Required reading, part 2

Abraham Verghese writing in The Wall Street Journal:

“Sacred bond,” alas, is not among the descriptors I hear when patients tell me what they think of us or our health care system. The descriptors fit to publish include “inattentive,” “no-one-in-charge” and “money grubbing.” In fact, a thoughtful lay friend recently said to me in the context of her medical care, “Face it, Abraham, medicine is corrupt.” She stated this casually, as if it were an obvious and well-known fact, not waiting to see if I would agree. At the time I remember that I sputtered. I wanted to protest but the sounds would not come out. That word “corrupt” gnawed at me for days.

The truth (should) hurt.  Lots of good stuff in the article.  Here’s part one.

Plea: Pursue Perfection

A collection of collections from across the internet, health care related, during the previous week, and worth reading/viewing/listening.

Dr. Atul Gawande admits to medicine’s role in our economic troubles and praises the power of positive deviancy to rectify the situation / some high-powered, done it right CEOs offer ideas to reform health care (ideas that even have teeth; e.g., “Regionalize high-cost, resource-intensive services under Medicare.”) / hospitals (taking a cue from the airlines?) start to nickel and dime passen…err, patients

the folks at my health innovation are doing cool things: sharing low-cost low-tech ideas / on the more high-tech side, this car knows when you’re having a stroke / the ten most creative people in health care / we could all be more creative if we were just willing to fail a little more often / health care at the mall is not new, but Mayo at Mall of America is most likely not an excess space filler

lots of ideas for solving problems / here’s an action: in a brilliant move, GE is helping hospitals make health IT purchases through no interest loans / medical errors, design, calls to action: fuzzy medical error math shouldn’t make you feel better about an overnight stay in a hospital / here’s a plea: pursue perfection

AND/OR/PS: Little Red Riding Hood could have had health care troubles / was there obesity in antiquity? / in the spirit of transparency

45. Forever Beta

So some people think the joke is on Google for its widespread use of the perpetual beta moniker.  And now, some commercial customers are said to be shying away from the Google productivity suite because of the always beta.  It’s led Google to, apparently, de-beta-fy some of its products.

Of course it’s just an illusion because the world is in perpetual beta.  Nothing is stagnant.  The shift is so that we’re fortunate just to continue standing.  Try to freeze the current environment, just try.  Leave the office for lunch and come back to find the afternoon you had planned is no more; the schedule has been burned by (metaphorical) fires across the organization.

Now extrapolate across an entire organization and it’s easy to see a different approach is necessary., “Think operating in a humble, transparent, unpolished, almost human-like FOREVER BETA mode, not just for one product, but for an entire organization.”

Forever beta is a frame of a mind.  It’s an acknowledgment that the operating environment is fluid, that service is never completely developed, and improvement is always possible.  It’s an acknowledgment that an organization is always in development, the individuals inside the organization always learning, (hopefully) improving.

Organizations in forever beta, wrote influx in 2007, show “vulnerability” and “humanity” (empathy!); they’re “open to questioning and ideas for improvement.”  Opposite (sounds a lot like health care…):

This is a radical contrast with most of the brands that came to life in the C19th and C20th, they have an industrialized view of the world, a view that assumes everything about them should be tightly controlled and perfect.

A world of them and us; the people that make and the people that buy.

Although they are created by humans and staffed by humans, they are somehow always perfect, shiny and immune to the failings of most human beings.

Sadly, for these industrial marketers, this level of control and infallibility longer endearing, the most interesting brands today and in the future are going to be the ones that are honest about their flaws and failings.

Principle #45: our own system is in forever beta. we’re always learning, we’re always working to improve; as Jay Cross writes, “after all, everything is an experiment.”  An experiment in creating excellence.

Plea: Simplicity Please

A collection of collections from across the internet, health care related, during the previous week, and worth reading/viewing/listening.

a hospital locked out nurses after their union failed to withdraw a strike notification, that’s how the process works / patient-centered care champion Don Berwick wrote an article / here’s a related interview / and a rebuttal / it may not represent both sides of the lengthy spectrum, but it’s the two most rational endpoints / is your service this good? / why are men uncomfortable going to the doctor? / the Brits are in the midst of National Men’s Health Week, the 2009 edition focuses on access to services

economic side-effect: the number of Harvard graduates entering the health care industry doubled in 2009 / hopefully they’re into solving problems / action is preferred to planning, since very few of us are any good at the latter (the “planning fallacy”) / mostly because we don’t consider this / and we’re too detail oriented; so read the second half of this and be a better planner

it would be cool if discharge instructions were similar to BOFA’s Clarity Commitment / a lack of simplicity is likely due, in part, to the monstrous size of organizations involved / yes it’s difficult, but extremely powerful / here’s another (simple) plea: simplicity please

AND/OR/PS: 20% of Americans have peed in the pool, that can’t be healthy

Plea: Commit to Simplicity!

A collection of collections from across the internet, health care related, during the previous week, and worth reading/viewing/listening.

Hippocratic-type oath for health care managers? / improved (has it even started?) hospital board trustee certification (education) would be good, too / knowing the operation would improve the “double down” conversation

search, like Wolfram Alpha, is going to do some great things for the practice of medicine / so will Google Wave for the art of communication in health care setting, enjoy the preview, Dr. Jay gets it, a few more resources / something like Get Satisfaction would be neat in health care, let an organization’s best patients share what they know

keep on an eye on the Innovation Learning Network, a community of innovative hospitals sharing with each other / do CEOs matter? / what is this failure-of-hospital-management apologist talking about? / speaking of failure, evidently there’s been an abundance of it in innovation during the last decade and health/medicine/science seems to be the culprit / real-time decision making should be a goal, especially in the world of health care bureaucracy

these folks mapped the most secretive country in the world, imagine what they can do/will do/are doing in your hospital / omnipresent: transparency, embrace it, period / here’s a solution to rising costs: elder care abroad / since more people may need government assistance

unrelenting improvement of the workforce should be the raison d’etre of an organization / doctors spend time on paperwork, shouldn’t they? / analysis of the original hawthorne effect study uncovers a lessening effect / improve your hiring process, ignore the interview /

at least one person likes the new building trend of single bed hospital rooms / the NHS is preparing for a female majority doctorforce / figuring out insurance benefits is extremely complex, though don’t place all the blame on the payers / it seems a commitment to simplicity would be a strategic advantage / actually here’s a plea: commit to simplicity!

AND/OR/POSTSCRIPT: God gets his health care at Mayo / Doogie Howser’s journal is now in blog format / health insurers own stock in Big Tobacco

It’s still, and always will be, about the costs; required reading

More care, worse outcomes.  Misaligned incentives.  Complete ignorance of the macro view.  Buckets of waste.  Gaps in medical education.  Lack of coordination and accountability.  Solving health care locally.

In other words, Atul Gawande’s most recent dispatch in “The New Yorker” is, in my opinion, required reading.  A snippet:

When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes.

The war against cross-subsidization

Using the time provided by a trans-Atlantic flight (and the spring break from normal studies), I’m finishing “The Innovator’s Prescription.”  Another great excerpt:

Not surprisingly, we reap the same inefficient results that characterized Communism.  Hospitals aggresively pursue some types of procedures—like coronary bypass surgery, for example—that are highly profitable.  And they often shun money-losing services such as psychiatric and trauma care, as well as services like preventative and primary care, which could save costs in the long run.  Eventually, more and more people lose “access,” as the services that aren’t paid well or must be provided at a loss become harder to find.  But the profits and losses aren’t a reflection of value to their customers, prices, society, or the forces of supply, demand, and competition: they are the phantom result of inaccurately set prices that are grossly ot of line with costs.  Yet as in the communist system, we muddle along because the prices that are set mistakenly high roughly offset those set mistakenly low, allowing most hospitals and physicians’ practices to eke out a modest profit after all cross-subsidization is complete. 

Can anyone provide a logical, believable, and defendable reason for why heart treatment is of more value (based upon treatment cost) than depression?

The free marketeers would claim that an absolutely free market would best distribute health care resources; the single-payer contingent is not comfortable with the fairness of that thought.  Opposite, a completely controlled government system would provide equal care for all; yet the free marketeers are uncomfortable with subjective pricing.

As we continue to debate our next health care reform effort; is an efficient system with limited government intervention fathomable?  The point is moot, regardless.  We’ve got some time yet in the system currently in operation.

As an extra thought, however, why not explore what has worked in Germany.  No, not the health care system; but the country itself and the path it has followed since recovering from Communist rule following World War II.  There are still socialist policies in place; however the country has grown into the world’s third-largest (Europe’s largest) economy and the largest exporter.

The thing to remember is that it’s possible for the free market and goverment intervention to co-exist.  Although far from ideal, it’s the American health system in its current form.   The system is in need of change to asure coexistance is mutually beneficial to all involved.  Easier. Written. Than. Done.

“No Margin, No Mission”

To be added to your summer reading agenda: “Hospital: Man, Woman, Birth, Death, Infinity, Plus Red Tape, Bad Behavior, Money, God and Diversity on Steroids” by Julie Salamon.

Here is the New York Times review.

It seems to be an ultra-insider look at the innerworkings of a hospital—Maimonides Medical Center in Brooklyn.

From the review:

To me, the big surprise in this book — I can hear the doctors out there laughing — is how much hospitals, even nonprofit community hospitals like Maimonides, think about money. As administrators there say, “No margin, no mission.” I was under the impression that hospitals have to treat anyone who comes to the emergency room, but there are many definitions of “treat.” Hospitals have to stabilize patients, it seems, but they do not have to cure them. If patients can walk and their wallets are empty, they can be walked to the door. Administrators track the performance of all the doctors. Operations are a gold mine and admissions are good, but only if the patient doesn’t stay longer than insurance permits. “We don’t want more of the elderly, complicated patient,” the head of the cancer center says — actually says! — at a meeting.

Tom Peters on Health Care

I’m a fan of Tom Peters. My dad turned me onto Re-Imagine! early in my undergraduate years; and now, as I look back, I can point to that book and say that it single handedly changed my approach to the world. There have been influences since then to be sure, but that book is solely responsible for my new (at the time!) approach to thinking about, well, everything.

Mr. Peters has been advocating for better health care for as long as I have been reading his blog. But it seems (which is good for us BTW) he has a renewed interest in health care. In fact, he recently spoke at Kindred Healthcare and graciously provided us with his slides from the presentation (find them here). Go check him and his crew out. There is some really good stuff like:

“As unsettling as the prevalence of inappropriate care is the enormous amount of what can only be called ignorant care. A surprising 85% of everyday medical treatments have never been scientifically validated. … For instance, when family practitioners in Washington were queried about treating a simple urinary tract infection, 82 physicians came up with an extraordinary 137 strategies.” Source: Demanding Medical Excellence: Doctors and Accountability in the Information Age, Michael Millenson

And this not by Tom Peters but from Thomas Goetz in the New York Times Magazine as a nice follow-up,

Doctors don’t like to admit it, but “most treatment decisions right now are still based on doctors’ judgments that don’t have real research behind them,” says Jodi Halpern, a physician and bioethicist at the U.C. Berkeley School of Public Health. “But it takes real data to make the right decisions, especially for patients. There’s a powerful improvement in health outcomes, people’s quality of life, when people are better-informed.”

Physicians, of course, have known this for decades; the idea of “evidence-based medicine” — that all decisions should be based on real data — was hatched in the 1980s. But the pace of traditional research is slow, and the number of outstanding questions far exceeds the body of evidence to answer them.”

Make an informed decision…

All of these early primaries/caucuses have made the winter blahs a bit easier for me to deal with. And whether you consider yourself a political wonk or a newbie it would be in your best interest to make an informed decision in any voting situation you may find yourself in the near future.

My focus here is going to be on links to information regarding the candidates’ plans for health care. Republicans and democrats differ (a lot!) in the plans they offer. Variation within their respective parties is less. As we continue on this process throughout 2008 I am going to assume plans may become more detailed.

Generally, comparisons amongst all candidates can be found here (Kaiser presents the information well) and here (HealthCentral’s spicier comparison).

Democratic plans (candidates who have a realistic chance): Clinton, Edwards, Obama

Republican plans (again, candidates who have a realistic chance): Giuliani, Huckabee, McCain, Romney

Analysis (courtesy of Health Care Policy and Marketplace Review): Clinton, Edwards, Giuliani, Huckabee, McCain, Obama, Romney

Banter: banter, banter, more banter, banter, banter, banter