Throwing money the wrong way

We have talked a bit on this blog about using financial incentives to encourage doctors to do a better, more efficient, and/or safer job in practicing medicine.  I have been skeptical of this approach because I do not believe that doctors find such measures to be highly motivational.  In my former hospital, we stayed away from financial incentives and even discussion of finances when we were instituting changes in work practices that improved quality and safety and the work environment.  Instead, issues were framed in terms of the underlying values of doctors.

I understand, though, why the government and insurers tend to lean towards financial incentives.  Payers, after all, deal in money.  Thus, they think they can use money to achieve their goals. When you have a hammer, everything looks like a nail.

The payers have been persuasive with legislators and the senior executives at both the federal and state level, notwithstanding insufficient data to support their policy prescriptions.  Later, as evidence emerges, the programs are proven not to work as expected.  The latest such analysis of which I am aware is a Perspectives piece by Gail Wilensky in the New England Journal of Medicine entitled, "Lessons from the Physician Group Practice Demonstration — A Sobering Reflection."  Here's the lede:

In early August, the Center for Medicare and Medicaid Services (CMS) announced the results of the Physician Group Practice (PGP) Demonstration project. Although the headline of the press release was glowing — “Physician Group Practice Demonstration Succeeds in Improving Quality and Reducing Costs” — the reported information suggests more mixed results. These results should dampen unreasonable expectations, particularly in terms of potential savings, for accountable care organizations (ACOs), which were modeled after the PGP demo.

I covered a different aspect of this topic in my recent article, "Never Events? Well, Hardly Ever," in Virtual Mentor.  I discuss the persistent rate of wrong-site surgeries and argue that financial penalties for such "never events" are ineffective:

In the face of slow progress, there is little doubt why the regulatory hammer is employed. But it is a crude tool. Its effectiveness as a deterrent is minimal because it does not address the structural issues underlying the problem. It emphasizes a particular outcome rather than a process that will achieve it. It penalizes people when it is too late to make a difference. Finally, it serves mainly to create resentment among those who are targets for improvement. Such is often the nature of regulation, no matter how well intended.

Ori and Rom Brafman take us a down a different path to explain this kind of result in their book, Sway, The Irresistible Pull of Irrational Behavior (Broadway Books, 2008.)  They cite experiments and real-life situations in which "throwing money into the mix diminished altruistic motivation and introduced unexpected behavior."  Apparently, our brains have two centers that influence behavior.  The posterior superior temporal sulcus, what they call the "altruism center," is responsible for social interactions -- how we perceive others, how we relate, and how we form bonds.  The other region is the nucleus accumbens, or "pleasure center," where we react to financial compensation.  Now here's the neat part:

Unlike, say, the parts of our brain that control movement and speech, the pleasure center and the altruism center cannot both function at the same time: either one or the other is in control.

Indeed, say the authors, offering a payment may undermine our altruistic motivations.

Doctors are the most well-intentioned people in the world.  They devote their lives to alleviating human suffering caused by disease.  We can count on their altruism in the patient care arena.  Admittedly, they are not always sufficiently trained in the science of process improvement, but a number of hospitals in the world have figured out that progress in that discipline comes from treating doctors with respect.  Framing the theories of process improvement by relating them to the underlying values and altruism of doctors is the way to go.  Throwing financial incentives into the mix, as noted by the Brafman's, may be the quickest possible way to turn off the altruism switch and end up with unintended consequences.

Managing Medication Shortage on WIHI

Managing Medication Shortage: Best Practices for a Crisis​
September 22, 2011, 2:00 PM – 3:00 PM Eastern Time

Guests:
Lynn Eschenbacher, PharmD, MBA, Assistant Director of Clinical Services, WakeMed Health & Hospitals

Michael R. Cohen, RPh, MS, ScD (hon.), DPS (hon.), President, The Institute for Safe Medication Practices

Frank Federico, RPh, Executive Director, Strategic Partners, Institute for Healthcare Improvement (IHI)

Medication safety has gotten a lot more challenging in the past year or so, due to circumstances health care providers can’t typically predict or control: a growing, critical shortage of prescription drugs, hundreds of them, including mainstay generics hospitals use to treat several forms of cancer. News organizations have begun to pay attention to the trend because of the tough decisions providers and patients now face when preferred treatments for certain types of aggressive leukemia or testicular cancer aren’t available. A recent story on The PBS NewsHour offers one of the more comprehensive looks at the underlying industry practices, product decisions, and manufacturing problems that have led to the crisis—a crisis that’s enabled a gray market to now traffic in scarce supplies of certain drugs in order to offer them for sale at astronomically higher prices.

Against this backdrop, and while policy makers, members of Congress, and the US Food and Drug Administration seek both short-term and longer-term solutions, hospitals have no choice but to develop strategies and best practices that assume, for now, prescription drug shortages. WIHI is pleased to welcome three people to the September 22 program who have their fingers on the pulse of what’s going on and are actively working to help organizations effectively manage a complex situation. IHI’s Frank Federico, the ISMP’s Michael Cohen, and WakeMed’s Lynn Eschenbacher are three pharmacy-trained improvers who’ve tapped their expertise on medication safety to come up with new strategies that can enable hospital staff to stay on top of the fast-moving drug shortage problem on a daily basis. WIHI host Madge Kaplan can’t think of a better moment to benefit from their knowledge and to learn how Lynn Eschenbacher’s hospital system in particular is effectively dealing with the crisis.

In addition to viewing the PBS broadcast, in preparation for the Sept 22 WIHI we invite you to read a new article in Healthcare Executive about the drug shortages, written by Frank Federico, Bona Benjamin, and Michael Cohen. We’d also like to draw your attention to a Premier healthcare alliance analysis of the gray market, which provides critical facts and guidance for hospital pharmacists and staff who purchase prescriptions.

We look forward to your participation on this next WIHI, and we hope you’ll encourage any of your colleagues who are trying to better understand and manage the drug shortage situation to join us as well. Thanks!

To enroll, please click here.

Next chapter in UPMC kidney transplant case

The UPMC kidney transplant story of a person infected by a diseased organ, about which I wrote in July, entered a predictable chapter yesterday with the filing of malpractice lawsuits.  I imagine some will say, "You see, this is why they should not be transparent about the underlying systemic causes of the error."  I would say, "Not so. Without sufficient transparency about the causes, and by simply blaming two clinicians, the chance of something else going wrong in the future is elevated. The lawsuit will rise or fall on its own merits.  It is better to derive something good from the learning opportunity presented by the incident.  But that can only happen when it is openly discussed and evaluated in a wider forum.  Also, you have a moral obligation to inform other transplant centers about the string of events that led to this conclusion."

Google+ is open to everybody

Back in July, I wrote about the introduction of Google+, which was only available to people by invitation.  Now, thanks to David Meerman Scott, I learn that it is open to all.

He also reminds us about the +1 button.  "Hey, it this was helpful, why not push that +1 button. If you are reading this on my blog, it right there below this sentence."

Owney, the Railroad Mail Dog

    Philately is another one of my interests. I would like to tell you and show you how I have used that interest to help youth become more interested in stamp collecting as a hobby.  I have prepared a presentation for the youth members of the ATA (American Topical Association) Chapter 5 at a monthly meeting. Recently the US Post Office released a stamp honoring Owney, a dog who lived in the late 1800s and became a mascot of the US Rail Mail Service. He was a Scotch Terrier mix stray who wondered into the Mail Service office, began to sleep on the mail bags, and was adopted by the mail clerks there in Albany, NY. He became so comfortable with the mail bags as his bed, perhaps attracted somehow to their scent, that he began to travel all over the United States on the mail cars with the bags. A mail bag once fell off the mail wagon and Owney jumped off, and sat on the mailbag until the wagon driver came back to get it.

     At that time railway accidents were very common. There were a lot of injuries and even deaths in the US railway mail departments. It soon became obvious that the trains on which Owney took passage had no accidents. He became a sign of good luck and was well taken care of , no matter where he went. He road the rails for about 9 years, traveling all over the United States. There is documentation of two visits to Milwaukee, and one to Lancaster, Wisconsin. He also took ship on mail boats that went around the world on at least one occasion. Owney became known to postmasters and to the mailmen who sorted mail on the railroad cars. They began to attach mail tags and other metal buttons to his collar. Then someone made him a jacket and these tags were attached to that piece of apparel. Soon he had so many tags, that the mailmen had to ship them separately back to his home office in Albany, NY.

The above two photos are provided courtesy of the US Smithsonian Institute.
More information about Owney including some videos about him, can be

found at the following URL: http://postalmuseumblog.si.edu/owney/

     Now the US Post Office is honoring Owney with his own Forever stamp. It should be available in your local post offices right now.

     The Smithsonian sells a stuffed little dog whose name is Owney patterned after the real mascot. My husband and I took the Smithsonian stuffed little dog with us to Southeast Asia last November and to Turkey and Israel in April. Similar to Flat Stanley, I forced my reluctant husband to take photos of Owney at various tourist sites, in front of post offices, on mail boxes, and with mailmen and postmasters in these locations. Then I used these photos to make cachets (special envelopes to be used with certain stamps and postal cancellations) to be used with the First Day of Issue cancellation at a special ceremony held at the Wisconsin Humane Center on July 27, 2011 in Milwaukee. The First Day of Issue cachets that I made are shown at the end of this post. At the ceremony, I was asked to read a Milwaukee Journal article from May 11, 1896 which nicely tells Owney's story. Here is that article quoted from that time:

The Milwaukee Journal - May 11, 1895, Page 6

The Globe Trotter

Railway Mail Service Animal Visits Milwaukee

-Fame of a Scotch Terrier


While in Milwaukee “Owney” was the guest of Chief Clerk Frank Smith – He Came Near Being an Elbe Victim.


A wanderer upon the face of the globe, if there ever was one, appeared in the office of Chief Clerk Frank P. Smith of the railway mail service this morning.


A veritable globe-trotter is he – one who is as persistent and constant a traveler as that restless but distinguished playwright, Mr. Bronson Howard, and one which can “do” a city in a style which discounts the swiftest accomplishments of a G. Washington Phipps. The visitor was none other than the widely talked about “Postoffice Owney.”


“Postoffice Owney” is a dog, but he is no ordinary dog. He s is the property of 7,000 railway clerks, who think a sight more of their property than they would of a pension amounting too half their salary should your Uncle Sam be disposed to be so generous with his gold dollars. Owney came to town at at 5:155 o’clock last evening, in the company with Railway Postal Clerk Dugard of the Milwaukee and Rock Island division. Last evening he was the guest of the clerk and today, previous to hiss departure for Rock Island at 12:20 o’clock, he called to pay hiss respects to the chief clerk. It was there that a reporter for thee Journal made his acquaintance.


A famous dog is Owney and one known by every postal c clerk in the railway service from St. Augustine to Seattle and from Santa Cruz to Bangor, for he has traveled ever since he s has been able to tell the difference between a porterhouse steak and a ham bone.


He travels exclusively in mail cars and always finds contentment and repose on top of a mail bag in sight of the clerks who are his constant companions. His journeys have extended across the waters, too, and he came near meeting hiss doom in the Elbe disaster, after making a trip to Germany. He a s was due to leave on the Elbe, Clerk Dugard explained today, b but did not embark, taking the next steamer.


He is a Scotch terrier, somewhat larger than the ordinary specimen of that kind of dog. He has had many a knock in his time and he looks it. One eye has ceased to serve its original purpose of discovering large, juicy bones, and the other looks as though it also would fail. A huge collar, from which dangled a half-hundred or more tags from almost every conceivable corner of the country, indicating that the possessor is entitled to almost everything from a chance in a raffle for an upright piano to a free lunch and a glass of beer, is fixed firmly about his neck. These tags collect so rapidly that it becomes necessary to remove them at times and the clerks along the line take them off and send them on to “Owney Albany, N.Y”, where they are carefully stored away in a room provided for the purpose in the Albany post office.


It was in Albany, more than a dozen years ago, that Owney went into the service of the government. He began as a tramp dog and after his first trip liked the business so well that he remained.

When Mr. Wanamaker was postmaster-general, he had a very handsome set of harness made for Owney and had his picture taken in a dozen different attitudes. Owney will go to Rock Island and then to Savannah, Ga, and away to the southwest. The clerks keep close tab upon him. He was once stolen in Toronto, Can, and was found again with great difficulty.

     Also while traveling with Owney as our mascot, I purchased postcards from the various countries, wrote on them as though Owney were describing his travels, and franked them with local stamps, of course. There is now a nice collection for the youth members. Also I put together stamps from those countries and photos we took while traveling, maps of the countries and our itineraries. All of these will be distributed to the youth members so that they can put together a nice Owney travel scrapbook. This project will also be an ongoing one. It allows stamps and Owney's example to help the children learn about other countries and cultures.

     Here are my First Day of Sale cachets, using my husbands photos, and a brief discription of our itinerary on each cachet.

     Here are also a couple of the postcards that Owney sent back to the United States. If you are at all involved in stamps or stamp collecting and wish to interest young collectors, these ideas will work very well.

Sport imitates art?

A friend offered a comparison between Manchester United fans mocking Chelsea rival Fernando Torres after he missed an easy goal and figures in Boticelli's Divine Comedy.  He says, "Too bad Botticelli is not around to render this on canvas."

I say he would have missed it anyway, since he'd be watching the Serie A games instead.

Crowdsourcing my PSA test choice

I had my annual physical yesterday, and my doctor and I were discussing whether it is worthwhile to have a PSA test.  (My previous test results, as late as last year, were very low.)  As I understand things, the test is not proven to be determinative of anything.  So, even if the value goes up dramatically, it is not necessarily a sign of cancer.  It might, for example, be a noncancerous condition like BPH.  The test can also produce false negatives, i.e., an indication that all is well when cancer is in fact present.

As noted here, by the man who invented the test:

[Richard J.] Ablin has been frustrated by the widespread use of the test. Each year, he notes, some 30 million men undergo PSA testing, at a cost of $30 Billion.  Yet “the test is hardly more effective than a coin toss. As I’ve been trying to make clear for many years now, P.S.A. testing can’t detect prostate cancer and, more important, it can’t distinguish between the two types of prostate cancer — the one that will kill you and the one that won’t. “

He acknowledges that “Prostate-specific antigen testing does have a place. After treatment for prostate cancer, for instance, a rapidly rising score indicates a return of the disease. And men with a family history of prostate cancer should probably get tested regularly. If their score starts skyrocketing, it could mean cancer. But these uses are limited. Testing should absolutely not be deployed to screen the entire population of men over the age of 50, the outcome pushed by those who stand to profit.”

Gary Schwitzer quotes from the American Cancer Society website:

"The American Cancer Society recommends that men have a chance to make an informed decision with their health care provider about whether to be screened for prostate cancer. The decision should be made after getting information about the uncertainties, risks, and potential benefits of prostate cancer screening. Men should not be screened unless they have received this information."

So, there we have it.  Should I cause scarce health care dollars to be spent on a test that will not give me useful information?  Or, to put it another way, why go through the potential stress of a higher number if it is not necessarily indicative of a problem?  Or should I cause these dollars to be spent so, if the number remains low, I have a false sense of security?

Your thoughts?