Monday, September 22, 2014

The irony of on-line advertising algorithms

Sometimes the irony of on-line advertising algorithms is made evident.  How about this article in the New York Times--focused on the adverse impacts of hospital mergers--being tagged with an ad from Partners Healthcare System!  ("We're rethinking health care," says the corporation.  Are we convinced?)

Mores seriously, this article explains why Partners needed the buy-in from the Massachusetts Attorney General in the recently filed settlement of its anti-trust case: "State action" precludes a more thorough federal involvement.  But the real question is why the federal government agreed to defer to the state in the first place, as opposed to pursing an FTC and/or DOJ case:  Was this a favor from the Obama administration to their preferred Democratic candidate?

Screening the screenings

Here's an excellent piece about "wellness screenings" by John Lundy at the Duluth News Tribune.  The underlying theme about unnecessary testing and the business of selling such tests is important.  John's presentation is very well done.

As Gary Schwitzer notes in a message to health care reporters, "Imagine the impact if this kind of story was published by papers big and small across the country."

An excerpt:

The screenings — for stroke, atrial fibrillation, abdominal aortic aneurysm, peripheral arterial disease and osteoporosis — “aren’t just routine procedures,” an enclosure in the envelope [a 74-year-old man] stated. The words were next to a photo of a solemn-faced man in a white jacket, with a stethoscope hanging around his neck.

“They can help save your life,” it concluded, with the final three words underlined.

But some health experts argue that some of the screenings offered by Life Line and similar companies actually can do more harm than good.

“The layman would be shocked to know we actually do not have science to show that these screening, early detection tests actually decrease mortality or are beneficial to the patient,” Dr. Otis Brawley said in a telephone interview.

The chief medical officer for the American Cancer Society and a professor at Atlanta’s Emory University, Brawley wrote the 2011 book “How We Do Harm” on practices he argues benefit everyone except the patient.

Sunday, September 21, 2014

In memoriam: Katherine McQuade Toig

The world lost of one its true angels this week with the death of Katherine McQuade Toig, RN.  Katie was a beacon of light to all who knew her.

We first met when she was a nurse in training at BIDMC.  She was always dropping by my CEO office with questions and ideas. As a colleague said, "She wanted to save the world."  In so doing, she constantly questioned her role and her place and was searching for the best way she could serve humanity.

Here's an excerpt from a blog she wrote while on a volunteer mission in Kenya, which inspired her to remain involved in that region:

I am uncomfortable. My senses did their job in Kenya. They collected sights, sounds and information for me to wrestle with. My mind will not be the same. Old beliefs and realities cannot accommodate the new information. The process of reconciliation is not tidy. It won’t work for me to come to simple explanations and conclusions. I will need to sit in the dissonance for a while and build new constructs of thought. 

I will continue to collaborate with Tatua. My energy will be aimed at empowering and supporting the Community Health Workers in the slums of Ngong, Ngando and Rongi. It isn't enough to provide mission work to the slums. The solution has to grow from within. The CHWs are uniquely positioned as access points to healthcare. My mind can rest on this. 

A new chapter begins for me here with the CHWs.  

Little did I know that Katie would help me heal after a difficult period I had in the hospital.  Here's how she responded to an email I sent to the staff apologizing for my bad judgment:

"I am moved by your letter and want to thank you for all your work. As for any transgressions you may have had, I feel you are only human and we all make mistakes. As I’m sure you know, it is how we handle them that makes us who we are."

Wisdom beyond her years.  Compassion and empathy that set an example for all who knew her. Deep sadness for all who will now miss her.

How fast can a proton go down a drain?

I've had a number of people write to me upon seeing Jaimy Lee's story in Modern Healthcare:

The Indiana University Proton Therapy Center will close in December, marking the first time a proton-beam therapy center in the U.S. has shut its doors since the rapid proliferation of the costly treatment centers began about a decade ago.

University executives and an independent review committee attributed the center's financial losses to a range of issues, including the cost of maintaining its aging cyclotron, but the committee also suggested the industry may be on the verge of a “proton bubble” as the centers struggle to serve a sufficiently large patient population.  

"Is this a trend?" they ask me.  The UI had a special committee to help them in this matter:

In the committee's report, the reviewers highlight many of the issues affecting the proton industry as a whole, including the lack of completed randomized clinical trials, improvements in alternative treatments, changing care patterns for patients with prostate cancer, and the rise in new payment models, such as bundled payments that may remove incentives to use the therapy.

“It is, therefore, quite possible that we are on the verge of a 'proton bubble' with the more indebted centers or those without a strong patient supply line closing,” the committee said in the report. 

Well maybe and maybe not.  Maybe there were local conditions at work: 

The losses and challenges were clearly outlined in the report. The IU center requires 63 people to staff the cyclotron, spelling high labor costs. The technology, which was adapted from a research cyclotron, needed a $30 million upgrade. The Bloomington site, which is an hour's drive from Indianapolis, is not ideal for clinical-trial participation because it requires most patients to travel.

The center reported a $3.5 million operating loss in fiscal 2013. Another challenge it faced: newer centers are expected to be opened by University Hospitals in Cleveland, Ohio, and by the Mayo Clinic in Rochester, Minn., key referral markets.

But one thing is for sure.  The investment in this machine represents a huge opportunity cost for the University and the patients served by it and, indeed, for other clinical departments.  That tax on the University will persist, as the bonds must still be paid off.  Millions of dollars have and will go down the drain in support of a technology with limited clinical applicability--all part of the edifice complex supported by selected physicians and hospital administrators.  (See the pride with which it is described on the website above and in this 2010 press release announcing a renaming: "We will be proud to be known as IU Health Proton Therapy Center," stated Dr. Peter Johnstone, president and CEO, who shared this important information with staff via executive email.)

And all of this is aided and abetted by perverse Medicare payments that CMS persists in maintaining--even as private insurers declare the treatment ineligible for payment.

Saturday, September 20, 2014

We use autonomy as a defense to the need to appear to be impossibly perfect

Gene Lindsey's weekly email letter invariably contains some gems.  Here's one from this week. He cites Sally Kilgore, president and CEO of Modern Red School House Institute, from her co-authored book Silos to Systems. The book is about how the education system might be improved. Gene says:

Her introduction concludes with insight that is applicable to healthcare.
Envisioned by Donald Schon (1973), a learning organization is one that is “capable of bringing about its own transformation.” But creating that condition requires that we pay attention to how we organize professional life at schools—how information flows, the form in which leadership is shared, the diversity of perspectives we use to solve problems, and the degree to which our interdependence as educators becomes an opportunity rather than a nightmare.
Her words are sweet notes to my ear. I love the construct that in a learning organization, interdependence could become an opportunity rather than a nightmare. Read this next excerpt:
Organizational systems theorists emphasize that solving important problems requires multiple perspectives and seemingly diverse approaches to the solution. Ian Mitroff and Abraham Silvers (2010) find that lacking diverse perspectives, we often solve the wrong problem.
In my own recent thinking, based on observations of hospitals and medical practices across the country, I have evolved an image of the toxic triangle that makes improvement in healthcare so difficult today. Our current sense of despair seems to arise from increasingly negative externalities that we all feel but do not understand. The culture of autonomy and our tendency to be in tribes of various states of understanding preludes progress. We are like a sailor in “irons”.
We use autonomy as a defense to the need to appear to be impossibly perfect, and the result is isolation or the use of silos for protection when the solutions to the problems of our patients, which are our professional responsibility, lie in interdependence.

Friday, September 19, 2014

Goal Play! hits 10K

I just received notice that Goal Play! has sold 10,000 copies.  I am honored that so many people have read and enjoyed these leadership lessons and recommended the book to their friends and colleagues.  Thank you!

Thursday, September 18, 2014

2014 Sepsis Heroes

I was so pleased to be invited by Dr. Jim O'Brien to participate in the Sepsis Alliance 2014 Sepsis Heroes ceremony in New York City.  Here are the awardees:

Laura Messineo is a critical care nurse who is passionate about increasing sepsis awareness among healthcare professionals and the public. Although she has been a nurse since 1991, it would be several years before she first heard the word "sepsis" being used. She has since become a driving force in her healthcare facility and community in promoting sepsis awareness and education.

"I have challenged myself to learn everything I can about sepsis through lectures, articles, and attending conferences such as the American Association of Critical Care Nurses' (AACN) National Teaching Institute (NTI) and the Society of Critical Care Medicine's Annual Congress."

According to Ms. Messineo, sepsis awareness is important because it is a treatable disease process, which can result in a positive outcome if early goal directed therapy is initiated quickly. Community awareness and clinician education is vital in decreasing septic shock mortality and improve the lives of sepsis survivors. Laura plans on continuing to speak nationally on sepsis, writing grants for more sepsis education, and championing national regulations for sepsis screening.
Sepsis remains a leading cause of maternal mortality around the world, even in the 21st century. Raising awareness about prompt treatment of infections, and improving hygiene and conditions where women deliver their babies will reduce the risk of sepsis and help to make pregnancy and childbirth safer for both mother and child.

Every Mother Counts is an advocacy and mobilization campaign founded to increase education and support for the global reduction of maternal mortality around the world. EMC's work in the United States ensures that more mothers have access to prenatal care and childbirth education.

"People are shocked when they learn that women are still dying in childbirth. We are committed to informing the public about the challenges and solutions."
The timing of sepsis suspicion, diagnosis, and management are essential to improved outcomes. That first hour in treating sepsis is as vital as that first hour after someone has a heart attack or stroke. Intermountain Health, a nonprofit system in Utah, has put into place a sepsis bundle for its dianosis and management. This bundle, which included 11 clinical elements to be addressed during the first 24 hours of treatment, resulted in a drop in mortality rate from sepsis from 25 percent to around 9 percent. This equates to saving about 100 lives per year.

Virtually everyone on the healthcare team is involved in the sepsis bundle, including nurses, emergency medicine physicians, hospitalists, critical care physicians, transport specialists, respiratory therapists, radiologists, laboratory technicians, and other providers. Intermountain Health hopes to expand sepsis awareness beyond their emergency departments in order meet patients with wherever sepsis is diagnosed, be it in the general hospital wards, clinics, or at home.
Helene and Jeff Zehnder were nominated and chosen as 2014 Sepsis Heroes for their work in raising sepsis awareness. While Helene is a nurse and is familiar with sepsis, when a family friend died of the illness, the couple realized that work needed to be done to raise sepsis awareness in their community. The result was the inaugural 5K Walkathon/Road Race, called Step on Sepsis.

Helene Zehnder has been a nurse for 35 years. She is currently the Director of Medical-Surgical Nursing and Magnet Program Director at Rex Healthcare in Raleigh, N.C. She has a BSN from the University of Pennsylvania and has a masters degree in nursing from Widener University in Chester, Pa. Member – of the NC Nurses Association, the Academy of Medical-Surgical Nurses and the American Association of Critical Care Nurses (AACN), she is the current president of the Greater Raleigh Chapter of AACN. Helene was named one of the Great 100 Nurses in North Carolina in 2013.

Jeff Zehnder is a graduate of Stockton State University in New Jersey with a degree in business administration. He worked in the corporate world for many years and now is a home inspection business owner in Cary, N.C. He is an avid reader and participates in multiple sprint triathlon and 5K events. He is the president of the neighborhood homeowners association and volunteered with Boy Scouts of America for many years.

Wednesday, September 17, 2014

SBIRT fights alcohol abuse

Last year, I wrote about the college drinking phenomenon known as Thirsty Thursday and pointed out that a significant percentage of Emergency Room patients at St. Elizabeth's Hospital come from nearby Boston College, arriving with a diagnosis of alcohol poisoning.

That's the bad news.  The good news is that a group of volunteer undergrad pre-meds from the same school participate in a Screening Brief Intervention Referral to Treatment (SBIRT) program at the hospital.

Aaron Lemmon, who developed the program for the hospital, reports, "Over the past four years 18 screeners have engaged 543 patients with substantial improvement in both recidivism rates and culture of care.  They also have produced a video documentary, video role-plays, and an 84 page manual to facilitate program replication, which were presented at two national conferences."

The video follows.  This is a lovely example of cooperation between two institutions, relying on the idealistic energy of future doctors.  Aaron's hope is to expand programs "through which major health care providers could selectively integrate aspiring healthcare professionals into expanded care teams with minimal cost."  After he finishes his MBA/MSIS in Health Sector Strategy at Boston University in 2015, he's bound to make a difference.

A bit harsh on Minute Clinics

I really admire Shannon Brownlee, but I have to take issue with the parts of her Providence Journal article in which she takes CVS to task for running Minute Clinics in their stores.  But perhaps we end up in the same place anyway!

In summary she argues:

For-profit retail clinics are a bad sign to anyone who understands the special role of primary care in providing good health care to a very sick nation.

Primary care is one of the few places remaining in the medical system where physicians and patients have direct personal relationships that last longer than any particular treatment or illness.  

But CVS and other companies diving into primary care aren’t interested in building relationships. Patients are customers, not vulnerable human beings, and the health professionals who work for them are employees, not caregivers. For these companies, health care isn’t about caring or healing — it’s a product — and their interest in providing it is aimed at the bottom line. In the future, your relationship with your doctor will be about as meaningful as your relationship with the local barista at Starbucks.

By siphoning the easy cases and easy revenue away from primary care offices, retail care further undermines their financial stability.

But then she points out the problems in maintaining traditional primary care practices:

You can’t blame retailers for jumping into the business of offering primary care services. The fact is, primary care doctors have failed to provide services that patients need: fast care for minor ailments, and care that’s available in the evenings and on weekends.

For the sake of all those who have a chronic illness now, or who are destined to get one as they grow old and frail, the nation had better figure out a way to support primary care practices. 

I don't think we should blame the retailers for filling a gap in the healthcare system nor should we demonize them or their clinical staff by saying they really don't care about people's health. Where Shannon and I appear to agree, though, is on a key point:  If the country really wants to support primary care, there are ways to do that, starting with fixing a perverse reimbursement system.

Tuesday, September 16, 2014

The third golden handshake

Blue Cross Blue Shield has, in some respects, been a leader in Massachusetts in pursuing the agenda to bend the health care cost curve.  But the company has a blind spot when it comes to Partners Healthcare System.  Worse, it has a history of caving to the economic interests of the dominant provider, even when doing so undercuts the company's stated goal of bending the cost curve.  It has now engaged in three golden handshakes with the health care system:

The first golden handshake occurred years ago, when BCBS acceded to Sam Thier's statement that, "This is what good health care costs," and began a practice of paying the system above-market rates--for care at the academic medical centers, for care at the community hospitals, and for care in the PHS doctors' offices.  Every layer of the PHS system received prices above the comparable layer of other hospitals.  Year after year after year.  The Boston Globe's Thomas Farragher retold that story this week.

The second golden handshake occurred in 2011.  It was spun by BCBS as securing a renegotiation of PHS contracts, lowering the rate of increase compared "to what would otherwise happen."  But it was actually an above-market increase given to a system with rates that were already substantially above the market.

The third golden handshake occurred this week. In the face of the most important proposed anti-trust settlement of the decade, the one between the Attorney General and Partners, the one on which dozens of parties have filed comments with the Court, BCBS was silent. Absolutely silent.

The Massachusetts Association of Health Plans, representing all the other insurers in the state, filed comments against the deal.  As noted in Priyanka Dayal McCluskey's Globe story:

The deal, insurers said, “could have the unintended effect of exacerbating the market dysfunction issues it seeks to address."

The highly substantive (!) response from Partners: “It’s no surprise that a lobbying group for the insurance companies has submitted comments that serve their own self-interest."

BCBS, which has more subscribers than all of the rest of MAHP combined, was missing in action.

Its actions over the years and its silence now join it irrevocably with Partners as an advocate for higher health care costs in Massachusetts.

Privileged parking

I don't want to appear to be nitpicking, but sometimes the decisions that are made by health care people are indicative of underlying problems--or just obliviousness.  Here, for example, I find it hard to understand why the doctors who work in this multi-specialty clinic--which includes orthopaedics and urgent care--should have reserved parking places that are closest to the entrance of the building.

Even if this non-patient-centric result doesn't bother you, consider the fact that only the doctors, among all the clinicians and ancillary health care professionals, get this privileged treatment.  Is the time of doctors more valuable than that of the nurses, the NPs, the PAs, and the techs?

I know, it's just a matter of a short distance to the other parking places in the lot, so it's not a big deal.  But why set up artificial class distinctions?  It would also not be a big deal for the MDs to walk that extra distance.

Sepsis Heroes

Will you be in New York City on Thursday evening, September 18?  Please join us for Sepsis Heroes.

Sepsis Alliance is hosting its 3rd annual Celebration of Sepsis Heroes on September 18, 2014. We received a record-breaking number of nominations this year from people who wanted to recognize healthcare workers, friends, family members, and facilities. This year, we are honoring two individuals and two organizations. Click here for event details.

Monday, September 15, 2014

Turning Turtle -- Is this how doctors are socialized?

Here's another short excerpt from a draft of a book--Turning Turtle--being written by my friend and colleague.  As I described below, Samuel Jay Keyser--Professor of Linguistics (Emeritus) at MIT--suffered from a debilitating fall that left him severely injured and experiencing the health care system in a way he could have never imagined.  This moment takes place after his second surgery for spinal cord injuries. 

One day a solo doctor came into the room, introduced himself, and without much preamble told me that while the operation was a success, I probably would never walk again. 

“Fuck you,” I said to myself.

To him, I said, “I’m sorry to hear that.”

“I know it isn’t what you want to hear,” he said in a consoling way. “But it’s best to be realistic in situations like yours.” 

I wonder why he felt the need to be “realistic.” Perhaps it was his way of defending himself from becoming too close to a patient.

I learned later that the nurse on duty had overheard the conversation and had given him hell when he left the room. Much later in my hospital stay, he exchanged his severe demeanor for one with an engaging smile. I wonder if the nurse’s dressing down had changed him. I wonder if that’s how doctors are socialized on the job.

Sunday, September 14, 2014

Turning Turtle -- Tribute to the EMTs

My friend and colleague Samuel Jay Keyser--Professor of Linguistics (Emeritus) at MIT--writes of a recent incident that left him severely injured and experiencing the health care system in a way he could have never imagined. He's in the midst of writing about the events and was kind to share a draft of his first chapter of a forthcoming book--Turning Turtle--with several of us.  He gave me permission to provide you with excerpts.  There are many themes even in this first chapter, but I thought you'd enjoy the one presented here.

I was like a turtle that some malicious child had turned.  My hands felt like flippers. They were slapping me in the face.  I couldn’t recognize them as belonging to me. Thank goodness Nancy was at home.  Or maybe I would’ve died. Maybe that would have been the best thing to have happened. But it didn’t. Instead Nancy came running.

She saw me floundering at the foot of the stairs where I had fallen in a disastrous attempt to exercise. I was trying to stretch my left leg. I lifted it toward the fourth step. Suddenly my right leg collapsed under me. I fell flat on my back.

"Don’t panic! Don’t panic!” Nancy said in a panicked tone of voice as she frantically dialed 911. In a matter of moments I heard a siren come to a high-pitched halt outside our house. Six black-clothed, heavy-booted first responders came stampeding up the stairs. The one in charge leaned over me. His face hovered above mine like a harvest moon.

“Can you hear me?” he bellowed.

“Yes,” I said.

“Good! Don’t move a muscle,” he commanded.

He said something to his partner. She disappeared and returned with what looked like a large valise. I heard it click open. Then some clanging of metal parts against one another. The next thing I knew my head was being screwed in place with something that felt like a vice. Nancy said the contraption made me look like Frankenstein’s monster.

They placed me on a stretcher. Although I could feel my body tipping from side to side as they navigated the landing and down the stairs, my head remained absolutely fixed. It was April 26, 2014. I was surprised at how cold the outside air felt. I heard the back of an ambulance open. The stretcher slid inside. Someone got in with me. Someone else slammed the doors shut. The ambulance started to move. I listened for the siren. I couldn’t hear it. All I could hear were noises from a game someone was playing on a cell phone. I remember staring at the ceiling wondering why the lights were so bright. Such small thoughts for so large an event. I couldn’t focus on the big picture – that is, that I might be dying and that these were my very last moments on earth, that I might never see Nancy or my children again. I concentrated on the ambulance’s suspension. The vehicle dipped and rocked at every pothole. I thought about the suspension on hearses. They were surely better than this. How odd that a vehicle carrying the living was badly sprung while a vehicle carrying the dead was not.

[After a couple of days, it was time for surgery:]

What “going under the knife” meant for me was 13 hours in the operating room. Divided into two operations weeks apart, the first lasted 9.5 hours, the second, 3.5. The condition I had was quite rare. In fact I never knew I had it. In a nutshell, my spinal column has aged faster than my body. This means that it is riddled with bone spurs. When I took the fall, the bone spurs at the top of the column hammered into my cord like tiny little hatchets. To make matters worse, my spinal column is abnormally narrow. A normal spinal column is about 15mm in diameter. Mine is about 7 or 8mm.

One doctor's report put it this way:

Patient has diffuse idiopathic spinal hypertrophy/DISH, leading to cervical stenosis, or narrowing of the cervical spinal column. Due to this, there was no room for the cord to move. This combined with minimal shock absorption from the CSF (cerebrospinal fluid) led to a cervical spinal cord injury.

After 33 days in MGH it was time for me to move on. That meant a six-week stay in a rehab hospital. I was wheeled on a stretcher to the loading dock.

“Aren’t you the driver who brought me here a month ago?” I asked. I won’t ever forget the face that hung over me like a harvest moon yelling, “Don’t move a muscle.”

“How are you doing?” he asked, nodding.

“Pretty well, considering,” I said. “These guys saved my life.”

“No, they didn’t,” he objected. “We did.”

“I don’t understand,” I said.

“When I saw you lying on the floor,” he explained, “I could tell from the angle of your head that you had suffered a spinal cord injury. If we hadn’t put your head in a vise, you wouldn’t be here now.”

He was right, of course. Had my head and spine not been frozen in place, those potholes en route to MGH would have chopped my spine into coleslaw. Even so, it strikes me as odd that the villagers who saved my life – the surgeons and the first responders – have never met one another.

Saturday, September 13, 2014

A terrible burden imposed on doctors

Please take a look at this short video from Danielle Ofri, author of What Doctors Feel.

A perceptive quote from her:

"As doctors, if we fail, it’s not something outside of us; it is us. We are the error. The shame is so powerful that most doctors will never come forward about an error. I think the socialization of doctors makes it extremely hard for us to admit a mistake. We tend to pick perfectionists as medical students, knowing that the medical system is not for the faint of heart. Then they’re trained to be perfectionist doctors. There’s no place for a 'good enough" doctor. You’re either excellent or terrible."

This is a awful burden, one reinforced by the medical education process, especially during many residency programs.  I wonder how to get those involved in medical education to understand that this attitude contributes to patient harm.

Thanks to Gene Lindsey for pointing out the article and video.  He also sends us to view some thoughts from Justin Locke, author of Principles of Applied Stupidity:

We all are imperfect of course, but our society is intolerant of such things, and demands that we conceal it. Doctors are under particular cultural pressure to “be perfect.” But when it comes to medical error, shame energy can actually blind the mind to reality. The ongoing pretense that we “don’t make mistakes” is a leading cause of why the mistakes we make don’t get acknowledged, much less fixed.

Our immersion in what I call “smartism” starts early and is taught systematically. We attach enormous shame (i.e., inner-directed personal loathing of self) to failing tests in school, and enormous pressure to get into Harvard. This is a flawed system. There is no big victory for the “A” students; they start to think that their social acceptance is based solely on superstar performance, and they become fractured spirits, becoming human doings instead of human beings. Instead of a sense of social teamwork, shame energy, i.e., our intolerance of the reality of our imperfections, puts us in an unwinnable bitter battle to always be better than someone else. No matter how well you do in such a battle, you lose, for in the end, you do not have community acceptance, the glorious opposite of the dark energy of shame.

Friday, September 12, 2014

A son's legacy

Here's a short video featuring Patty Skolnik in which she explains how the tragic death of her son led to her engagement in helping clinicians learn how to help patients and families be more properly involved in making informed medical decisions.

Thursday, September 11, 2014

Experts file in Court: The proposed AG-PHS settlement is flawed

Following my earlier post about comments from an FTC official, please see a bit more on the proposed agreement between the Massachusetts Attorney General and Partners Healthcare System--in the form of a filing with the Court from the American Antitrust Institute.  AAI is an independent and non-profit national research, education and advocacy organization devoted to advancing the role of competition in the economy, protecting consumers, and sustaining the vitality of the antitrust laws.  The filing also includes an expert report from Professor John Kwoka of Northeastern University outlining the deficiencies in the settlement and explaining why it should be rejected.

This is powerful stuff and again suggests that both the Democratic and Republican candidates for Attorney General should ask the current AG to withdraw her proposal from the Court and leave future action on this issue to her successor--someone who will assemble an approach that fully addresses the documented anticompetitive practices of this player in the Massachusetts healthcare market.

The introduction:

AAI has an interest in this matter not only because it will affect consumers in a large and important health care market, but because Massachusetts’ national leadership in health care innovation and regulation, as well in as antitrust enforcement, could make the settlement an unfortunate precedent for resolution of anticompetitive hospital mergers by other states. As we shall explain, the proposed remedy is not in the public interest because it will likely fail to restore competition lost as a result of the acquisitions by Partners Health Care Systems, Inc. (“Partners”) of South Shore Health and Educational Corporation (“South Shore”) and Hallmark Health Corporation (“Hallmark”), and it will embroil the Attorney General’s Office and the court in extensive regulatory oversight for which they are ill suited. Therefore, it should be rejected.

(We address the Proposed Final Judgment filed on June 24, 2014. While the Attorney General and Partners are apparently renegotiating the Hallmark aspects of the deal in light of the recent objections by the Massachusetts Health Policy Commission (“HPC”), and this could resolve some of our concerns about the details of the settlement, our fundamental concerns about the effectiveness of using a regulatory decree to resolve anticompetitive horizontal mergers undoubtedly will remain.)

The major points (with my emphasis):

If litigated the Mass AG would have prevailed in court and the merger would have been enjoined.

--Conduct remedies are clearly inferior to blocking an anticompetitive merger or other structural relief, and are typically unsuccessful.  Antitrust enforcers and courts lack the expertise and institutional capability to adequately regulate firms with market power, and to counteract the firms’ natural incentives to exploit it.  Accordingly, the federal enforcement agencies and courts have consistently rejected these types of conduct remedies in hospital and other mergers between direct competitors.  And where remedies like these have been used in the past they have failed.

The proposed settlement is generally flawed for several reasons:
--The settlement is time limited and does nothing to alter Partners’ increase in market power resulting from the mergers.  Accordingly, prices can be expected to rise once the price caps are removed, as has been the case in the few other instances where caps have been tried.
--The settlement is highly complex and technical, with numerous ambiguities that will likely require extensive and continuing court involvement to resolve.  The proposed independent monitor will be helpful, but administering the regulatory decree will still require significant judicial resources.
--Conduct remedies are particularly problematic where, as here, the product is highly complex, the market is undergoing significant changes, and enforcement depends on parties in long-term business relationships with the enjoined firm (here, payers) willing to complain when violations occur.

The major elements of the proposed remedy are inadequate to protect consumers from the loss of competition.  Where they have been used in the past they have failed.  Besides the fact that they are time limited, the price caps are flawed because:
--The price caps are limited in scope, with the total medical expenditure (TME) cap covering only 11% of Partners’ commercial business.  Moreover, the caps do not cover quasi-private plans such as Medicaid Managed Care and Medicare Advantage.
 --The proposed price regulation would be difficult to administer—even by a regulatory agency, much less a court—and fails to take into account important considerations, such as how to deal with changes in the scope and types of services.
--The price caps may be ineffective insofar as prices, absent the mergers, would increase by less than the general inflation or medical inflation in the index used in the settlement.
--The price caps do nothing to address the potential diminution in quality competition, and perversely provide incentives to reduce quality.
--If the price caps are exceeded in any year, ultimate health care or insurance consumers may not benefit from the refund mechanism.
--To the extent it is relevant, the price caps do nothing about Partners’ existing supra-competitive pricing and rate advantage over other providers

Besides being time limited, the component contracting provision is flawed because:
--Component contracting will do little or nothing to alter Partners’ ability and incentives to increase prices post-merger.
--The settlement does not provide sufficient protection from actions Partners could take to make component contracting unattractive to payers, such as offering pricing differentials for bundled and non-bundled components and engaging in subtle forms of retaliation against payers that seek to take advantage of the unbundling option.
--There are reasons to be skeptical that payers and consumers will find it attractive to utilize component contracting and when utilized Partners’ physicians can still seek to steer consumers to out of network Partners’ providers.
--Component contracting works at cross purposes with the purported efficiency justification of the mergers, namely the deep integration of South Shore and Hallmark into the Partners’ network.

Once competition is gone, it's gone

Here's something for the two Attorney General candidates in Massachusetts to ponder, some recent statements from Martin Gaynor, the director of the Bureau of Economics at the FTC.  As reported in Politico, he notes:

“The ACA and all other reforms in health care system are built on top of the market-based system” and “will only work as well as those markets.”

“Layered on top of many markets that are dominated by a small number of very large systems, it can be a concern so it’s something we pay very close attention to,” Gaynor said.

Barak Richman, a Duke University law professor, said there was “very little evidence” that consolidation had “provided any efficiencies at all.”

“Barak is right,” Gaynor said. “We’ve had mergers for a very long time. There are a lot of data, and we’ve seen almost no evidence of real efficiency claims. That doesn’t mean it won’t happen, but the most recent evidence doesn’t support those claims.”

Such deals have to be reviewed and if necessary fought before they happen because they are very hard to unwind once they’re completed, he said.

“Once competition is gone — to paraphrase Bruce Springsteen — it’s gone and it ain’t coming back,” Gaynor said.

Does either of these candidates have the guts to ask the current AG to withdraw her pending deal with Partners Healthcare System and let the next AG take a fresh look at the case?

It Ain't Necessarily So

There's an elegant article at Medscape by Christopher Labos called "It Ain't Necessarily So: Why Much of the Medical Literature Is Wrong." Key points:

Given a statistical association between X and Y, most people make the assumption that X caused Y. However, we can easily come up with 5 other scenarios to explain the same situation.

1. Reverse Causality

Given the association between X and Y, it is actually equally likely that Y caused X as it is that X caused Y.

2. The Play of Chance and the DICE Miracle

Whenever a study finds an association between 2 variables, X and Y, there is always the possibility that the association was simply the result of random chance.

The Frequency of False Positives

It is sometimes humbling and fairly disquieting to think that chance can play such a large role in the results of our analyses.

3. Bias: Coffee, Cellphones, and Chocolate

Bias occurs when there is no real association between X and Y, but one is manufactured because of the way we conducted our study.

4. Confounding

Confounding, unlike bias, occurs when there really is an association between X and Y, but the magnitude of that association is influenced by a third variable. 

Real-World Randomization

Confounding can be dealt with through randomization. When study subjects are randomly allocated to one group or another purely by chance, any confounders (even unknown confounders) should be equally present in both the study and control group. However, that assumes that randomization was handled correctly.

5. Exaggerated Risk

Finally, let us make the unlikely assumption that we have a trial where nothing went wrong, and we are free of all of the problems discussed above. The greatest danger lies in our misinterpretation of the findings.

Wednesday, September 10, 2014

Robots around Le Monde

I present this view from France courtesy of patient safety and quality expert Michael Millenson, who saw a copy of Le Monde while in Europe.  Rough translation:  Robotic Surgeons: Stop the Fraud!  The article is by Professor Abdel Rahm√®ne Azzouzi, Chief of Urology of the University Hospital of Angers.

Here are Google-assisted translations of some key excerpts:

For over ten years now, proponents of robotic surgery bombard shameless untruths about the value of surgical robots in their field. As Ezekiel J. Emanuel said, a former adviser on health to the White House and a columnist for the New York Times, this pseudo-innovation increases costs without improving quality of care (New York Times, May 27, 2012 ).  

Given the lack of evidence of the superiority of robotic techniques in the prostate removal surgery, how can we not question the inertia of regional health agencies (ARS), the Council of the College of Physicians and the French Association of Urology, who prefer not to offend, for reasons that escape us, the holders of an innovation with questionable benefit to the patient.  

The overly commercial strategy of Intuitive Surgical - the monopoly on this robotic technology with its model Da Vinci - is shocking in health care and particularly affecting patients with cancer.

In its approach to its surgeon customers, it is only a question of increasing the number of cases for surgery by attracting psychologically fragile patients at the announcement of their disease and touting their results they do not have scientific proof. In other words, if the Da Vinci robot was a drug, it would never have obtained authorization to market.

For their part, supporters of the robot, having invested in the order of 2 to 2.5 million euros to acquire this surgical tool, betting on a return on investment by increasing the number of procedures, which in the case cancer localized prostate would increase the stock of patients operated incorrectly or prematurely. This irresponsible move strengthens the opponents of screening for prostate cancer, and delay the quality of the management of the disease. 

A Republican practice of medicine as expected in France must ensure that patients' interests and those of the community are always higher than the activity of so-called "expert" centers, in terms of fame and financial benefits .

Given the lack of rigorous evaluation today and to better protect patients from a natural attraction to new technologies, our advice to all patients who are diagnosed with prostate cancer . . . is to be vigilant before a proposal to remove the prostate, especially in centers with a robot, and to ensure that all available treatment options has been offered to them.

In other words and as stipulated in Article 35 of the Code of Public Health, the physician must provide clear and honest information, and provide proper care to his patients.

Therapeutic innovation, when it is real, is essential to the evolution of medical practice, but it is only if it is dedicated to the patient, and not to those who support it or to manufacturers who are at the origin.

No more treading water, on WIHI

Madge Kaplan notes:

Hi there,
The next WIHI broadcast — Tread Water No More! Making Sense of Patient Experience Data — will take place on Thursday, September 11, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:
  • Kevin Little, PhD, Improvement Advisor, Institute for Healthcare Improvement (IHI); Principal, Informing Ecological Design, LLC
  • Kristine KS White, RN, BSN, MBA, Faculty, IHI; Principal, Aerate Consulting; Co-founder, Aefina Partners, LLC
  • Kathy Klock, Senior Vice President, Human Resources & Clinical Support Services, Gundersen Health System
  • James Bonner, LMSW, Director of Patient Experience, Spectrum Health
Enroll Now
Have you been poring over some patient survey or patient experience data lately? Chances are good you have. How did you make sense of what you saw? What actions are you taking as a result of what you learned? Not sure? Unclear what to make of the information or what to do with it? You are not alone! In fact, as the ways to learn about how patients experience their care and their caregivers have grown, so has the confusion about how to interpret the data and how to make the best use of it.

That’s why we’ve invited Kris White and Kevin Little to head up our panel on the September 11, 2014, WIHI: Tread Water No More! Making Sense of Patient Experience Data. The two are determined to pull you out of whatever morass of patient-generated information you might be drowning in. Proof positive that it’s possible will be provided by Kathy Klock from Gundersen Health System and James Bonner from Spectrum Health. 

Kris and Kevin have put together a terrific set of guiding principles for appreciating and distinguishing among a wide range of methods health care organizations are using to learn more about and from patients. They’ll discuss everything from patient surveys, to focus groups, to patient and family advisory councils, to patient letters and complaints. When looked at in combination with staff surveys, patient safety metrics, rounding observations, and other organizational performance data, a comprehensive picture can emerge.
We hope you’ll add your ideas to the ones you’re sure to learn about on the September 11 WIHI. You can enroll for the broadcast here.

Tuesday, September 09, 2014

Thanks, Don

The votes are in, and Don Berwick did not succeed in his quest to obtain the Democratic nomination for Governor.  While this is surely a disappointment to Don, his family, and his many supporters, the primary election process has nonetheless been good for the Commonwealth of Massachusetts.

Don's campaign was a principled one--stressing substantive themes in a variety of policy arenas.  He did not duck hard issues: He straightforwardly set forth his positions, supported by logic, reason, and passion.

His demeanor was consistently professional, friendly, and good humored.  While he was direct in disagreeing with his rivals, his approach was civil, never stooping to ad hominem attacks.

In choosing to run from the position of private citizen, Don had the courage to offer himself and his family to the blood sport that is Massachusetts politics, exposing his views, his vulnerabilities, and his private life to the magnifying glass of traditional and social media.  That kind of decision takes courage, undergirded by a commitment to the public good.

By example, then, Don provided us with a refreshing civics lesson.  It is no surprise that he became a Pied Piper of sorts for many young people looking for a political cause.  Hundreds of people in their 20's and 30's joined in helping in the campaign offices and in the field, adding enthusiasm and zest to the political process.  Many of those young people will choose to be active in future political activities, for the good of us all.

So, thanks, Don.  Your campaign--like the rest of your distinguished career--leaves behind a legacy of strength and goodness for the people of the Commonwealth.

Must things be the way they are?

Something to think about as you make your election day choices.  Which candidates are most likely to ask why things must be the way they are?

Refusing to be intimidated by the received traditions and confident of their own integrity and creative capacities, the Founders demanded to know why things must be the way they are; and they had the imagination, energy, and moral stature to conceive of something closer to the grain of everyday reality, and more likely to lead to human happiness.[W]e have the obligation, as inheritors of their success, to view every establishment critically, to remain in some sense on the margins, and forever to ask why things must be the way they are, knowing that it is never enough to say they must be so -- one needs to know why. -- Bernard Bailyn  (age 92 today)

Monday, September 08, 2014

The technology proliferation story that's not often told

Gary Schwitzer puts into perspective the issue surrounding the desire of Ashya King's family for the child to have proton beam therapy.  Excerpts:

In all of this, there is a golden opportunity to improve the public dialogue about new medical technology. Issues such as: how many such devices does one city, one region, one country, the world need?

Why does the US (with more than a dozen operating and more than a dozen in the works) have so many proton beam facilities?  Much of the proliferation – not all of it – is for reasons other than treating kids with difficult-to-treat brain cancer, where the evidence is strongest but where the number of cases is relatively small.  It’s to treat the prostate cancer cash cow, for a condition where the evidence is questionable.

That’s a part of the technology assessment, technology proliferation story that isn’t often told.  

So while the Ashya King story has many ugly angles, let’s not turn it into a story of the big, bad British health care system that doesn’t have any proton beam facilities up and operating for kids like this yet.  That angle – about allocation of limited resources – is a lot more complex.

How not to write a headline

Headline writing is an art and hard to do well.  Some headline writers, though, fall into the trap of just reading the lede and then presenting us with a misleading tag to the story.  Reporters usually have no say over the headline that is assigned to their stories.

You judge in this case.

The headline in this well written and informative Aaron Gregg Washington Post story is:

Companies race to adjust health-care benefits as Affordable Care Act takes hold 

The lede is:

Large businesses expect to pay between 4 and 5 percent more for health-care benefits for their employees in 2015 after making adjustments to their plans, according to employer surveys conducted this summer.


Few employers plan to stop providing benefits with the advent of federal health insurance mandates, as some once feared, but a third say they are considering cutting or reducing subsidies for employee family members, and the data suggest that employees are paying more each year in out-of-pocket health care expenses.

Bracing themselves for an excise tax on high-cost plans coming in 2018 under the Affordable Care Act, 81 percent of employers surveyed by Towers Watson said they plan to moderately or significantly alter health-care benefits to reduce their costs.

But wait.  Further into the story we learn:

Others see these changes as less of a result of the Affordable Care Act and more a response to the steadily increasing costs of health care. The expected increase of 4 to 5 percent from 2014 to 2015 is no greater than in previous years, but the continued pressure on businesses has forced a wave of cost-sharing innovation, giving employees what the industry calls more “consumer-directed” choices to make between the quality of care and the cost. 

“I think this in many ways has very little to do with the Affordable Care Act,” said Gail Wilensky, a senior fellow at Project Hope, a health-care advocacy and services group. “It started 10 to 12 years ago, and is being used by employers to try to get their employees to react in what they see as a more responsible way.”

So what should the headline say? Maybe this?

Companies feel pressure to adjust health-care benefits