Friday, August 31, 2007

Health Savings Accounts - HSAs and The Entitlement Syndrome

I favor HSAs, and wrote about them at length in my book. (1). But HSAs are growing painfully slowly. The federal HSA law making them widely available is now nearly 4 years old. By 2007’s end, 8 million Americans will be in HSAs, a pittance compared to the more than 200 million that HMOs and PPOs cover.


Why the slow start? One can cite multiple reasons – distrust that HSAs simply shift costs, pundits claiming they’re a Republican gimmick, difficulties explaining how HSAs actually work, Americans’ natural resistance to radical change, suspicions HSAs will only benefit the healthy and wealthy, the prevailing orthodoxy you can’t trust the market to distribute or pay for health care, and deep belief HSAs won’t totally “fix” the health system. (2) I happen to agree with the latter, simply because no overarching policy – be it market or government driven – will ever totally “fix’ the system.


Chief among the reasons for the slow start is the “entitlement syndrome.” Thanks to third parties, we’ve been conditioned to think we’re “entitled” to free, first dollar, or low cost care from the government and health plans and the “dollar be damned.”


We’ve been taught there’s something special, even sacred about health care, something that separates it from other goods, something that shouldn’t be subject to market considerations relating to price, transparency, value, and quality. Not the least of these considerations is trust in doctors to do the right thing.


But what do health care professionals think about HSAs and the stress on price, market competition, and price transparency? That’s a hard to discern.


All I know is when I talk to hospital audiences about HSAs or consumer-driven care, I get collective yawns. And when I speak to doctors, I receive sometimes puzzled, sometimes appreciative, usually disbelieving looks. In Feb. 2007, the Minnesota Medical Association ran an article “Single Payer, Health Savings Accounts, or Managed Care.”


The article featured a poll asking 390 physicians which method they favored. The votes were single payer 64%, HSAs 25%, managed care 12%. Minnesotans, including doctors, tend to have a collectivist mentality, and this small survey may not represent the feelings of physicians as a whole But, at the very least, it shows HSA proponents have a long way to go in convincing doctors HSAs are for real.


1. Innovation-Driven Health Care; 34 Key Concepts for Transformation (Jones and Bartlett, 2007), chapter entited “Health Savings Accounts; Wall Street, Health Plan Websites, and Preventive Services”


2. “Analysis: HSAs Wont Cure Health Care ‘Crisis,’ Denver Post, August 29, 2007, see complete analysis at Bell Policy Center’s blog, www.thebell.org/blog/208

Thursday, August 30, 2007

Consumer-Driven Care - Credit and Health Care

The Aug. 31, NYT features business section piece “No-Interest Loans for Health Care.” It says more and more doctors and dentists are offering no-interest loans for 12 months or more to credit-worthy individuals for such elective procedures as Lasix, ceramic tooth implants, and cosmetic nose reconstructions, and it mentions UnitedHealth and others are moving into the health loan field with loans bearing rates of 12-13% or more. The hooker in many of these loan plans is a 20% default penalty.

Is this a sign of things to come? Is it desirable? Is it inevitable? Will it extend beyond elective procedures? It might. After all, U.S. credit markets are a $900 billion industry, and health care is just a drop in the credit bucket. There’s plenty of room to grow in. Credit-driven health care could become widespread because of high costs, high deductibles, and high co-pays. And 100,000 health professionals are already offering no-interest loans.

Earlier this year I interviewed Kenneth Bloem, executive chairman of MedDirect, LLC, a Grand Rapids, Michigan company founded in 2000 to provide loans for elective dental and medical procedures. Boehm is no fly-by-night operator. He has been COO or CEO of such prestigious academic institutions as the U. of Chicago, Stanford, and Georgetown and is a sought-after international health care consultant.

Bloem believes health care credit-needs will steadily grow. Under any reform scenario, he says, health plans, state government, and the national government can’t afford first dollar coverage. Regardless of what policy prescription evolves, Bloem maintains future health care funding will require sharing between patients, employers, and government and patient loans will be part of the mix.

Wednesday, August 29, 2007

Diabetes care - Measuring and Control;ing Diabetic Outcome

Three themes dominate the literature on quality – how to measure it, how to apply it to chronic disease, and how to achieve better outcomes.


No chronic disease preoccupies quality experts more than type 2 adult diabetes, which is closely related to the obesity epidemic and to over-ndulgence in eating the wrong foods and under-ndulgence in exercise.


Diabetes is the most costly chronic disease ($15,000 per patient per year). It is the easiest to track with measurable quality indicators (eye exams, foot inspections, hemoglobin A1C, lipids, and glucose). And its incidence has reached epidemic proportions( afflicting 10 in 1000 Americans, growing by 65% over the last ten years, and being closely linked to obesity, which itself has grown by 75% over the same time period).



Surely diabetes outcomes ought to be manageable through meticulous attention to diabetic regimens and life style adjustments.



But measuring diabetic outcomes and stemming the epidemic tide has two major problems: 1) how to measure the long-term outcomes once the disease has been diagnosed and treated; and 2) how to persuade diabetics to change the habits (overeating, eating the wrong foods, not exercising) that led to the disease in the first place.


Two types of metrics, process and outcome metrics, exist. Process metrics measure the means of getting a desired result, i.e. measurements that track the state of the disease. Outcome metrics measure the things that really matter-- rates of morbidity and mortality, good patient experience, patient understanding and control of their disease.



Most quality reporting today focuses on process. Did doctors use an EMR? Did they give the right pill? Did they check on a body part or a sign or blood test associated with the disease?


Unfortunately, while process metrics is an essential and good first step, process metrics take place in a narrow clinical window--what took place in the doctor’s office. Process metrics may overlook the big picture – what happened to the patient in the larger context of their lives? Did the treatments really work? Did the patients truly comply and adhere to the doctors’ orders? Did the patients fundamentally understand their control their disease over time?


Answers to these questions are often intangible and difficult to measure, often fall outside the doctor’s control, and may control long-term studies by independent observers outside to the doctor’s office to triangulate in on answers, and may only be addressed negatively – reduced rates of hospitalization, blindness, kidney failure, and amputations.


But the questions, though answerable, will take time to resolve. And they may take intense education support teams and psychological techniques to persuade patients to change habits and life styles.


One technique is forestalling insulin therapy. A young diabetic friend of mine confided to me,” My hemoglobin A1C is 6.6%. I keep it there because my doctor told me if it goes above 7.0%, she may have to put me on insulin.” Clear authoritative orders may also work. A nationally known endocrinologist has diabetic patients sign a contract saying they will abide by his rules. He also espouses group support. His group stages pep rallies for diabetics at which patients wear T-shirts bearing the message “In Control.”


Controlling diabetes will require all the educational campaigns all the media publicity, all the best doctor-patient relationships and counseling, and all the measurements and educational techniques we can muster.

Tuesday, August 28, 2007

Government vs. Market Reform -Three Health Reform Solutions – Your Opinion Please!

This week I came upon three health care reform solutions. I’d like to know what doctor readers think about these proposals.

• One – Medicare for All, Jacob S. Hacker, “Healing Our Sicko Health Care System,” New Eng J Medicine, August 23, 2007

The author, a professor of political science at Yale, comments on Michael Moore’s Sicko! In general, he agrees with Moore that HMOs are bad and a government system is good. He only complaint is that Moore ignores Medicare. Of Medicare, Hacker says, “it has controlled expenses better than the private sector, spends little on administration, and allows patients to seek care from nearly every doctor and hospital..Medicare is the secret weapon in the campaign for affordable health care for all..but it means threatening the private coverage n which so many Americans rely and requiring our cash-strapped government to raise the highly visible taxes.”

• Two – Mary Jacoby and Sarah Lueck, “Romney’s
Federal Prescription: Health Plan Relies on Tax Incentives, not Massachusetts’s Mandates,” WSJ, August 24, 2007


The reporters describe GovernorRomney as a “successful Republican leader in a Democratic stronghold, where success required balancing on a political high wire that didn’t lean too far to the right. The Mass plan requires businesses to provide insurance for workers and all residents to have some form of coverage, even if they have to purchase it for themselves. The plan he’s pushing on the national stump differs – allowing everyone to deduct health premiums, co-pays, and out-of-pocket expenses; getting government out of people’s health-care decisions; reforming state health regulatory agencies so costs are the same from state-to-state; and allowing states the flexibility to design their own Medicaid plans.

Three – A Short Term Solution, Stephen M. Schuster, “While We Wait, A Modest Proposal,” Healthleaders News, August 24, 2007.

The author, a lawyer and health care consultant, points out the U.S. health system has a short-term problem: “Forty-five million people are uninsured and we need to quickly get them access to appropriate healthcare. I propose the following solution to the short-term problem:”

• Issue a healthcare credit card to every person nationwide.

• Set the interest rate on the credit card at a maximum of less than 1 percent annually.

• Set a limit for the credit card at $5,000.
• Limit healthcare providers to charging Medicare rates for all services paid for with the card.

• Give every credit card holder the right/option to participate in the Medicare Part D Prescription Drug program.

• Process claims for payment through the current Medicare system.

• Finance unpaid card balances through a federal government guarantee program similar to student loans or home mortgages and/or issue a tax credit to the credit card companies for claims that need to be written off.

Monday, August 27, 2007

Hospitials and Doctors - What Makes for a Great Hospital?

Most doctors must affiliate with a hospital to practice in any community. There are exceptions, of course. Some physicians, like dermatologists ophthalmologists, and other office-based practitioners , practice mostly out of their offices or do procedures at ambulatory care centers disconnected with hospitals.

But for most physicians, a hospital relationship is a must. What makes a hospital great? In a recent book, The Seven “Cs” of Hospital-Physician Relationships, Jim Hawkins, a former hospital CEO, and I explored this relationship from hospital CEOs’ points of view. But what about the physician’s viewpoint?

I’d like to see how you react to an article in Healthleaders Magazine, “What All Great Hospitals Do.” See Healthleadersmedia.com. Here’s what hospital executives said great hospitals do.

• Make Decisions Based on What is Right – In the example given, a 25 bed hospital in Northern Ohio added “seven or eight” physicians to keep patients in town. This decision was based on community research showing many doctors were leaving town to seek care.

• Innovate – Cites CEO of Memorial Hospital in South Bend, Indiana, who says, “Innovation is the best way to solve the problem all of us have today.” Organized “Innovation Propulsion Leaders,” :who among other things, built a $40 million heart and vascular center.

• Set High Goals – Gives example of Scripts Health in San Diego, who develops metric-driven targets, and rebounds with $100 million in margins since 2000. Scripts is said to be great place to work and attracts scare health care workers.

• Have a Culture of Professionalism – Quotes a senior EVP, of Arlington-Based Texas Health Resources, a large faith-based delivery system, “We take care of our nurses and doctors, so they are free to take care of our patients, Everyone is a vital part of one team.”

• Share, Even When It Hurts - Tells of PeaceHealth, a six hospital system in Bellevue, Washington, which over the last 12 years developed a community health record. Peace shares its data with competitors. Says the senior VP,” We realized that in order to provide high quality, safe, and effective care across the continuum, up to and including the patient’s home – providers and patients had to have all the necessary information wherever care was delivered.”


• Have Balanced Leadership Chemistry – President and CEO of Irving-Tx Christus Health, says of his senior team, “They have to have clear technical knowledge of their primary care of responsibility, the ability to function as a total team when we are making strategic diction, and enough confidence to make a leadership decision in isolation.”

• Make Money – CFO of Oregon Health and Science Center says, “Understand that to continue to provide high-quality care, they need to make ongoing investments in new service, plant, and equipment.”

• Want to be Great Hospital –Christus executive says, “Excellence is not a luxury. It is a necessity, because every day people come through our doors and turn their most precious gift over to us: their lives.”

And here are a few more.

• Communicate with the public with one voice.

• Take pride in the physical plant.

• Don’t take themselves too seriously.

• Promote from within.

• Serve a decent cup of coffee.

Give us your thoughts what makes a great hospital.

Sunday, August 26, 2007

Physician Mindsets - Unconventional Wisdom

A close friend of mine, Dr. Don Copeland, who has been a solo family physician, organizer of a large FP group, and co-creator with two other FPs of the a family medicine program at Bowman Gray Medical School, and I were venting our feelings about the sorry state of medicine in the clinical trenches the other day. Don lives in Cornelius, North Carolina.


He made the following comments, which I paraphrase from memory.


• “ I hate the term ‘primary care’ almost as much as I dislike the word ‘gatekeeper.’ I told people in the beginning these concepts wouldn’t work, and they haven’t. I much prefers to call family physicians ‘personal’ physicians, for that am exactly what we are. We’re ‘personal’ doctors. We know our patients personally, advise them, and guide them. We’re not intermediariies for some specialist or lackeys for some insurance company.”


• “The medical schools don’t get it. They treat as secondary citizens. They don’t realize we’re on the frontlines, and we’re just as important, if not more so, than their cherished faculties of specialists. Some of the major academic centers, like Harvard and Johns Hopkins, don’t even acknowledge that the specialty of family practice exists. They think everybody goes to their internist first. “


• “The people who design these pay-for-performance programs, quality indicators, clinical guidelines, and physician profiles have never been in practice. They’re not really doctors. Most of them are medical bureaucrats who have never been there and done that.”


• “People don’t come into the office with a diagnosis pinned on their foreheads. You have to listen to them, understand their social and work situation, and know them as friends, neighbors, and members of your community. Sure, you can follow these “metrics” once you know what going on and have established a diagnosis. But that’s child’s play. Anybody can do follow guidelines once the diagnosis of hypertension, diabetes, thyroid disease, or some mental disorder has been established. But it’s getting to the diagnosis that counts. The skill in establishing a diagnosis is just as important as tracking and monitoring patients with an established diagnosis.”


• “These young doctors who are selling out to hospitals don’t understand they are handing over their license to practice medicine to the hospital. They also don’t understand that hospitals will demand that lab tests, x-rays, and other tests or procedures be done at the hospital -- at grossly inflated prices over what they could be done on the outside. Hospitals have negotiating clout with hospitals, Doctors don’t.”


• “When I read new types of innovative practices they all write about same day access, better communications with patients, computerized medical records, ‘medical homes,’ ‘team practices,’ use of non-physicians for routine care, but none write about The need to strengthen the doctor-patient relationship.”


• “There is no other profession as personal as the medical profession. If physicians continue to allow non-physicians for routine care, and hospitals and insurance companies to control them, they will lose their patients and will nothing more than over-educated hired technicians.”


• “Our best hope is for doctors to embrace health savings accounts, endorse high deductible plans, and to deal with patients on a personal basis rather than through remote third parties who don’t have the slightest idea about what being a personal doctor is all about. To back my beliefs, I founded HSA Healthcare, Inc, a PPO devoted to educating patients, physicians, employers, and community banks about the benefits of HSAs.”

Friday, August 24, 2007

Consumer-Driven Care - Convenience Care

I’ve always been reluctant to call the profession of medicine a business. And I shall not do so now. But when it comes to innovation, physicians may have a lot to learn from retailers, who understand the importance of convenience.

Take Walmart. It grew from a small Arkansas company to the world’s largest company in a scant 40 years, using the simple innovation strategy of a winning Civil War general, “Hit ‘em where they ain’t.” Walmart made it convenient for shoppers in non-urban markets to shop for goods at reasonable prices.

Or take Retail Clinics, started as MinuteClinics in Minneapolis three years ago, it is now 700 outlets strong and slated to grow to 10,000 by 2012. How? By stressing convenience - long open hours, no waiting, low price. Indeed, one could argue retail clinics have started a whole new form of health care: Convenience Care.

Retailing is America’s most productive sector. In the last dozen years, chains like WalMart, Starbucks, Staples, Home Deport and Home Stores have sparked America's remarkable productivity.

How have they done this? They have done it by paying attention to convenience. They’ve done studying behaviors and demands of customers from the "outside-in," i.e., through the eyes of time-short shoppers in hardworking two-career families. Retailers have introduced multiple sites for shopping (mail-order catalogues, Internet, television), increased convenience by minimizing travel time (by placing outlets in malls, neighborhood stores, office buildings, transportation terminals), placing goods in huge stores offering one-stop shopping, reorganized contents around lifestyles and trained employees to play defined roles concentrated on serving the customer. And they’ve done it by placing retail clinics in stores owned by CVS/Pharmacy, Target, Rite-Aid, H-E-B, Publix, Kroger, Duane Reade and Walgreens. Health marketers expect the clinics to be profitable because they fit into a healthcare niche by offering convenience, access, and affordability

A Medical Staff Briefing article, dated August 20, 2007, says of retail clinics:

Walk-in health clinics are becoming more and more prevalent each day, offering health care consumers quick, convenient access and low prices.

These so-called convenience care facilities don't necessarily mean competition for traditional healthcare models and may, in fact, boost referrals and thin out common patient choke-points at ERs and urgent-care facilities.

For basic care, they offer convenience, affordability, and accessibility that traditional healthcare providers generally do not.
Retail clinics are probably not a passing fad because of,

• an acute long-term shortage of primary care physicians

• consumers paying more for healthcare out of pocket

• high cost of health insurance

• insurers paying for retail clinic services

• high-deductible health plans gaining traction

• technology allowing for new care settings, new pace of diagnosis, and lower costs

• Investors backing innovation in health care delivery
Rick Kellerman, MD, president of the American College of Family Physicians (AAFP) says, "The major lesson is that patients want convenience,"
To that end, the AAFP encourages members to simultaneously collaborate and compete with retail clinics. Members collaborate with retail clinics by serving as a supervising physician or as a referral physician for medical problems beyond the retail clinic scope. They compete by having longer hours, less waiting, and lower fees.

Opportunities created by retail clinics include:

• Creating an inside track for downstream referrals.

• Thinking of retail clinics as a mechanism for drawing new patients...
• Recognizing half of retail clinic customers who need referrals are sent to physicians or groups named specifically by the clinic.

• Meeting with medical directors of these clinics to build bridges and open dialogue.
• Acknowledging these clinics are probably not a passing fad, to wit, Harris Interactive Surveys indicate a 92% satisfaction rate among users, and large physician organizations, ProHealth Physicians in Connecticut, Sutter Health of California, Geisinger Health System in Pennsylvania, and Memorial Hospital & Health System of Indiana have already opened retail clinics.

Don’t condemn or ignore the trend. Watch it closely for opportunities to establish relationships and attract referrals.

Thursday, August 23, 2007

U.S. health care system - U.S. Health Care Quality – Compared to What?

If you’ll recall, I recently did a post commenting on a NYT editorial “The World’s Best Health Care?” The Times concluded the U.S. system was lousy. My post, which said you can’t judge a national health system unless you take its culture into account, evoked a flurry of responses. Many dismissed the NYT piece as political.


On August 22, Real Clear Politics, a website which prints articles from across the ideological spectrum, headlined a piece by John Stossel, a commentator for 20/20, an ABC News program. The article was written specifically for Real Clear Politics.


Here are a few of Stossel’s comments:


The New York Times recently declared "the disturbing truth that the United States is a laggard not a leader in providing good medical care."

As usual, the Times editors get it wrong.

They find evidence in a 2000 World Health Organization (WHO) rating of 191 nations and a Commonwealth Fund study of wealthy nations published last May.

In the WHO ranking the United States finished 37th, behind nations like Morocco, Cyprus and Costa Rica. Finishing first and second were France and Italy.

So the verdict is in. The vaunted U.S. medical system is one of the worst.

First let's acknowledge that the U.S. medical system has serious problems. But the problems stem from departures from free-market principles. The system is riddled with tax manipulation, costly insurance mandates, and bureaucratic interference. Most important, six out of seven health-care dollars are spent by third parties, which means that most consumers exercise no cost-consciousness. As Milton Friedman always pointed out, no one spends other people's money as carefully as he spends his own.

It strains credulity to hear the U.S. ranks far from the top. Sick people come to the United States for treatment. When was the last time you heard of someone leaving this country to get medical care? The last famous case I can remember is Rock Hudson, who went to France in the 1980s to seek treatment for AIDS.

So what's wrong with the WHO studies? Let me count the ways.

The WHO judged a country's quality of health on life expectancy. But that's a lousy measure of a health-care system. Many things that cause premature death have nothing do with medical care. We have far more fatal transportation accidents than other countries. That's not a health-care problem.

Similarly, our homicide rate is 10 times higher than in the U.K., eight times higher than in France, and five times greater than in Canada.

When you adjust for these "fatal injury" rates, U.S. life expectancy is actually higher than in nearly every other industrialized nation.

Diet and lack of exercise also bring down average life expectancy.

Another reason the U.S. didn't score high in the WHO rankings is that we are less socialistic than other nations. What has that got to do with the quality of health care? For the authors of the study, it's crucial. The WHO judged countries not on the absolute quality of health care, but on how "fairly" health care of any quality is "distributed." The problem here is obvious. By that criterion, a country with high-quality care overall but "unequal distribution" would rank below a country with lower quality care but equal distribution.

It's when this so-called "fairness," a highly subjective standard, is factored in that the U.S. scores go south.

The U.S. ranking is influenced heavily by the number of people -- 45 million -- without medical insurance. Our government aggravates that problem by making insurance artificially expensive with, for example, mandates for coverage that many people would not choose and forbidding us to buy policies from companies in another state.

Even with these interventions, the 45 million figure is misleading. Thirty-seven percent of that group live in households making more than $50,000 a year, Nineteen percent are in households making more than $75,000 a year; 20 percent are not citizens, and 33 percent are eligible for existing government programs but are not enrolled.

For all its problems, the U.S. ranks at the top for quality of care and innovation, including development of life-saving drugs. It "falters" only when the criterion is proximity to socialized medicine.

Health Plans - HMOs and Beanbag

Politics ain’t beanbag, 'tis a man's game, and women, children 'n' prohibitionists had best stay out of it.

Finley Peter Dunne, 1867-1936, Chicago Humorist and Writer


In my last two posts, I spoke of physician leadership at the level of national politics and private innovation.

I neglected to speak of leadership of state medical societies. Two years ago, I interviewed Tim Norbeck, then executive director of the Connecticut State Medical Society for Voices of Health Reform (Physician Support Resources, Inc, 2005). Under Tim’s leadership, in 2001 the Connecticut Medical Society sued Connecticut HMOs for downcoding and artificial down bundling of physician.

Eventually in 2003, 19 medical societies joined with Connecticut to bring suit against Aetna, Cigna, Health Net, Prudential, WellPoint/Anthem, Humana, Blue Cross Blue Shield and 30 subsidiary Blue Cross Blue Shield plans eventually settled.

Settlements have amounted to $2.5 billion, including cash, future payments, and business changes. Out of these settlements in 2005 arose the Physicians Advocacy Institute (PAI), whose board includes nine state medical society executives. The purpose of PAI is to keep insurers feet to fire to comply with settlement terms.

According to Robert Seligman, PAI President and EVP of the North Carolina Medical Association, physicians will receive over $500 million in cash. Seligman says the PAI’s most important initiative is developing a Claims Data Warehouse, which will allow physicians to analyze claims data and prepare for future P4P programs which health plans are now implementing.

Dealing with HMOs ain’t beanbag; it’s hardball.
________________________________
Here are other Finley Peter Dunne quotes.
"A fanatic is a man who does what he thinks the Lord would do if He knew the facts of the case."

"Trust everybody, but cut the cards."

"A man expected to train lobsters to fly in a year is called a lunatic; but a man who thinks men can be turned into angels by an election is a reformer & remains at large."

"An appeal is when you ask one court to show its contempt for another court."

"There is one thing to be said in favor of drink, and that is that it has caused many a lady to be loved that otherwise might have died single."

"Swearing was invented as a compromise between running away and fighting."

"You can lead a man up to the university, but you can't make him think."

"Minds are like parachutes; they only function when open."

"Alcohol is necessary for a man so that now and then he can have a good opinion of himself, undisturbed by the facts."

"Comfort the afflicted, afflict the comfortable."

"The best husbands stay bachelors; they're too considerate to get married."

"Freedom is like drink. If you take any at all, you might as well take enough to make you happy for awhile."

"A man has more fun wishing for the things he hasn't got than enjoying the things he has got."

"I wonder why you can always read a doctor's bill and you never can read his prescription."

"One of the strangest things about life is that the poor, who need money the most, are the very ones that never have it."

"When the American people get through with the English language, it will look as if it had been run over by a musical comedy."

"If you go to the zoo, always take something to feed the animals, even if the signs say 'Do Not Feed Animals'. It wasn't the animals that put them signs up."

Wednesday, August 22, 2007

Clinical Innovation - Physician Innovator’s Conference

I’m not in the habit of promoting conferences, but I ran across one which I can’t resist talking about. My fascination grows out of a book I wrote on innovation-driven care and a daily blog I maintain on the subject of innovation. I am also much taken by examples of physician leaders developing new innovations.

The spirit of innovation differentiates the U.S from other nations. Innovation is something over which physicians have more control than government or health plan rules, regulations, and mandates, which are notably bereft of innovation. Furthermore, innovation is a fruitful area for physician leadership in developing less costly, more convenient, and better care.

On November 9, 2007, The Patient and Family Centered Workshop Series, sponsored by the AMD3 Education and Research Foundation and The Innovation Center, Magee-Womens Hospital at the University of Pittsburgh Medical Center will sponsor “The Innovator’s Conference” at the Heberman Conference Center at UPMC Shadyside Hospital in Pittsburgh. The cost is $200 for standard registration for non-UPMC employees,

Speaker will talk of the next generation of medical and surgical techniques to improve health care delivery. The purpose is to develop innovative solutions to support patients and family centered care. “Only then,” says the brochure, “ will innovations benefit patients, their families, physicians, allied health professionals, staff, hospitals and the business community.

This conference, and similar orthopedic-based and surgery-based conferences preceding it, are the brainchild of Anthony M. DiGioia, MD, an adjunct professor at UPMC, who has pioneered techniques in robotic surgery, minimal invasive surgery, and computer- assisted surgery.

Innovation will, Dr. DiGioia, believes;

• Change the way we deliver care
• Improve the way we perform surgery and medical interventions
• Enable value-added competition.

For more information, go to info@amd3.org or call 1-866-232-9499.

Monday, August 20, 2007

Medicare - Medicare Will No Pay for Hospital Errors

An Aug. 19 NYT article “Medicare Says It Won’t Cover Hospital Errors.” says Medicare won’t pay for conditions “that could reasonably have been prevented.”

These preventable conditions, sometimes dubbed “never events,” i.e. events that should never have happened, may include:

• Bedsores or pressure ulcers not present on admission.
• Injuries caused by falls
• Infections caused by catheters left in blood vessels or bladders
• Sponges or other objects left in patients during surgery
• Incompatible blood transfusions
• Death from other blood products
• Misuse or malfunction of medical devices
• Wrong site surgeries.
• Restraint strangulation.
• Deaths from medications.
• Deaths from childbirth.

The list is probably longer, but we won’t know until Medicare publishes its final rules next week. Medicare’s move is designed to save lives and $400 million from bad things that can happen to good people that could have been prevented.

Like all rules and regulations emanating from the top-down these rules have intended and desirable consequences.

• Reduction of hospital-acquired infection through gowning, hand washing, and discarding of items used on infected patients.
• Systematic steps to reduce hospital injuries
• Careful inspection and screening of patients on admission to check for pre-existing problems.
• Alerting patients to dangers lurking in hospitals
• Decline in medication errors
• Cessation of “never” errors
• Saving money for Medicare
• Enhanced patient safety

But there may be unintended consequences, as well. These include, in no particular order.

• New opportunities for the nation’s malpractice attorneys. .
• Heightened expectation among patients that their hospital admission will have good results, and if not, why not.
• Hospitals absorbing new costs for unexpected complications.
• New expenses for hospitals in the form of laboratory tests to check for staph infections by nasal swabs for every patient and preadmission testing for urinary tract infections
• The reporting of every adverse event by hospitals.

On balance, these new rules are a good thing. They culminate a series of converging events. :

• The Institute of Medicine’s 1999 report To Err is Human
• the 2005 The Institute of Healthcare Improvement campaign on saving 100,000 lives in hospitals
• Kenneth Kizer’s diligent work at the National Quality Forum and the VA
• active engagement and education of patients of patients through online programs as to what expect from surgical procedures before admission
• the movement among safety advocates that payers should never reward hospitals for “never events,” i.e. events that should never have occurred
• the Geisinger Clinic’s recent report that it will pay for complications occurring 90 days after CABG surgery.

Will these rules protect seriously ill patients, many at the end of life and many immunologically compromised, against all dangers even if they receive scrupulously correct care? Probably not. Nothing in medicine is absolute, including patient safety, but they’re a start.

Sunday, August 19, 2007

Action, Not Name Calling

Calling health reformers and health plan and government officials “commies,” “fascists,” or “socialists,” and lashing out at “corporations,” helps frustrated doctors blow off steam, but name calling isn’t helpful in advancing our cause, doesn’t solve any problems, and isn’t particularly realistic.


The reality is we’re part of the $2.2 trillion U.S. health industry, which costs the average American family $12,000 a year. We are, to use Arnold Redman’s 1982 term, part, of the “medical industrial complex,” an integral part to be sure, but still just a part of the vast American health system.


Redman warned of a profit-making companies taking over health care. Redman was half right. He left out one crucial element, the government. The truth is physicians one segment of the medical government industrial complex. Government pays for about 50% of health costs, and industry for the other half.


This near-equal sharing of health expenditures has led to interlocking government and industrial triangles.


The Government Iron Triangle. In the triangle’s three corners are, 1) 110 million Medicare, Medicaid, and VA beneficiaries; 2) 100,000 bureaucrats, public and private, thriving on government health care laws; 3) 535 politicians in the House and Senate who seek votes by instituting and institutionalizing health care entitlement programs and handing out health care goodies.


•The Private Iron Triangle, in one corner, are the health care institutions – 5000 hospitals, 125 academic centers, 100 or so large integrated systems; in the second corner, 1500 HMOs and PPOs and other forms of managed care; and in the third corner, supply-side companies – pharmaceuticals, device manufacturers, IT technology firms, hospital buying chains, medical supply companies.


Ninety percent of patients first enter the system through our offices, so we’re right in the middle of both triangles. We are, in fact, at the base of both triangles, which is why I believe we are most effective in changing the system from the bottom-up rather than the top-down.


Those who work for public and private organizations within these two huge triangles aren’t doing anything illegal or subversive. They simply control and manage a continually evolving American system. They represent a reality. The truth is our society entrusts large organizations, run by managers, to perform major social tasks, whether economic performance, health care, or education. We all know this, even as we rebel against it.


As independent physicians, our job becomes to work within the context of these organizations to do the best we can. Calling those who administer the medical government industrial complex names isn’t going to do any good, though calling people names makes us feel good.


Our alternatives are to form our own countervailing organizations, to work together to arrive at solutions, to work as leaders within the two triangles to bring enlightenment, to gain and justify the trust of our patients, and to manage and innovate to maximize our individual effectiveness as healing professionals.
.

Government vs. Market Reform - Action, Not Name Calling

Calling health reformers and health plan and government officials “commies,” “fascists,” or “socialists,” and lashing out at “corporations,” helps frustrated doctors blow off steam, but name calling isn’t helpful in advancing our cause, doesn’t solve any problems, and isn’t particularly realistic.


The reality is we’re part of the $2.2 trillion U.S. health industry, which costs the average American family $12,000 a year. We are, to use Arnold Redman’s 1982 term, part, of the “medical industrial complex,” an integral part to be sure, but still just a part of the vast American health system.


Redman warned of a profit-making companies taking over health care. Redman was half right. He left out one crucial element, the government. The truth is physicians one segment of the medical government industrial complex. Government pays for about 50% of health costs, and industry for the other half.


This near-equal sharing of health expenditures has led to interlocking government and industrial triangles.


• The Government Iron Triangle. In the triangle’s three corners are, 1) 110 million Medicare, Medicaid, and VA beneficiaries; 2) 100,000 bureaucrats, public and private, thriving on government health care laws; 3) 535 politicians in the House and Senate who seek votes by instituting and institutionalizing health care entitlement programs and handing out health care goodies.


• The Private Iron Triangle, in one corner, are the health care institutions – 5000 hospitals, 125 academic centers, 100 or so large integrated systems; in the second corner, 1500 HMOs and PPOs and other forms of managed care; and in the third corner, supply-side companies – pharmaceuticals, device manufacturers, IT technology firms, hospital buying chains, medical supply companies.


Ninety percent of patients first enter the system through our offices, so we’re right in the middle of both triangles. We are, in fact, at the base of both triangles, which is why I believe we are most effective in changing the system from the bottom-up rather than the top-down.


Those who work for public and private organizations within these two huge triangles aren’t doing anything illegal or subversive. They simply control and manage a continually evolving American system. They represent a reality. The truth is our society entrusts large organizations, run by managers, to perform major social tasks, whether economic performance, health care, or education. We all know this, even as we rebel against it.


As independent physicians, our job becomes to work within the context of these organizations to do the best we can. Calling those who administer the medical government industrial complex names isn’t going to do any good, though calling people names makes us feel good.


Our alternatives are to form our own countervailing organizations, to work together to arrive at solutions, to work as leaders within the two triangles to bring enlightenment, to gain and justify the trust of our patients, and to manage and innovate to maximize our individual effectiveness as healing professionals.

Friday, August 17, 2007

Reforming Fee-For-Service – Reality or Fantasy?

I have a friend, Brian Klepper, PhD, a prominent health care reformer and analyst, maintains revitalized managed care can reign in excess fee-for-service costs. When I point out 35 years of utilization review and gatekeepers have failed to reform fee-for-service doctors, and antagonized patients in the process, he shrugs and insists managed care “has never really been tried.”

Here are selected excerpts of Brian’s reasoning from The Health Care Blog, August 15, in a piece called “Managed Care Redux.”

Of course, the excess in America’s health system doesn’t just happen. Its structure creates incentives for waste. Fee-for-Service reimbursement, the prevailing payment methodology for the last several decades, rewards the delivery of more products and services rather than the right services. A lack of pricing and performance transparency makes it difficult to see poor or even dangerous performance when it occurs and, worse, has created an opportunistic culture throughout the entirety of the health care sector. And by spending a small but still significant portion of the largesse – about $350 million out of $2.2 trillion in industry revenues in 2006 – on lobbying, the industry convinces our federal lawmakers that the status quo is worth preserving.

My friend Jerry Reeves MD, the national Chief Medical Officer for the Unite Here Union and a consultant to many health management projects around the country, shows a simple slide that illustrates this point dramatically. It was developed several years ago, when he was the Medical Director for the Culinary Fund Health Plan in Las Vegas. In it, he takes several straightforward conditions, holds outcomes constant, and then shows the resources required by the lowest cost, highest cost and average Vegas physician. The results are startling. The most expensive doctor often costs 8 times as much as the least expensive one to get the same outcome.

Physician Costs for Specific Conditions in the Las Vegas Market

FP, otitis media, low cost, $46, average (+137%), high $412 (796%)
IM, angina, low cost, $86, average $297(245%), high $743 (764%)
Cardiology, angina, low cost ($241), average $611 (+154%), high $1389 (476%)
Orthopedics, knee surgery, low $2727, average $4473 (+64%), high $9383 (+244%)

My sense is that we’re about to see a new era of managed care, where the market players finally do all the things they promised to do last time but never did: analyze and reward performance, give patients, providers and purchasers better information to make better decisions, and invest in tools and processes that drive waste and inappropriateness out of the system. All this would be a breath of fresh air for America.


Brian isn’t alone. Inside CMS, serious discussions are underway seeking ways to contain and rationalize fee-for-service, as reflected in this comment by Peter Bach, MD, now of Memorial Sloan Kettering and formerly senior advisor to CMS,

Medicare patients bounce between many doctors, most of whom are unaffiliated with one another and as a result, few patients have a single doctor who is central to the care they receive. Health care is like this because of the way doctors are paid. Few doctors receive an hourly rate or a set annual salary; most are paid according to a system called “fee for service,” in which visits, tests and procedures are reimbursed separately. Doctors face incentives to provide more services and more expensive services and they do just that.

Imbedded in these remarks are four beliefs: 1) distrust in the integrity of independent practicing physicians to do the right thing without being monitored and disciplined 2) the premise that fee-for-service, the central cog in the transactional machinery driving the U.S. economy, shouldn’t apply to health care; 3) faith in the concept among managed care believers, introduced 35 years ago by Doctor Jack Wennberg of Dartmouth, that somehow one can achieve practice homogeneity and zero variation among fee-for-service doctors in different sections of the country; 4) third parties can effectively micromanage what doctors charge and how they practice.

When I ask Brian how FFS reform how this is be done, he talks of new IT management platforms, strong leadership by fed-up business executives burdened by health costs, doctor fee profiles and quality protocols, rewarding good doctors and punishing bad ones, introducing total transparency for all to see , organizing doctors into mega-groups numbering in the tens of thousands, and creating market pressures forcing doctors to comply.

I follow Brian’s logic, I applaud his idealism, but I fear he may be fantasizing. In America, every economic sector has high, middle, and low ends. Health care is no exception. ONe diffence, which has to be corrected, is that consumers up-front don't always know what costs and benefits are.

Electronic Health Records - AAFP Committed to EHRs

In 2005 I interviewed Doug Henley, MD, EVP of the Academy of Family Physicians, for Voices of Health Reform (Practice Support Resources, 2005), a book consisting of 41 interviews with national health leaders. (My book concluded health reform would likely end in gridlock because any significant reform would gore the ox of powerful vested interests.)

Doug and the AAFP were wholly committed to the EMR concept as an efficiency, quality, and reform tool. Doug had this to say,

Back in 1998, the AAFP board was visionary when it set two goals: 1) we would have all of our members using the Internet by end of 2003; and 2) by the end of 2005, we would have ½ of our members using electronic health records. We met the first goal. It will be a significant challenge this year to meet the second goal.

Doug and AAFP set about organizing a systematic program to promote EHR use, setting up a Certification Commission to set standards and give a seal of approval to EHR vendors, developing attractive pricing packages for members, and preparing EHR adoption and readiness strategies for their 93,700 members consisting of four steps: preparation, selection, implementation, and maintenance.

An April 2007 spot survey of 459 AAFP members indicates AAFP is gaining ground towards achieving its goals:

•37% fully implemented
•26% plan to purchase
•25% do not plan to purchase
•13% in the process of purchasing.

Carrying out an organized and ambitious campaign to persuade FPs to adopt EHRs isn’t easy. As every IT health technology expert knows, physicians fall into categories when it comes to EHRs: visionaries, early adopters, mainstream adopters, late adopters, and resisters.

Some IY enthusiasts think physicians should be required to use EMRs and are bringing pressures to bear in the form of P-4-P programs, protocol compliance, and provider profiling that would make it difficult to function without EHRs.

The pressure became so great in 2006 that at the AMA’s Annual meeting, delegates adopted a policy saying that public and private payers should not require doctors to use EHRs. Certain benchmark Institutions – like Kaiser, Intermountain Healthcare, Brigham and Women’s in Boston, and the VA - require physicians to use EHRs, and other institutions are following suit.

But does this mean all physicians, 75% of whom practice in groups of 5 or less, should follow large institutions over the electronic cliff? Should independent physicians, who must choose commercial off-the-shelf software be mandated to install EHRs? Or will market conditions, including patient demand, and the need for market leadership, ultimately force the hands of physicians to install EHRs?

I don’t know, but I know I belong to the school that says no technology fits all situations, and that includes other technologies that can be used to spur efficiency and improve quality such as electronic scanning of paper documents, electronic and paper templates, combinations thereof, and other techniques for skinning the documentation cat.

Thursday, August 16, 2007

Blogging, general - Confessions of a Health Care Contortionist

As an Internet blogger, I’m a bit of a contortionist, with my nose in the air, my ear to the ground, my eye on the horizon, my finger in the wind, my tongue in my cheek, my face in the sun, and my back to the wind.

What have I learned from being a contortionist?

Well, I’ve learned Sermo posting and Internet blogging can be powerful communication tools when they do ten things.


1.Posts and blogs must point new directions the health system is going-- more innovations, less employer coverage, more cuts in physician reimbursements, more restrictions from ancillary services revenues, more consumer-demands, more efforts to “engage” patients, more pressure for hospital-physician collaborations, more universal coverage experiments in States—and what to do and think about these developments.

2.Posts and blogs require comments, conversation, and constant feedback from physicians and other bloggers: you can’t improve the system by working in a vacuum or twisting in the wind by yourself.

3.You must always stand ready to engage in dialogue even if it leads to repartee, rejoinders, and outright disagreements. Controversies shed light and pierce the darkness.

4.Relay the message the system is moving towards a visual world to engage and educate patients, overcome health illiteracy, and to reduce misunderstandings between providers and patients: words alone will never do it.

5.Your posts and blogs are just part of a larger world, sometimes called the sermosphere or blogosphere: think of critics as friends dedicated to making sense out of your occasional nonsense. Distrust flattery and compliments, but take them like a gentleman. .

6.Ideally what you say will make a difference by bringing everybody together so we’re all singing from the same page – through synthesis, consensus, and commonsensus.

7. Highlight innovations that are changing the worlds of medicine and health care for the better.

8.Stress innovations that cut costs, enhance convenient, increase productivity, and prepare for incoming tide lest we be swept away by exploding health costs, and drowned in debt.

9.Always be humble, for you have a lot to be humble about. When engaged in a heated controversy, remember: it’s not the heat, it’s the humility.

10) Never over-promise innovation’s virtues, and recall this tale:

During the early years of the first century, the disciples wandered far and wide preaching and making converts. One day, St. Peter and St. Paul both arrived an inn in Jerusalem on the same night, weary and footsore. They called for wine and refreshed themselves, then fell into an argument as to who should pay. Peter suggested throwing the dice. Paul fetched them, shook the box and threw a four and a five. He handed the box to Peter, who shook, and threw two sevens. Paul gave him a long look, and said sadly, “Peter, all man, no miracles among friends, please.”

Offer no miracles, only guidance and examples of what can be done for a better future

Wednesday, August 15, 2007

U.S. Health Care System - Does The U.S. Have The "World's Best Health Care?"

Comments on New York Times editorial, “World’s Best Medical Care?”

The New York Times and other progressive news outlets often compare the performance of U.S. health care to other industrialized Western nations. In its latest August 12 editorial on the subject “The World’s Best Medical Care?” the Times notes;

•Michael Moore was right in Sicko! in labeling the U.S. as a “laggard not a leader in providing good health care.”

•Seven years ago, the World Health Organization (WHO) ranked the U.S. health care system 37th out of 191 nations (France and Italy were #1 and #2).

•In its latest report, WHO ranked the U.S. next to last compared to these countries with these populations: Australia (20 million), Canada (33 million), Germany (82 million), New Zealand (4 million), and the United Kingdom (61 million) – countries with 1.3% to 26.9% of the U.S. population.

Progressives overlook several major factors.

•Our culture, size, and diversity differs from other countries. We have a greater proportion of immigrants, a richer racial mix, more violence, more dynamic population growth, and greater regional variations in a vast continental nation. The U.S. receives 85% of the world’s immigrants; our population is now nearly 1/3 African American, Hispanic, and of other ethic origins. American culture tends to be less “pure” in its population mix, more conservative, less trustful of government, more litigious, less tolerant of rationing, and more desirous of having quick access to the latest technologies. These cultural factors don’t lend themselves to neat and swift health care reform.

•Medical care accounts for only about 15% of the health status and longevity of any given population, life style for 20% to 30%, and other factors - poverty, inferior education, income differences, and lack of social cohesion of the other 55%. This isn’t ideal or what most Americans want, but it’s reality, and it negatively impacts infant mortality and life expectancy statistics – the chief measuring rods of national health comparisons. In the U.S, there are vast differences in longevity among races (whites 81.5 years, other ethic groups 74 to 75 years), and in northern Midwestern states (81 to 82 years) and Southeastern states (74 to 75 years). This differences, and such things, such as “urban killing fields” within our cities, are beyond health system or physician control.

•Superimposing universal care on our current system would likely break State Budgets and the Federal Treasury. Somehow we must find a way to lower costs within the context of the current systems before proceeding to coverage for all. Many states –among them, Massachusetts, California, Illinois, and Pennsylvania – are finding universal coverage may cost more than their budgets will allow.

That said, most physicians would agree with the Times goals.

•Reduce the number of uninsured. This will be the #1 or #2 (it’s a toss-up between health care and immigration) domestic issue in the coming presidential campaign. Physicians can help through free clinics, charitable care, cash-only clinics with lower costs, and politically supporting the cause of reducing the number of uninsured.

•Improve coordination of care – In a public-private system with thousands of overlapping, sometimes competing entities, creating a unitary solution will take time, even with the best of intentions.

•Increase use of computerized records - As long as the costs outweigh benefits in physicians’ minds, this will be an elusive goal. Government financial incentives will be needed.

•Improve communications between doctors and patients – In the abstract, this is a great idea; but in today’s rushed and litigious environment, with the myriad of health care choices, and many patients seeing multiple specialists, it’s easier said than done.

Physicians might disagree with the Times that “this country lags well behind other countries in delivering timely and effective care.” That’s an opinion, and the Times is entitled to it, but it lacks roots in the realities of our culture.

Electronic Health Records - Words to the Wise and the Wired: EMRs No Quality Panacea

Three articles – 1) July 8 Archives of Internal Medicine “Electronic Health Records Use and the Quality of Ambulatory Use in the United States;” August 13 AMA News, “EMRs Don’t Quarantine Quality Care,” 3) August 9 NEJM “The Tension between Needing to Improve Care and Knowing How to Do It” – remind us EMRs as indicators and enforcers of quality remain works in progress. In the Archives piece, a study of 50,000 patient records, paper-users did just as well as EMR-users and in the case of appropriate prescriptions for high cholesterol, 14% better.

Two quotations from these articles are worth beating in mind.

1.Jeffrey Linder, MD, assistant professor of medicine, Harvard, “You just can’t take all the paper in doctors’ file cabinets and pour it into the computer and watch quality magically improve.”

2.NEJM authors, “Interventions that appear to be promising on basis of preliminary studies often prove to have no benefit, and those that are beneficial typically result in modest improvement, not monumental breakthroughs.”

Monday, August 13, 2007

Physicians and Health Plans - Third Parties are Killing Physician Entrepreneurship

I champion doctor innovation and entrepreneurship. (1) I believe doctor entrepreneurs, freed from third party shackles, can lower costs, better care, provide superior service, and give consumers more choice and convenience. This will take a consumer-driven system with consumers responsible for their own health care decisions and spending more of their own money.

John Goodman, PhD, founder and CEO of the National Center for Policy Analysis (NCPA) in Dallas, and Regina Herzlinger, professor of business administration at Harvard Business School, senior fellow at the Manhattan Institute and author of Who Killed Health Care? (McGraw-Hill, 2007) agree with me.

Goodman says:

In our fee-for-service payment system, doctors are slaves to the way they are paid. It doesn’t matter whether the payor is public or private. It also doesn’t matter whether we are in the United States or Canada. Doctors have no freedom to repackage or reprice their services. More specifically, regardless of how they repackage, they cannot reprice. So almost any innovation that raises quality or lowers the patient’s cost means less – not more- income-- for the physician.

Herzlinger says:

Entrepreneurs avoid health-care delivery because status quo providers, abetted by legislators and insurance companies, have made it virtually impossible for them to succeed. Unlike other U.S inducers, consumers do not set prices. A third party -- government or an insurance company –- not only sets prices but goes so far as to specify procedures and kinds of patients to be covered.

Herzlinger’s solution?

Luckily there is a solution; consumer-driven health care. Let’s take back our $2.2 trillion system from the suppressing status quo and allow consumers to reward entrepreneurs. Until we control our health system, the entrepreneurs who could reform it –and make our lives better – will continue to look elsewhere for opportunities – who can blame them?

Until we stop passively letting third parties dictate the terms, prices, and conditions of patient engagement, we’ll perpetuate our government and health plan controlled system. The alternative is to put consumers in the driver’s seat through use of high deductible plans and HSAs. It’s important to be realistic about our future health system – government run systems (Medicare, Medicaid, the VA, and state-run children’s insurance and corporately-dominated health plans - will not go away, but consumer-driven care may change the system for the rest of us who prefer freedom to choose what kind of health care we want.

References

1.Richard Reece, Innovation-Driven Health Care: 34 Key Concepts for Transformation, Jones and Bartlett, 2007.

2.John Goodman, “Entrepreneurs,” NCPA Policy Report, August 13, 2007.

3.Regina Herzlinger, “Where are the Entrepreneurs in Health Care,” Wall Street Journal, July 19, 2007.

Physician Business Ideas - One More Time: Doctors and Money

My July 30 Sermo post “Do Doctors Make Too Much Money?” evoked a brisk response and put the matter in context. If you’re recall, I was commenting on a July 29 NYT piece “Sending Back the Doctor’s Bill.” It said in essence American doctors make 2-3 times what European counterparts make, and that’s a big reason why our health costs are so much higher than Europe.

Sermo readers, some of whom had practiced in Europe, commented,

•Americans must pay off educational debts of up to $200,000 while European college and medical training is subsidized.

•Europeans may work half the hours of Americans.

•Europeans enjoy miniscule malpractice costs.

•American practice costs are higher.

To sum up, comparative incomes of American and European doctors must be put in cultural context.

In the August 6 NYT, readers responded in a series of letters to the editors. Here are a few excerpts what all of them had to say.

•Uwe Reinhardt, Princeton medical economist .

Any college graduate right enough to get into medical school surely would be able to get a high-paying job on Wall Street. The obverse is not necessarily true. Against that benchmark, every American can be said to be sorely underpaid…The total amount Americans pay their physicians represents only 20 percent of total national spending. Of this total, close to half is absorbed by the physicians practice expenses, including malpractice expenses, but excluding the amortization of college and medical-school debt, this makes the physicians’ take-home pay only about 10 percent of total national health spending. If we somehow managed to cut that take-home pay by, say, 20 percent, we would reduce total national health spending by only 2 percent, in return for a wholly demoralized medical profession to which we so often to look to save lives. It strikes me as a poor strategy.

•Amelia Hershberger, of Albany.

If we are to restructure the system by which we pay doctors to match Europeans, we must also finance education as Europeans do, but using state dollars to finance the full or majority costs of higher education, including professional school.

•Robert Brinham, Morristown, New Jersey

The concept of prepaid group practice remains sound today. Although attractive to participating physicians and patients alike, this model has not gained wide acceptance beyond the West Coast and certain progressive markets like Minneapolis-St. Paul and Boston. As you suggest, the forces resisting change to the status quo remain formidable.

•Ray Groves, New Canaan, Connecticut

You seem to advocate further reducing the incomes of doctors to the levels reported in a survey five years ago in Europe of $60,000 to $120,000. How many of our brightest sons and daughters will seek these positions?

•William Baker, Fairview Park, Ohio

The cure is obvious. End the AMA monopoly. Since the American public has accepted relocation of much of our manufacturing to China and India, why not accept opening our medical schools to everyone qualified and accept an unlimited number of doctors from foreign countries?

•Trevor Burnham, Missoula, Montana

Doctors will be able to charge high prices for their services as long as demand for theirservices outstrips supply. Health care conservatives favor the free-market approach of denying services to those who cannot afford them. If liberals want to remove this restraint, they will have to bolster supply. The fact that so few people become doctors despite the job’s salary, stability and prestige tells us that some somewhere in the pipeline of medical training and accreditation lurks a bottleneck. Conservatives has put forward one possible solution: tort reform. Liberals should give it careful consideration.

That’s all folks. I will now put the whole matter to rest.

Saturday, August 11, 2007

Hospitals and Doctors - Should Hospitals Own Doctors, or Vice Versa, Or Should They Go Their Separate (and Occasionally) Collaborative Ways

Back in the early 1990s, I co-founded the National Association of PHOs . At the time, I thought physician and hospital could collaborate in some magical way to, among other things, create bundled bills for common procedures.

I quickly discovered five things:

1) the high tech, high income specialties were reluctant to collaborate because they were doing just fine on their own, thank you;

2) a natural mutual suspicion exists between the two as to who is going to be King of the Hill;

3) hospitals generally end up running the PHO ( hence, the expression, “Big H,” little “P”);

4) health plans prefer to negotiate with hospitals and doctors separately;

5) as long as doctors can afford to remain, autonomous, they will..

Fast forward 15 years, and things have changed.

• Doctors, primary care and specialists alike are now approaching hospitals for employment.

• Hospitals and doctors are vigorously competing for high margin ancillary services – joint replacements, heart procedures, CT and MRI imaging services.

• Doctors in various sections of the country are pursuing the “clinic model,” in which physician leaders consider hospitals are considered just another service.

• Multispecialty groups – unable to raise capital to upgrade facilities, fund retirement, recruit and retain physicians,-are turning to hospitals for help and to be merged or acquired.

Now, a whole new spate of hospital physician interactions are evolving to unite doctors and senior leaders. These vary

•from physician employment
•to joint ventures,
•from gainsharing projects
•to creating of centers of excellence,
•and even consideration of the time-honored tradition of the clinic model.

What should be is the ideal relationship? I don’t know. The relationship varies enormously from one region and from one hospital and from one physician to another. It doesn’t lend itself to facile explanations. Many guess is that most hospitals and doctors will run an parallel tracks as long as they can, unless market conditions force them to converge.

Friday, August 10, 2007

Pay for Performance - In Evaluating P-4-P, Consider the Source

When evaluating the value of P4P, consider the source.

CMS Press Release


Read the latest CMS press release, “Physician Groups Improve Quality and Savings Under Medicare Physician Pay for Performance Demonstration,“ and P4P would seem an unqualified success, to wit, “The Centers for Medicare & Medicaid announced today that all participating physician groups improved the clinical management of diabetes patients in the first year of the three-year Medicare Physician Group Practice Demonstration (PGP Demonstration.” The casual reader might think it doesn’t get any better than that: improve care and save money. What more could one ask?

American Medical News

Read the August 6 AMA News, and you’ll get a different spin, “P4P Pays Off for Medicare, but Not for Most Doctors Involved.” The article says eight of the 10 medical groups involved in the study said costs required to meet P4P reforms exceeded bonuses. In other words, the amount of the money most groups “saved” in improving “quality” didn’t qualify them to share in P4P payment rewards. Groups were unable to get money back from Medicare to pay for improvements. Furthermore, the government changed its initial reward rules in midstream by saying at first all savings would count but adding later that only savings exceeding 2% would count. Nine of 10 groups had some savings. Dartmouth-Hitchcock medical director complained, “They changed the rules in the middle of the game?” So much for government trustworthiness.

The New England Journal of Medicine

Authors of articles and editorial in the NEJM ride the fence. A two year study of 613 hospital P4P programs achieved only modest gains of 2.6% to 4.1%, and authors concluded “Additional research is required to determine whether different incentives might stimulate more improvement or whether benefits of these programs outweigh their costs.” An accompanying editorial hedged even more,” The reality, however, is that we are at the tipping point with pay-for-performance programs, and such information is unlikely to be forthcoming before political pressure forces policymakers to act. In this situation, the CMS may have much to gain from recognizing that pay for performance is fundamentally a social experiment likely to have only modest incremental value."

Harvard Business School Professor


Regina Herzlinger, PhD, professor of business administration at Harvard Business School and the “godmother of consumer driven care,” is less kind. In Who Killed Health Care (McGraw Hill, 2007), she comments, “ Congress is now practicing medicine. Its pay-for-performance (P4P) initiatives enable governments to tell health care providers how to practice medicine. The higher the performance, the higher we pay. The health care system lacks metrics of performance. Despite its name, P4P does not pay for performance – the attainment of improved care at a reasonable price. Instead, it pays for conformance – the adherence to a government-dictated recipe for the provision of health care. The government pays for adherence for its recipes for the process of delivering health care rather than for outcomes.”
The End Game

As you ponder these different points of view, remember there are two types of metrics – process and outcome metrics. P4P currently rests solely on process metrics in the form of percent of quality indicators achieved. Outcome metrics, however, are things that really matter – morbidity and mortality, adherence to therapy, good patient experience, altered behaviors, patient understanding and control of their disease. Those are the goals of the end game, and P4P is not there yet

Thursday, August 9, 2007

Limits of Technology - Data Uber Alles: Or: P’s (Physician Profiling, Physician Protocols, and Pay-for-Performance) Be Upon You


In God we trust. All others use data.

Mary Walton, The Deming Management Method, Perigree Press, 1986

I’m part of a drowning minority swimming against the incoming data tide. Numbers don’t capture human interactions or intangibles, and I don’t believe data alone captures physician quality.

Mine is a hard position to defend. I have frequent conversations with two friends. One is a former VP of medical affairs for an international corporation. The other is a prominent health care analyst and reformer. Both are wholly dedicated to this proposition:

Scientific and process data on physicians is an effective tool for separating and rewarding high performers from also-rans, and will measurably improve health care performance and cut costs.

I’m dubious. My question is: cut costs for whom? For government, health plans, society? EMRs may save money for society but not for doctors.(1) And it’s yet to be determined if quality gains outweigh costs. (2)

I argue,

•Many patients have idiopathic, vague, and emotional conditions that don’t lend themselves to scientifically-evidence or treatment. Further, I have yet to see a comprehensive study of serial patients in a busy medical practice documenting what conditions can be pigeon-holed as scientifically based or indeterminate.

•If you try to apply data-driven physician profiling and pay-for-performance cookie-cutter measures to masses of physicians, you will drive many out of the profession they entered because they thought they could use their own judgment – not that of some detached health plan or government agency. This doctor exodus may exaggerate an already acute physician shortage.

•Combinations and permutations of patient-physician interaction are so vast that the various Ps (physician profiling. protocols, and P4P) can’t pin down physician behaviors or define outcomes--mortality, morbidity, changed habits, good patient experience, or patient understanding and control of their disease. P4P may be a good first step, but it’s not the final step, and costs often outweigh benefits.

But to my friends, it’s data uber alles. CMS and health plans have mounted the data bandwagon, and they’re not to be denied. Judging physician by the Ps has become “imperative” separating the wheat from the chaff. I appreciate the logic of the P’s initiative; I applaud its intent; I simply assert it may have unintended and costly consequences. What you foresee may not be what you will get.

In any event, here are 15 strategies advanced for the P’s argument as set forth as a future “provider profiling and pay for performance” conference to be attended by CMS and health plan grandees

•Reward physicians who consistently demonstrate safe, timely, effective, equitable, and patient-centered care.

•Evaluate appropriate incentive options and select the best measurement strategy that will achieve your goals.

•Measure ROI from P4P and profiling initiatives.

•Create viable options for both primary physician and specialists.

•Measure physicians and hospitals, tying results directly into a program that links rewards to Centers of Excellence hospital-ranking process.

•Reap robust financial and quality rewards without expanding health care expenditures.

•Link hospital ranking and physician ranking to get results.

•Leverage economic profiling data on PPO network physicians in multiple specialties.

•Develop new revenue streams by offering profiling data served service to employers.

•Improve transparency and build collaborative profiling by openly sharing prance information with providers.

•Achieve clinically appropriate variation management by incorporating evidence-based medicine into clinical practice.

•Reduce variation in utilization.

•Leverage coalitions of employers, physicians, hospitals, patients, health planes, and other shareholders to drive quality improvement and efficiency.

•Develop reporting mechanism that compares health care quality performance in clinics and hospitals to improve decision making in all constituencies.

•Capitalize on a P4P program that pools reliable information from multiple health plans.

There you have them – noble goals all. They describe plans for your future. What about these strategies? Will they accomplish their goals of rewarding good doctors and improving quality? Or will they simply be another layer of bureaucracy?

References

1. Steve Lohr, “Who Pays for Efficiency,” New York Times, Juue 11, 2007

2. Am Epstein, “Pay-for-Performance at the Tipping Point,” New England Journal of Medicine, Februa

Wednesday, August 8, 2007

Culture, effect of, Medical Trends - Medical Mindsets -Five Physician Mindsets and Trends

Medical Mindsets -Five Physician Mindsets and Trends

Mindsets work like fixed stars in our heads. Holding on to them, our mind drifting like a ship in an ocean of information, finds orientation. They keep it on course and guide it safely to its destination.

John Naisbitt, Mind Set! Collins, 2006

In what follows, I describe five physician mindsets. Mindsets are sets of beliefs or ways of things that determine how one behaves or acts. Physician mindsets change only slowly, are rooted in the present and past, and reflect bottom-up cultural beliefs. America is an overwhelming bottom-up society. Most physician behavioral changes come from the physician culture below rather than from government above.

Finding Top-Down Trends


It’s easy to find top-down trends, which represent mindset shifts. from such sources as government reports, PriceWaterhouseCooper, The Kaiser Family Foundation, the Center for Studying Health System Change, the Robert Wood Johnson Foundation, Modern Healthcare, JAMA, AMA News, or the New England Journal of Medicine. These are excellent sources, but they may not capture what individual physicians are doing, saying, or thinking.

Discovering What Individual Physicians Are Thinking

It’s hard to discern what doctors are thinking individually. On occasion, you’ll find physician mindset shifts described in the sources noted above. And you can find what physicians think at Sermo. com, a website created by Daniel Palestrant, MD, a Cambridge, Massachusetts general surgeon. On the site, doctors exchange ideas and talk. Wall Street firms support and study the site to track physician trends. The AMA likes Sermo. It recently signed a deal to promote it among its members to see where doctors are trending.

I’ve contributed many “posts” to Sermo, and it’s my impression doctors, though conservative, aren’t necessary ideological. Physicians want the uninsured covered, health care to be affordable, to show compassion, and deploy the tools and technologies of modern medicine. Physicians know doing all these things at once poses cost dilemmas. They’re realistic and recognize change is likely to arise from present adjustments, rather than from some future revolution. They instinctively know changes happen slowly.

Low Physician Morale

Physician morale is low because of decreasing Medicare and health plan revenues, rising malpractice rates, overwork and burnout secondary to physician shortages, unceasing criticism from pundits and managers about inconsistent quality, patient safety, and business inefficiencies.

Doctors tend to suspect commercial ventures intruding on their turf. Retail clinics for convenient non-emergent care and enterprises like LifeLine Screening to screen for potentially fatal vascular lesions in asymptomatic patients are cases in point. They’re also leery of fellow physicians who profit from dispensing drugs from their office or who sell alternative drugs or herbs.

Doctors feel they’re doing the best they can and working as hard as they can, which some equate to treading water. These struggles leave scant time for speculating about trends. The physician culture, and the mindsets it represents, form the basis for the trends I’ve selected..

Physician Mindsets


In assessing mindsets and their evolution into trends, I’ve found it useful to consider John Naisbitt’s thoughts about trends in his new book (Mind Set! Collins, 2006). Naisbitt, as you may recall, was the author of Megatrends 25 years ago. Megatrends accurately forecast where American society was headed.

Here are Naisbitt’s current thoughts on how he analyzes mindsets and trends (bold print). My responses, in italics, follow.

1.While many things change, most things remain constant (No matter what turns reform takes, most things will remain constant .Indeed, maintaining the status quo can be thought of as a trend, In other words, with reform everything is likely to change, but the status quo).

2.The future is embedded in the present (Future changes are likely to evolve out the present and aren’t likely to be a radical departure from present practices).

3.Focus on the score the game (The score of the game will be cost versus outcome metrics. In other words, what will improved health outcomes cost, and what will be the most effective way to increase the score – engaging and educating patients, preventive programs, work site clinics, disease management programs, or inter-operative management systems).

4.Understanding how powerful it is not to have be right
( Create your own bandwagon. Innovate, change, and adjust. If you think having a compute to take each patient’s history will be what it takes to achieve standardization and consistency and productivity, say so; If you think retail clinics will lower quality and discourage patient follow-up, say so).


5.See the future as a picture puzzle (Trends rarely occur in a vacuum; they’re made up of multiple converging trends, of recognizing, for example, that the Internet will change multiple things at once).

6.Don’t get so far ahead of the parade that people don’t know you’re in it (Radical changes are, well, radical. In IT applications to health care, leaders are expected to be ahead of the pack. But in the end, the marketplace and health consumers will decide what works).


7.Resistance to change falls if benefits are real (A good example of this is physician resistance to EMRs. When physicians find EMRs benefit them, or see physicians using EMRs are market leaders due to EMRs, they will change – and fast).

8.Things that we expect to happen always happen more slowly (Changes are always evolutionary rather than revolutionary. The slow migration of physicians into larger integrated groups is a good example).


9.You don’t get results by solving problems but by exploiting opportunities ( The explosion of retail clinics in sites where people shop and fill prescriptions represents seizure of an opportunity – filling a gap in convenience and low cost care).

10.Don’t add unless you subtract (For physicians, one of the purposes of adding information technologies is to subtract staff).


11.Don’t forget the ecology of technology ( When physicians add technology, they should simultaneously ratchet up humanism. Patients seek high tech/high touch, not one over the other).

Blog Lessons

I’ve learned a lot about physician trends through my blog and physician comments on its contents. Over the last nine months, I’ve made 250 entries, largely based on material culled from newspapers medical journals, policy reports, Physician Practice Options (a newsletter I edited for the last 11 years), responses to my recent books, healthleaders news features, and countless phone conversations with authorities and analysts around the country. I’ve used material from some of my own writings in this commentary. As one perceptive writer observed, “How do I know what I’m saying until I’ve read what I’ve written?”

Out of this miasma of sources and my own writing have raised five physician mindsets.

Five Mindsets


Physician Mindset Number One - Physicians on the ground prefer incremental changes through expanding coverage through tax incentives and market-driven changes rather than through a single-payer system.

Forty years of experience with inadequate payments and burdensome regulations by Medicare and Medicaid has soured doctors on government solutions. One exception to this may be SCHIP (State Children’s Health Insurance Program) legislation, It aims to spend $50 billion or more for 3.2 million children from low-income families too well off for Medicaid not wealthy enough to afford private insurance. The AMA, most medical societies, and most physicians support this legislation, which is likely to survive a presidential veto. The AMA is on the cusp of launching a national campaign stressing universal coverage through tax credits and other measures. But the real AMA hot bottom issues are tort and payment reform. Individual physicians like the idea of a system based on market principles with more choice, but remain leery about negotiating with patients about price, engaging patients in extended “partnership” discussions, rushing to embrace high deductible plans with HSAs, and even being paid at the point of care with credit or HSA cards. Most practicing physicians don’t favor single-payer, although there are exceptions, such as the 14,000 doctors who belong to Physicians for a National Health Program.


Physician Mindset Number Two
– Physicians are adapting to downward pressure on their incomes and harassing rules and regulations by becoming hospital employees.

The evolution of this mindset can’t be disputed. Increasing numbers of primary care physicians and specialists alike are approaching hospitals to become employees. This is a twist from the past. Seven or eight years ago, hospitals were hell-bent on acquiring primary care practices. This turned out to be an economic disaster for many hospitals. But now the tide has turned. The reasons are many. Physicians feel overworked with too many patients and too little time. Practice expenses are mounting while incomes are dropping. Establishing individual and small practices carries too much risk for doctors, and loans from banks and other sources of capital are hard to come by. Many doctors feel they can’t afford to invest in EMRs, and the return of investment doesn’t justify the expenditure. The malpractice specter looms large, and young doctors in particular simply want a more balanced life style with the fringe benefits of hospital employment. Merritt, Hawkins, and Associates reports that 23% of its search assignments in 2006 were from hospitals, up from 19% in 2004/2005m and 11% in 2003/2004. Another unexpected development is multispecialty groups approaching hospitals asking to be absorbed, merged, or acquired so groups can recruit physicians, retain the ones they have, fund retirement programs, and gain access to sufficient capital to invest in EMRs and other improvements.

Physician Mindset Number Three – Physicians regard consumer-driven care with skepticism and tend to be reactive rather than proactive in adapting to change.

Proponents of consumer-driven care call it the “silent revolution,” which poses a problem. It is too silent. although membership in consumer-directed high deductible plans (CDHP) with HSAs now exceeds 4 million, and may grow to 40 million in the next five years, consumer-directed care isn’t getting a big play among pundits, the media, and the reform crowd. Among some liberal critics, CDHPs draw a collective yawn because it’s said they fail to address the problems of the uninsured and costs of disease management. Some hard-pressed employers are switching from HMOs and PPOs to CDHP with HSAs. But employees, given a choice, are reluctant to change because of the uncertainties and unknowns of CDHPs. Perhaps a third of employees are uninsured and signing up because they can now afford premiums. Inducements, such as free preventive care, are attracting a few employees but not many. And there is still a great deal of caution out there whether these new plans are good for employees with chronic disease. Among most doctors, CDHP are still too small to have much of an impact, and the idea of dealing with consumers armed with data still frightens some.


Physician Mindset Number Four
- Physicians do not look upon EMRs, physician websites, or Internet outsourcing as the Holy Grail but are slowly adapting.

Among the physicians to whom I talk, the idea that the computer will change everything – make health care better in every way, render health care pricing and quality more transparent, separate high performers from low ones, help doctors become more productive, increase accuracy of diagnosis, empower consumers, facilitate and streamline billing processes, enhance patient safety, eliminate duplicated histories, drugs, and tests; and somehow transform and rationalize health care just as it has the retail, financial, and service industries -- is met with reluctance and resistance to change. A big part of the problem is organizational structure; physicians don’t have the group size - economies of scale, managerial expertise, and access to capital – to make the changes. Another aspect are a series of fears – radical adjustments in practice styles, outdating of what one learned in medical school and residency programs, dark suspicions of how data will be used, apprehensions about being reduced to a mere technicians behind a computer screen, and the disbelief that you can judge quality on data alone or on insufficient numbers of patients in any given disease category. Some doctors say that over-zealous data-mongers are suffering from hardening of the categories.

Physician Mindset Number Five - Physicians are beginning to recognize economies of scale and organizational structure are important if physicians are to retain control of their destinies.

As I speak to practicing physicians, I sense the idea is dawning they need size, critical mass, and performance data to compete. Some clinics and health systems are adopting Mayo-clinic type arrangements to become more efficient and competitive and to leverage their inherent power and closeness to patients. Those that don’t feel they can compete on these terms are forming concierge practices, going solo, retiring, practicing on a cash only basis, joining hospitals as employees, switching careers, or sticking to their existing practices, hoping to ride out current poor reimbursement and praying Medicare and health plans will increase reimbursement and the doctor shortage will force political change. Roughly 20% of doctors are installing EMRs in hopes of increasing productivity, pleasing consumers and payers, and anticipating EMRs will be needed to participate in consumer-driven markets; meet standards for P4P bonuses, meeting quality indicator, and metrics requirements. Other doctors are aggregating into larger virtual groups, using their wits to make process changes to increase work flow and productivity, adopting efficiency models like the Toyota lean business model, and collaborating or being acquired by hospitals in order to have access to capital, capture more of the health care dollar, and pay for the infrastructure needed to compete. As one practice management expert said, either one “competes or retreats.”

Tuesday, August 7, 2007

Limits of Technology - An Apology to a Surgeon

In a recent Sermo post “Wild, Crazy, and Creative Doctors” I carried on how important innovations are to every field of medicine. I cited several IT innovations that saved time. A surgeon protested. He said, in the main, IT innovations had never saved him time or helped him become more productive.

I flippantly commented he was wrong. I apologize. I was wrong, and he was right. Most IT innovations - EMRs, email, computer history taking – are designed to help primary care doctors, not surgeons. There may a few Internet innovations out there to help surgeons – online programs helping prepare patients for surgery, patient education videos, and doctor-controlled coding programs – but not many.

I should have also said effects of innovations are uneven. They cut both ways. Surgeons have always been extremely innovative in developing surgical devices, and laporascopic and bariatric surgery have been advances. But in other ways, innovations have shrunk the general surgeon’s world. Proton inhibitors and antibiotics for helicobacter organisms have helped make gastrectomies almost obsolete; surgeons at trauma centers have replaced many independent general surgeons; CTs and MRIs have lessened the need for exploratory laporatomies; stents and endovascular devices have minimized endovascular surgical procedures; endoscopies have reduced the number of surgical explorations; interventional radiologists are now performing deep biopsies; and there’s a general and inevitable movement towards non-interventional approaches to disease.

Innovations have profoundly effected general surgery. I apologize for over-generalizing about the uniformly positive effects of innovation on every specialty.



In a recent Sermo post “Wild, Crazy, and Creative Doctors” I carried on how important innovations are to every field of medicine. I cited several IT innovations that saved time. A surgeon protested. He said, in the main, IT innovations had never saved him time or helped him become more productive.

I flippantly commented he was wrong. I apologize. I was wrong, and he was right. Most IT innovations - EMRs, email, computer history taking – are designed to help primary care doctors, not surgeons. There may a few Internet innovations out there to help surgeons – online programs helping prepare patients for surgery, patient education videos, and doctor-controlled coding programs – but not many.

I should have also said effects of innovations are uneven. They cut both ways. Surgeons have always been extremely innovative in developing surgical devices, and laporascopic and bariatric surgery have been advances. But in other ways, innovations have shrunk the general surgeon’s world. Proton inhibitors and antibiotics for helicobacter organisms have helped make gastrectomies almost obsolete; surgeons at trauma centers have replaced many independent general surgeons; CTs and MRIs have lessened the need for exploratory laporatomies; stents and endovascular devices have minimized endovascular surgical procedures; endoscopies have reduced the number of surgical explorations; interventional radiologists are now performing deep biopsies; and there’s a general and inevitable movement towards non-interventional approaches to disease.

Innovations have profoundly effected general surgery. I apologize for over-generalizing about the uniformly positive effects of innovation on every specialty.

Monday, August 6, 2007

Clinical Innovations - Wild, Crazy, and Creative Doctors

As editor for 11 years of Physician Practice Options, a monthly newsletter devoted to improving patient care through increased practice efficiency, I’ve noted many practices succeed by innovating rather than strictly through blocking and tackling and paying attention to management details.

It sometimes pays to be wild, crazy, and creative rather than hidebound. I believe in creative, innovative, and entrepreneurial doctors – individually and collectively – to make a difference. I believe we control our destinies. I believe physicians are the central decision makers in health care, and we must keep open to new possibilities. We are closest to patients, and we know what they need – and want.

Here are a few samples of the power of new ideas.

•A family physician in California comes up with the idea of “Be seen on time, or your money back.” He and his staff made sure the practice could deliver on the promise, and business boomed.

•Two Seattle internists, Garrison Bliss and Mitchell Karton, start a “concierge” practice, based on the idea patients will willingly pay for 24 hour access, more time spent with doctors, health counseling, and help navigating through the medical maze.

•Eugene Stead, MD, professor of medicine at Duke, seeing Vietnam medics come back with skills but no work, launches physician assistants movement.

•Marshall Zaslove, MD, a physician productivity expert, advises doctors to have a nurse follow them around on the office and then to turn to the nurse often and ask, ”How could I do this better?” Zaslove says this simple idea enhances productivity enormously.

•Practices begin creating the position of Chief Innovation Officer. The officer may be themselves, a nurse, the practice manager.

•Allen Wenner, MD, a Columbia, South Carolina FP, creates the Instant Medical History, software containing clinical algorithms allowing patients to create their own histories before seeing the doctor.. The software saves 6-8 minutes in each patient encounter and creates room for 5 new patients each day.

•Susan Baker, a patient satisfaction consultant, says patient satisfaction soars when doctors train themselves and staff to meet patient satisfactions during 15 “moments of truth” that occur in every patient encounter.

•Robert Berry, MD, A family physician in Greenville, Tennessee, an area with many uninsured patients, starts a “cash only” practice and lists his prices in his front office. The uninsured, who can’t afford to pay health premiums, flock to his office for care they can now afford.

•Harry Lukens, chief information offer at Lehigh Valley Health Network, conceives a “Wild Idea Team.” He put together a team of frontline people and to have them suggest “wild ideas” to improve care and please people. It has a rotating membership of 18 to 25 people, at all levels of the organization. Meetings, open to all new ideas, not matter how wild, had only one rule” “No snickering.”

Within five years, I predict health care organizations of all sizes, shapes, and functions – health plans, hospitals, practices, support groups, consultants, and supply chain vendors, health care associations, consumer groups -- will select a Chief Innovation Officer.

The Chief Innovation Officer will generate ideas, sift through them, pick winners, and lead organizations towards a future geared to productive change.

The CIO’s chief functions are to stimulate, generate, and instigate ideas, principally from below – from managers, employees, people on clinical front lines, patients, staffs in medical offices, from consumers and the public at large. Most workable new ideas generally do not come from the top rungs of an organization, but from service and interactive personnel on the front lines of care.

The CIO’s job is to keep ideas flowing and to try them out, again and again, failing again and again, then starting out again. My favorite definition at the moment for “innovation” is this one, which I read in the March 20 New York Times.

Innovation is a constant process of trial and error. You need the willingness to fail all the time. You have to generate many ideas and then you have to work very hard only to discover they don’t work. And you keep doing that over and over until you find one that does

What does a chief information officer do? Jonathan Lord, MD, chief innovation officer of Humana since 2002, says,

The CIO becomes the spiritual leader within the enterprise. His basic role to bring new ideas into health care and to find talented people who can handle ambiguity and who have passion for change – people who have comfort with new ideas, who can align beliefs, and who can co-create.

The CIO, in short, constantly co-generates idea, keeps the ideas flowing, and tests them out to see if they work or fail. Be your own CIO.

References

1. Marshall O Zaslove, The Successful Physician: A Productivity Handbook for Practitioners, An Aspen Publication.1998,

2. Susan Keane Baker, Managing Patient Expectations: The Art of Finding and Keeping Loyal Patients, Jossey-Bass, 1998.

3. Richard L. Reece, Innovation-Driven Health Care: 34 Key Concepts for Transformation, Jones and Bartlett, 2007.