Vacation Plans: The National Health Museum?

The Miami Herald:

Atlanta has been selected over Washington and other cities as the site of a $250 million National Health Museum designed to teach visitors about healthier living and serve as a stage for international health events.

My hope is that their healthy living programming will reach nationwide, not just those who visit in Atlanta.

I also have slight objections to museum-ization of the topic.  Is the health of the people in this country really worth exhibiting?

The museum will incorporate a conference facility of some sort along with installations like:

A ”Move” zone, for instance, will focus on how the human body works and how exercise and activity is important, for instance. A ”Connect” zone will show how everyone’s health is connected around the globe.

Most of the funds raised will be done so privately.

Pardon the realism, but wouldn’t multiple less-expensive healthy living centers located around the country do more to impact health in the U.S. than a centralized shrine to our health breakthroughs?

We can’t have it both ways…

In Boston they fight the spread of the retail clinic (from The Boston Globe):

The mayor has argued that retail clinics providing episodic care will fracture the medical system, ultimately hurting patients.

But in St. Petersburg, Fla., traditional care providers are going retail (from St. Petersburg Times):

“A lot of hospitals are getting into more retail medicine” to boost their bottom line, said Donna St. Louis, vice president of outpatient services for BayCare.

So basically hospitals want to be able to operate in retail environments—and have no new competitors in that arena.

Hmm.  “Have your cake and eat it too?”

In Washington D.C., Senator Grassley is up to his old tricks (from the Health Blog):

Sen. Chuck Grassley took another swipe at lucrative tax breaks of nonprofit hospitals yesterday–-at a hearing that wasn’t even about hospitals.

But again, in Florida, this (from St. Petersburg Times):

Bayfront Medical Center operates Bayfront Rejuvenations at one of its convenient care walk-in clinics at 7000 Fourth St. N. And BayCare Health System, which runs several nonprofit hospitals in the Tampa Bay area, plans to open a medical spa at its St. Anthony’s Carillon Outpatient Center in late August.

Tell me how to go about defending the important nonprofit tax benefit hospitals receive when they are offering cosmetic procedures like Botox injections.  Can anyone rationalize how these medical spas are providing enough community benefit (i.e., free care) to make up for that tax free benefit?  I’m sure there are plenty of self-pay patients utilizing the services—but definitely not the traditional self-pay (i.e., no-pay) patients hospitals have become accustomed (averse?) to in recent years.

Here is an attempt:

“We do not have a medical spa. We have an aesthetic medical practice,” said Waldrep, medical director of the new practice and of Bayfront’s convenient care clinics.

OK, we’ll call it AMP for short.

Throw us a bone…

Here is another attempt:

As medical spas have multiplied, so have concerns about the quality of services they offer and the level of medical supervision present. The hospitals see themselves as a natural alternative. They hope people will automatically associate their names with higher-quality medicine.

OK, better.  But need we be reminded that traditional health care organizations have quality concerns of their own?

Finally, the real reason for the service expansion:

Just as primary care doctors have found spas a way to bolster their bottom line, medical spas are a way for hospitals to bring in dollars to balance out other services that communities need, but lose money for the hospital, such as trauma and indigent care.

Misplaced incentives make for mislaid business plans.  But building barriers around hospital fiefdoms isn’t the answer.  And dabbleing in borderline health care services isn’t either.

The answer comes from concentrated efforts to improve what we were created to do: care for patients who truly need our help.  Competition helps us get there.  Focusing on what we do best helps us do it.

The Revolution from Below (and the Edges)

I oft wonder why our system has been broken for so many years. And for so many years why nothing has changed—why has it worsened? And I don’t know the answers. To be honest, I couldn’t care less about the explanations for why, the reason I have entered this industry is to help rectify the situation. I’m not just talking about affordable care and access for all, I’m also including making health care personable, responsive, adaptable, innovative, enjoyable, etc. (And believe me, there is a lot of E-T-C.)

I’m sure someone, somewhere, at some time has shared the same thoughts—but the struggle continues. I can’t help but think that this time is different. That our generation’s efforts will be different. I have no business doing what I’m doing if I didn’t feel this way. I have respect for what you do and what you have built, but if it makes little sense and stands in the way of changing what we have for the better, don’t expect me to nod my head in agreement as you defend the archaic system.

Do you know what is great? How scared people are of “millennials.” Do you know why this is great? Because being scared means things are changing. If you have googled “managing millennials” you know what I am talking about.

Health care should be the most scared of any industry—its general opposition to change is in for a huge shake-up at all levels. The only thing I’m going to apologize for is the topsy-turvy future this is going to create. We would like to make (positive) change collaboratively. But we’re going to do it whether or not you’re on the bus.

Stick us at the bottom, we’ll change it from below. Marginalize us and we’ll start at the edges.

Chet Gulland guest posted at Noah Brier’s blog this week. He writes on young people graduating and the annual “entering the workforce” conversation:

Here’s the little story I’m picking up on: Millennials have reached critical mass in the workplace (front edge 27ish now), are exerting some real power and influence on business and culture, have more like-minded folks coming in behind them that amplify their perspectives, and now, according to some folks, it’s time to get defensive.

But Chet reminds us it need not be a war:

In this complex story of who this generation is and what they mean, I think the biggest (and most exciting) point is missed if we don’t look at everything through the lens of the changed digital communications DNA that they are the leaders of. The great upside to this, as Shirky points out, is that all generations benefit. The way young people operate and the tools they use spread everywhere. The new ways they are organizing themselves will spread everywhere (I’ll be surprised if the biggest, most historic story this year is not about how young people organized themselves to vote in their choice to the White House). I think this is a healthier way to look at the situation. We can be excited that we can work and collaborate with a group that brings a fresh approach to communication, among many other things.

So, together, please, together. I know I’m idealistic. But it beats being pessimistic and stagnant.

The Emergency Department Experience: Redux

Yesterday I expressed the need to improve/master the emergency department experience for the patient.  And I completely believe that.

It can be easy to express ideals on a blog.  In fact, I do it weekly on purpose (see 1001 Principles).  But it also can be easy to forget the realities of every day health care.  So today when Kevin MD posted link after link after link of E.D. related challenges, it was a subtle, but necessary, reality check.

Read about a day not many would choose to endure.

Read about trying to match supply and demand.

Read about being unappreciated.  And being OK with it because it’s your job.

I’m still “all in” on the need for a great E.D. experience.  I’m still “all in” on ideals.  Ideals are important.  But so is reality.  And I would suppose the best doctors, the best managers, the best organizations are constantly trying to find that balance.

Health Care Bubble?

I have been reading a lot about economic bubbles lately. There may be a commodities bubble. There may be an agriculture bubble. We all know about the housing bubble that burst (it’s spreading around the globe now).

Well, that got me wondering. Could there be a health care bubble?

Not being an economic whiz, I turned to some online resources.

The Financial Dictionary says: “A temporary market condition created through excessive buying, and an unfounded run-up in prices occurs.”

Some have argued that we buy too much health care. The foundations of rising prices are not clear cut.

Next to the trusty Wikipedia to find a foolproof system to determine when a market is bubbly. Turns out there are no hard and fast rules. Excerpts follow:

The cause of bubbles remains a challenge to economic theory. While many explanations have been suggested, it has been recently shown that bubbles appear even without uncertainty, speculation, or bounded rationality.

OK, good to know.

Most recently, it has been suggested that bubbles might ultimately be caused by processes of price coordination or institutionalization.

We have laws in place to discourage price coordination, but a true market has little impact in determining health care prices. Institutionalization: health care is highly regulated.

Because it is often difficult to observe intrinsic values in real-life markets, bubbles are often identified only in retrospect, when a sudden drop in prices appears. Such drop is known as a crash or a bubble burst.

So we won’t know until afterward.

Not extremely helpful. But take into consideration some of the issues we’re dealing with: building boom, worker shortages, Medicare’s trust fund issues, drug costs (up), labor costs (up), expensive new technology (the efficacy is debatable in some products)…care to add more?

Very little in health care is governed by real market incentives (that could be good or bad, depending on your thoughts). The problem remains: it all just keeps going up. The spending may be able to continue; it may not; but reality is that health care continues to become more expensive. Because we try to sustain all parties (and try to keep them happy) in the health care industry, the requirement (like, when we have no choice) for change is quickly arriving.

If we get to that point (when reform is not by choice, but by necessity), some party(s) must lose. That is when the health care bubble will bust.

What health care actually costs

Our employer based health insurance system distorts the real cost of health care.  Some (rightfully so) attribute our current consumption activities to this distortion.

A classmate was relaying a conversation last week that she had had with a group of law students.  She asked, “How much do you think open heart surgery costs?”  One response, “a couple of thousand bucks.”

The WSJ Health Blog wrote a couple of weeks ago about San Francisco restaurants reacting to a local mandate to provide health insurance to employees.

Since the beginning of the year, San Francisco businesses have been required to offer health insurance to employees or pay a fee to the city to fund health care.

Some restaurants are passing the fee on to consumers in the form of a health surcharge, which shows up on the bill as a flat fee ($1 per person, or so) or as a percentage (like sales tax).

Interesting thought.  A surcharge at the bottom of a Wal-Mart receipt?  Or a hotel bill?

Can you imagine GM placing a line item at the bottom of the sticker on a new car detailing a $1,500 surcharge for health insurance (back when they offered it to retirees).  Not that it would change the bottom line price.  But do you think that would make someone think twice about purchasing the vehicle?

Health Care and the Mafia

Coincidentally, a couple of relevant mafia stories…

If we’re in need of a scapegoat for any health care insurance reform, Dr. Jonathan Kellerman has found the party in a biting Wall Street Journal opinion piece:

The health insurance model is closest to the parasitic relationship imposed by the Mafia and the like. Insurance companies provide nothing other than an ambiguous, shifty notion of “protection.” But even the Mafia doesn’t stick its nose into the process; once the monthly skim is set, Don Whoever stays out of the picture, but for occasional “cost of doing business” increases. When insurance companies insinuate themselves into the system, their first step is figuring out how to increase the skim by harming the people they are allegedly protecting through reduced service.

Once they affix themselves to the host – in this case dual hosts, both doctor and patient – they systematically suck the lifeblood out of the supply chain with obstructive strategies. For that reason, the consequences of any insurance-based health-care model, be it privately run, or a government entitlement, are painfully easy to predict. There will be progressively draconian rationing using denial of authorization and steadily rising co-payments on the patient end; massive paperwork and other bureaucratic hurdles, and steadily diminishing fee-recovery on the doctor end.

He actually suggests ridding ourselves completely of insurance, it’s worth a read.

The Guardian, last week, had an intriguing story on how to do (good) business like the mafia.  Despite some of the questionable tactics employed by the mafia over the years, Clare Longrigg writes there are lessons to be learned from organized crime.  My favorite (of the seven):

Rule 6: Reinvention

In case of a political scandal, or a business failure, it is vital for the new boss to be able to distance himself from the whole affair. Indeed, he may find it useful to take on a new persona altogether. When Stuart Rose returned to Arcadia after three years to rescue it, he said: “What is interesting is that people here think I haven’t changed, but I have been gone three years. I am not the same Stuart Rose, I have changed a lot.”

With Provenzano’s new directives, not only did the negative headlines cease, but he managed to dissociate himself from the scandals that had gone before. Like everyone else, he had emerged from Cosa Nostra’s most violent decade with his reputation in tatters; his advisers helped him to “get his virginity back”, in Giuffrè’s interesting phrase. With the help of his PR-savvy advisers, he made sure no one associated him with the violent years, and created his image as the peacemaker.

“When I got out of prison,” Giuffrè recalled, “I found Provenzano a changed man; from the hitman he once was, now he showed signs of saintliness.”

Understanding the Differences

One of the best aspects of my MHA program (and one of the reasons I chose it) is a clinical rounds class that places MHA students with a hospital service for five weeks to observe medical students, interns, residents, fellows, and attendings do  rounds.  I have often heard that learning on the job is the best way to learn; this experience is no different, a key to understanding others and learning about what they do is to immerse yourself in their situation.

One of the important differences that separates health care from other “business” is that most providers—who are directly responsible for admitting patients into the hospital and thus, relied upon in order for hospitals to make money—are not employees of the hospital.  It is understandable why problems develop.

The age-old health care management problem involves a disconnect between providers and management—most likely to do with a lack of communication.  This class, while admittedly too short, is an effort to help administration students (most with limited clinical experience) gain an understanding of the medical education process (and a general look into the provider’s decision-making process).

I’ve always respected physicians, but my respect has increased dramatically after just a few meetings with my care team.   Decision making can be difficult as there is always some uncertainty in the decision making process.  Limiting that uncertainty is a key to making good decisions.

Here is what I’ve come to understand well: Uncertainty rules the day in medical care.  And patients expect miracles.  While the competent provider (of which I have yet to meet one on the other side) often has a good idea/understanding of a patient’s medical problem, they just never know for sure.  Here’s the problem: (constant!) vague and incomplete information.  Besides a detective, who else deals with so much constant uncertainty?  Or if that isn’t enough, how about dealing with uncertainty and knowing the decisions made could have a negative impact on another human life?

Differences between providers and administrators will always exist.  The two have very different job descriptions with very different expectations.  The differences create a necessary balance.  While only for a short period of time, being exposed to providers doing their job is helping me visualize those differences.  The hope is that this experience will translate to a better understanding of it all.