Grand Rounds, the best of the week’s medical blogging, is hosted today at the Health Business Blog. You’ll find intriguing posts including:
Enjoy!
Join us in Boston from August 6-8 for the 5th Annual World Congress Leadership Summit on Healthcare Quality and Pay-for-Performance (Please note: when you register be sure to use the following code for a special discount available only through this blog: BYH788).
The conference convenes over 350 executives and addresses the most current and emerging issues in creating sustainable pay-for-performance programs and driving quality improvement across different industry sectors. See below for information or visit the event’s website.
Among those speaking:
Dennis Batey, MD
SVP & CMO
Fallon Community Health Plan
Roberta Herman, MD
Chief Medical Officer and Senior Vice President of Health Services
Harvard Pilgrim Health Care
Jeffrey L. Kang, MD, MPH
Chief Medical Officer and SVP, CIGNA
Andreas L. Mang
Senior Director, Medical Innovation and Leadership
Blue Cross Blue Shield MA
Joel Allison
President and CEO, Baylor Health System; Board Member, National Quality Forum
Bruce Bagley, MD
Medical Director, Quality Improvement
American Academy of Family Physicians
Mary Reich Cooper, MD, JD
Vice President and Chief Quality Officer
Lifespan Corporation
Thomas H. Lee, MD
CEO
Partners Community HealthCare
Network President
Partners Healthcare System
Lee Sacks, MD
President
Advocate Health Partners
Gary Young, JD, Ph.D
Chair, Health Policy and Management
Boston University School of Public Health
Associate Director, Center for Organization,
Leadership and Management Research
Department of Veterans Affairs
Principal Investigator
Rewarding Results
Jon Kingsdale, Ph.D.
Executive Director, Commonwealth of Massachusetts, Commonwealth Health Connector
Charlotte S. Yeh, MD, FACEP
Regional Administrator (Region I)
Centers for Medicare & Medicaid Services
Mary Bradley
Director of Healthcare Planning
Pitney Bowes Inc.
Jim Guest
President and CEO
Consumers Union (publisher of Consumer Reports)
Frank A. Johnson
Executive Director, Office of Employee Health & Benefits
State of Maine
Deven McGraw
Chief Operating Officer,
National Partnership for Women & Families
Cyndy Nayer
Executive Director
Center for Health Value Innovation
Laurel Pickering
Executive Director,
New York Business Group on Health
Janet Marchibroda
Chief Executive Officer
eHealth Initiative and Foundation
Barbra G. Rabson
Executive Director,
Massachusetts Health Quality Partners (MHQP)
Tom Williams
President
Integrated Healthcare Association
George Bennett
Chairman and Chief Executive Officer
Health Dialog
Michael F. Cannon
Director of Health Policy Studies
CATO Institute
Michael Chernew
Professor, Department of Health Care Policy, Harvard Medical School; Co-Editor, The American Journal of Managed Care
Jeffrey Hanson
Vice President, Pay for Performance, Thomson Healthcare Medstat
former Regional Healthcare Manager, Verizon Communications
Bert White, MBA, DMin
Project Director, National Evaluation Team, Rewarding Results, Boston University School of Public Health
For more information on the agenda and participants, click here. And again, if you decide to join us remember to use the code - BYH788 - to qualify for a special discount.
World Congress
I have heard and read reports with a wide range of conclusions regarding the future of managing health, in contrast to and competition with treating sickness. Some have suggested that the consistently unenthusiastic evaluations of disease management, the most widespread example of managing health, portend the demise of at least this narrow range of “solutions”. Others have predicted that the “wellness” or “healthy living” market will reach the $1 trillion a year level within the next few years or decade.
Just as the original “health maintenance” and “managed care” organizations ended up focusing almost entirely on managing costs, so managing health has a major focus on reducing costs, though with a far broader range of “costs” than either HMOs or MCOs. It includes the costs to patients in terms of health and life quality as well as longevity of life, for example. And it includes the costs to employers and the overall economy of the absences, reduced performance at work, turnover, shortened work life, and other effects caused by “unhealth” in general.
While the “healthcare system”, and hospitals, in particular, are fond of describing the value they represent to their communities in terms of jobs and total economic impact on local economies, which naturally add up to the total costs of the system, over $2 trillion each year. But the illegal drug industry could as easily brag about its economic impact as well, if only the money involved were used to measure it. The real point is that the healthcare system has done extraordinarily little to promote the health, prevent and reduce disease risks, and manage patients with chronic diseases so as to reduce the crises, complications, and worsening thereof.
But there are signs that the larger health system, which includes the entire population and its health, all providers, all payers, and all other stakeholders that are affected by and affect the health of the population, are approaching a “critical mass” or “tipping point” level in terms of a far different balance of health management vs. sickness treatment. Developments in essentially all stakeholder categories are moving in that direction, at least.
For example, “Revolution Health” has most recently partnered with Medco Health Solutions to empower consumers with a personal health record to better manage their own health and healthcare expenditures. This adds to its investments in health spas, the RediClinic chain of retail clinics, which is the one I know of with a significant focus on “Stay Well” as well as “Get Well” services, and its own online health information memberships. [“Revolution Health and Medco to Partner on New Portal” E-Health Trend Watch July 26, 2007 (www.healthleadersmedia.com)]
Disney has joined in the effort to reduce the promotion of unhealthy behaviors by banning depictions of smoking in its movies. [“Disney Films to Ban Depiction of Smoking” MSNBC.com July 25, 2007 (www.msnbc.msn.com)] Google and Microsoft are both competing for the e-health market, with Google focusing mainly on consumers, and Microsoft on patient/physician interaction and information therapy. [“Google vs. Microsoft e-Health in Medical Search War for Big Profits” DirectTraffic.org July 26, 2007
Positions on controlling chronic disease costs through disease management and preventing current epidemics in new cases are being taken by both liberals and conservatives. And most of the daily increasing number of presidential candidates seem to have a position in favor of health promotion and disease prevention, as well as disease management as essential to the solution of the “healthcare cost crisis”. [T. Pugh “Curbing Chronic Diseases New Issue in Health Care Politics” KansasCity.com July 26, 2007]
Canada is taking essentially the same position, with British Columbia complaining how far it has fallen behind other provinces in its investments toward preventing, rather than waiting to treat and pay for sickness. [“An Ounce of Prevention” Straight.com (Vancouver, BC) July 26, 2007] Employers are shifting toward “value-based approaches to employee benefit design, health plan purchases, which promotes by reducing financial barriers to employees obtaining prevention, early detection and disease management services.
Intel, Inc.’s Digital Health Group is focusing R&D efforts on finding better ways to use computer and communications technologies to enable consumers to protect and enhance their own health over a “health lifetime” as a way to promote both physical and financial independence. [S. Love “Intel in Health Care” Intel.com July 2007] Cell phones will soon be able to store individual’s medical history for access by providers in both sickness care and health management. [“New Cellphone Projects to Save Lives with Medical History Information” World e-Report/Disease Management Alliance July 12, 2007 (www.dmalliance.org)] Physicians are poised to join health management vendors and health insurers as providers of proactive health management services, based on the “medical home” model agreed to by primary physicians’ associations. [V. Kuraitis “Disease Management and the Medical Home Model” Disease Management & Health Outcomes 15:3 2007 135-140]
And these are but a few of the literally hundreds of examples of just about every stakeholder in the “system” poised to or already heavily involved in attacking the healthcare crisis proactively. Some focus just on short-term gains from disease management, while others look longer term at health promotion, risk prevention and reduction. But all are persuaded that proactive interventions that will reduce the incidence and prevalence of disease and injury, along with the crises, complications and worsening of existing chronic diseases are clearly an essential component of any serious and potentially effective solution to the crisis. And instead of merely calling for such interventions by others, almost all stakeholders are implementing their own.
In a recent article in the MIT Sloan Management Review, authors Seung Ho Park and Wilfried R. Vonhonacker argue that
“To succeed in China, multinational corporations must turn the aphorism ‘think global, but act local’ on its head. Although they have to master the art of local operation, their behavior must match their global standards, as expected by the Chinese. . . Beijing has been looking to (multinational corporations) to set global standards in China — a particularly important contribution at this stage in the development of the country’s economy.”
While the authors were not talking about health care per say, I found the message being conveyed clearly something to be considered by those involved in China’s health care reform efforts: specifically, by those from the international community now trying to help China address some of its most pressing health care problems. What the Review authors suggest is that, while compromises may have to be made, the expectations of the Chinese people are not simply to make do. There are growing public aspirations that China’s time has come for its people to have full access to the benefits of the modern world. For better or for worse, foreign helpers carry the burden of representing that world to a struggling population desperately seeking entry.
And these aspirations certainly include health care.The public frustration in China with health care is palpable and its temperament volatile as demonstrated by continued outbursts of violence and threats against medical workers. For foreign companies or health-related NGOs, difficult issues arise around what people do when the situation on the ground is drastically different than the standards of health care patients believe they deserve or, in the case foreign health care organizations, what they may be accustomed to in their home country.
The Review authors believe foreign companies should be responsive to local sensibilities, but act according to global standards. In health care, that is a very difficult, but very necessary, challenge. Global health standards are often mired in cultural, political and scientific controversy despite many serious and well-intentioned international collaborations.
Foreign companies and NGOs in China may also increasingly find themselves in their own Catch 22 as the local expectations surrounding their efforts pale in juxtaposition to media-dramatized health scandals and the intrinsically slow nature of social change. As foreign health care organizations become more deeply involved in direct activities related to health care reform in China, they also become more vulnerable to the political dark side as well and the unsettling tendency at times to vilify international assistance when things go wrong to satisfy domestic politics.
So the course is set, and the travel is known to be dangerous. But there is a tremendous opportunity for discovery on the horizon. Yet, how well we navigate the treacherous currents in between still remains to be seen.
China plans to expand its medical insurance program for urban citizens over the next three years to include children and the unemployed, according to remarks this week by Chinese Premier Wen Jiabao. The increase in coverage will be financed by the central government extending coverage to an estimated 200 million additional urban residents. Pilot programs are to be launched in 79 cities by the end of September. Those cities will have some role in designing “a reasonable and practical policy for the pilot program in accordance with their own government revenue and living standards,” Wen said.
Wen’s comments are no surprise given the attention to health care reform from Beijing over the past year. The government has been reviewing a number of specific proposals and reform schemes in the last few months and public expectations are high for introduction of new programs. We should see some variety in these pilot projects as a result of this massive research effort on how to proceed in rebuilding the country’s health care system. And all eyes are now on Beijing to give the provincial and municipal leadership some guidelines and a more solid sense of direction not only for its urban population but for its rural citizens as well.
There have long been serious disconnects between what healthcare providers are willing to promise and deliver, and what patients want to get from their healthcare encounters, episodes and relationships. Providers have tended to focus on “doing the right thing”, i.e. using their best judgment, adhering to evidence-based-medicine guidelines, etc. while avoiding accountability for the clinical outcomes and health/life quality value of their services. Patient satisfaction and loyalty to providers is certainly affected by the process of care, the “patient experience” that physicians and hospitals deliver, but are often much more concerned about the results they get.
On occasions when providers look at results, they often fail to recognize the full range of and variations among patients in results desired. Surgeons at the New York Hospital for Special Surgery, for example, focused on the single outcome of pain reduction when assessing the success of their procedures. Patients, on the other hand, looked for regaining ability to do normal activities of daily life, to resume favorite leisure and sports activities, improve their overall quality of life, not merely pain relief, and the specific outcomes desired varied by individual patient. [“Patients and Doctors Often Differ on What Constitutes Successful Surgery” Strategic Health Care Marketing 20:3 March 2003 p.12]
When patients have been the sole or main source of payment for care, however, providers have often been more sensitive to results. Fertility clinics, for example, have frequently guaranteed results or offered patients some or all of their money back if they failed to become parents. The 20/20 Institute in Denver offers a guarantee for its Lasik surgery: if patients do not achieve at least 20/20 vision in the treated eyes, they get a full refund of their payments. (www.2020institute.com/guarantee.htm)
Even hospitals have, on occasion, guaranteed results to some extent. Shouldice Hospital in Toronto has long guaranteed that if hernia repair patients must return for a repetition of the procedure, the surgeon’s fees will be waived. Hospital charges cannot be waived under Canadian law. Geisinger Clinic recently introduces a “ProvenCareSM” program for its coronary bypass surgery, with a warranty covering all needed care during the 90 days post procedure. [A. Casale, et al. “ProvenCareSM: A Provider Driven Pay for Performance Program for Acute Episodic Cardiac Surgical Care” American Surgical Association 2007 Abstracts (www.americansurgical.info/abstracts/2007/20.cgi)]
What such guarantees and warranties tend to do, in addition to promoting patient confidence in getting the desired results, is to motivate providers to strive for the absolute best processes and outcomes of care they can achieve. It alters the current “perverse” incentives in healthcare payment where providers who deliver worse care get paid more, as patients need more care for complications and repetitions or extensions of care, and payers add to their payment for individual episodes. [W. Lynch & H. Gardner “Getting Paid More for Doing Worse…Only in Healthcare” Health as Human Capital July 23, 2007 (hhcf.blogspot.com)
As Lynch and Gardner pointed out, this practice creates what amounts to pay-for-performance incentives for providers, self-imposed rather than offered by payors. It figures to fit very well with the increasing burden that consumers are bearing as employers shift more costs to employees and insurers sell more health spending account plans. It also figures to serve the providers well as they reduce the long-established disconnect between what consumers want to get out of healthcare, and what providers are willing to promise and deliver.
I’ve wrapped up my medical tourism research trip to Singapore and am at the airport for my return journey. I’ve made several posts on MedTripInfo and will continue to churn out more thoughts over the next several days. Here’s what’s there so far:
Interviews and speeches (audio recordings)
Travel log
The politics and science around obesity continues to become more complicated and more urgent. Just about everyone sees it as a problem, but no one seems to be addressing it in a meaningful way. Maybe it’s because obesity has emotional, social, psychological, physiological, socioeconomic, racial/cultural, and genetic dynamics all entangled together. As an example, just take a look at the obesity-related news from the last few week:
- HealthAffairs: This is why a fat tax doesn’t make sense - if done the wrong way, it could actually increase the cardiovascular-related death rate. If fatty foods are too expensive, people will just end up buying and eating more salty foods.
- NYT: Apparently, Obesity is socially “contagious”. Do you have an obese friend? Even if the friend lives hundreds of miles away, you are 3x more likely to also be obese.
Obesity can spread from person to person, much like a virus, researchers are reporting today. When a person gains weight, close friends tend to gain weight, too.
The author of the study explains why in this BBC article:
“Rather, there is a direct, causal relationship. What appears to be happening is that a person becoming obese most likely causes a change of norms about what counts as an appropriate body size.
“People come to think that it is OK to be bigger since those around them are bigger, and this sensibility spreads.”
- FOXNews: A Missouri man claims that he was denied adoption because of his weight.
- SanDiego Union Tribune: Maybe this will all be irrelevant if we can all just pop anti-obesity pills. Another potential obesity drug just announced great results - 620 people lost an average of 10% of their body weight in 6 months. Interestingly enough, this new drug candidate is actually a combination of an anti-convulsant and an anti-depressant.
Nonetheless, the word “epidemic” is increasingly being used for obesity (and diabesity). And for an epidemic, it’s not getting enough press. I think the million (or trillion) dollar question is this: How do you get 300 million people to take more walks and eat less?
The Argus Leader newspaper of Sioux Falls, South Dakota reports on a new arrangement between a local medical center and a TV station. The “medical minute” will carry the medical center’s name. Clearly only news from that medical center will appear in the segment. This is news? Not the way I was brought up. If it walks like a commercial and talks like a commercial and is paid for like a commercial, it’s a commercial. The parties wouldn’t disclose how much the relationship costs.
Another TV station in Sioux Falls already has a somewhat similar relationship with another medical center.
So, yes, the invasion of health care commercial interests through the wall that’s supposed to exist between news and advertising has extended into the prairie lands. A former student of mine, hearing of the Sioux Falls incident, wrote to me about her TV station in another Midwest market. She reports:
“We have health segments. They’re strictly advertisements, aired during the breaks in our newscasts with our logo on them. However, they’re created to look like news stories, with a “reporter” asking doctors questions. We get calls all the time, asking about this story we aired… and we have to say, sorry that’s a commercial… don’t know anything about it…”
If this is news to you, wake up and smell the stench. As Trudy Lieberman wrote in a terrific but troubling piece in the Columbia Journalism Review a few months ago, this practice
“…has spread to local TV newsrooms all across the country in a variety of forms, almost like an epidemic. It’s the product of a marriage of the hospitals’ desperate need to compete for lucrative lines of business in our current health system and of TV’s hunger for cheap and easy stories. In some cases the hospitals pay for airtime, a sponsorship, and in others, they don’t but still provide expertise and story ideas. Either way, the result is that too often the hospitals control the story. Viewers who think they are getting news are really getting a form of advertising. And critical stories—hospital infection rates, for example, or medical mistakes or poor care—tend not to be covered in such a cozy atmosphere. The public, which could use real health reporting these days, gets something far less than quality, arms-length journalism.”
For those of you who are still non-believers in the power of a healing environment, I just received this note from one of our most outstanding physician healers. Of course this is NOT quantifiable science. It is not about shots, or antibiotics, or standard medicine. It is about human touch, comfort, respect and love. So, all of you who don’t believe it yet, take a moment and read this.
“I see the same, sad and unfortunate situations every time that I admit a patient from many other hospitals into our hospice. They come in facing impending death, and get discharged to their home or a nursing home two weeks later, eating, sometimes ambulating, most importantly COMMUNICATING, and often on no medications. In fact, I am discharging one man today who was SCREAMED at by his PCP because the patient wanted NO MORE aggressive measures done.
His PCP was obviously threatened by this, and the poor man was dismissed from the physician’s service on the spot, and Hospice came to the rescue. The man had respiratory failure, was on at least 10 different medications, and was dying. His daughter said no when the doc suggested a feeding tube, (the man even had a living will), and, as I said, the doc promptly dismissed them all, right in front of the patient in the next bed and right in front of the nurses’ station.
So now, after a few days with us, I am sending him home on nothing but our own hospice blend of flower essences like angel’s trumpet to help to prepare him for the transition into the spiritual world. He is talking, blowing us kisses, and eating pudding. I LOVE MY JOB!”
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Matthew Holt interviews Jonathan Cohn, a senior editor with The New Republic whose book - "Sick: The Untold Story of America’s Health Care Crisis — and the People Who Pay the Price” - was recently published.
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