregiver or team of caregivers with direct patient contact in Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island or Vermont is eligible. Nominees may include physicians, nurses, physical and occupational therapists, social workers, psychologists, nurse practitioners, physician assistants, certified nursing assistants, home health aides, and chaplains – as well as interdisciplinary teams. Nominations may be made by patients or healthcare professionals.
In 2010, the Schwartz Center Compassionate Caregiver Award® was given to the Haitian Mental Health Team at Cambridge Health Alliance in Massachusetts. In 2009, the award went to Dr. Amy Ship, an internist in the Division of General Medicine and Primary Care at Beth Israel Deaconess Medical Center in Boston. [My note: Listen to her speech here.]
The winner and finalists will be selected by a regional review committee based on how well the individual or team embodies the characteristics of compassionate healthcare, which are defined by the Schwartz Center as follows:
- Showing respect for the patient, the patient’s family, and those important to the patient
- Conveying information in a way that is understandable
- Treating the patient as a person, not just a disease
- Listening attentively to the patient
- Striving to gain the patient’s trust
- Always involving the patient in treatment decisions
- Apologizing to a patient if a caregiver makes a mistake
- Communicating test results in a timely and sensitive manner
- Comfortably discussing sensitive, emotional or psychological issues
- Considering the effect of an illness on the patient, the patient’s family, and those important to the patient
- Expressing sensitivity, caring and compassion for the patient’s situation
- Spending enough time with the patient
- Striving to understand the patient’s emotional needs
- Giving the patient hope, even when the news is bad
- Showing understanding of the patient’s cultural and religious beliefs
The Schwartz Center for Compassionate Healthcare was founded in 1995 by Ken Schwartz, a prominent Boston healthcare attorney who died of lung cancer at the age of 40. Based at Massachusetts General Hospital in Boston, the center sponsors programs to educate, train and support caregivers to provide compassionate, patient-centered care. Its signature program, Schwartz Center Rounds, has been adopted by 215 hospitals, outpatient centers and nursing homes in 32 states and reaches more than 60,000 clinicians a year.
The Schwartz Center Compassionate Caregiver Award is made possible in part by the generosity of AstraZeneca, a leading pharmaceutical company.
Cheaper than newspaper ads, I guess
You can tell it is spring in New England when your yard gets pelted with these. They are advertisements for landscaping companies. The proprietors drive through the neighborhoods tossing out plastic bags weighted down by pieces of pea gravel.These seem to be about as effective as hospital advertising -- which is to say, not very -- if we are to judge from the fact that most of them lie untouched for weeks.
Thursday, March 24, 2011
Two Degrees delivers
You may remember my post about Two Degrees, a company that donates a packet of food supplement for each nutrition bar they sell. Well, they recently went to Africa and made their first delivery -- 10,800 nutrition packs to malnourished children in Malawi. Here is a picture of co-founder Will Hauser and a local community health worker preparing to disburse the Two Degrees/Valid Nutrition RUTF packs. You can read more about it on Will's blog post. You can also follow this activities of this innovative company on their Facebook page.Remember, the food supplement is produced locally, so jobs are created, also.
The company is seeking companies, colleges, schools, and other institutions who might want to distribute and sell the bars in company cafeterias and snack bars and other corporate settings. I will vouch for the taste and nutrition (as they helped me and some friends get through a bike trip in the Atlas Mountains), the integrity of the founders, and the good cause. (I have no financial interest in the company.)
Wednesday, March 23, 2011
Choosing to stop dialysis
I know there has been a lot written about assisted suicide, but this is in the category of a patient choosing to forgo treatment when he or she knows it will lead to death. It comes from a friend who writes about a relative, noting, "I think this is an interesting situation, with a lot of moral threads hanging from it." There are no children involved or living parents.
M (age in mid-60s) is stopping dialysis because his quality of life is too sucky for him to want to continue. He is legally blind and can't read or watch movies for more than a short time per day. As far as I know there is no physical pain. He did have a long time dealing with infection from a botched surgery, about a year, which might be influencing his thinking, but I don't know.
I have mixed feelings. He is relatively young, but I know you join me in wishing him the least painful way out. Neither I, nor you, dear readers, have a right to judge the actions of the patient. (Remember that Art Buchwald did the same thing?) Perhaps, though, we can offer advice to my friend as to how to handle the situation now and afterward, for he feels he will have to explain to other friends and relatives that he knew what was coming but could not reveal it.
M (age in mid-60s) is stopping dialysis because his quality of life is too sucky for him to want to continue. He is legally blind and can't read or watch movies for more than a short time per day. As far as I know there is no physical pain. He did have a long time dealing with infection from a botched surgery, about a year, which might be influencing his thinking, but I don't know.
I have mixed feelings. He is relatively young, but I know you join me in wishing him the least painful way out. Neither I, nor you, dear readers, have a right to judge the actions of the patient. (Remember that Art Buchwald did the same thing?) Perhaps, though, we can offer advice to my friend as to how to handle the situation now and afterward, for he feels he will have to explain to other friends and relatives that he knew what was coming but could not reveal it.
Tuesday, March 22, 2011
That will be a marvelous kiss!
Although I have talked before about the tendency for medical priorities to be based on the "rule of rescue" rather than more cost-effective reasoning, who cannot be moved by this recent surgical success at Brigham and Women's Hospital? Excerpts from the Boston Globe story by Kay Lazar:
[A] 25-year-old Texas man suffered horrific burns in a 2008 electrical accident that obliterated his lips and most of his other features, but last week he received the nation’s first full face transplant.
“Dallas is looking forward to giving his daughter a kiss again,’’ Dr. Bohdan Pomahac, director of the Brigham’s burn unit and the plastic surgeon who led the transplant team, said in an interview after yesterday’s announcement. “It’s such a simple human function that we take for granted.’’
To modify a quote from The Princess Bride:
“Since the invention of the kiss, there have only been five kisses that were rated . . . the most pure. This one will leave them all behind.”
Indeed. Congratulations to the team!
[A] 25-year-old Texas man suffered horrific burns in a 2008 electrical accident that obliterated his lips and most of his other features, but last week he received the nation’s first full face transplant.
“Dallas is looking forward to giving his daughter a kiss again,’’ Dr. Bohdan Pomahac, director of the Brigham’s burn unit and the plastic surgeon who led the transplant team, said in an interview after yesterday’s announcement. “It’s such a simple human function that we take for granted.’’
To modify a quote from The Princess Bride:
“Since the invention of the kiss, there have only been five kisses that were rated . . . the most pure. This one will leave them all behind.”
Indeed. Congratulations to the team!
Monday, March 21, 2011
Mystery Photo 6: Palace of the Winds, Jaipur, India. And other photos.
Yah, this one was a tough one. Unless you have actually been there, or maybe by some chance recognize the Moghul architecture, you wouldn't have known this one. Someone thought this one was too difficult.
Jaipur, also called the "Pink City" because of the pink sandstone that is used to build many of its buildings, was planned and built by Maharaja Sawai Jai Singh, the ruler of Rajasthan from the Kachwaha clan. The city was built in 1727. But it was this ruler's grandson, Sawai Pratap Singh who built the Palace of the Winds, Hawa Mahal in 1799 as an extension to the Royal City Palace. This Wind Palace is not a complete building but rather a 5 story facade. It is only one narrow room deep with lots of lattice work covered windows on both sides. It is connected to the Women's Quarters of the Palace where the royal harem lived. It was built right on the central square of Jaipur City so that the royal women who had to always remain covered (purdah) in public, could stroll from their quarters to this building and observe life in the city, and royal processions and other events without going into the public and having to cover up. Also due to its windows on both sides and small fountains in the middle of some of the chambers, it tended to be a cooler relief during the Rajasthani summers. The designer of Hawa Mahal intended the structure to resemble the headgear of the Hindu god, Krishna, who was a favorite of Pratap Singh. The white sandstone lattices covering the windows each carved from a single plate of sandstone are very characteristic of many Moghul palaces and buildings. Again they were intended to let in light and air but not allow people outside to see who was behind the lattice work.
The photography in this city was absolutely phenomenal. It was a gorgeous clear day with bright blue sky. And the colors of the buildings with their sandstone, and painted stucco provide just the perfect color combinations. Also there are such nice Indian scenes.
The city of Jaipur has many other interesting structures to see. Below are two photos from our hotel which was an architectural delight in and of itself. It is part of the Taj series of hotels and resorts. Notice the life size chesspieces in the gardens below our suite.
On a hill overlooking the valley containing Jaipur is a large fort connected to a lengthy wall that winds up and down over the ridges, reminding me of the Great Wall of China. It is called the Jaigarh Fort named after the hill it sits on. Below that more primitive fort is the Amber Fort and Palace. This is a beautiful structure with many beautiful rooms, and gardens.
Wind Palace, Hawa Mahal, Jaipur, India
Jaipur, also called the "Pink City" because of the pink sandstone that is used to build many of its buildings, was planned and built by Maharaja Sawai Jai Singh, the ruler of Rajasthan from the Kachwaha clan. The city was built in 1727. But it was this ruler's grandson, Sawai Pratap Singh who built the Palace of the Winds, Hawa Mahal in 1799 as an extension to the Royal City Palace. This Wind Palace is not a complete building but rather a 5 story facade. It is only one narrow room deep with lots of lattice work covered windows on both sides. It is connected to the Women's Quarters of the Palace where the royal harem lived. It was built right on the central square of Jaipur City so that the royal women who had to always remain covered (purdah) in public, could stroll from their quarters to this building and observe life in the city, and royal processions and other events without going into the public and having to cover up. Also due to its windows on both sides and small fountains in the middle of some of the chambers, it tended to be a cooler relief during the Rajasthani summers. The designer of Hawa Mahal intended the structure to resemble the headgear of the Hindu god, Krishna, who was a favorite of Pratap Singh. The white sandstone lattices covering the windows each carved from a single plate of sandstone are very characteristic of many Moghul palaces and buildings. Again they were intended to let in light and air but not allow people outside to see who was behind the lattice work.
The photography in this city was absolutely phenomenal. It was a gorgeous clear day with bright blue sky. And the colors of the buildings with their sandstone, and painted stucco provide just the perfect color combinations. Also there are such nice Indian scenes.
Inside the Amber Fort are wonderful courtyards, mixing the Rajasthani art work with the Moghul architecture. The Public Audience hall with all its arches, the Hall of Mirrors, and wonderful gardens all with other landmarks in the backround in these hills around the city of Jaipur.
Below is the Nahargarh Fort, also called the Tiger Fort on a hill overlooking Jaipur.
Below is a view of part of the city of Jaipur from the Amber Fort. And below that is the Jal Mahal or Water Palace which is planted in the middle of a beautiful little lake in the middle of this arid location, located on the way out of the hills where the Forts are located.
Hindu Temple on way down to Jaipur from Amber Fort.
In the city of Jaipur is City Royal Palace, of which one extension is the Palace of the Winds. The royal family still occupies some of this City Palace (the multiple story pale yellow portion in the photo above). Also the City Palace grounds contain the Jantar Mantar, a large outdoor observatory that has a multitude of stone and metal structures that tell the time like very large and complex sundials. This was a favorite occupation of the Maharaja who built Jaipur. He was quite interested in the sun and the moon and the workings of the heavens. It is quite interesting to walk among these structure and observe with what precision the time is represented by sunlight and shadow. The photos below are of Jantar Mantar, the largest stone observatory in the world.
Maryly proceeding off course
Maryland, the only state with a hospital rate-setting process, also has an interesting financial incentive program related to quality indicators. It is described here. Some excerpts:
This initiative, which commenced July 1, 2009, links payments to hospital performance on a set of 49 Maryland Hospital Acquired Conditions (MHAC) across all-payers and patients in the State.
The head of the Maryland Hospital Association says the complication list is too broad and that part of a reported drop last year in the overall rate of complications may simply have been hospitals doing better record-keeping. One leading patient safety expert says the Maryland program – and other national efforts – are moving forward despite insufficient evidence to truly measure and verify the types of preventable complications that should be targeted.
This initiative, which commenced July 1, 2009, links payments to hospital performance on a set of 49 Maryland Hospital Acquired Conditions (MHAC) across all-payers and patients in the State.
During fiscal year 2008, these hospital-based preventable complications were present in approximately 53,000 of the State’s total 800,000 inpatient cases and represented approximately $500 million in potentially preventable hospital payments.
The MHAC methodology provides a system of payment incentives based on a hospital’s actual number of complications versus a statewide target rate for each of the 49 MHAC categories. Under this approach, hospitals face strong financial incentives to reduce complication rates. They will also be armed with a sophisticated data analysis tool that will enable them to systematically help achieve this collective goal of reducing complications.
The Washington Post recently (March 19) published a letter to the editor from Robert Murray, the Executive Director of the state's Health Services Cost Review Commission, which offered more detail:
The [MHAC] method of applying hospital rewards and penalties is based on measuring each hospital's performance and determining whether the complication rates are lower or higher than, or on par with, expected rates. The expected rates of complications for each hospital are calculated using statewide average rates for the type and severity of illnesses of the patients treated by a given hospital. Therefore, hospitals with more complex patients are not disadvantaged because their expected complication rates would be higher than those hospitals with less complex patients.
The MHAC approach to funding the rewards and imposing penaities is revenue-neutral and does not raise money for the state through fines; for poorer-performing hospitals, a portion of their approved increase in prices for the current year has been withheld and redistributed to the better-performing hospitals based on performance in the previous year.
In this article, you can see some of the objections to this scheme:The head of the Maryland Hospital Association says the complication list is too broad and that part of a reported drop last year in the overall rate of complications may simply have been hospitals doing better record-keeping. One leading patient safety expert says the Maryland program – and other national efforts – are moving forward despite insufficient evidence to truly measure and verify the types of preventable complications that should be targeted.
"There is so much pressure to drive down cost and improve quality that politics have gotten ahead of the science," says Dr. Peter Pronovost, a professor at Johns Hopkins University School of Medicine and winner of a MacArthur Foundation "genius grant” for his work on improving hospital safety, often through the use of simple checklists. "There’s a gap between regulators, who say the measures are good enough and clinicians, who say they’re not."
From this vantage point, I am hard-pressed to see how a "focus" on 49 metrics makes much sense. That is unlikely to stimulate a sensible approach to process improvement. Also, the dollars at stake are de minimis -- 0.5% of total inpatient hospital revenue in the state or about $60M -- unlikely to act as much of a financial incentive. Dr. Pronovost has it right. Government regulation of this sort is invariably crude and off-point. It would be much better if the medical profession demonstrated that it is capable of self-regulating in a way that persuasively exhibited a commitment to quality and safety and to patient involvement in the design and delivery of care.Medical innovation grows in Boston
Now that I am free of the day-to-day responsibilities of running a hospital, I have had more chance to meet people working on new medical diagnoses, therapies, and services in the Boston area. There are a slew of them, as this is a hotbed of innovation and invention because of the concentration of hospitals and research universities. From time to time, I will tell you about some of these.* In particular, I will try to focus on innovations that, in my opinion, have the potential to decrease the cost of health care or provide more patient-centric care.
Here's one I learned about recently, a new company called Novocure. (I have no financial interest in this company.) They have developed a potential non-invasive treatment for solid tumors. Mild electrical currents are applied from an external source through the skin into the body, with the idea of interfering with the growth mechanism of cancer cells. The most promising arena is currently brain tumors, glioblastoma multiforme.
Of course, there is an extensive FDA-guided clinical trial regime to go through, as there is with all such inventions. Last week, the FDA's Neurological Devices Panel Advisory Committee met to review the company's application for recurrent GBM and provide guidance to the agency on approval. The panel voted in favor of the treatment, bringing the company one step closer to being able to offer this treatment option to GBM patients. You can read more here and here.
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* I will only report publicly available information. I will, of course, disclose if I have a personal financial interest. I will no longer comment on any financial interest of my previous employer or staff there, as I in no way represent them; nor do I keep track of such matters and therefore neither can I speak knowledgeably about them.
Here's one I learned about recently, a new company called Novocure. (I have no financial interest in this company.) They have developed a potential non-invasive treatment for solid tumors. Mild electrical currents are applied from an external source through the skin into the body, with the idea of interfering with the growth mechanism of cancer cells. The most promising arena is currently brain tumors, glioblastoma multiforme.
Of course, there is an extensive FDA-guided clinical trial regime to go through, as there is with all such inventions. Last week, the FDA's Neurological Devices Panel Advisory Committee met to review the company's application for recurrent GBM and provide guidance to the agency on approval. The panel voted in favor of the treatment, bringing the company one step closer to being able to offer this treatment option to GBM patients. You can read more here and here.
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* I will only report publicly available information. I will, of course, disclose if I have a personal financial interest. I will no longer comment on any financial interest of my previous employer or staff there, as I in no way represent them; nor do I keep track of such matters and therefore neither can I speak knowledgeably about them.
Insurance companies dancing without touching
A story in the Washington Post talks about health insurance companies seeking new lines of unregulated business as the profitability of health insurance falls and as more and more requirements are placed on that line of business as a result of the federal health reform law. Here's an excerpt: "Insurers have moved into technology, health-care delivery, physician management, workplace wellness, financial services and overseas ventures in wide-ranging efforts to mitigate the new rules imposed by the law."
I raised some of these issues several months ago, where I also suggested that a merger of the Number 2 and Number 3 Massachusetts health plans might be forthcoming. Well, they tried, but decided not to, as they announced a few weeks ago.
Meanwhile, Blue Cross Blue Shield of Massachusetts is clearly laying the groundwork to shed its non-profit status. And, really, why not? It is in no way a charitable organization of the sort envisioned in earlier years, and the constraints of being a nonprofit bind in a number of ways.
When the HPHC and Tufts merger fell through, the operative statement was: "We have now determined that we are stronger as individual competitors than one company."
I predict that will turn out to be a strategic error. In the new world order, scale matters. This statement is, to me, revealing in its own way: "Our operations are very different and, in many important aspects, not fully compatible without significant changes to existing processes and applications." In other words, they chose not to merge because it felt like it was not currently cost-effective to change. This suggests that the operations of the two plans as presently configured are not scalable. But if they don't merge, they will be left behind by those with stronger market power. For now, that is BCBS of MA. In the future, as the business becomes less about taking on insurance risk and more about other services, it could well include some major national players as well. Now, rather than later, would be a better time to consolidate assets and use the cash on hand to make the investments that will be needed to grab market opportunities in the future.
I raised some of these issues several months ago, where I also suggested that a merger of the Number 2 and Number 3 Massachusetts health plans might be forthcoming. Well, they tried, but decided not to, as they announced a few weeks ago.
Meanwhile, Blue Cross Blue Shield of Massachusetts is clearly laying the groundwork to shed its non-profit status. And, really, why not? It is in no way a charitable organization of the sort envisioned in earlier years, and the constraints of being a nonprofit bind in a number of ways.
When the HPHC and Tufts merger fell through, the operative statement was: "We have now determined that we are stronger as individual competitors than one company."
I predict that will turn out to be a strategic error. In the new world order, scale matters. This statement is, to me, revealing in its own way: "Our operations are very different and, in many important aspects, not fully compatible without significant changes to existing processes and applications." In other words, they chose not to merge because it felt like it was not currently cost-effective to change. This suggests that the operations of the two plans as presently configured are not scalable. But if they don't merge, they will be left behind by those with stronger market power. For now, that is BCBS of MA. In the future, as the business becomes less about taking on insurance risk and more about other services, it could well include some major national players as well. Now, rather than later, would be a better time to consolidate assets and use the cash on hand to make the investments that will be needed to grab market opportunities in the future.
Saturday, March 19, 2011
Real Life entered into my blog life!
So Sorry Dear Readers! I have not posted for 12 days. First of all I have left all you Mystery Photo Followers up in the air with the Wind Palace in Jaipur, India. And I haven't posted the other great pictures I have from this city. I still plan to do that.
Why haven't you posted lately, you ask. Well like I said Real Life entered in.
First of all, I had signed up for a free two weeks of usage on Ancestry.com, the greatest genealogy website in the world. I have not been on it in a year or so. And low and behold, I found all kinds of family pedigrees that extended several lineages by a generation or two. But the most exciting was finding a lineage on my mother's father's side that goes back to the 1700s in Maryland, USA. But then by crossing over to the female line and following it back a couple generations, I could again jump to the male line taking this line, the Winder family back to Lancashire, England in 1635. Wow. That was impressive. I reviewed this pedigree quite extensively and it does seem to be my line. John Winder was born in 1635; his son John Jr was born in 1668 and had a 3 year old son with his wife, when he died in Y, Somme, Picardie, France. First of all that town, Y (pronounced E) is the shortest town name in the world. But what was this young man doing in Y, Somme., Picardie, France in 1688 that made him die there. England and France were not friendly then, so this would not have been a tourist trip. But they also were not at war, so he was not there in a military capacity at least that had to do with war. 1688 was the year that Charles II abdicated his throne, and escaped to France in December. William and Mary from Holland were invited to take the English throne. Charles II was Catholic and fled to France after he abdicated. But he would have come ashore near Calais, and Picardie is well inland. Someone suggested that perhaps John Winder Jr. was engaged in something nefarious such as smuggling. It is possible. I am going to try to find out what happened here. At any rate, his 3 year old son Thomas grew up and came to the US, to New Jersey along the Delaware River, eventually moved west to western Maryland. That's where his descendents married into my Spielman family line. Anyway if you understand a genealogist's addiction and excitement at finding these lines, I had to use up that free Ancestry.com membership before it ran out.
Secondly, we are getting our two downstairs bedrooms and their walk in closets recarpeted. So we have been emptying those rooms and the closets. And I really don't want to put all that stuff back in the closets, so I am trying to weed out a lot of stuff and throw it away. This has been occupying me for some time now. The carpeters are coming on Tuesday next week. Then I will have to work to get the stuff back where it goes.
And thirdly, lastly, but not leastly, my son's family was here this last weekend and I had to sort of get ready for them, with some food and with the house and my toy collection rady for my grandson's onslaught. It was great having them here and we (Grandma, and the two little boys) played with those toys all weekend.
So now I am back to normal. Expect a posting with photos of Jaipur, India soon.
Why haven't you posted lately, you ask. Well like I said Real Life entered in.
First of all, I had signed up for a free two weeks of usage on Ancestry.com, the greatest genealogy website in the world. I have not been on it in a year or so. And low and behold, I found all kinds of family pedigrees that extended several lineages by a generation or two. But the most exciting was finding a lineage on my mother's father's side that goes back to the 1700s in Maryland, USA. But then by crossing over to the female line and following it back a couple generations, I could again jump to the male line taking this line, the Winder family back to Lancashire, England in 1635. Wow. That was impressive. I reviewed this pedigree quite extensively and it does seem to be my line. John Winder was born in 1635; his son John Jr was born in 1668 and had a 3 year old son with his wife, when he died in Y, Somme, Picardie, France. First of all that town, Y (pronounced E) is the shortest town name in the world. But what was this young man doing in Y, Somme., Picardie, France in 1688 that made him die there. England and France were not friendly then, so this would not have been a tourist trip. But they also were not at war, so he was not there in a military capacity at least that had to do with war. 1688 was the year that Charles II abdicated his throne, and escaped to France in December. William and Mary from Holland were invited to take the English throne. Charles II was Catholic and fled to France after he abdicated. But he would have come ashore near Calais, and Picardie is well inland. Someone suggested that perhaps John Winder Jr. was engaged in something nefarious such as smuggling. It is possible. I am going to try to find out what happened here. At any rate, his 3 year old son Thomas grew up and came to the US, to New Jersey along the Delaware River, eventually moved west to western Maryland. That's where his descendents married into my Spielman family line. Anyway if you understand a genealogist's addiction and excitement at finding these lines, I had to use up that free Ancestry.com membership before it ran out.
Secondly, we are getting our two downstairs bedrooms and their walk in closets recarpeted. So we have been emptying those rooms and the closets. And I really don't want to put all that stuff back in the closets, so I am trying to weed out a lot of stuff and throw it away. This has been occupying me for some time now. The carpeters are coming on Tuesday next week. Then I will have to work to get the stuff back where it goes.
And thirdly, lastly, but not leastly, my son's family was here this last weekend and I had to sort of get ready for them, with some food and with the house and my toy collection rady for my grandson's onslaught. It was great having them here and we (Grandma, and the two little boys) played with those toys all weekend.
So now I am back to normal. Expect a posting with photos of Jaipur, India soon.
Probably right, or wrong
In the post below, I ask you to make a diagnosis of a medical condition. Most people get it wrong, probably because the actual diagnosis is far removed from the setting presented. People apply their inductive forces to a new problem, based on probabilistic inferences from other situations with which they are more familiar.
I attended a seminar on Friday at which MIT's Joshua Tenenbaum presented a theoretical basis for this learning process. If you subscribe to Science Magazine, you can read his recent article on the topic: "How to Grow a Mind: Statistics, Structure, and Abstraction."
It turns out that people are reasonably good at inference, from a very young age, as Joshua notes:
Generalization from sparse data is central in learning many aspects of language, such as syntactic constructions or morphological rules. It presents most starkly in causal learning: every statistics class teaches that correlation does not imply causation, yet children routinely infer causal links from just a handful of events, far too small a sample to compute even a reliable correlation!
In a more theoretical section, the author describes a probabilistic, or Baysian, model to explain this learning process:
How does abstract knowledge guide inference from incomplete data? Abstract knowledge is encoded in a probabilistic generative model, a kind of mental model that describes the causal processes in the world giving rise to the learner's observations as well as unobserved or latent variables that support effective prediction and action if the learner can infer their hidden state. . . . A generative model . . . describes not only the specific situation at hand, but also a broader class of situations over which learning should generalize, and it captures in parsimonious form the essential world structure that causes learners' observations and makes generalizations possible.
Except when it doesn't work! As several of you demonstrated below, that same probabilistic model can lead to cognitive errors.
I summarized Pat Croskerry's explanation below:
Croskerry's exposition compares intuitive versus rational (or analytic) decision-making. Intuitive decision-making is used more often. It is fast, compelling, requires minimal cognitive effort, addictive, and mainly serves us well. It can also be catastrophic in that it leads to diagnostic anchoring that is not based on true underlying factors.
Why the dichotomy? How can a learning process that works so well in some cases led us awry in others? I asked Joshua, and he suggested that it might have to do with the complexity of the issue. For those functions that were important in an evolutionary sense as humans evolved -- e.g., recognizing existential threats, sensing the difference between poisonous and healthy plants -- a quick probabilistic inference was all that mattered.
Now, though, in a complex society, perhaps we get trapped by our inferences. The sense of tribalism that led us to flee from -- or fight -- people who looked different and who might have been seeking to steal our territory or food becomes evident now as unsupported and destructive racial or ethnic prejudice.
Likewise, the diagnostic approach to illness or injury that might have sufficed with simple health threats 10,000 years ago no longer produces the right result in a more complex clinical setting. Think about it. If you were a shaman or healer in a tribe, most conditions or illnesses healed themselves. You recognized the common ailments, and you knew you didn't need to do much, and whatever herbs or amulets or incense you used did no harm. If you couldn't cure the disease, you blamed the evil spirits.
In contrast, as a doctor today, you are expected to apply an encyclopedic knowledge to a variety of complex medical conditions -- cancer, cardiovascular disease, liver and kidney failure -- that were relatively unknown back then. (You were more likely to die from something more simple at a much younger age!) Many cases you see today have a variety of symptoms and multivariate causes and different possible diagnoses. It is no surprise that your mind tries to apply -- in parsimonious form -- a solution. The likelihood of diagnostic anchoring is actually quite high, unless you take care. As I note below:
Croskerry thinks we need to spend more time teaching clinicians to be more aware of the importance of decision-making as a discipline. He feels we should train people about the various forms of cognitive bias, and also affective bias. Given the extent to which intuitive decision-making will continue to be used, let's recognize that and improve our ability to carry out that approach by improving feedback, imposing circuit breakers, acknowledging the role of emotions, and the like.
I attended a seminar on Friday at which MIT's Joshua Tenenbaum presented a theoretical basis for this learning process. If you subscribe to Science Magazine, you can read his recent article on the topic: "How to Grow a Mind: Statistics, Structure, and Abstraction."
It turns out that people are reasonably good at inference, from a very young age, as Joshua notes:
Generalization from sparse data is central in learning many aspects of language, such as syntactic constructions or morphological rules. It presents most starkly in causal learning: every statistics class teaches that correlation does not imply causation, yet children routinely infer causal links from just a handful of events, far too small a sample to compute even a reliable correlation!
In a more theoretical section, the author describes a probabilistic, or Baysian, model to explain this learning process:
How does abstract knowledge guide inference from incomplete data? Abstract knowledge is encoded in a probabilistic generative model, a kind of mental model that describes the causal processes in the world giving rise to the learner's observations as well as unobserved or latent variables that support effective prediction and action if the learner can infer their hidden state. . . . A generative model . . . describes not only the specific situation at hand, but also a broader class of situations over which learning should generalize, and it captures in parsimonious form the essential world structure that causes learners' observations and makes generalizations possible.
Except when it doesn't work! As several of you demonstrated below, that same probabilistic model can lead to cognitive errors.
I summarized Pat Croskerry's explanation below:
Croskerry's exposition compares intuitive versus rational (or analytic) decision-making. Intuitive decision-making is used more often. It is fast, compelling, requires minimal cognitive effort, addictive, and mainly serves us well. It can also be catastrophic in that it leads to diagnostic anchoring that is not based on true underlying factors.
Why the dichotomy? How can a learning process that works so well in some cases led us awry in others? I asked Joshua, and he suggested that it might have to do with the complexity of the issue. For those functions that were important in an evolutionary sense as humans evolved -- e.g., recognizing existential threats, sensing the difference between poisonous and healthy plants -- a quick probabilistic inference was all that mattered.
Now, though, in a complex society, perhaps we get trapped by our inferences. The sense of tribalism that led us to flee from -- or fight -- people who looked different and who might have been seeking to steal our territory or food becomes evident now as unsupported and destructive racial or ethnic prejudice.
Likewise, the diagnostic approach to illness or injury that might have sufficed with simple health threats 10,000 years ago no longer produces the right result in a more complex clinical setting. Think about it. If you were a shaman or healer in a tribe, most conditions or illnesses healed themselves. You recognized the common ailments, and you knew you didn't need to do much, and whatever herbs or amulets or incense you used did no harm. If you couldn't cure the disease, you blamed the evil spirits.
In contrast, as a doctor today, you are expected to apply an encyclopedic knowledge to a variety of complex medical conditions -- cancer, cardiovascular disease, liver and kidney failure -- that were relatively unknown back then. (You were more likely to die from something more simple at a much younger age!) Many cases you see today have a variety of symptoms and multivariate causes and different possible diagnoses. It is no surprise that your mind tries to apply -- in parsimonious form -- a solution. The likelihood of diagnostic anchoring is actually quite high, unless you take care. As I note below:
Croskerry thinks we need to spend more time teaching clinicians to be more aware of the importance of decision-making as a discipline. He feels we should train people about the various forms of cognitive bias, and also affective bias. Given the extent to which intuitive decision-making will continue to be used, let's recognize that and improve our ability to carry out that approach by improving feedback, imposing circuit breakers, acknowledging the role of emotions, and the like.
Eye couldn't guess!
Quiz for doctors and lay people out there: What is your diagnosis for this eye condition?Be honest and put your answer as a comment below before looking at this article.
Friday, March 18, 2011
In their boats . . .
There is an old joke about a university with a certain ethnic background (mine) that decides to set up a rowing team. After months of practice, the crew arrives at the Head of the Charles Regatta to compete. They are demolished -- recording by far the worst time of any 8-person boat.Discouraged, the coach sends out the captain of the team to visit with other college teams to figure out how to get better at the sport. Hours later, Sam comes back and says, "Coach, I figured out the secret of their success!"
"What is it?" asks the coach.
"In their boats, eight people row and only one person talks!"
Apropos of that, please see the photo below of a sculpture from Jaffa, Israel, which seems to exemplify the lesson:
Those who have worked in hospitals already see the relevance of this story, but I present it more to provide a warning of what I see happening in the Massachusetts state government.You may recall a post from a few months ago in which I set forth great hope about the usefulness of an all-payer claims database. Here's an excerpt:
Over the coming months, in accordance with an act passed last summer, the Division [of Health Care Finance and Policy] will be constructing an all-payer claims database (APCD). It will comprise medical claims, dental claims, pharmacy claims, and information from member eligibility files, provider files, and product files. It will include fully-insured, self-insured, Medicare, and Medicaid data. It will also include clear definitions of insurance coverage (covered services, group size, premiums, co-pays, deductibles) and carrier-supplied provider directories.
The Commissioner noted that the result will be "a dataset that allows a broad understanding of health care spending and utilization across organizations, population demographics, and geography." In my view, it will be a moving force in rationalizing payments to providers across the state....
One of the things then-Commissioner David Morales promised was that the database would be widely accessible, so that independent researchers, policy analysts, advocates, market participants, and others would be able to manipulate it to test hypotheses and assumptions. Well, the Commissioner has since announced he is leaving his post, and it already has become evident that there is no one in the government who is steering the boat along the lines he so clearly presented. Instead, there appears to be the classic bureaucratic situation: Too many people involved, none with authority, and certainly no one exercising the leadership needed to make this incredibly useful tool available to the public.
It is time for one person in the Executive branch to talk, and for the others to row, to make sure the Legislature's intent with regard to the transparent presentation of these claims data occurs in a timely and useful fashion.
Thursday, March 17, 2011
The Inspector General observes
A recent report by the Massachusetts Inspector General raises a thoughtful concern about the implementation of global payments in the state.
In the effort to contain health care costs, much discourse has centered on moving from a predominantly fee-for-service system to one based mainly on global payments to providers organized as Accountable Care Organizations (“ACO”). There is little doubt that fee-for-service reimbursements create incentives for providers to increase utilization of health care services, with obvious inflationary consequences. But moving to an ACO global payment system, if not done properly, also has the potential to inflate health care costs dramatically.
There is nothing inherent in the current marketplace that would cause an ACO-based global payment system to contain health care costs. The evidence, in fact, suggests the opposite conclusion. For the past two years, the primary experiment with global payments in the private insurance market in Massachusetts has been the Alternative Quality Contract (“AQC”) popularized by Blue Cross Blue Shield of Massachusetts (“Blue Cross”). The payments to providers under this contract are made on a global capitated basis. The capitated amounts are determined by starting with the previous year’s experience of the population of lives covered by the specific AQC. That entire amount becomes the base year from which all future payments are derived. Therefore, the AQC embraces and adopts any excessive or wasteful payments in that base year, including all overutilization resulting from over a decade’s worth of fee-for-service provider contracts. Implicitly, the premium increases of that decade, which overall were well in excess of 100%, are made a permanent part of our health care system’s cost structure.
Once the base year is determined, any excessive provider costs from that year are trended into the future. And the rate of the trend is alarmingly high. While specific details of individual AQCs are kept confidential by Blue Cross and the contracting providers, the OIG estimates that increases in reimbursements to providers over the five-year term of an AQC could be in the 50% range.
The IG's remarks are especially apt in that the first global contracts contained very good deals for those providers who signed on, as rewards for being early adopters. The big problem he identifies, as I have mentioned before, is the lack of transparency surrounding this issue. Absent an open presentation of rates and practice patterns, we will never know how effective this payment regime really is. Meanwhile, the Governor and other policymakers have chosen to proceed, blindly trusting a path that has huge ramifications for patients.
I know of no other arena in public policy in which so many decisions are being made with so little substantive support and so little data-driven debate. Reporters, too, seem willing to accept relatively unsupported and undocumented assertions that global payments are working -- parroting statements made by stakeholders who have tremendous financial interests -- while demanding no independent verification.
In the effort to contain health care costs, much discourse has centered on moving from a predominantly fee-for-service system to one based mainly on global payments to providers organized as Accountable Care Organizations (“ACO”). There is little doubt that fee-for-service reimbursements create incentives for providers to increase utilization of health care services, with obvious inflationary consequences. But moving to an ACO global payment system, if not done properly, also has the potential to inflate health care costs dramatically.
There is nothing inherent in the current marketplace that would cause an ACO-based global payment system to contain health care costs. The evidence, in fact, suggests the opposite conclusion. For the past two years, the primary experiment with global payments in the private insurance market in Massachusetts has been the Alternative Quality Contract (“AQC”) popularized by Blue Cross Blue Shield of Massachusetts (“Blue Cross”). The payments to providers under this contract are made on a global capitated basis. The capitated amounts are determined by starting with the previous year’s experience of the population of lives covered by the specific AQC. That entire amount becomes the base year from which all future payments are derived. Therefore, the AQC embraces and adopts any excessive or wasteful payments in that base year, including all overutilization resulting from over a decade’s worth of fee-for-service provider contracts. Implicitly, the premium increases of that decade, which overall were well in excess of 100%, are made a permanent part of our health care system’s cost structure.
Once the base year is determined, any excessive provider costs from that year are trended into the future. And the rate of the trend is alarmingly high. While specific details of individual AQCs are kept confidential by Blue Cross and the contracting providers, the OIG estimates that increases in reimbursements to providers over the five-year term of an AQC could be in the 50% range.
The IG's remarks are especially apt in that the first global contracts contained very good deals for those providers who signed on, as rewards for being early adopters. The big problem he identifies, as I have mentioned before, is the lack of transparency surrounding this issue. Absent an open presentation of rates and practice patterns, we will never know how effective this payment regime really is. Meanwhile, the Governor and other policymakers have chosen to proceed, blindly trusting a path that has huge ramifications for patients.
I know of no other arena in public policy in which so many decisions are being made with so little substantive support and so little data-driven debate. Reporters, too, seem willing to accept relatively unsupported and undocumented assertions that global payments are working -- parroting statements made by stakeholders who have tremendous financial interests -- while demanding no independent verification.
Wednesday, March 16, 2011
Radio gets it right on end-of-life issues
Here is an excellent interview with WBUR's Sacha Pfeiffer and Dr. Lachlan Forrow about the Massachusetts Expert Panel on End of Life Care report I cited below.
It is deeply disappointing that the newspapers in Boston did not cover this important report, one of the most thoughtful pieces of work in the health care field.
It is deeply disappointing that the newspapers in Boston did not cover this important report, one of the most thoughtful pieces of work in the health care field.
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