The difference between empathy and sympathy

As I head off into a blogging break through New Year's Day, I pass along this view by Dr. Brené Brown of the difference between empathy and sympathy, a distinction that those of us in the health care world would be wise to understand. "Empathy fuels connection. Sympathy drives disconnection."

Animation by Katy Davis. 

Happy New Year!

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The sun is not only a painter but a sculptor.

With thanks to Judy Miller--one of the finest nursing administrators I have met--now at Galloway Consulting.  Look at this lovely excerpt from Florence Nightingale:

Light essential to both health and recovery.  
It is the unqualified result of all my experience with the sick, that second only to their need of fresh air is their need of light; that, after a close room, what hurts them most is a dark room. And that it is not only light but direct sun-light they want. I had rather have the power of carrying my patient about after the sun, according to the aspect of the rooms, if circumstances permit, than let him linger in a room when the sun is off. People think the effect is upon the spirits only. This is by no means the case. The sun is not only a painter but a sculptor. You admit that he does the photograph. Without going into any scientific exposition we must admit that light has quite as real and tangible effects upon the human body. But this is not all. Who has not observed the purifying effect of light, and especially of direct sunlight, upon the air of a room? Here is an observation within everybody's experience. Go into a room where the shutters are always shut (in a sick room or a bedroom there should never be shutters shut), and though the room be uninhabited, though the air has never been polluted by the breathing of human beings, you will observe a close, musty smell of corrupt air, of air i.e. unpurified by the effect of the sun's rays. The mustiness of dark rooms and corners, indeed, is proverbial. The cheerfulness of a room, the usefulness of light in treating disease is all-important.  

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Can you help this pregnant woman?

A friend called to ask for help on an issue related to her pregnancy. Do you know anyone who might be able to provide advice? Here is the situation:

A bad termite infestation has been discovered in her apartment, as well as the other units in her block in San Franciso. The entire block of apartments will need to be tented and sealed while a pressurized gas called Vikane gas is pumped in over a period of 3 days to kill the termites. The active ingredient in the gas, which is supposed to be quite noxious, is sulfuryl flouride. All building occupants will have to vacate the premises for 3-4 days, taking all foodstuffs and clothing with them as the gas can contaminate those items. Apparently, the gas can also go into any fiber containing furniture items - mattresses, pillows, etc. Once it settles in these items, it can take 45 days to dissipate.

My friend is just at the end of her first trimester of pregnancy. She's concerned about whether the exposure to after-gas effects is likely to cause harm to her fetus. She's looked up whatever literature she can find, but there's not much of it, and it's inconclusive. The gas is sufficiently noxious that people who have gone into a treated area too soon have been sickened and/or died.

The manufacturer says this:

Will Vikane affect my pregnancy?

Your fumigator is required to test the air in your home using specialized equipment to ensure that the Vikane level is below the EPA requirement before allowing you to re-enter your home. The EPA requirement is 1 ppm or less in all breathing zones. At such a level, no fetal effects or long-term health effects would be expected.

That description does not give my friend enough precision or satisfaction.

So, the options she is considering are:

1) Move to a new place (the landlord will release them from the lease, but finding something new is a challenge. They prefer not to move at this time, but will do so if it is unsafe.

2) Remove all fiber furniture before the fumigation and put it into storage, then go back a week later.

3) ???

She'd love to understand the potential side effects and hazards of the Vikane gas a little better. Is there anyone reading this who might be able to help provide advice on the pregnancy or toxicity side of things?

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On learning organizations

Please check out this new article I wrote for the Athenahealth Leadership Forum.  The lede:

A colleague once said, “Every plan is excellent, until it’s tested. It’s execution that’s the problem.” And so it is. 

Excerpts:

Project advocates enter every endeavor with a theory of the case, a vision of how things should be. But, as my late colleague Donald Schön noted, reflective practitioners are constantly reviewing the evidence to modify their framework in response to reality.

Lean organizations understand that there is no group of central planners clever enough to design an optimum complex process. Lean leaders do not lack for a strong purpose—indeed audacious goals are favored—but neither do they lack humility. 

Lean and other similarly designed organizations can only exist where the senior leadership is a strong advocate for the proposition that reflective practice is the best way to achieve outstanding performance for their customers. The leaders of such organizations embed that modesty and reflection in every aspect of their lives.

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A turning point for Partners Healthcare?

As we look back at the history of Partners Healthcare System (PHS) in Massachusetts, it is useful to consider what it is and what it might have been.  What it is is an extraordinary collection of extremely dedicated and talented people--clinicians, researchers, and teachers--who do their best to serve humanity.  What it is also is an incredibly successful business enterprise, carrying out a series of strategic plans that have led to market dominance in Eastern Massachusetts.  What it is not is a leader in quality, safety, process improvement, and transparency.  As I noted in March 2009:

The Partners hospitals are full of well intentioned, dedicated people. But there has not been a corporate public commitment to reduction of harm and to transparency of clinical outcomes that could help build broad public confidence in the quality and safety of patient care -- and with this a confidence that we are also attempting to control costs. . . . The Partners system should be a world leader in the science of health care delivery, along with the fields in which it already holds prominence.

I'm not the only person to notice this.  As I have traveled throughout the country, I often find people curious as to how a health care system that has comprised people like David Bates, Atul Gawande, and Tejal Gandhi has failed to adopt the principles espoused by, and to utilize the guidance of, these world-class experts.

I believe--although there is no way to prove it--that if founder Richard Nesson had lived longer and had thereby been able to exercise a lasting influence on the heart and soul of PHS, that this would have occurred. As noted in this obituary, Nesson had a deep connection to community service and to people's well-being, as well as a thoughtful sense of business matters. In the absence of his social conscience, the leadership of PHS has focused on influencing the body politic and building its business presence more than on the leadership role it might have taken in quality, safety, process improvement, and transparency.

But a recent announcement has given me hope.  Gregg Meyer, MD, is joining the system as Chief Clinical Officer in January.  Most recently, Gregg has served as Chief Clinical Officer and Executive Vice-President for Population Health at Dartmouth-Hitchcock and as the Senior Associate Dean for Clinical Affairs and Paul B. Batalden Professor and Chair at the Geisel School of Medicine. While he was formerly at PHS, it was in a more limited role at MGH. Now, he is moving up to a system-wide position.

This has the potential to be the most significant single appointment at PHS in many years.  Gregg has substantial expertise in the matters I have discussed, but he also has an insider's view of how to achieve change and deal with the many political jurisdictions within this spreading healthcare system. I believe that he is not the kind of person to take on the assigned task without having received assurances from the top leadership that they will support his efforts--and without a personal belief that he can succeed in helping to transform this system.

But it is late in the game, if the goal is to offer PHS to the world as a leader in quality, safety, process improvement, and transparency.  Other systems--including but not limited to Ascension, ThedaCare, and MedStar--have head starts.  Each of them intends to be "the best at getting better." Importantly, too, each of them approaches the task with modesty, being unafraid to admit where they need to improve and learn from others. PHS has been a bit short on the modesty front over the years. I'm hoping Gregg's arrival not only is a sign of corporate commitment to a quality and safety agenda, but is also a sign that the arrogance characterizing this system is on the wane.

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The next patent cliff

Much attention has focused on the "patent cliff" faced by pharmaceutical companies. As their proprietary drugs lose patent protect, the drug companies face competition from low-cost generic drugs.  With an exceptionally high cost and long lead time for new drug development, the pharmaceutical companies face significant strategic problems.

There is another patent cliff approaching that has not yet received much attention--the end of patent protection for many minimally invasive surgery devices.  Whether the basic stapling devices or more complicated instruments, the 20-year protection period on much laparoscopic equipment is coming to an end.

This change will be a major disruption in this industry.  Many of the equipment suppliers have been resting on their laurels for years, relying on relationships with surgeons to force sales of their equipment to hospitals.  Multi-product line companies also have buried the high cost of their instruments into an overall contract pricing regime with other hospital supplies. What most equipment suppliers have not done is to engage internal process improvement, taking waste and inefficiency out of their cost structure. Indeed, some have become separated from the potential for such improvement by relying on outsourced production. 

When new entrants to the market arrive, selling the same quality goods for a much lower price, the established equipment suppliers will face a challenge. Their ability to use contract pricing to hide the costs of this equipment will disappear.

From what I hear, the one company that seems ready for this change is Applied Medical.  Here's a quote from its website:

One of the main facets of our business model is vertical integration. Instead of outsourcing or offshoring our operations, we continuously focus on expanding our areas of expertise and manufacturing capabilities. As a vertically-integrated organization, we develop and manufacture our products in-house and provide exceptional customer service, support and education. Our high level of vertical integration allows us to quickly and efficiently make product enhancements and develop new technologies—reducing the amount of time required for innovative ideas to positively impact patient care. Vertical integration also allows us to control costs, closely manage supply lines and ensure the highest product quality, availability and compliance. 

I'm told that Applied Medical has currently been able to retain much of the extra margin it garners from efficiency improvements, as opposed to lowering prices to customers.  But is is ready for the day that prices drop in the industry. Its lower production cost will allow it to track down the price curve and still make a profit.  It may be one of very few companies that are able to do that and still maintain an active R&D program, allowing it to be a leader in the industry for some time to come.*

Something to watch as this new aspect of the medical arms race unfolds.
---
*Note: I have no financial interest in this company and am not providing investment advice.

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Outsourcing as an element of the private equity model

One of the things to consider about private equity ownership of a hospital system--given the inevitable desire of the investment firm to flip the system--is what it is has done to the cababilities of the organization during the holding period.

For example, one such firm has a policy of outsourcing as many of the hospital functions as possible.  It removes staff from the payroll and shifts their functions to a third party.  Examples are campus security, food service, mechanical engineering (the people who maintain medical equipment), and laundry.

What does this do? Well, if the goal is to attract as a potential buyer of the system a for-profit hospital chain that has a central services organization, that buyer would not need to worry about taking on as many of the staff of the hospital system it is purchasing.  It would avoid the discomfort of layoffs and also obligations like unemployment tax, accumulated pensions, and the like.  It could also provide these services with little incremental cost from its own central services department--simply cancelling or not renewing the local third-party contracts that have been in place.

In summary, outsourcing avoids costs and obligations and therefore enhances the likely purchase price in the flip.

But what if the original private equity owner had made promises of enhancing the capabilities and professional advancement opportunities of the local workforce? Well, that's a commitment that goes by the board.

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Sign of the times

Here's a sign in the Jacksonville, FL, airport. I've always had the highest regard for hospitalists, as I believe they make a substantial difference in the quality of care offered in hospitals.  But I never realized that they had risen in stature to being viewed as a competitive differentiator in the obstetrics world, in which women often comparison shop before deciding where to give birth. 

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For students: Telluride Patient Safety Summer Camps Applications for 2014

David Mayer has just posted a request for applications for medical and nursing students for the Telluride Patient Safety Camps for this coming summer.  Excerpt:

Through the generous support of The Doctor’s Company Foundation and MedStar Health, scholarships are now available for 40 medical and 20 nursing student leaders to engage in an immersive experience with leaders, educators, and advocates in patient safety at the 10th Annual Telluride, CO and Washington DC Patient Safety Educational Roundtable and Health Science Student Summer Camps. The student scholarships cover travel, lodging, meeting registration fees and many meals during the week.

Each of the Patient Safety Student Summer Camps are one-week, and offer an in-depth exploration of current patient safety issues and risk reduction strategies to achieve optimal patient care. Two, week-long student summer camps will be offered in 2014. Dates are:

• Sunday June 15^th – Wednesday June 18^th, 2014 (to be held in Telluride, Colorado)
• Tuesday July 29^th – Friday August 1^st, 2014 (to be held in Washington, D

The Telluride Roundtable Vision is to create an annual retreat where experts in patient safety come together with patients, residents and students in an informal setting to explore, develop and refine a culture of patient safety, transparency and optimal outcomes in patient care. The 2014 Patient Safety Summer Camps will again use an immersive, interactive format to examine ethical, professional, legal and economic issues around patient safety, transparency, disclosure, and open and honest communication skills when medical errors and adverse events occur.

To whet your appetite, watch this video of Ravi Grandhi, a third year medical student at the University of Cincinnati College of Medicine. This talk was given at a session by Telluride Summer Camp alumni and faculty entitled "Student- annd Resident-Driven Patient Safety Programs" at the 2013 Institute for Healthcare Improvement Annual National Forum in Orlando, FL on December 11, 2013.

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Oatmeal at IHI: The sequel

I never thought that I would be compelled to write another post about the manner in which oatmeal is served at the IHI Annual National Forum at the Marriott World Center in Orlando.

Let me take you back to the original posts from 2010: 1, 2, 3, 4.  Short version: The ladles (see above) provided to guests on the breakfast buffet were too large relative to the bowls, so oatmeal was being spilled all over people's hands and their bowls.  

Unsanitary and messy work-arounds were developed by the guests (like using the tea cup seen above.)  I wrote a blog post about the issue, and the hotel responded by eliminating self-service and assigning staff to serve oatmeal at several stations, providing them with slightly smaller ladles.

Now, three years later, I stopped by an oatmeal station and noticed that the ladle used by the server was still too large relative to the bowl size. So even with an experienced server, the oatmeal often spills over the edge of the bowl onto the hand of the server and the outside of the bowl.  The server then has to use a small towel to clean off both the hand and the bowl.

I say, sympathetically, "That would be easier with a smaller ladle."

Response, "These are the smaller ladles. We use them instead of the regular ones when this group [i.e., IHI] is here.

"You mean you use bigger ones when there are other groups here?"

"Right."

I'm speechless.

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Evans: Let's make our day harder

Check out this great animation from Mike Evans.

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How to learn nothing from patients

As we consider again the expertise shown by the folks at Legoland in responding to customers, consider this alternative view presented by Rob Markey on the HBR Blog Network.  The article is called "Five Ways to Learn Nothing from Your Customers' Feedback."  I'm struck by how often hospitals behave in these ways--sometimes on their own volition, but often with the wrong kind of "encouragement" from the government and insurers. An excerpt:

I have studied a lot of customer feedback systems in the 25 years I’ve spent working with companies on customer strategy. Many of them leave me sad and befuddled. So many companies make the same mistakes over and over.

The leaders of these companies seem to want to hear from their customers — that’s why they spend so much money on elaborate “voice of the customer” and other feedback systems. But the approach many of these companies take to implementing such systems seems almost as if it were designed to ensure nobody in the organization will actually learn anything from what they hear. And if employees don’t learn anything, how can they take action to make things better?

If I were writing a “how-not-to” manual for customer feedback — a manual that would guarantee your feedback system taught your employees nothing about how to delight customers and earn their loyalty — here are the five rules it might include:

1. Aggregate the feedback into scores, percentages, and averages — and stop there.  
2. Hold the feedback.
3. Eliminate the human voice.
4. Ensure that there’s a lot at stake.
5. Never close the loop with customers.

(Thanks to reader Nonlocal MD for sending along this link!)   

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Echoes of Telluride

As we turn to the final day of the IHI Annual National Forum on Quality Improvement in Health Care, our intrepid band of Telluride graduates prepares for their session, "Student- and Resident-Driven Patient Safety Programs"  The presentation will draw on their experience at Telluride in examining issues of quality, safety, disclosure, and apology--as well as work they have done at their home institutions following the Colorado seminars.

Teambuilding was an important part of the Telluride experience.  You see here that there is some residual of that training several months later.

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A fantastical experience at Legoland

One of the highlights of IHI's annual National Forum on Quality Improvement in Health Care is the opportunity for attendees to take a full-day excursion to one of the major theme parks in the vicinity. I had the pleasure of helping to lead one yesterday to Legoland.  We all know about Legos, those versatile, creativity-building blocks, and this park is a physical embodiment of the toys. It is targeted at children from ages 2 to 12, including this little lady who was enjoying a gentle sprinkle in the new World of Chima section.

Our 44 participants were greeted in the moning by the smiling faces of my colleagues Azeem Mallick and Kate Bones. We decided to engage in an opening exercise designed to get the group thinking about the operational issues facing a theme park of this sort. The pedagogical scenario we created was: "You have been brought in as a consultant. What do you imagine are the major challenges facing this company in meeting the standards it has set for famimly visits? Pick the highest prioirity and develop your theory about how to address this challenge. What will you do with regard to interventions with leadership, front-line staff, and interactions with visitors.”

The breakout groups jumped in enthuiastically.  Here, patient advocate Ziva Mann from the Cambridge Health Alliance reports from her group.  Later, with the help of a colleagues, Lelsey Anne Smith (Quality Improvement Programme Director at NHS Education for Scotland) votes on her priorities.

The idea was to compare our preconceptions of the issues facing such a theme park with the actual experience of those working in the park.  So, next it was off for the visit.

First impressions are key, and the thing that grabbed ours was this nifty name tag worn by our guide Kim.  Everyone wanted one!  Sorry, the product is not for sale . . . but we learned that park guides-- getting down low to be face-to-face--trade the little people from their name tags with ones offered by young visitors to the park.  It is a way to establish personal connections between the staff and the guests and reinforce the park's friendly atmosphere.

From the entrance, we headed to the model shop, the place where those fantastical creatures and other designs are conceived and constructed--block by block. As far as we could see, being a master model-maker at Legoland is a career to be envied. Angie, shown here, made a point to show us one of her favorite set of small models based on a favorite movie,

as well as this familiar-looking creature, complete with movable mouth:

We also had time to view Miniland USA in the heart of the park.  This miniature set of depictions of major sites in the country is a favorite of the children, and they spend hours looking at the models and pushing buttons to create animations like this depiction of a dolphin show.

.

We eventually convened for some serious talks with park management and focused on the kinds of questions we had previewed during our working session back at the IHI conference center.  We were left with very favorable impressions about the efforts made by the people in the theme park company to deliver the highest quality guest experience.  Of particular note was a rigorous system to collect and analyze each and every customer complaint and suggestion.  Once per month, every such comment is reviewed at a high level management meeting, comprising people from all divisions--not just those departments facing the visitors--at which action plans are made to resolve the issues systemically.  I should note that this monthly meeting does not in any way substitute for real-time problem solving.  When a guest brings up an issue in person, the staff member who receives the complaint "owns" the problem and stays with the guest until it is resolved.  The guest liaison staff and all frontline staff have the authority to solve the problem then and there, without further bureaucratic process.  Guests can also submit issues by texting messages to the park, and the problem is often solved in real time by a park official going to the site of the problem.

We (sadly) noted the comparison with most hospitals on this front, and people left with a resolution to explore ways to improve customer service at their home institutions.

We concluded with some free time to explore the park and, yes, go shopping: The bus was definitely more crowded on the ride back to the conference center!

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Will OpenBiome be #1 in the #2 business?

I recently learned of a fascinating non-profit start-up based at MIT called OpenBiome. The lead organizers are Mark Smith, a bio-science Ph.D. candidate and James Burgess, an MBA candidate.  The topic? Fecal microbiota transplant (FMT), which is now recognized as an effective cure for C. difficile patients.  In fact, its about 90% effective in patients that have failed three or more rounds of antibiotics.

Despite the potential, FMT has been slow to take off, largely because not many people want blenders of poo floating around their facility. Clinicians that do perform FMT spend hours doing consults with donors, sending samples out for screening, interpreting results and preparing material. FMT takes 20 minutes, but the related work takes 2 hours. This is not a good use of their time.

OpenBiome addresses this problem by centralizing the entire process into a universal donor bank, offering clinicians frozen, pre-screened, ready-to-administer microbiota preparations for use in FMT. The four-part goal is described in their website: Create a safe, standardized, reliable product; improve convenience; expand access; build a platform for open-source science.

Here's the quick summary:

OpenBiome supports clinicians in the emerging field of fecal microbiota transplantation (FMT).  We offer carefully screened, frozen stool samples for use in clinical research. By taking care of the logistical and regulatory burden of supplying material for FMTs, including FDA compliance, we hope to open the FMT field to a broader pool of clinicians, accelerating progress in this exciting area and treating patients in need.

The folks at OpenBiome will face some interesting and challenging business development issues over the coming months, but their concept is sound and has the potential to bring great value to society.  Keep an eye on this one!

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Mom, this is how Twitter works.

Here's a site that gives an excellent and easily understood description of some of the aspects of Twitter that might not be known to all.

For example, did you know?

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Do portals lead to a better view?

I very much enjoy the "contrarian, brainy and literature-based resource by Jaan Sidorov" over at The Disease Management Care Blog.  A recent post provides an example of how he makes us think. The lede:

In the November 19 issue of the Annals of Internal Medicine, Caroline Lubick Goldzweig and colleagues examined the published science on the purported advantages of electronic health record (EHR) portals.

Recall that portals are web-based entryways that on-line health consumers can reportedly use to access their records, request medications, correspond with their doctors, manage their health conditions, reduce health care costs, increase U.S. life expectancy, reduce our national dependency on jumbo-sized sugary drinks and fix everything else that ails the U.S. health system.

Unfortunately, facts have intruded.  After looking at fourteen randomized prospective trials, 21 observational, hypothesis-testing studies, five descriptive studies and six qualitative studies, the authors concluded...

 "...evidence that patient portals improve health outcomes, cost, or utilization is insufficient."

Ouch.  

Of course, Jaan cleverly makes us notice by creating the straw man and then knocking it down.

I, for one, never believed that patient portals would do much with regard to outcomes, cost, or utilization--although, as e-Patient Dave has pointed out, sometimes patients notice mistakes in their records and thereby avoid harm.

No, the main advantage I see is one of convenience, and once you have experienced that, it's hard to go back to the old way.  But the convenience is not made universally available.  In my health care system, for example, some doctors permit appointments to be made and changed electronically, and some do not.  One of my best doctors has still not caught on to the fact that his refusal to play makes life harder for his patients and his staff and, ultimately, himself.

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The SEIU is back: This time with ballot initiatives

As you watch the Service Employees International Union in action, you are inevitably left with the feeling that this is a union that has such substantial trouble relating to workers that it has to resort to powerful political tactics to accomplish its enrollment goals.  I documented one such tactic--the corporate campaign--in my book How a Blog Held Off The Most Powerful Union in America.  The object is to publicly denigrate a hospital to put pressure on it to sign a "neutrality agreement," a promise not to argue against or even discuss unionization while workers are considering which way to vote on the issue. (See an example of how a neutrality agreement works here.)

Now, under the guise of lowering health care costs, the union is involved in ballot initiatives with the purpose of obtaining these same types of agreement. The Wall Street Journal reports:

The nation's largest health-care union is threatening to mount ballot initiatives in California and Oregon that it says would lower health-care costs, but industry officials say the real goal is to pressure hospitals into making it easier for the union to organize thousands of workers.

In the SEIU's case, hospitals could be spared the cost of fighting the ballot initiatives if they agree to a partnership that includes neutrality, said Michael Lotito, a San Francisco lawyer who has represented hospitals against SEIU. "The real 'thing of value' that the union offers is, 'I'm going to stop attacking you,' " he said. 

The SEIU's approach is simply a shortcut based on using money and political influence to accomplish what it chooses not to do, i.e., engaging individual workers in good old time organizing to learn of their concerns and to offer solid ideas upon which to generate support for collective bargaining.

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Sensible thoughts on concussions

Given our inability to accurately measure the neurological damage from concussions, this seems like a prudent step.  From ScienceDaily:

Any athlete with concussion symptoms should not be allowed to return to play on the same day, according to the latest consensus statement on sports-related concussion. The updated guidelines are summarized in Neurosurgery, official journal of the Congress of Neurological Surgeons.

The fourth consensus report from the Concussion in Sport Group (CISG 4) represents the latest recommendations from an expert panel, sponsored by five international sports governing bodies. "The statement now makes clear that no athlete at any age or level of competition should be returned to play on the same day a concussion is diagnosed," write Drs. Allen K. Sills, Gary Solomon, and Richard Ellenbogen.

Wouldn't it be great, though, if the article were available for public view? Why can't these journals make articles of general public interest available to the public, like the New England Journal of Medicine does?

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Heavenly start-up?

My friend Dhaya Lakshminarayanan's mother offers this comment about Nelson Mandela:

"He had a long life. He was 95 and did many good things. Now in heaven maybe he and Gandhi and King will do start-up company for freedom." 

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Dear health care reporters: Look this way

I bet Robert Langreth (and his colleague Shannon Pettypiece) over at Bloomberg News never thought they would become experts in robotic surgery, but the travails of Intituitive Surgical. Inc. keep providing fodder for these business reporters.  How ironic.  What a sad statement about the lack of depth and coverage by many health care reporters that this business media outlet becomes dominant on this topic.

The latest? Here's their article about an “urgent medical device recall” from the company in which they relate  that friction in the arms of some devices may cause the units to stall. Why does this matter?According to the FDA, "The stalling may result in a sudden 'catch-up' if the surgeon pushes through the resistance."

Why my comment about the slow pace of healthcare reporters?  Well, the Bloomburg report notes that the recall affects 1,386 of the systems worldwide.  You'd think that some health care reporter in one of those thousand-plus jurisdictions would write a story in his local newspaper about this issue--especially since hospitals have garnered gobs of publicity (and market share) in their localities when they installed the devices.  For a start, how about questioning health systems that are offering the robot for OB/GYN surgery, notwithstanding advice from the ACOG president to the contrary.  (Reportorial hint: Do a Google search on "robotic surgery for OB/GYN" and see who shows up in your city or town.)

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Is a different kind of collective bargaining possible?

The New York Professional Nurses Union has an interesting history.  Among other things, it accomplished something unusual, decertifying the SEIU, which had previously represented its members.  From its website:

The Registered Nurses at Lenox Hill Hospital were first organized into a union in 1980 by Local 1199, the Health Care Workers Union. By 1984 a number of the staff nurses were disillusioned with the representation provided by Local 1199. They considered affiliating with other unions, but ultimately decided that the best union for Lenox Hill staff nurses would be one devoted exclusively to representing them. Thus, the New York Professional Nurses Union (NYPNU) was born.

The staff nurses then launched a drive to decertify Local 1199, and the National Labor Relations Board (NLRB) ordered an election in December 1984. The options on the ballot included Local 1199, no union, and NYPNU. NYPNU won a majority of the votes cast and the NLRB certified the Union as the exclusive bargaining agent for staff nurses in early 1985.

The union has not been shy about standing up for its members, and there is an example currently at play.  The Executive Director recently wrote her membership:

The union started getting calls from both Delegates and members over the last few weeks alerting us that most or all units in the Critical Care Division/all units with monitors, will be required to sit for an EKG exam over the next few weeks. Our position is that the Hospital does have the right to assess competencies of its employees, or in other words – they have the right to give us a test.  However, what we object to is to, and what we will vehemently fight against, is what has been coined T-cubed: Testing/Transfer/Termination.

NYPNU is meeting tomorrow (12/5) with leadership from the Human Resources and Education Departments about this issue. While LHH may have the right to compel nurses to take this EKG interpretation exam, we want to ensure that there is appropriate opportunity for in-person education.  And if a nurse does not pass (there is still clarification needed to determine if a passing grade is 90 or 95 per cent), there should be collaboration between the nurse and Education Department to receive appropriate review and education of material to give that nurse all the tools necessary to pass the exam.

It is isn't often that we get to see these issues splayed out for the world to see, and my purpose here is not to take sides.

I'm struck mainly by an environment that results in a combatative approach when the objective is so clearly in the interest of patients.  Most of us would think that nurses and hospital admininstrators would agree on the need for competency training and assessment in the interpretation of critical clinical data. Here, the union appears to have a belief that such assessments may be used as a excuse to transfer or fire nurses. I don't know the background, but perhaps the union has evidence that such might be the case.  If so, is it because the normal procedures for personnel assessment and progressive discipline are so difficult or lacking in effectiveness because of other provisions of the hospital-union contract?  Or is it the case that hospital managers are just not very good at carrying out the kinds of human resource policies that one would hope for.  We can't know from this short excerpt and without understanding the long-term relationships between the parties. And, as I said, I am not taking sides.

But what makes me sad is to think about the lost opportunity for earlier collaboration--what might happen in an alternate universe--one in which the hospital and the union had together designed and implemented this training and assessment protocol. Imagine if the front-line staff had been consulted on lesson plans and other pedagogical details.  Perhaps, then, it would not have felt like a case of compulsion, but rather an opportunity for personal growth and professional advancement.  And taking it a step further, imagine a process in which patient advocates were also engaged. After all, patients have a rather large interest in the manner in which tests are taken and results are communicated to them.

I don't think there is anything inherent in the concept of unions that would preclude such an approach.  But it takes two to tango.  Both sides, early on, must believe in the need to establish an atmosphere of such cooperation.  Then, ongoing practice with such collaborations is necessary to build and maintain confidence.  Maybe this specific case will help send that message for future clinical initiatives.

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Pro Publica tells the prisoners' health care story

Some part of the 18% of GNP spent by the United States on health care is the medical care given to prisoners in state and federal correctional facilities.

A recent article by Christie Thompson at Pro Publica provides a summary of the problem:

And as the elderly population in prison grows, so do their medical bills. Housing an inmate in a prison medical center costs taxpayers nearly $60,000 a year — more than twice the cost of housing an inmate in general population.

I'm not sure if the medical cost accounting includes this, but there is also the additional cost of requiring prisoner patients in hospitals to be accompanied by armed guards when they leave the prisoner medical center for tertiary care in a public hospital.

Thompson's story also shows that one of the unspoken tragedies in American life occurs when a prisoner is terminally ill and represents no risk to society, but is kept as part of the correctional system.

Federal inmate and lawyer Lynne Stewart tried to seek compassionate release from a federal judge after she was diagnosed with breast cancer. Stewart is serving a 10-year sentence in a Texas federal prison for serving as a messenger for her client, Sheik Omar Abdel Rahman, who was convicted of terrorism charges in connection with the 1993 bombing of the World Trade Center.

Prison officials denied Stewart’s request in June, saying she hadn’t proven she had less than 18 months to live. So Stewart took her case to court, hoping a federal judge would overrule the prisons’ decision.

“There is no doubt that Lynne is dying,” said Stewart’s husband, Ralph Poynter. “She can’t breath, the cancer has taken over both lungs.” Stewart “sounds like she’s running” when they talk on the phone, Poynter said.

The judge wrote that he had no choice but to deny her request. “The court would give prompt and sympathetic consideration to any motion for compassionate release,” the judge wrote, “but it is for the [Bureau of Prisons] to make that motion in the first place.”

Thompson's article brings to light the bureacratic hassles that end up costing taxpayers millions of dollars and deny compassion to those who need it.  This is another excellent exposition of an important issue by Pro Publica.

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MVP is a most valuable principle

A few weeks ago, I wrote about the tendency of many start-up companies who try to sell their wares to hospitals to ignore the needs of the various constituencies and therefore fail to make sales.  I concluded:

It is possible to sell great new ideas to hospitals, but they need to satisfy the interests of several constituencies in those organizations.  They must improve the work flow of the staff on the floor and units, making day-to-day life easier and not harder. They must improve the safety and quality of care, but in a manner that does not expose the hospital to greater liability: Indeed they should help reduce liability. Finally, they should demonstrate cost savings and be priced in such a manner as to allow the hospital to show cash flow improvements rather than be a drain.

I was reminded this week by Caren Weinberg, senior lecturer of invovation and entrepreneurship at Ruppin Academic Center in Israel, that even this prescription is not necessarily going to result in a successful product roll-out.  The element that I neglected to mention is the Lean concept of minimum viable product.  Taking off on the practice of PDCA (plan, do, check, act) cycles, Ash Maurya notes that "the basic idea is to maximize validated learning for the least amount of effort. After all, why waste effort building out a product without first testing if it’s worth it?"

Coincidentally, this message was reinforced at an MIT Enterprise Forum at Tel Aviv University, where Wix founder & CEO Avishai Abrahami was providing advice to entepreneuers.  Here's one of his slides:

Over time, he explained, the firm can add incremental features and improvements, all the while testing them with customers.

The alternative approach that I have seen is for a firm to spend inordinate amounts of time and effort designing a spectacular technological fix to a series of problems without testing early concepts or prototypes against customers' needs and wants.  It enters the market with a perfectly engineered product, only to discover that it is off track from what the market demands. Having depleted the company's capital, it falls into a financial hole and has trouble digging out.

Thanks to Caren for the reminder that MVP stands for a "most valuable principle!"

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Joining Lean practitioners in Israel

Many thanks to Boaz Tamir, head of Israel Lean Enterprise (part of the Lean Global Network), for an invitation to present at a session for a number of businesses that are involved in adopting the Lean process improvement philosophy in their organizations.  Examples included Intel, the Strauss Group (food and beverage supplier), Bank Hapoalim, and yes (satellite broadcasting.)  The attendees were intrigued with the lessons from my book Goal Play! about how to create learning organizations.

I was honored to share the stage with Micha Popper, from Haifa University, who studies and teaches about leadership.  He told a particularly apt story about how the Israeli Air Force improved their learning process.  Years ago, after the missions, the pilots would sit around and tell each other stories about what had happened during their flights. Later, when technology had improved to document the actual flight conditions and history of each flight, their stories were bolstered by actual data.  The debrief sessions that resulted were much more accurate. More to the point, the flight teams–who previously had a natural tendency to hide or forget their mistakes–became much more open about disclosing their errors, comparing them one with the other, and then learning from the experience.  The result was a documented improvement in pilots’ abilities.

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MIT SDM deals with the prisoner's dilemma

This looks really fascinating for those of us interested in how incentives do or do not work:

Systems Thinking and the Inevitability of the Dreamliner Delays

MIT SDM Systems Thinking Webinar Series

Yao Zhao, Ph.D.
Associate Professor, Rutgers University

Date: December 2, 2013
Time: Noon – 1 p.m. EDT
Free and open to all

Register

 

About the Presentation

 

Although the Boeing 787 Dreamliner was the fastest-selling plane in the history of commercial aviation, its development was a nightmare. The first flight was delayed by 26 months, and the first delivery was 40 months overdue with a cost overrun of at least $10 billion. Using the results of a comprehensive empirical study of the actual events and facts, this webinar will discuss strong evidence suggesting that the majority of delays were intentional.

 

Dr. Yao Zhao will:

• Describe a mathematical modeling and analysis of economic drivers in joint development programs that showed the 787's risk-sharing arrangement forced Boeing and its partners to share the "wrong" risk. This led each partner into a "prisoner's dilemma" wherein delays were in the best interests of the firms even while they were driving themselves into disaster;
• Discuss the reconciliation of the analysis with empirical evidence, which reveals the rationale behind many seemingly irrational behaviors that delayed this program; and
• Suggest a new "fair sharing" partnership to share the "right" risk and greatly alleviate delays for development programs of this kind in the future.

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How to deal with performance anxiety

Here's a really interesting insight from a musician about one way to deal with performance anxiety.  Or Ben-Natan is a vocalist who sings bass in classical and other music concerts in Israel. At a recent rehearsal with a chamber group in Zichron Ya'akov, his wife made sure that their little granddaughter was sitting near her in the front row to watch the performance.

When we asked Or if this was a distraction, he said that it actually helped him.  "When I am performing, I feel the tension between the anxiety of the performance and the desire to relax and enjoy the music. I know that my granddaughter would immediately sense it if I became too anxious, and so she helps me consciously move along the spectrum towards relaxation and enjoyment of the music."

A remarkable and lovely insight.

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Shaking the hubris of the profession

My friend Danny Sands writes a remarkable story about a recent medical problem he faced. It's called "On The Ultimate Loss of Control, Living with Uncertainty, Reflecting on the Future, and Being a Patient."  It is beautifully written and worth a look.

I have been struck by a number of similar types of stories recently in which doctors have become patients or have been with close families members in that situation.  I think it is a wonderful thing that physicians now feel comfortable relating such experiences.  The common theme is one of shock and a new understanding of what it is like to be a "customer" in the health care system, especially when the episode involves an error or near-miss that is made in your treatment.  Here is a "minor" example in Danny's case: 

Because of the uncertainty of the diagnosis, I was prescribed atorvastatin to lower my LDL cholesterol and risk of future strokes. When I asked if they measured it in the hospital, I was told it was 107 (which is rather low already) so I politely declined. Besides, the imaging showed no evidence of plaque in my carotid arteries, my blood pressure was low, and I had no family history of cerebrovascular disease or coronary artery disease.

But--and I mean this with great affection for my colleagues who have written, in that I view them as among the best of their profession--isn't it a sign of the hubris of our profession that these doctors do feel the shock they write about?  After all, they have spent years in training and practice and treated thousands of patients.  In other fields of endeavor, the most important part of being and staying in business is to understand the needs of the customers.  The most successful firms, indeed, are driven by the needs of their customers.

In contrast, look at what Ashish Jha noted after a recent injury brought him to the emergency room:

The biggest lesson for me was that this was not an extraordinary story at all.  When I told my story to colleagues the next day, no one was surprised. We accept that when we walk into a hospital, we give up being people and become patients.  We stop receiving care, the way I did on the bike path.  Instead, we receive services. And when you are in pain, the difference between care and services is stark.

This is why I implore the medical profession to move to the idea of patient-driven care.   

As I have said at some recent conferences, patient-driven care does not mean foregoing the expertise, judgement and experience of clinicians.  Nor does it suggest the abdication of their clinical responsibilities. But we must go beyond patient-centered care, in which the doctors and nurses decide what is best for the patient.  Patient-driven care, in contrast, is based on a partnership between the provider and the customer.

And one thing more, returning again to Ashish's story:

Now that we are measuring patient experience and ER wait times as quality measures, I wondered how Falmouth hospital did.  Out of curiosity, I looked up its ratings. They are fine.  Average. This is not an outlier hospital. My experience was not an outlier experience. And that is the biggest disappointment of all.

I often say, "There is no virtue in benchmarking yourself to a substandard norm." Hospitals have come to accept that a "normal" level of (even just) patient-centered care is acceptable.  It is not.

I am pleased to see the hubris of my doctor friends being shaken by their personal experiences.

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In memoriam: Arik Einstein

The story goes that, on his 70th birthday, Arik Einstein was invited to lunch by the president of Israel. "Mr. President," he replied, "please let me stay home."

This week this legendary performer, an icon in the country, died from a ruptured aneurysm at age 74.  The outpouring of grief and appreciation has been truly remarkable.  For example, thousands of people attended hours-long open-air concerts in Tel Aviv, singing the well-known lyrics of dozens of his songs.  The participants?  People of all ages, from teen-agers through the elderly.

Although Einstein had been writing and recording songs into his later years, he had not appeared in concerts for three decades.  How is it that young folks, then, took him into their hearts in such a manner?  After all, their musical heroes tend to be the people who give concerts, dance in sexy clothes, construct music videos, and the like.

One theory is that Einstein embodied the values of "the old Israel," and that this resonates with mutiple generations. Let's face it: Ever since the 1967 war (the Six Day War), this has been a country in which hubris has grown in disproportion to other characteristics.  It was that hubris that likely led to the debacle of the Yom Kippur War in 1973.  It is that hubris that encourages governments to support settlements in the Occupied Territories.  It is that hubris that impedes multiple chances at the peace process.

Meanwhile, in the manner that is the contradiction that is this country, Israel sets a remarkable standard in other respects.  We know, for example, of its reputation as "start-up nation" and other well deserved credit in other realms, like the medical education advances I recently discussed.

But, perhaps the young people responded to the unassuming nature and modesty of Arik Einstein, as exemplified in the story above.  Perhaps the message of Einstein's death is that the next generation seeks that kind of guidance, direction, and example from their national leaders.

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Happy holidays!

My friend Lisa Popick Coll offers this version of a Thanksgivukkiah on Facebook.

Reportedly the two holidays will not coincide for another 70,000 years.  More or less. The explanation:

The overlap this year is because according to the Jewish calendar, this is a leap year, meaning that an entire extra month is added to the calendar. Because of that, most major Jewish holidays moved up by nearly a month. Couple that with the extremely late date of Thanksgiving in 2013, and you've got a convergence of holidays that comes once in many, many generations.

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Ma, can we go to the hospital mall?

Traveling in Chicago recently, I saw these ads on the side of a major hospital.  I was struck by the idea that advertising for a mall was getting equal billing to advertising for orthopaedic services.  Orthopaedics has always been a high profit item for hospitals.  I guess dining and shopping has now reached that same level.

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Remembering Monique Doyle Spencer

A reminder of some of the impact of Monique Doyle Spencer, noted on the second yarzheit (anniversary of her death.)  The Sunshine Girls, a breast cancer support group in Southeast US, with copies of The Courage Muscle. 

We'd often laugh about how she was always misplacing her reading glasses!  Here's part of the collection she maintained by her bedside just in case.

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The future of simulation is to be found in Tel Hashomer

Simulation centers have been popping up in hospitals across the world.  These are useful, but for the most part their function is to provide technical training in surgical and other interventional techniques, as well as to practice resucitation and the like. Sometimes, too, they are used to study teams in stressful situations to provide lessons in team dynamics.

Amitai Ziv has a broader view of the purpose of simulation. His goal is nothing less than to use this tool to help in the transformation towards a safe, humane, ethical, and patient-centered medical culture.  As the director of MSR, the Israel Center for Medical Simulation at Sheba Medical Center on the outskirts of Tel Aviv, he is pursuing this goal with passion and energy and the support of his home base, philanthropists, and medical professionals throughout the country.

When an adverse event occurs in hospitals, we sometimes say that "the holes in the swiss cheese lined up" to permit a series of small problems to cascade into a big medical error.  Amitai draws on that imagery to describe "the educational Swiss cheese model."

He sees flaws in several key components that comprise the continuum of education and practice for physicians and other health professionals. He suggests that targeted use of simulation can help address the holes in the continuum, and he and his colleagues are out to test that proposition.

MSR is designed as a virtual hospital, offering a wide spectrum of medical simulation technologies. These include computer-driven physiological mannequins, advanced task trainers for manual skills and live simulated patients played by role-playing actors.  MSR combines these different technologies in "high-risk" scenarios to develop and build crucial clinical and communication skills and enable team training in risk-free environments.  Customized audiovisual equipment and one-way glass facilitates real-time observation and allows effective debriefing and constructive feedback to trainees.

Beyond technical training, MSR:

Enhances communication skills through programs dedicated to teaching challenging tasks, such as delivering bad news, obtaining consent and the detection of domestic abuse.

MSR training in a variety of technical and interpersonal competencies is now required of all medical students in Israel before they start their internships.  Interestingly, the center is also working in collaboration with the Tel Aviv University Sackler Faculty of Medicine to provide simulation-based personality screening of medical school candidates.  The aim is to improve the humanistic quality of medical school candidates by assessing their personal and interpersonal characteristics.

MSR conducts hands-on experiential simulation training in a wide variety of clinical domains such as Anesthesia, Cardiology, OB-GYN, Trauma, Chemical & Biological Warfare Management, and more. MSR is an integral part of the accreditation and licensure process of several of Israel's healthcare professional bodies.  These include competence-based board exams for Anesthesiology Residents and for Paramedics. 

The center also conducts a faculty development program for those interested in developing simulation programs in their home institutions.

In short, this is not a view of simulation as an adjunct to the medical education system.  It is a conception of simulation as being deeply integrated into many of the phases of a physician's career--starting before medical school, leading through that school and residency, and then staying with the person throughout his or her career. This larger vision welcomes the use of simulation by regulators and professional societies, as well as risk management organizations. Beyond a focus on safety, there is an attempt to influence the practice of medicine in many dimensions, consistent with the underlying values of clinicians and the roles expected of them by patients and families.

As someone who has been involved in several aspects of simulations, I will tell you that the MSR vision is expansive beyond anything I have seen.  The future of simulation is to be found in Tel Hashomer.  If I were running a center anywhere else in the world, I would be doing my best to learn from Amitai and his colleagues lest my own center fall behind and fail to meet its potential value to society.

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Scott Adams: I hope my father dies soon.

Dilbert's Scott Adams writes an entirely serious (and angrily raw) post about an important topic, doctor-assisted suicide.  Excerpts:

I hope my father dies soon.

And while I'm at it, I might want you to die a painful death too.

I'm entirely serious on both counts.

My father, age 86, is on the final approach to the long dirt nap (to use his own phrase). His mind is 98% gone, and all he has left is hours or possibly months of hideous unpleasantness in a hospital bed. I'll spare you the details, but it's as close to a living Hell as you can get.

If my dad were a cat, we would have put him to sleep long ago. And not once would we have looked back and thought too soon. 

. . .

I'm okay with any citizen who opposes doctor-assisted suicide on moral or practical grounds. But if you have acted on that thought, such as basing a vote on it, I would like you to die a slow, horrible death too. You and the government are accomplices in the torturing of my father, and there's a good chance you'll someday be accomplices in torturing me to death too.

. . .

[Update: My father passed a few hours after I wrote this.]

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New medical device emerges

At first, I thought it was an isolated incident.  @Bob_Wachter from UCSF reported on Twitter:

Lines betwn personal/professional contnue 2 blur, as I now use my @iPhone flashlght 2 look into my patients mouths. OK 2 clean it w/ alcohl?

I jokingly responded:

This makes me feel a bit uneasy, Bob. What if the phone rings? Or worse, buzzes! :)

He answered:

Good point, tho its not inside mouth (just outsde). Its 1 more sign of Swiss-army-knife nature of iPhone: 1 less thing 2 to carry

But then @drsusanshaw from Saskatchewan jumped in:

Just the other day I used iPhone flashlight to help surgeon identify bleeding vessel in an ICU patient.

They say it usually takes 14 years for a new medical device or procedure to infuse the market. Is this one faster?  Please comment if you have seen similar examples.

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Exploring Lean in Tel Aviv

A colleague and I are in the midst of an introductory training session about the Lean process improvement philosophy at Sheba Medical Center on the outskirts of Tel Aviv, Israel.  We were invited by Dr. Eyal Zimlichman, head of quality management for the hospital (seen here with Jessica Livneh, head nurse of the oncology outpatient unit.) As is often the case, we find highly committed, engaged staff and managers facing the usual assortment of hospital management problems. Their interest in the opportunities offered by Lean is palpable, but part of our job is to explain that adoption of this philosophy takes extensive time and effort. Our hope is that this session will give them a taste of the possibilities so they and their leaders can make a more informed decision about the path forward.

We were honored to be joined by Boaz Tamir, Israel's Lean guru.  You see him here with (from right to left--appropriately!) Yoav Shalem (pharmacist); Dr. Einav Nili Gal-Yam (head of the oncology outptient unit); and Miriam Adam (director of pharmacy services).

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Competition matters on both sides of the Atlantic

There is often a lot to learn by comparing the US and UK health care systems, but as often as not we revert to Shaw’s “two nations separated by a common language” when looking for lessons. Let me give one example.

Although the UK has had a single payer, nationalized system for over six decades, there also exits a small but vibrant private sector system. In this sector, private insurance companies—supported by premiums paid by individuals or corporations (on behalf of employees)—contract for services from private hospitals and consultants (i.e., doctors.) The system operates in a similar fashion to the US private care system. Insurance companies negotiate with the provider groups as to the rates that will be paid for the various clinical services.

As in the US, there are some private provider groups that have sought to obtain geographic dominance in certain markets. One purpose of that dominance is to have monopoly-like leverage over the insurance companies to obtain super-normal profits.

In the US, when this kind of dominance occurs, it is—for the most part—ignored by public policy makers and regulatory officials. Indeed, it is explained away by assertion that such ACOs (as we now call them) are better able to coordinate care for their patients and thereby achieve efficiencies that will lead to lower costs. As best I can tell, no one with training in economics believes that such an offset is likely to be the result.

Recent rulings by the Competition Commission in the UK have given the lie to those kinds of hopes.  The CC found that dominant private health care networks, particularly by not exclusively those in major metropolitan areas, were able to extract monopoly rents from the insurance companies. The regulatory response: Requiring the divestiture of a sufficient number of hospitals to enable competition to emerge.  The specifics remain to be decided, and portions of the ruling are likely to be contested or appealed, but the logic of the CC will remain intact: Too much market concentration is bad for consumers.

I am struck by how this differs from the situation in the US.  Even Don Berwick, one of the most informed candidates for public office when it comes to health care, avoids the market power issue in his recent platform statement—notwithstanding how many times it has been documented that the dominance of one health care provider network in Massachusetts single-handedly accounts for a substantial portions of the state’s high health care costs.

The CC’s report should be required reading for US health care policy-makers. The UK has a lot to teach us if we can learn to understand our common language.

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