Wednesday, July 23, 2014

Continuum of Care on WIHI

Madge Kaplan writes:

The next WIHI broadcast — From Prehospital to In-Hospital: The Continuum for Time-Sensitive Care — will take place on Thursday, July 24, from 2 to 3 PM ET, and I hope you'll tune in.
Our guests will include:
  • Kedar Mate, MD, Vice President, Institute for Healthcare Improvement (IHI)
  • David Williams, PhD, Improvement Advisor and Founder, TrueSimple
  • Jonathan R. Studnek, PhD, NRP, Quality Improvement Manager, Mecklenburg EMS Agency (North Carolina)
  • Kevin Rooney, MBChB, FRCA, FFICM, Consultant in Anaesthesia and Intensive Care Medicine; Professor of Care Improvement, University of the West of Scotland
Enroll Now
When it comes to reliability, it’s hard to beat the track record of paramedics and EMTs. Whether it’s speed, knowing just what to do in the event of an accident, serious injury, gun violence, or heart attack, or the amazingly calm and reassuring way emergency responders go about their work, there are plenty of reasons to heap praise on this group of individuals. This also includes how patients are cared for during that ambulance ride to the hospital emergency department.

Could our opinion of EMTs get even higher? Maybe so, now that emergency medical services (EMS) are becoming part of fully integrated health care systems and paramedics are being trained and equipped to initiate even more life-saving and beneficial treatments in the field. This is the evolution we’re going to look into on the July 24 WIHI: From Prehospital to In-Hospital — The Continuum of Time-Sensitive Care.

Our guides — Kedar Mate, David Williams, Johnathan Studnek, and Kevin Rooney — have a compelling story to tell about dramatic changes underway with EMS, not just in the US but globally. The very use of the term “prehospital” reflects new strategies and capabilities to respond more effectively to patients suffering heart attacks, strokes, and traumatic injuries. In a growing number of communities, the suite of possible activities and early interventions have become part of overall best care, continuous with what happens next in the hospital. Patients at risk for septic shock are also being targeted for early recognition and initiation of treatment by EMS staff.

Advances in remote technology and communications are enabling many of the changes taking place with the most urgent types of medical events. But this isn’t the full story. EMS systems are also starting to bring their expertise and sometimes routine care to the bedsides of patients who live in remote rural areas, to elderly patients who are homebound, and to people with behavioral health issues — all requiring medical attention and support, but not necessarily a trip to the hospital​.

We hope you’ll join us on July 24 to learn more and to share your journey with prehospital care. You can enroll for the broadcast here.

Time for HOPE Award nominations

Recognize someone who is doing great work!

Nominations are now being accepted for the 2014 MITSS HOPE Award.  This prestigious award is being sponsored by RL Solutions, and the winner will receive a cash prize of $5,000 to continue their important work.

Take this opportunity to honor someone who is making a difference.  Note that self-nominations are welcomed, and submissions from anywhere in the United States and Canada are encouraged.

Nominations are due by Friday, September 19th, 2014, and the award will be presented at the MITSS 13th Annual Dinner and Fundraiser to be held on Thursday, November 13th, 2014, at the Westin Boston Waterfront, Boston, Mass.  Click here or visit for eligibility criteria and submission requirements, to access an online nomination form, check out past winners, and much, much more!

Not at the beach

We have to award the best quote of the season to the Boston Globe's Shirley Leung:

You don’t have to go to the beach to look for flip-flops this summer. There’s a pair in the gubernatorial race.

She then tells the story of how two candidates changed their positions with regard to the Attorney General's deal with Partners Healthcare System.

For my part, I don't care of they changed their positions, as long as they have come to realize the flaws in the deal.

Robots invade the rest of the world

There's a lot of good news in this story by Jaimy Lee at Modern Healthcare, but there is also a warning.  The good:

Intuitive Surgical saw its revenue and income fall again in the second quarter as sales of its da Vinci robotic surgery systems continued to drop.

The use of robotic surgery systems in gynecologic procedures such as hysterectomies continued to decline, and that trend is not expected to reverse, company officials noted during a call with investors.

The warning:

Worldwide procedure volume for the company's products went up 9%, led by . . . a higher number of urologic procedures outside of the U.S.

This reminds me of what happened when demand for cigarettes went down in the US.  The tobacco companies then focused on new markets abroad.  The company reports:

The da Vinci Surgical System is being used in hundreds of locations worldwide, in major centers in the United States, Austria, Belgium, Canada, Denmark, France, Germany, Italy, India, Japan, the Netherlands, Romania, Saudi Arabia, Singapore, Sweden, Switzerland, United Kingdom, Australia and Turkey.

Gary Schwitzer presents comments, though, that suggest that some of our Canadian friends are looking at this all a bit more rationally:

With surgical robots popping up all over Ontario and other provinces, eventually the public will be asked to cover the costs of these robotic surgeries. Perhaps these robots should be regionalized to maximize efficiencies and thereby lower operating costs? However, every institution wants to be on the cutting edge and have their own robot. Currently in Ontario there are daVinci robots in London, Ottawa, Hamilton and at 5 sites in Toronto. A number of high-volume community hospitals have successfully raised funds to purchase a robot in the near future. With the proliferation of robots, individual institutional volumes will be lower, driving up costs per case. Perhaps regional robotic centres of excellence in each province would be more efficient and cost effective.

Will other countries learn from the US experience?

Tuesday, July 22, 2014

A sign of the times

There's a good article by Paul Demko at Modern Healthcare about narrow networks, "Providers, insurers grapple with narrow-network backlash." Here's the lede:

Narrow networks are a reality of the new health insurance landscape. Nearly half of all insurance plans sold on the public exchanges in 2014 were narrow network plans, defined as those with less than 70% of area hospitals included, according to an analysis by the research firm McKinsey & Company.

But given that reality, insurers and providers need to do a better job of providing consumers with accessible, easily understandable information about networks when they shop for coverage. That was the message conveyed by participants in a panel discussion about network adequacy on Monday in Washington sponsored by the Alliance for Health Reform.

Need to do a better job?

Sorry, but didn't they think about this beforehand? If we add in the expanded use of high-deductible plans, there is a sea change in what "insurance" actually means. I'd have hoped the industry was more attuned to consumer response than to look back and say, "We need to do a better job."

Monday, July 21, 2014

Coaching through failure

I hope you enjoy my latest submission at the athenahealth Health Leadership Forum.

And please be sure to read Jim Conway's commentary on that site.


Barry opines on the AG-Partners deal

Barry Carol often offers thoughtful comments on this blog about health care issues in general and about Massachusetts in particular (even thought he lives out of state.)  He has chosen to comment to the Trial Court about the proposed settlement between the Attorney General and Partners Healthcare System.  He, like others, submitted comments in time for the July 21 deadline.  We all later learned that the AG had asked for a postponement, so that the case will not be heard until after the September gubernatorial primary in which she is a participant.

I've previously posted excerpts from Professor Alan Sager's comments, as well as my own.  I'm sure there are many more that will be submitted in objection to this deal.  If you have filed comments, please send them to me at goalplayleadership [at] gmail [dot] com, and I'll do my best to publish excerpts.  Thanks!

Here's Barry's filing:

I would like to offer a comment on the Attorney General – Partners Health System proposed agreement.

First, I think the proposed deal does not do enough to mitigate the significant price premium paid to the Partners Health System facilities compared to competing hospital systems for similar work and comparable outcomes. These price premiums are paid because of PHS’ dominant local and regional market power. The resulting higher healthcare costs and health insurance premiums make it more difficult for Massachusetts employers to raise wages as much as they might otherwise.

To mitigate this problem, I think there needs to be full price transparency from all providers and all payers. Confidentiality agreements that currently preclude disclosure of actual contract reimbursement rates need to be eliminated so both patients and referring primary care doctors can more easily determine the cost of care before services are rendered and compare prices charged by all providers in the market. We want as much care as possible to be delivered by the most cost-effective high quality providers and we need full price transparency to facilitate this.

I also think insurers should be able to contract with either Massachusetts General Hospital or Brigham & Women’s instead of having to either accept both hospitals in their network or neither.

To the extent that patients like to go to higher cost hospitals that offer better amenities even if they don’t affect medical outcomes, insurers need to be able to charge insured members enough more to go to those facilities to get their attention. Tiered insurance networks should be encouraged.

Healthcare in Massachusetts is the most expensive in the country, I believe. Since the 2006 reforms signed by then Governor Mitt Romney were largely a model for developing the Affordable Care Act, healthcare developments in Massachusetts are closely followed at the federal level. I think the proposed deal with PHS shortchanges the people of Massachusetts and is way too favorable for PHS.

A letter to the Trial Court

Here are my comments to the Court on the proposed settlement offered by the Attorney General and Partners Healthcare System.  (I include them here even though the AG has recently asked for a delay in the court proceeding until after the primary election in September.)  I've previously posted excerpts from Professor Alan Sager's comments.  I'm sure there are many more that will be submitted in objection to this deal.  If you have filed comments, please send them to me at goalplayleadership [at] gmail [dot] com, and I'll do my best to publish excerpts.  Thanks!

Re: Comments on the Proposed Final Judgment in Massachusetts v. Partners Healthcare System, Inc., South Shore Health and Educational Corp., and Hallmark Health Corp., Civ. No. 14-2033 (BLS).

I offer these comments in this proceeding as a citizen of the Commonwealth.  For the benefit of the Court, I first include a short summary of my professional background with regard to matters of market power in general and the state’s health care system in specific.  I then turn to the substance of my arguments.

Following receipt of degrees from MIT in 1974, including a bachelor of science degree in economics, I have had almost forty years of experience in service in public agencies and non-profit institutions.  In many of these positions, I have had to deal with and rule on matters related to market power and make determinations about how to best serve the public interest.  For example, when I was Chairman of the Department of Public Utilities (1983-1987), I issued rulings concerning the manner in which competition should be introduced and encouraged in the electric power industry, the natural gas industry, the telecommunications industry, and the transportation common carrier industry.  Before holding that position, I participated as an expert witness (from 1981 to 1983) before several public utility commissions across America and offered advice to those bodies on how to deal with the extraordinary market and pricing power of the Bell Operating Companies—before those companies were divested from AT&T as a result of a Consent Decree before the US District Court for the District of Columbia in United States v. AT&T. Following my service at the MA DPU, I served as the arbitrator under the Telecommunications Act of 1996 to determine the pricing regime and other aspects of introducing competition into the local exchange market in Massachusetts.  I have published numerous articles on the issues surrounding regulation of public utilities and telecommunications companies, and particularly on the transition from regulated markets to competitive markets.

Since 2006, I have served as a member of the Board of Directors of ISO-New England, the non-profit corporation charged with overseeing and regulating the wholesale electric power market in the region.  Among other responsibilities, the Board is charged with ensuring that market participants do not engage in abuse of market power in the purchase and sale of electric power.

My experience in the health care marketplace of Massachusetts began when I was Executive Dean for Administration of Harvard Medical School (1998-2002).  This was followed by service as Chief Executive officer of Beth Israel Deaconess Medical Center (2002-2011).  In the latter capacity, I had the opportunity to view the dominant provider group, Partners Healthcare System (PHS), exercise substantial and growing market power.  Since leaving BIDMC, I have remained active in the health care field and have been invited by numerous audiences domestically and abroad to speak on health care matters.  I have continued to observe and write about this field and have documented the ongoing market power of PHS and the deleterious effect the exercise of such market power has on the public interest.

Turning to the instant case, the Attorney General offers the Court her interpretation of the appropriate standard of review for the proposed final judgment.  I excerpt a section of her filing:

Judicial review of consent judgments is primarily focused on legality and considerations of procedural fairness. Courts properly review consent judgments to ensure several core requirements are met. First, a court should ensure that they are not ordering conduct that contravenes the law. Second, a court should ensure that any terms that the court might one day have to enforce are reasonably clear. Third, a court should ensure that the consent judgment relates to a genuine dispute by virtue of having some reasonable relationship to the claims asserted.

As in any case in which the Attorney General seeks injunctive relief, the court must consider the public interest. But the public interest inquiry is a narrow one: the inquiry is not "what the district court believes might have been the optimal settlement" the court's duty is to determine "whether the settlement is within the reaches of the public interest."  [Cites omitted.]

It is not my place, nor do I have legal expertise, to suggest a different standard of review.  Instead, I respectfully offer my opinion and advice to the Court as to how it might interpret that standard of review—as a general matter and with specific regard to the case at hand.  I believe that the Attorney General has the burden of demonstrating that such a standard has been met.  In summary, it is my recommendation that the Court rule that she has not done so.  If the Court agrees, the remedies—as I understand them—are to deny the motion altogether or to return it to the parties with instructions to renegotiate an improved settlement.

In applying the Attorney General’s advice that the proposed settlement must be within “the reaches of the public interest,” we must demand that the result achieved is no worse than the status quo and preferably better than the status quo.  In that regard, we have the benefit of the Attorney General’s own work products over the years.  She has concluded that the disparity in rates charged by PHS is not the result of a higher level of quality offered by that organization, but that it is a result solely of the exercise of market power.  She has also concluded that such price disparities are, in themselves, a source of ever-rising health care costs for the citizens of Massachusetts.  In other words, the mere existence of those disparities makes things worse for the consumers of the Commonwealth.

At a minimum, then, we would hope that a settlement with PHS would act firmly and decisively to reduce those disparities—and quickly enough to make a difference.  It is not enough to have the hope that the proposed settlement would achieve this result:  The end must be measurable and enforceable.

At heart, instead, the proposed settlement offers a wish and a prayer towards this result.  Yes, the rates for PHS would be limited to the rate of inflation.  Theoretically, other hospitals and physician groups might then “catch up” if their own rate increases exceeded those of PHS.  However, other providers have not been able to receive rate increases above that of PHS.  There is nothing in the settlement that empowers them to do so, and, indeed, the settlement cannot force insurers to do what they have never done before.

Further, even if providers could get such preferential treatment, the base upon which rate increases would be granted compared to the already substantially higher rates garnered by PHS forecloses the possibility of narrowing the gap by any appreciable amount within any reasonable time frame. By allowing the disparity of rates to continue, the Attorney General offers a result that is worse than the status quo.  That disparity permits PHS to accumulate additional revenues disproportionate to the value it provides to society, extracting ever-increasing funds from the public, and giving it the resources to engage in further expansion, magnifying its market power.  The Attorney General ignores her own conclusion from her past analyses, turning a blind eye to the fact that it cannot be in the public interest to permit a dominant provider to become still more dominant.

If the Court concludes that the public interest standard must result in a reasonable probability that the result will be better than the status quo, the proposed settlement obviously fails for the same reasons.  But the problem is compounded in that the proposed settlement gives explicit permission for PHS to acquire new hospitals and new physicians, expanding its geographic reach and its dominance.

As others will point out, conduct remedies of the sort contained in the proposed settlement are clearly inferior to blocking an anticompetitive merger.  Such conduct measures are typically unsuccessful, in part because antitrust enforcers and courts lack the expertise and institutional capability to adequately regulate firms with market power. In part, too, there are inevitable disputes before the courts as to whether the merger proponent has complied with such measures.  It is for these reasons that federal enforcement agencies and courts have rejected these types of conduct remedies in hospital mergers and other cases.

When faced with similar issues in this or other sectors, the federal government has ordered divestiture of key productive assets, or it has declined to permit mergers. I recognize that the Court may not have the authority to order such a result in this case, but it certainly does have the authority to conclude that the proposals and conduct remedies included in this proposed settlement do not meet the public interest. I respectfully suggest that Court reach such a conclusion.


Paul F. Levy

Sunday, July 20, 2014

Professor Sager offers lessons in market power

Boston University Professor Alan Sager has filed comments with the Trial Court about the proposed settlement between the Attorney General and Partners Healthcare System.  They are cogent and powerful.  (I include them here even though the AG has recently asked for a delay in the court proceeding until after the primary election in September.)  If you have filed comments, please send them to me at goalplayleadership [at] gmail [dot] com.  Thanks!  Some excerpts from Alan's:

I’m concerned that the agreement is not in the public interest.

First, since 1993, Partners has claimed that its various mergers and affiliations (which, for convenience, I’ll call “combinations”) sought to save money, and that they would save money or have saved money. But Partners has adduced no credible evidence to support those claims. Therefore, no one should believe Partners’ assertions that still more combinations will save money.

Second, Partners has claimed that its combinations would improve quality of care. But it has provided neither credible evidence of past improvements in quality attributable to its combinations nor plausible arguments that its combinations are essential to future improvements in quality.

Third, Partners has generally argued that its various combinations would be good for the public. I contest this assertion and have long argued, with colleagues, that these combinations were designed mainly to benefit Partners by boosting the prices it is paid for care and thereby increasing its revenues, and thereby liberating it to spend and grow without fear of price competition.

The original Partners combination, with successive accretions, help to explain why the cost of Massachusetts hospital care specifically and Massachusetts health care generally has continued to rise. By reducing competition, Partners’ combinations have helped to deepen the financial anarchy that allows health costs to rise. When anarchy prevails, the strong hospitals profit, and insurance premiums rise.

Addressing the AG, he says:

You have negotiated and publicly trumpeted a set of apparent constraints on Partners’ behavior. But you offer no convincing evidence that these constraints on behavior are likely to be practical, effective, or even enforceable. Have they been tried elsewhere? Did they work? How often? Without this evidence, it is likely that the constraints you have negotiated will actually enable Partners to garner substantial revenue increases. Right now, the constraints look like feeble regulatory Lilliputians, unable to restrain Partners’ Gulliver.

Instead of providing evidence that the negotiated constraints on Partners’ behavior are likely to work, you have focused on the procedural superiority of negotiating settlements over going to trial. You thereby trumpet form over substance—negotiating a deal with Partners instead of providing evidence that those constraints are likely to be enforceable and effective in restraining growth either in the prices paid to Partners’ hospitals and doctors, or in the total revenue they garner.

Despite the absence of evidence to support Partners’ claims that its consolidations save money and improve quality, and despite the absence of evidence to support the enforceability and efficacy of your negotiated remedy that allows substantial new consolidations, you assert that your negotiated settlement will be financially and clinically beneficial to the people who need or pay for health care in the Commonwealth. Sadly, this assertion is not credible.

Attorney-General Coakley, I don’t doubt for a second that you mean well. I believe that you hope to get the best deal from Partners that you can, given its great political influence. But I think the time has come to recognize that your negotiated agreement is not in the public interest, and to instead confront Partners in court by suing to divide it into two halves.

Saturday, July 19, 2014

Let's give credit, not throw brickbats

A recent story in the Washington Post makes a common error that causes the casual reader to reach an inappropriate conclusion.  Here's the background.  The Agency for Healthcare Research and Quality offers to help hospitals conduct periodic surveys of their staff on the topic of patient safety culture.  As designed by AHRQ, the survey assessment tools are designed to help hospitals:
  • Raise staff awareness about patient safety.
  • Diagnose and assess the current status of patient safety culture.
  • Identify strengths and areas for patient safety culture improvement.
  • Examine trends in patient safety culture change over time.
  • Evaluate the cultural impact of patient safety initiatives and interventions.
  • Conduct internal and external comparisons.
Hospitals are not required to conduct the surveys.  According to the Post, "About 650 of the country’s roughly 5,000 hospitals took part this year."  Staff who participate in the surveys are promised that their responses will be held confidential.

As the result of  a petition by the National Nurses United to the National Labor Relations Board, the results of the 2012 survey at MedStar Washington Hospital Center were released for public view.  The hospital then decided to also release the 2014 survey results.

Here's the mistake made by the Post in its story:  It compares the Washington Hospital Center results with the national average and concludes that WHC has "low marks." Notwithstanding the language on the AHRQ site about external comparisons, this is a mistake because such results across multiple hospitals cannot be assumed to be comparable.  Indeed, it is well known that some hospitals with higher grades in the survey achieve those results because there is a lack of awareness of the depth of patient safety issues in their institutions: People therefore have false confidence that they are doing well.  Likewise, some hospitals that have excellent safety programs get lower grades because the people in those hospitals have done enough work in the field to believe that they need to do even better to reach the standard to which they hold themselves accountable.  (Indeed, I have found that the one of the best way to judge the commitment of a hospital to quality and safety improvements is to ask people how it's going and have them respond, "OK, but we have so much to learn!"  Such modesty is a good marker for those serious about process improvement.)

So, a hospital-to-hospital or a hospital-to-national-average comparison is not the point.  Rather, the key set of statistics is how a hospital compares to itself over time, and how staff participation in the survey changes over time.  It is on that front that WHC has actually done quite well.  As noted in the story:

In a letter sent to all employees, John Sullivan, the hospital’s president, said the hospital was posting survey results from 2012 and 2014 on its internal communication system. He said he was encouraged that overall hospital results showed improvement and that staff participation increased 24 percent over the two years.

“This is a big step,” he wrote. “Research shows that organizations that regularly share this kind of information with associates make greater gains and improve safety — and that is certainly our goal.”


The survey is one tool that hospital officials say they use to measure the safety of hospital care. In another key area, the hospital has made dramatic improvements in lowering its rate of central-line infections, according to Arthur St. Andr√©, the hospital’s director of quality and safety. Officials are also encouraged that clinicians are self-reporting more incidents, including near-misses, using a new electronic system installed more than a year ago that allows individuals to report anonymously, he said.

Mr. Sullivan, though, was not claiming victory:

He noted that more than half of respondents said the hospital needs to do better in two critical areas — teamwork across units, and reporting errors without fear of punishment.
As we encourage more transparency of clinical outcomes in hospitals, let's remember the message I set forth many years ago:

There are often misconceptions as people talk about "transparency" in the health-care field. They say the main societal value is to provide information so patients can make decisions about which hospital to visit for a given diagnosis or treatment. As for hospitals, people believe the main strategic value of transparency is to create a competitive advantage vis-à-vis other hospitals in the same city or region. Both these impressions are misguided.

Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

On this front, WHC deserves credit for its commitment to improving quality and safety for its patients and its honesty in traveling the road ahead.  I hope that, in the future, the Post will ask outside experts to comment on these kinds of stories, rather than relying solely on those internal to the hospital.