Friday, May 22, 2015

A strong sense of purpose from "the bottom"

Melanie Evans at Modern Healthcare reports: "One of the nation's largest health systems, Ascension Health, will for the first time set a system-wide minimum wage of $11 an hour."

This is good and as it should be, but these folks are slow to have made these changes.

A decade ago, when I was CEO of Beth Israel Deaconess Medical Center, I made a decision that no one in our hospital should be paid less than $10 an hour.  There was no market-based reason to change their wages.  Other Boston academic medical centers were also paying their lowest paid workers--housekeepers, transporters, and food service workers--below $10 an hour.  I just thought it was wrong for a health care organization, particularly one with a faith-based heritage, to pay people so little.

Later in 2009, when the majority of people in the hospital made sacrifices and took pay and benefit freezes to help avoid layoffs during the  recession, we exempted those same low-wage earners from having to make any such sacrifices.

It's been my experience that hospital managers often forget about this group of vulnerable workers even though, as you think about it, they have more interactions with patients than anybody else in the hospital.  I always found them to represent the heart and soul of organization. As Gloria Martinez, one of our transporters, once said to me and our Board:

We view our job as providing the kind of care we would want for members of our own family.

Let's never forget that the "bottom of the organization" has just as strong a sense of purpose as those highly trained and better paid doctors and nurses! Our job, as hospital leaders, is to remember that and treat them with the caring and respect they deserve.

Thursday, May 21, 2015

A different kind of help for migraines

With the growing concern about the use of opioids, I recalled a Chronicle program from a few years ago in which Dr. Carolyn Bernstein explains other types of therapies that can help mitigate the pain and distress of migraine headaches.  Here's the link to this short segment.

In their own words

As the country moves toward ever greater concentration of market power in hospital systems, it is worthwhile to look back to the "mother" of all mergers, the creation of Partners Healthcare System in the 1990s.  This event should provide a warning to other parts of the country, as it resulted in substantially higher rates for this health care system compared to others in the state.  For those who think that creation of ACOs, as encouraged by federal legislation, is likely to reduce costs to insurance companies and consumers, think again.

This kind of market dominance often comes with a plausible sounding--but deeply flawed--rationalization by those who achieve it. As an example, here is a video of the president of Massachusetts General Hospital describing why their high rates were necessary and how they used the creation of Partners to achieve this result.

Start at minute 42:00 when the question is asked and follow through for just five minutes.  Listen carefully to the response.  As you face similar issues in your region of the country, it's important to deconstruct what's being said and what isn't being said.

I'll paraphrase portions of the answer, add emphasis, and reorder things to create some adjacencies for purposes of this discussion:

One of the reasons that Partners was created was that the insurance companies were playing MGH and the Brigham off against each other.  We came together and now insurers have to take both of us or neither of us and that has helped level the playing field with the insurers.

We built an organization that could level the playing field with the insurers.  Unfortunately, not many other provider organizations in this state did that, and now we're viewed as the problem when we negotiated rates that we thought were reasonable and others didn't become more indispensable and didn't increase their leverage vis-a-vis the payers and weren't able to get rates as high as ours.

This is what market dominance looks like, a chart showing the size of PHS relative to other healthcare systems in the state:

The creation of Partners was not just about joining the two tertiary hospitals into one group. The merger also brought in a number of community doctors and thousands of physicians. Those tertiary discharges shown above are the result of this immense referral network.  While it might have been theoretically possible to create another system of comparable size, it was not practical to do so.

Indeed, once PHS had higher rates, it could pay more to unaffiliated community-based doctors and grow its referral base even further, building still more market power.

What were those rate "requests?"

We were very judicious in what we asked for.  We compared our rates with other teaching hospitals around the country that we compete with--Johns Hopkins, Mayo, Cleveland Clinic, etc.--and we set out to get reimbursement that covered [our] costs

Similarly on physician contracts.  We did some studying to see what academic physicians in other parts of the country were getting.  We were losing physicians because we couldn't match salaries in Cleveland etc.  So we set out to get physician salaries that were comparable to other parts of the country.

Putting aside whether there is really much competition for patients across the country, seeking rates based on other regions in which other dominant systems exist was merely using other monopoly pricing power to justify the results that Partners sought here.  In addition, PHS was not just setting rates for its academic functions.  Those high paying insurance contracts also covered the PHS community hospitals and community-based doctors.  The leverage gained was system wide, not just for the two tertiary centers.

When Blue Cross Blue Shield balked during the first PHS negotiation at the level of rates, PHS CEO Sam Thier's words to the CEO of BCBS were, "This is what good health care costs."  The insurance company acceded.  When Tufts Health Plan balked, PHS simply threatened to leave them out of the network. Tufts folded with 72 hours.

Recall this comment from 2010 to understand the persistence of the degree of market power exercised:

"Andrew Dreyfus, executive vice president of health care service for Blue Cross Blue Shield of Massachusetts – the state's largest insurer – said he doesn't believe his company has the market power to eliminate disparities in the way doctors and hospitals are paid for their services."

If you look at markets around the country, in every market there is variability in payments.  For example, in New Hampshire, Dartmouth has very high rates.  Premiums in MA are fourth highest in NE, not highest.

Yes, there is variability. But it is in the range of five, or maybe 10 percent. In Massachusetts, PHS' rates can be 30% or more above those paid to other hospitals and doctors.

And note how he then he switches from rates to premiums.  Premiums are based on the total mix of payments made by insurers, across all providers.  A focus on premiums masks the fact that because PHS rates are higher, those to other hospitals and doctors are forced down.

And then the ultimate canard:

What we've done with those rates.  Our psychiatry program is one example. If our rates get cut dramatically, that's in jeopardy.  Ditto for five neighborhood health centers caring for the poor.  We have to invest in infrastructure to support our research program, the largest in the country.  We use our rates to help support our research program.  We invest in a lot of public goods as result of those rates.

Teaching hospitals have special mission: research, education, specialized units, taking care of more poor people. That's what's in jeopardy if our rates are equalized with community hospitals.

Notice how the conversation is switched to one of apples and oranges--what MGH should  be paid relative to other system's community hospitals.  The reports produced by the Attorney General did not suggest that the rates for PHS academic centers were too high relative to community hospitals: The showed that they were too high relative to the other academic centers--all of whom offer the public goods as well.  The analyses also showed that the rates paid to the PHS community hospitals were too high relative to other community hospitals. They also showed that rates paid to PHS community doctors were too high relative to those paid to other community doctors.

The evidence from Massachusetts is that once you let the market power horse out, it will be too late to close the barn door. Notwithstanding consistent evidence of the adverse impact on healthcare costs from PHS' dominance, there is no state action that has reversed it.  Indeed, recent "cost control" legislation in the state is a nullity when it comes to reducing the disparity in provider rates in the state.  By its language, the law bakes in the PHS advantage.  By its interpretation thus far, it has done even worse, permitting PHS to have a larger increase on a larger base than other systems.

Here's hoping it is not too late in your state.

Wednesday, May 20, 2015

Hep C irony renews questions of public confidence

In a nice touch of media irony, on the very day that Gilead Sciences, Inc. purchased a full page ad in the New York Times (web version here) talking about "new resources" available to fight Hepatitis C, a story by Andrew Pollack started with this lede:

Activists in several countries are seeking to void patents on the blockbuster hepatitis C drug Sovaldi, saying that the price being sought by the manufacturer, Gilead Sciences, was prohibitive.

The Initiative for Medicines, Access and Knowledge, a legal group in New York, is expected to announce Wednesday that it has filed challenges in Argentina, Brazil, China, Russia and Ukraine. In all those countries except China, the organization is being joined by local patient advocacy groups.

The actions are a sign that the controversy over Sovaldi is spreading beyond the United States, where the $84,000 charge for a course of treatment has strained Medicaid budgets, to middle-income countries.

My purpose today is not to offer an analysis of the pro's and con's of this issue. There's plenty of that discussion elsewhere.

My purpose instead is to again bring up the slippery slope that exists between academia and pharma.  As I discussed a year ago, when this controversy first arose, one of the board members of Gilead is Richard Whitley, a distinguished infectious disease doctor and researcher at the University of Alabama at Birmingham, who receives over $400,000 per year as compensation in his board role.  As I said then:

We can only imagine the extent of Dr. Whitley's personal commitment to eradicating disease.  This is truly an outstanding record.  I'd bet, too, that he would strongly support expanded access to Sovaldi for humanitarian reasons.  But in all the searches I have done, I can find no public statements from him concerning the financial issue raised in Andrew Pollack's [earlier] story.  Indeed, it would be very difficult for someone on the Gilead board to make a statement about such matters, as it would be viewed as inconsistent with the duty of loyalty and care required of corporate directors.

An extremely respected scientist with Dr. Whitley's credentials could be among the most qualified in society to "referee" this kind of issue--to help us understand and balance the legitimate financial needs of the pharmaceutical industry with the equally important humanitarian concerns about a drug's availability and cost in America.  He cannot do so while on the board of the company producing the drug. The loss to society is that someone of Dr. Whitley's expertise and compassion is taken out of the public debate on these matters.

Beyond that, what does his silence on this issue say to the country about his duty to two masters, a federally subsidized drug research effort and a pharmaceutical company? What message does that send to the public about how they should view the relationships between academic medical centers and industry? I think it doesn't help either sector retain the public's confidence.

Norman learns to show respect . . . again

I had the pleasure of meeting Norman Faull late last year in Johannesburg when we presented together some thoughts on process improvement to South African hospital folks. He is as kind, thoughtful, and respectful a person as you could imagine.  So when he reports that he is not necessarily respectful, I take notice.  His message is important, so please stick with me--especially if you are a Lean advocate or practitioner.

Here's a recent column he wrote.  Excerpts:

Some of us are not very good at showing respect.

‘Show respect’ is one of the core calls we make to lean leaders. That simple phrase was presented to me at a Lean Summit in the USA around 2007. The speaker was John Shook and he was quoting from a conversation that he had recently had with his former Toyota boss and then Global Chairman of Toyota, Fujio Cho. It was the third of ‘Three keys to Lean Leadership’; John presented them thus (in these exact words):
  1. Go See – “Senior management must spend time on the shop floor.”
  2. Ask Why – “Use the ‘Why?’ technique daily.”
  3. Show Respect – Respect your people.
The cherry on the top for me was when John gave us Cho’s expansion on the last point: you respect a person when you work with them with an attitude that shows you believe in them.

And here is the important bit of self-awareness:

I’m not good at this ‘show respect’ thing. Not that I want to be disrespectful, but I like my thinking and feeling to flourish. And all too often I do this by telling and advising, rather than asking others for their thoughts and reflections, because I think I have the answers so why waste time in asking.

And the particular example:

I had a good lesson a few weeks ago. I was sitting in on a meeting between members of the Gauteng Department of Health first cohort of lean learners and an embattled departmental team at a busy public hospital.

The learners presented their analysis. The departmental staff listened patiently. Without pushing the point, the learners were suggesting a reallocation of staff, from areas of low intensity to the bottleneck process. At a certain point they asked the departmental staff, “What do you think would help to reduce waiting time for the patients?”

“We need more staff,” came the reply. And I sighed in silent exasperation, as I have too often heard this kind of reply, a reply that shows that the analysis set out has not been understood. It is also the reply you get before you even start the analysis. So my knee-jerk is to explain all over again, running the risk of sending a message of impatience and exasperation, rather than respect, to my colleagues.

Fortunately it was not my meeting. So the response was far better. “If you had more staff, where would you allocate them?” was the response from the lean learners. With that question the discussion could continue ‘with respect’ and with thinking and feeling fully engaged.

The message:  Even those versed in Lean--and especially those overconfident about the power of Lean thinking--need occasional reminders about how to show respect.

Tuesday, May 19, 2015

Seeing things clearly at the children's hospitals

It's hard to overstate the importance of the work being done by the multi-state Children’s Hospitals’ Solutions for Patient Safety (SPS) Network.  What started as a cooperative effort among the Ohio hospitals--"We compete on everything, but we don't compete on safety"--has spread beyond, representing over 70 pediatric hospitals across the country.

The network sets forth an urgent mission: To eliminate serious harm across all children’s hospitals.

They note:

The Network has compelling evidence that shows that if the SPS Prevention Bundles are implemented reliably, the Network will reduce harm.

Employing high-reliability concepts and quality improvement science methods, SPS is focused on reducing harm by preventing readmissions, serious safety events, and the ten hospital-acquired conditions (HACs) below:
  • Adverse drug events (ADE)
  • Catheter-associated urinary tract infections (CAUTI)
  • Central line-associated blood stream infections (CLABSI)
  • Injuries from falls and immobility
  • Obstetrical adverse events (OBAE)
  • Peripheral intravenous infiltration and extravasations (PIVIEs)
  • Pressure ulcers (PU)
  • Surgical site infections (SSI)
  • Ventilator-associated pneumonia (VAP)
  • Venous thromboembolism (VTE)
And, significantly, they are measuring the results and are posting the outcomes for the world to see.  Check that out here.  I post just one example for illustration.

And for those who argue that the key to quality and safety improvement is government regulation and changes in hospital and physician pricing, look at this summary:

Through implementation of the Network’s best practices, children are being protected from harm. Since 2012, this national effort has led to an estimated savings of more than $79 million and saved 3,699 children from serious harm, with a consistent upward trend in harm prevented every month.

These doctors and nurses and their associated hospitals are doing what they are doing not because the government is telling them to and not because rate structures may or may not have changed--but because it is consistent with their sense of purpose and motivational to them as professionals.

Now, if we could just get the adult hospitals to grow up and follow the lead of the children's hospitals!

Monday, May 18, 2015

In Washington State: It's not NICE, but it's good.

Back in 2006, the state of Washington enacted a law creating the Washington State Health Technology Assessment Program. Since 2007, the state's Health Care Authority has administered a Health Technology Clinical Committee (HTCC)--composed of eleven independent health care professionals who review information and render decisions at open public meetings. They determine whether and how selected health technologies (medical and surgical devices and procedures, medical equipment, and diagnostic tests) are covered by several state agencies. Participating state agencies include the Health Care Authority; Department of Social and Health Services (Medicaid); Labor and Industries; Department of Corrections; and Department of Veterans Affairs. In some respects, the program is analogous to the United Kingdom's National Institute for Health and Care Excellence (NICE), which performs similar functions for the National Health Service.

The agency sets forth the following problem statement:

New innovations in medicine, even in the last ten years, have improved the health and lives of patients, yet they have come at a high cost in terms of health, safety, and affordability. Health care spending and costs are rising dramatically, but patients in the U.S. are not getting healthier nor using health care that is available, recommended, and proven to work. Medical products and treatments are introduced without independent, scientific evidence about whether they are safe, effective, and provide benefits that are better than existing alternatives. The information age has compounded the problem – there is a flood of information, but doctors and patients don’t have the tools or the time to sort through it all.

It engages in this process:

[Chosen] technology topics will be posted for thirty (30) days to gather public comment. An impartial research firm, called a Technology Assessment Center, will then conduct a review of the evidence about safety, effectiveness, and cost comparisons and write a report that summarizes the evidence and the methods used to analyze it. These assessment reports typically take between two and six months to complete. Once the report has been completed, it is given to the Health Technology Clinical Committee. The clinicians on the committee will use the evidence report to decide whether the technology is shown to be safe and effective; whether Washington state agencies will pay for the technology; and under what circumstances. The initial review and decision process will take between six and twelve months, and technologies will be considered for re-review at least every eighteen months.

So what did the HTCC conclude about proton beam therapy?  They unanimously decided that its use should be restricted to clinically appropriate cases, based on the best available scientific evidence.

Proton Beam Therapy is a covered benefit with conditions for: Ocular cancers; Pediatric cancers (e.g., medulloblastoma, retinoblastoma, Ewing’s sarcoma); Central nervous system tumors; Other non-metastatic cancers with the following conditions: Patient has had prior radiation in the expected treatment field with contraindication to all other forms of therapy; and at agency discretion.

Proton Beam Therapy is not covered for all other conditions.

Well, here we go.  One state, at least, has the sense to mandate that clinical effectiveness analyses take place and the spine to take on the medical-industrial-hospital complex in disapproving clinically unsupported uses of a high-cost technology.

At the national level, it's another story, as noted in this 2014 Modern Healthcare article by Jaimy Lee:

The CMS hasn't issued a national coverage decision for proton-beam therapy. All local Medicare contractors have approved paying for the treatment.

In a 2013 Brookings Institution paper, [Amitabh] Chandra wrote that the willingness of Medicare to cover the average total cost of proton-beam therapy is incentivizing hospitals to build centers that cost hundreds of millions of dollars and also to “run through as many prostate cancer patients as possible to pay off the bonds.” Other policy experts, writing in the New York Times' opinion page, called proton-beam therapy “crazy medicine and unsustainable public policy.” 

(Note:  Thanks to @pash22 on Twitter for the lead on this story.)

Sunday, May 17, 2015

Wachter and Jha trudge through the CMS readmissions Slough of Despond

When two of my favorite observers of health care policy talk, I pay attention.  So I was captured by Bob Wachter's comment on Twitter:

.@ashishkjha blog on readmissns is mastrpiece: rigorous anlysis, wise interpretatn, willing 2 change mind w/ new data

Recall that Ashish was pretty hard on the readmissions penalty in the past, citing the disproportionate impact on safety net hospitals.  In March 2014, I summarized an earlier piece prepared by him and Karen Joynt here:

Over two years ago, I summarized a research paper from Karen E. Joynt and Ashish K. Jha at Brigham and Women's Hospital that suggested that a one-size-fits-all readmission rate penalty policy would have the unintended consequence of harming safety net hospitals.  They said: 

"Conclusions—Given that many poor-performing hospitals also have fewer resources, they may suffer disproportionately from financial penalties for high readmission rates.  As we seek to improve care for patients with heart failure, we should ensure that penalties for poor performance do not worsen disparities in quality of care.  (Circ Cardiovasc Qual Outcomes. 2011;4:53-59.)"

So, I was intrigued by Bob's summary, limited by Twitter to 140 characters. The click-through got me to Ashish's article, here. Here's the lede:

I was initially quite unenthusiastic about the HRRP (primarily feeling like we had bigger fish to fry), but over time, have come to appreciate that as a utilization measure, it has value. Anecdotally, HRRP has gotten some hospitals to think more creatively, focusing greater attention on the discharge process and ensuring that as patients transition out of the hospital, key elements of their care are managed effectively. These institutions are thinking more carefully about what happens to their patients after they leave the hospital. That is undoubtedly a good thing. Of course, there are countervailing anecdotes as well – about pressure to avoid admitting a patient who comes to the ER within 30 days of being discharged, or admitting them to “observation” status, which does not count as a readmission. All in all, a few years into the program, the evidence seems to be that the program is working – readmissions in the Medicare fee-for-service program are down about 1.1 percentage points nationally. To the extent that the drop comes from better care, we should be pleased.

OK.  But on a key point, Ashish has not changed his tune at all:

HRRP penalties began 3 years ago by focusing on three medical conditions: acute myocardial infarction, congestive heart failure, and pneumonia. ... [W]e know that when it comes to readmissions after medical discharges such as these, major contributors are the severity of the underlying illness and the socioeconomic status of the patient. The readmissions measure tries to adjust for severity, but the risk-adjustment for this measure is not very good. And let’s not even talk about SES.

The evidence that SES [socieoeconiomic status] matters for readmissions is overwhelming – and CMS has somehow become convinced that if a wayward hospital discriminates by providing lousy care to poor people, SES adjustment would somehow give them a pass. It wouldn’t. As I’ve written before, SES adjustment, if done right, won’t give hospitals credit for providing particularly bad care to poor folks. Instead, it’ll just ensure that we don’t penalize a hospital simply because they care for more poor patients.

On surgery, he reaches a different conclusion:

Surgical readmissions appear to be different. A few papers now have shown, quite convincingly, that the primary driver of surgical readmissions is complications. Hospitals that do a better job with the surgery and the post-operative care have fewer complications and therefore, fewer readmissions. Clinically, this makes sense. Therefore, surgical readmissions are a pretty reasonable proxy for surgical quality.

He looks at the data, and summarizes the program's experience over three years:

Your interpretation of these results may differ from mine, but here’s my take. Most hospitals got penalties in 2015 and a majority have been penalized all three years. Who is getting penalized seems to be shifting – away from a program that primarily targets teaching and safety-net hospitals towards one where the penalties are more broadly distributed, although the gap between safety-net and other hospitals remains sizeable.  It is possible that this reflects teaching hospitals and safety-net hospitals improving more rapidly than others, but I suspect that the surgical readmissions, which benefit high quality (i.e. low mortality) hospitals are balancing out the medical readmissions, which, at least for some conditions such as heart failure, tends to favor lower quality (higher mortality) hospitals. Safety-net hospitals are still getting bigger penalties, presumably because they care for more poor patients (who are more likely to come back to the hospital) but the gap has narrowed. This is good news. If we can move forward on actually adjusting the readmissions penalty for SES (I like the way MedPAC has suggested) and continue to make headway on improving risk-adjustment for medical readmissions, we can then evaluate and penalize hospitals on how well they care for their patients. And that would be a very good thing indeed.

As Bob suggests, and as comes as no surprise to those of us who know Ashish, he looks at the data and gives his best view of what it all means.  The message for me, though, is a bit less pleasing.  It is clear that this whole program had an insufficient analytical and clinical basis at the start, might be improving a bit, but is a lot of time and effort spent on the wrong things. As things at CMS wend through a statistical Slough of Despond on this issue, the agency knowingly contributes to billions in waste in the system by employing rate structures and regulatory rulings that enable high cost technologies to propagate throughout the land, often in ways that harm the very constituency they are charged with protecting.

Thursday, May 14, 2015

A Cerberus exit strategy for Carney Hospital: The SEIU

Jessica Bartlett at the Boston Business Journal reports that Steward Healthcare System, owned by private equity firm Cerberus Capital Management, has named Walter Ramos, CEO of DotHouse Health, a health center in Dorchester, to be the new CEO of Carney Hospital.  By all accounts, Mr. Ramos is an excellent choice, with a good administrative background and understanding of the needs of the neighborhood.

No, what's more interesting about Jessica's story is her placement of two sets of assertions.  Here's one from Steward's president:

“Carney Hospital is in the midst of an exciting resurgence. In recent years, Carney has consistently earned national awards for quality patient care, grown the number of primary care and specialist physicians, and significantly expanded available services and improved the facilities. We believe Walter Ramos will provide the leadership needed at this important time at the Carney.”

Here's the adjacent paragraph:

The change is the latest update at Carney, which saw its former president, Andy Davis, announce in January that he would be stepping down after only three years in the position. In a statement at the time, Davis announced he had been looking to leave the hospital for awhile. Under his leadership, the institution has continued to struggle financially, seeing a $1.3 million operating loss in fiscal 2011, a $10 million operating loss in fiscal 2012, a $9 million operating loss in fiscal 2013, and a $6.2 million operating loss for the first two quarters of 2014.

That trajectory of losses doesn't sound like "an exciting resurgence." Indeed, those are pretty big losses for a 159-bed facility.  Add to that the past problems retaining effective leadership for this hospital. As reported in the Dorchester Reporter in April 2012:

After 14 months at the helm, Savin Hill’s Bill Walczak is out as president of Carney Hospital. The sudden shake-up raises questions about the future of the Dorchester Avenue facility, which was sold to a private equity firm in 2010 and is now facing the appointment of its fourth president in two years.

So, best wishes for success to Mr. Ramos. It looks like he has a vote of confidence from the main union representing workers at Carney:

“1199SEIU members are looking forward to working closely with Walter Ramos in his new leadership position to help Carney Hospital continue to grow and improve,” said Veronica Turner, Executive Vice President of 1199SEIU, in a release.

Back in 2007, noting the ongoing financial problems at Carney, I made a suggestion that the SEIU could do even better than working closely with hospital leadership:

Why not . . . have the union purchase, own and operate Carney Hospital? Let the union show how it can handle the full panoply of issues of running a hospital and demonstrate how it can profitably operate a neighborhood facility without the kind of state aid that has been pouring into Carney for all these years. Let the union negotiate contracts with the insurance companies, encourage access for low-income patients, maintain high regulatory standards for patient care, and do all the other things required of hospital management, while, of course, providing excellent working conditions for staff members and physicians.

What better way for the SEIU to demonstrate its potential value to the community than to take on this worthy assignment and to do a good job at it?

It's not too late.  I bet Cerberus would be happy to sell the place at a hefty discount from its original purchase price.

Wednesday, May 13, 2015

Is it in Rochester, Mayo? Or Boston?

In the post below, I report on a technical study that reviews the clinical efficacy of proton beam machines.  In short, for the most common forms of cancer, there is no appreciable difference in results, but the cost of the proton beam technology greatly exceeds that of technologies generally in use around the world.

The exceptions are some of the more difficult forms of cancer, and who can argue with making this modality available to the few people who can benefit from it?  Such was clearly the case with 12 year old David Gerfast, who received several weeks of treatment for chordoma, a rare type of cancer that occurs in the bones of the skull and spine.  As noted here: "Chordomas are generally slow growing, but are relentless and tend to recur after treatment. Because of their proximity to critical structures such as the spinal cord, brainstem, nerves and arteries, they are difficult to treat and require highly specialized care."

What more moving presentation could be offered by Mayo Clinic than to present David's case as an example of what will be possible in its new $180 million proton beam facility, particularly in association with the grand opening event this past week?

There's only one problem with Mayo's use of David's story.  He was treated at the proton beam facility at Massachusetts General Hospital.  This is not mentioned by Mayo--here's the script from the video--although at one point in the story, there is an onscreen credit associated with some of his images.

And, if you search old stories about the case, you can learn the same thing. Here's one from the local ABC affiliate back in January: "David is preparing to undergo Proton Beam Radiation Therapy in Boston, his father said."

Why does this matter?  The good news is that David was effectively treated, something for which we should all be grateful. And, as I note above, the issue is not the efficacy of proton beams in these types of cases.

The issue is how many $200 million machines do we need in the country.  Yes, it was inconvenient for David and his family to travel to Boston. But look again at this map and note how many proton beam facilities there are and will be within just a few hundred miles of one another in the Midwest--and Texas--and Florida--and the East Coast--and California--and the Southeast:

For the remarkably small number of appropriate cancer cases that would benefit from proton beam therapy, we could spend a tiny portion of the billions being invested in facilities and offer deluxe travel arrangements for all affected families, including support for those left back home.  Instead, we spend the billions, and then hospitals justify the use of the machine on cancers that are not appropriate clinical targets for this form of radiation.  It is hard to imagine a less rational form of health care planning for the country.

Beyond this issue of national policy, I would be remiss if I didn't say something about Mayo's use of a case treated elsewhere as part of its own publicity, with no acknowledgement of that fact.  (Here's the script again.)  I am at a loss to find the right words for this oddly deceptive presentation. What possible purpose was served by the omission?

Tuesday, May 12, 2015

Evidence about proton beam efficacy

Source: The National Association for Proton Therapy
Starting in 2011, I raised concerns about the proliferation of very expensive proton beam radiation therapy centers, made possible by investors who leverage the extra payments for use of this treatment modality that have been authorized by CMS and private insurers.  I asserted, based on my contacts in the radiation therapy profession, that the use of proton beam technology offered no significant advantage over lower cost intensity-modulated radiation therapy (IMRT) in most cases.  In short, I characterized proton beam developments as an example of the medical arms race, a rush by hospitals to compete on a high cost approach that offered little value to the public.

Now comes a thoughtful analysis published by the Health Technology Assessment Program of the Washington State Health Care Authority: Proton Beam Therapy, Final Evidence Report. The analysis was carried out by the Institute for Clinical and Economic Review (ICER), an independent non-profit health care research organization "dedicated to improving the interpretation and application of evidence in the health care system."

First, ICER gives the context for the early interest in this modality:

Initial use of proton beam therapy (PBT) focused on conditions where sparing very sensitive adjacent normal tissues was felt to be of utmost importance, such as cancers or noncancerous malformations of the brain stem, eye, or spinal cord. In addition, proton beam therapy was advocated for many pediatric tumors because even lower-dose irradiation of normal tissue in pediatric patients can result in pronounced acute and long-term toxicity (Thorp, 2010). There are also long-standing concerns regarding radiation’s potential to cause secondary malignancy later in life, particularly in those receiving radiation at younger ages. Finally, radiation may produce more nuanced effects in children, such as neurocognitive impairment in pediatric patients treated with radiotherapy for brain cancers (Yock, 2004).

Then, they set up the current issue of concern:

The construction of cyclotrons at the heart of proton beam facilities is very expensive ($150-$200 million for a multiple gantry facility); accordingly, as recently as 10 years ago there were fewer than 5 proton beam facilities in the United States (Jarosek, 2012). More recently, however, the use of PBT has been expanded in many settings to treat more common cancers such as those of the prostate, breast, liver, and lung. With the growth in potential patient numbers and reimbursement, the construction of proton centers has grown substantially. There are now 14 operating proton centers in the U.S. Eleven additional centers are under construction or in the planning stages, and many more are proposed.

The bulk of the report looks at the best available evidence:

We focused primary attention on randomized controlled trials and comparative cohort studies that involved explicit comparisons of PBT to one or more treatment alternatives and measures of clinical
effectiveness and/or harm.

The summary:

We judged PBT to have superior net health benefit for ocular tumors, and incremental net health benefit for adult brain/spinal tumors and pediatric cancers. We felt PBT to be comparable to alternative treatment options for patients with liver, lung, and prostate cancer as well as one noncancerous condition (hemangiomas). Importantly, however, the strength of evidence was low for all of these conditions. We determined the evidence base for all other condition types to be insufficient to determine net health benefit, including two of the four most prevalent cancers in the U.S.: breast and gastrointestinal (lung and prostate are the other two). 

Not exactly a ringing endorsement for adding billions of dollars to America's health care budget.  The original concept behind PBT was to have just a few across the country, to which patients who could most benefit would travel.  The idea was not to have as many as currently exist and are planned.

The results published by ICER hold little sway with the hospitals that have bought these machines.  Here's a sample web page from the The University of Florida Health Proton Therapy Institute:

In case you can't read the small image, it says:

Proton radiation is most effective in the treatment of localized cancers that have not metastasized or spread to other parts of the body.
These include:

Click through on any of those links and you can find clinically unsupported assertions about the benefits of this technology.  Taking prostate as an example:

Traditional prostate cancer treatment involving surgery or radiation carries the risk of serious toxicity and side effects. The potential long-term impact of these side effects on quality of life forces men to make a difficult choice during a stressful time. Proton radiation for prostate cancer treatment, however, offers an innovative method of radiation treatment intended to lower the risk of prostate cancer treatments and side effects.

For treating cancer of the prostate, proton therapy offers multiple benefits:

  • Excellent control of tumors, thanks to more precise targeting of radiation
  • Lower risk of damage to healthy tissue surrounding the prostate cancer
  • Better quality of life for patients undergoing prostate proton therapy treatments
An alternative to traditional prostate cancer treatment, proton radiation for prostate cancer delivers precise doses of radiation with a lower risk of side effects.

With ICER's help, we now see that this verbiage is a lie.

So what we have in place in America is simply this:

Federal reimbursement policy supports the construction and operation of high cost, unnecessary machines.

Investment bankers rely on the above to offer hospitals financing plans, operational plans, and marketing plans for something the public doesn't need.

Hospitals engage in direct-to-consumer advertising in which they present misleading and inaccurate information about the benefits of the machines.

And we wonder why US health care costs keep rising.

Monday, May 11, 2015

Some thoughts on overuse of sedatives, opiates, and stimulants

A recent article over at the Why is American Health Care So Expensive blog discussed the patterns in overuse of sedatives, opiates, and stimulants, noting:

There is no good evidence that these medications are either safe or effective when used long term. In fact there is good evidence that they are NOT safe, and quite a bit of circumstantial evidence that they are not effective. We prescribe many times the number of controlled substances now than we did a decade ago, and overall Americans are not less anxious or less in pain or better able to concentrate than they were before. Those of us who prescribe opiates to patients with chronic pain very rarely see the pain become significantly more manageable though we do see the patients become less active and more likely to ask us for ever increasing amounts of the medications which don't work very well.

I, as a cutting edge physician of my generation, prescribed these drugs with enthusiasm, glad to be able to lessen the burden of anxiety, pain or distraction in my patients. Eventually I noticed that these patients were having real problems, including emergency room visits for confusion or for increased pain, worsening of their pre-existing breathing problems, severe constipation requiring hospitalization, one died by deliberately overdosing. Others' deaths were probably hastened. More subtle has been the increasing number of people who are becoming inactive, apathetic and stuck in poverty who appear to live mostly for their prescription medications. This group of people are not being identified at all by statistics on overdose.

Ok, that sounds like the problems that can come from a single doctor treating a patient.  But the problems can be compounded when a patient is seeing more than one doctor.  A 2014 BMJ article by Anupam Jena and colleagues reviewed the frequency and characteristics of opioid prescribing by multiple providers in Medicare.  They found:

Concurrent opioid prescribing by multiple providers is common in Medicare patients and is associated with higher rates of hospital admission related to opioid use.

Some doctors are bucking the trend, but it takes a concerted effort, patience, and thoughtfulness.  I note this piece from NPR on treatment of migraines, where Dr. Carolyn Bernstein notes:

"The majority of [desperate patients] have really been suffering a number of years and they're really miserable with the pain," Bernstein says. They say, " 'I hope you have a magic pill,' and of course there is no magic pill."

... [P]atients receive a thorough medical history that includes headache patterns, disability and mood assessments. Then the center works with patients to try to identify what triggers their headaches and how they can avoid those triggers in the future.

Some people find relief through exercise. "I write an exercise prescription probably as often as I write a prescription for medication," Bernstein says. She acknowledges it's sometimes difficult to encourage a patient with cracking head pain to get up and exercise. But even a little can help, and according to Bernstein it doesn't have to be jogging for miles and miles. It can be yoga, tai chi or even just a little stretching.

Do they deserve a medal?

The United Hospital Fund has posted a quarter page ad in the New York Times, entitled "They deserve a medal."  The ad celebrates hospital trustees whose "leadership and dedication make life better for all New Yorkers," and there will be a presentation in their honor at the Waldorf-Astoria.  This is an annual event by the UHF.

I firmly believe that hospital trustees are dedicated and thoughtful folks, who devote time, energy, and money to support local institutions.  We should indeed be grateful for their devotion to the cause.  But it's been my experience that many hospital governing boards fail to address fully the patient experience.

So, I wondered what, other than personal commitment, the boards of these hospitals have achieved on that front.  I tapped the government's Hospital Compare website to explore just a few of the named hospitals.

I looked at the grades for patient experience and found the following for St. Barnabas Hospital. (The first column is the hospital, the next is a comparison to New York hospitals, and the last column is a comparison to the national average.)

The hospital was below both the regional and national average when it came to getting information to patients about what to do during recovery at home, how well patients understood their care when they left the hospital, the percentage of patients who gave the hospital the highest ratings, and the percentage of patients who would recommend the hospital.

Ditto for Wyckoff Weights Medical Center:

In contrast, Eastern Long Island Hospital did well, matching or beating the average in all four categories:

Not fair, some will claim.  For one thing, the Hospital Compare numbers don't show a trend.  But the data are reasonably current (from July 2013 to June 2014) and are collected in a uniform manner across the region and country.

I join the UHF in praising these trustees for what they have done.  And perhaps a number of trustees mentioned in its advertisement have been champions for the kind of results we all seek.  If so, it would be great if the UHF could connect the dots between individual trustee action, governance processes they have put in place, and the results for patients.

Tribal warfare

A comment on my post below about unnecessary testing before cataract surgery presents a striking example of one problem in medicine--the inability of specialists from different disciplines to agree on and incorporate best practices in patient care:

In my experience this process (pre-op testing prior to cataract surgery) is completely driven by anesthesiology.

At my institution we have fought to change this process to no avail so recently we started having topical days without any anesthesia staff present. We give the patient a mild oral anti-anxiety medication (if needed) and do the short case under topical conditions. Without anesthesia monitoring the cost is even lower.

Friday, May 08, 2015

Snapping defeat from the jaws of victory

What is it about opthalmologists and cataract surgery?  If there were ever a success story in the world of medicine it is this:  Better and more consistent quality than years ago delivered at a remarkably lower cost.  But it seems like the profession insists on ways to make it more expensive.

I have discussed one such "innovation," the femtosecond laser, and the thousands of dollars in direct consumer cost that it entails and that has been authorized by CMS, the Medicare agency.

Now Michelle Andrews at Kaiser Health News summarizes a recent NEJM article.  Excerpts:

Requiring patients to get blood work and other tests before undergoing cataract surgery hasn’t been recommended for more than a dozen years. There’s good reason for that: The eye surgery generally takes less time than watching a rerun of “Marcus Welby, MD” — just 18 minutes, on average. It’s also incredibly safe, with a less than 1 percent risk of major cardiac problems or death.

Yet more than half of Medicare patients received at least one pre-operative test in the month before undergoing surgery to remove cataracts in 2011, a recent study found.

“Their patients [tested] were no sicker or older,” says Catherine Chen, an anesthesiologist at the University of California, San Francisco, and the lead author of the study. “It suggests that it’s habit or practice patterns.”

Cataract surgery used to take a few hours and require general anesthesia. In those days, preoperative testing made more sense, says Chen. Now people often receive only a topical anesthetic eye drop to numb the eye or sometimes a local anesthetic that may include a sedative for relaxation.

But research shows that today, pre-operative testing for cataract surgery doesn’t result in fewer adverse events or better surgical outcomes, regardless of a patient’s health, says Chen.

Where is the American Academy of Opthalmology on such issues?  Who stands for the patients?  Where is CMS, and why do they allow this pattern of testing?  Who stands for the costs incurred by the American public?

The cost that is hiding in plain sight

Jack Sullivan at Commonwealth Magazine summarizes recent findings surrounding high deductible health insurance plans.  I covered some of these points back in November, and it is helpful to have them restated with the latest analyses. The American Academy of Pediatrics has likewise made the case strongly. Jack's lede:

U.S. News & World Report is out with its annual index on health insurance and its impact on the economy. To the surprise of few, many of the costs are declining or at least not rising at the dizzying pace they had been.

But much of those savings are going into the pockets of businesses and insurance companies, with consumers picking up an increasing share of out-of-pocket expenses because many companies are going to higher deductible plans to offset hikes in premiums. That, according to new studies, is actually making people sicker because they cannot afford or don’t want to pay the thousands of dollars required for visits or higher drug co-pays.


For most American workers, the passage of the Affordable Care Act was good news and bad news. Many more now have access to insurance. But while premiums have risen only 3 percent in recent years, the shifting of the cost burden through deductibles, coinsurance, and copays has heaped a heavier burden on those who buy the insurance, especially families in low-income and blue-collar jobs such as construction or trades. Between 2000 and 2013, out-of-pocket expenses by consumers nearly doubled to $1,217 per person, with the biggest jump coming after the Great Recession in 2009.

Regulators and health plans posit that higher out-of-pocket expenses force consumers to make more prudent choices in accessing health care. In practice, subscribers are avoiding many necessary treatments and drugs rather than pay for them out-of-pocket.

But the problem clearly isn’t limited by age or income. Part of the formula for getting everyone covered is for health plans to get everyone into the pool and the way they do that is through lower premiums. And the way to lower premiums is through higher deductibles.The plans calculate that younger, healthier workers will be attracted to the lower premium and not pay attention to what it may cost them if they actually get sick.

It is a cost that is hiding in plain sight.

Thursday, May 07, 2015

Is this what you call success?

“I am not sure how to explain it. It's hard to tell exactly what's going on, but whatever it is, it looks like it's good."

Well, that's sure a ringing endorsement of the Pioneer ACO experiment.  Medicare is so intent on proving that this ACO model is a success that they have to use words like this (reported by Melanie Evans in Modern Healthcare) to describe the results.

Previously, though, they acknowledged that the model does not work.  Let's go back to December, when Jordan Rau at KHN reported:

Health care systems experimenting with a new way of being paid by Medicare would have three extra years before they could be punished for poor performance, the federal government proposed Monday.

As I noted at the time:

The rule comes because many organizations have withdrawn from the ACO scheme or threaten to do so.  They have concluded that the risks just aren't worth the potential gain.  So now, CMS tries to solve that problem by essentially removing the risks.

This kind of reversal represents a kind of muddied thinking that is an indication of ideological public policy formulation. 

Melanie's report is rife with CMS's reported contradictions, starting with the lede:

Medicare says the pilot did well enough to expand. But it's unclear how the participants got the savings and to what extent others can replicate the success. 

Let's look at the criteria for program expansion under the Affordable Care Act:

The program did not add to Medicare's budget and the quality of care did not suffer.

That's sure a low legislative hurdle.  But what actually happened?  Read these sentences together and try to make sense of them.  They raise huge questions about the structure of the program and the methodology used to evaluate it.

As a group, the ACOs reduced spending on hospitalizations, which is one of the primary aims of the model. 

One perplexing result from the CMS analysis was a drop in spending for primary care office visits.

McWilliams' analysis found an increase in outpatient spending but a shift away from care in hospital-based outpatient centers.

An independent review of Pioneers' first two years offered few insights into why primary care spending declined or what may have contributed to success among those that saved money. 

Researchers with L&M Policy Research who analyzed the organizations' results said it was hard to identify strategies that helped to save money. 

I really wish CMS would focus instead on its own practices that encourage billions of dollars in wasteful hospital investment in high-cost technologies.  That's where to find the savings, not in these poorly constructed and evaluated programs.

Wednesday, May 06, 2015

How do I invest?

Here is a new, groundbreaking EHR vendor with an amazing website.  It offers the most honest presentation in the industry.  I'm sure it will do well, and I write this post as I wait on hold with the VC people to learn how to invest.


At the confluence of extortion and conformity lies Extormity, the electronic health records mega-corporation dedicated to offering highly proprietary, difficult to customize and prohibitively expensive healthcare IT solutions. Our flagship product, the Extormity EMR Software Suite, was recently voted “Most Complex” by readers of a leading healthcare industry publication.

The Extormity EMR software suite requires wholesale, revolutionary workflow change that dramatically impacts practice patterns. Our slow and painful change process significantly interrupts patient volumes and revenues, and this cumbersome transformation can only be appreciated in hindsight and with the aid of prescription medication (which can be prescribed via the Extormity EMRX Upgrade Module and Pharmacy Interface Pack).

Under the Extormity Uptime Guarantee section, we see:

** This section of the site is experiencing technical difficulty. Please check back in 30 days…better make that 45 days, just to be safe.** 

Taking steps to achieve more steps

I've noted the unsupported assertions of many wellness programs, but it's also important to acknowledge the interventions that can make a difference.  Here's an excellent article from the European Respiratory Journal that documents how affixing pedometers to people with COPD can make a difference in their health.  From the abstract:

Physical inactivity is a cardinal feature of chronic obstructive pulmonary disease (COPD), and is associated with increased morbidity and mortality. Pedometers, which have been used in healthy populations, might also increase physical activity in patients with COPD. COPD patients taking part in a 3-month individualised programme to promote an increase in their daily physical activity were randomised to either a standard programme of physical activity encouragement alone, or a pedometer-based programme. 

Both groups had comparable characteristics at baseline. The pedometer group had significantly greater improvements in: physical activity 3080±3254 steps·day(-1) versus 138.3±1950 steps·day(-1) (p<0.001); SGRQ -8.8±12.2 versus -3.8±10.9 (p=0.01); CAT score -3.5±5.5 versus -0.6±6.6 (p=0.001); and 6MWD 12.4±34.6 versus -0.7±24.4 m (p=0.02) than patients receiving activity encouragement only. A simple physical activity enhancement programme using pedometers can effectively improve physical activity level and quality of life in COPD patients.

Oregon CCOs on WIHI

Madge Kaplan notes:
The next WIHI broadcast — Leaning In: Oregon's Coordinated Care Organizations (CCOs) — will take place on Thursday, May 7, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:
  • Chris DeMars, MPH, Director, Systems Innovation, Oregon Health Authority - Transformation Center
  • Ronald Stock, MD, MA, Director of Clinical Innovation, Oregon Health Authority - Transformation Center
  • Trissa Torres, MD, MSPH, FACPM, Senior Vice President, IHI
Far from the epicenter of Washington, DC, and the federal government’s efforts to expand health insurance coverage and usher in health care delivery and payment reform, states are moving ahead with amazing innovations of their own these days. Medicaid waivers, which offer states running room to experiment with public dollars, are one big reason. And one big example of what’s possible is unfolding in Oregon.

No stranger to trail-blazing with transformative ideas and initiatives, Oregon’s latest efforts to provide better care and value to nearly one million Medicaid recipients will be the focus of the May 7, 2015, WIHI: Leaning In: Oregon’s Coordinated Care Organizations (CCOs). The groundwork and the enabling policies and legislation for CCOs have been several years in the making, and the careful shaping of the program is leading to some impressive results. Since 2011, emergency department visits are down 21 percent, preventable hospital admissions among adults for complications associated with diabetes have decreased nearly 10 percent, and enrollment in Patient-Centered Primary Care Homes has increased 55 percent.

And what about Oregon putting itself on a global budget with a fixed rate of growth — how is that going? We’re going to find out about the money, the care, the measures, how the 16 CCOs across the state function as one system, the innovative use of community health workers and more, thanks to two key people in the know from the Oregon Health Authority’s Transformation Center: Chris DeMars and Ronald Stock. They’re eager to share what they’re learning and to field your comments and questions. IHI’s Trissa Torres will offer commentary about this work, discuss how it relates to the Triple Aim and changes in primary care happening everywhere, and suggest ways to apply what’s happening in Oregon to your own state and setting.

Please join us on May 7. You can enroll for the broadcast here. 

Tuesday, May 05, 2015

I would have guessed they were Tories

A true story I heard from a colleague in London:

My nine-year-old daughter came up to me and said, "Dad, Kate is voting for the Labour party."  

"How do you know that?" I asked.

"I just heard on the radio that she's into Labour."

Success in surgery? Not so fast.

Richard Harris at NPR interviewed Marty Makary on the subject of how to know if your surgery was successful.  The summary in a nutshell:

For 99 percent of people in America, when they go in to have surgery, the outcome [of that operation] is not measured. Nobody's keeping track. So I'm amazed at how one-fifth of the economy, [the share accounted for by the healthcare system], functions with so little measure of its performance.

I've noticed this, too, but an even more insidious fashion.  Lately, I've been reading published, apparently peer reviewed, medical papers about certain surgical procedures in which the authors (usually the surgeons in question) claimed that the surgery was successful.  But I've learned of a number of high profile cases of this sort in which the patient or the organ donor later suffered long-term complications that were not evident in the few short weeks following the procedure.

My problem here is piercing the veil of physician and hospital self-interest and patient confidentiality to present those cases to you. I'm working on it, though.  I welcome stories from my readers that fit into this category, particularly when patients or families are willing to share their confidential information or when the information is otherwise public (e.g., in court documents).

Sunday, May 03, 2015

First aid class turns out to be dangerous

This could be one of the strangest stories I've read in a while, from The Globe and Mail. Here's the lede:

Randy Theriault spent 30 years captaining ships and was praised as an expert seafarer who honed his craft through experience. So, when the Nova Scotia man landed a well-paying job as first mate on a massive fishing vessel this spring, only one small hurdle stood in his way – a first aid course that seemed to be merely a formality.

Now his grieving family is struggling to understand how the 48-year-old Mr. Theriault could die suddenly of pneumonia during a first-aid course designed to deal with such situations. On the morning of April 17, after suffering through fever, shortness of breath, nausea and chest pains while attending the week-long Maritime Advanced First Aid course at Nova Scotia Community College, Mr. Theriault was found dead at a Port Hawkesbury bed and breakfast where he had been staying.

Later in the story:

The college says it is investigating what went on inside the classroom. The first-aid course is run by St. John Ambulance, which says Mr. Theriault exhibited normal vital signs during the course, although he “complained from time-to-time of flu-like symptoms.” In a statement, St. John Ambulance spokeswoman Clara Wicke said “instructors agreed to provide Mr. Theriault with reasonable accommodation to complete his certification by allowing him to make up missed time at a later date.”

That statement has upset Mr. Theriault’s family, who say text messages in the days leading up to his death indicate he was faced with the choice of staying in class or failing the course because it was not offered regularly. 

They want to know how Mr. Theriault could die while learning how to deal with emergencies such as respiratory ailments at sea, which includes pneumonia.

The family questions the assertion that Mr. Theriault displayed normal vital signs in the class. In one of his final texts to Ms. Tobin, he says he has a fever, and that he felt embarrassed about his laboured breathing in the classroom.

(Thanks to Dr. Susan Shaw for citing this story on Twitter.)

Like Canada, like the world

“When asked to think about their end-of-life planning, 75% of Canadians express a desire to die in their own homes. Yet in actual fact, 70% of Canadians die in hospital."

That's the summary of recent poll, as reported in the Ottawa Sun. I imagine there would be similar results in much of the developed world.

The article continues:

How we want our lives to end is not how they’re ending. That’s a tragedy. It’s also a clear sign that we need to adjust our public policy priorities to better reflect the needs of the people that the system was created to serve.


(Thanks to Dr. Susan Shaw for forwarding the article.)