In the streets? No, in the gutter.

I have reached a new level of disgust with regard to the international political activities of Hadassah Women's Zionist Organization of American.  Recall that HWZOA has overseen the systematic failure of Hadassah Medical Organization.  But rather than acknowledging any flaws in its own governance and oversight of this crown jewel of Israel's health care system, it seeks to impose blame on the government of Israel.  While there are clearly policy changes that are needed to help the role of non-profit hospitals like Hadassah, it is totally inappropriate for the American Jewish community to expend political capital in this self-serving manner.  I hope that Israeli politicians see this tactic for what it is.

Here's the latest missive from the head of HWZOA:

Now is the time to stand in solidarity with Hadassah Medical Organization (HMO). My previous emails and our dedicated HMO UPDATE webpage have kept you informed about the recovery effort at HMO. But now is the time for you to take action. Negotiations with the Government of Israel continue, but to date have not resulted in the changes we need to keep Hadassah's hospitals thriving and serving the people of Israel. 

On Tuesday, March 18, a large tent will be erected outside the Knesset in Jerusalem. Hundreds of supporters—including physicians, nurses, former patients, and concerned citizens—will make their voices heard. I will be leading a contingent of HMO Board members, HWZOA past presidents, Hadassah Office in Israel and representatives from Hadassah International, Youth Aliyah and Young Judaea. We will present a petition in support of HMO with more than 20,000 signatures to the Government of Israel, and invite Members of the Knesset to visit the tent and meet with us. On the same day, we are calling for a show of solidarity at the Israeli Consulate in New York City.

There are three important ways to show your love of Hadassah and your support of Israel’s finest medical organization, even if you are not in the New York area.

1.     Sign the petition today.
It must be signed by Wednesday, March 12.
2.      Join our virtual rally! ! Take a “selfie” (photo of yourself) holding a sign in support of Hadassah's hospitals, and post it on Hadassah’s Facebook page. And get together with members of your chapter and take a group “selfie” for Facebook.
Suggested signs:

o    I stand with Hadassah's hospitals

o    Support Hadassah's hospitals

o    I want fair treatment for Hadassah's hospitals

o    I’m with Hadassah's hospitals 

3.    Tweet your support to #ImWithHadassahHospitals. Encourage your family and friends to do the same.

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Time to undo the readmission penalty damage to safety net hospitals

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

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

To the best of my knowledge, these concerns were never addressed by the federal government, or by state governments applying similar standards through Medicaid.

Now comes this thoughtful argument by Richard Fuller at 3M Clinical and Economic Research in an article entitled: "Payment policy bias against high Disproportionate Share Hospitals (DSH)."An excerpt:

The bias against high Disproportionate Share Hospitals (DSH) apparent in the CMS payment policy is particularly concerning. This comes at a time when Medicare DSH payments are being directly adjusted as part of ongoing reforms and Medicaid DSH payments are being cut nationally in accordance with the Affordable Care Act. This heightened sensitivity brings urgency to the discussion of how to correct for the perceived SES [socioeconomic status] bias, specifically whether measures reflecting SES should be included in the current risk-adjustment formula. If additional measures reflecting SES are to be considered, it will be important to separate the effects that may be attributed to generally lower performance in low income areas from those attributable to the complexities of treating a challenging population. In other words, can the risk adjustment method help us distinguish whether hospitals that care for poorer patients perform worse because they don’t do a good job, or because their patients are more difficult to care for?

His summary:

Risk adjustment for provider rates that account for SES should include additional clinical and demographic factors that can be shown to improve predictive performance. In addition, those additional factors should be incorporated into a model that is based on continuous variables rather than a categorical model based on peer groups.

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Will it be a whitewash?

In five days, the president of the University of Illinois is due to receive the report from the Vice President for Research that will evaluate the circumstances surrounding the use of the University's name and reputation in support of a private medical equipment supplier.  Recall that the VP was charged to "conduct a methodical assessment of policies, guidelines, procedures and practices, and where corrective changes are required we will take the appropriate action."

As I have noted:

Karisa King and Jodi Cohen at the Chicago Tribune have published an excellent story about how some doctors and admininstrators decided to use the name and reputation of the University of Illinois in support of a medical device company.  With access to internal emails, it becomes clear that an explicit decision was made to do so by very high-ranking officials:

Benedetti, the head of surgery, sought advice and permission from Jerry Bauman, interim vice president for health affairs, and Dr. Dimitri Azar, dean of the College of Medicine, according to an Oct. 23 email obtained under the Freedom of Information Act.

"On one side it would be a lot of free publicity for our program, on the other side we could be criticized to be included in an industry generated campaign," Benedetti wrote. The two responded separately that the visibility would be good for the program.

It will be revealing to see how the report deals with the question of how these people recklessly gave themselves an exemption from the specific language of the Campus Administrative Manual:

In general, the University cannot permit its image to be used in any commercial announcement, in a commercial or artistic production, including the World Wide Web or in any other context where endorsement of a product, organization, person, or cause is explicitly or implicitly conveyed.

There are two possibilities.  The one offered to date by the University's spokesperson is that participating in the ad was "a good faith effort" to promote expertise that has "demonstrably beneficial outcomes for patients," but the execution was perhaps not well thought-out.

With such a conclusion, the University would be admitting that its policies are a nullity.  As long as someone felt that the business interests of the hospital would be well-served, the rules could be abrogated.

The second possibility is that these three high administrative officials are found to have knowingly violated the University's rules but get a mild slap on the wrist or less.  In such a case, the University would likewise be admitting that its policies are a nullity: As long as you are high up enough in the organization, the rules need not be followed.

Well, there is a third possibility, that the University sends a message--through appropriate punishment--that the ethical rules under which it operates are real.  As I noted back in January:

Regular readers know that I tend to operate in a no-blame mode, i.e., be hard on the problem and soft on the people.  But when someone has violated the public trust in an institution to support the commercial goals of a private company, they have shown such poor judgment that consideration must be given to terminating their employment.

And how much more so now that we know that this equipment manufacturer has provided cash support and has other close relations with UIC faculty.

I'm guessing we won't see much in this report that indicates a serious look at the recent violations.  The University has invested too much in its robotic surgery program to take an action that might suggest that any aspect of that program is untoward, influenced by the equipment manufacturer, or unsupported by clinical evidence.  Likewise, the University has made it clear that the highest ranking official who rules on matters of potential conflicts of interest can have deep and close financial relationships with firms whose interests overlap UIC's.

So, what's it to be?  Whitewash #1 or whitewash #2 or a clean break from past practices?  The resolution will eventually reflect on the Board of Trustees, some members of which are especially known for their public service reputation.  Will they stand by and watch as the reputation of their University is again dragged through the mud?

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Let's spend time calling instead of coding

Way back in 2008, my friend and colleague John Halamka wrote this post about the transition from ICD-9 to ICD-10 codes, the codes that are used to record clinical activity for the purpose of reimbursement by Medicare and other insurers. John is the unquestioned national expert in health care IT systems. At the time, he was "enthusiastic about the adoption of new standards that enhance semantic interoperability. The use of modern vocabulary standards such as ICD-10 improve administrative efficiency, enhance the ability of decision support systems to enforce guidelines, and enable a more granular reimbursement process." But, he also pointed out the logistical and training problems inherent in this kind of transformation:

The overall cost of implementing this change is technological and operational. For example, there must be modifications to existing training curriculum as well as claim submission and payment policies to ensure no adverse impact to the revenue cycle. I anticipate a real challenge to train, recruit, and retain ICD-10 savvy coders.

Well, that may have been one of the biggest understatements in health care for the decade.  As I have traveled the country, few issues have raised more concern than this one. 

By 2011, John Halamka was warning us:

If Congress was doing its job of regulatory oversight, they would sponsor hearings to learn what payers and providers are actually spending on ICD-10 conversion. Costs for consulting services alone run into the millions. This does not count the application software conversion, training and education, and other "in-house" costs. At our medical center, we would be paying $380,000 according to HHS estimates. Instead, the marginal cost of ICD-10 will be in excess of $5m. For multi-hospital systems, the costs may exceed $100m.

A Congressional review of transition costs would turn the regulatory impact assessment on its head. Costs could easily become double the estimated benefit savings.

With ICD-10, the government is perpetuating a reimbursement system that is far too complex. We spend more than any other country on healthcare administrative overhead. The Medicare Claims Processing Manual, for example, is over 4,000 pages in length. The reimbursement system needs simplification to bring the cost of this function in line with other industries.

In 2013, he noted:

We learned from healthcare.gov that end to end testing with a full user load and complete data set is important to validate the robustness of an application. ICD-10 go live for every provider and most payers (other than Workman's Comp) is 11 months away. Does CMS have time for a full end to end test of all functionality with its trading partners? I am concerned that not enough time is available. Will most payers and providers be ready to process transactions on October 1, 2014? Maybe. Will new documentation systems, clinical documentation improvement applications, and computer assisted coding to ensure auditable linkage between the clinical record and the highly granular ICD-10 billing data be in place? Doubtful. Will RAC audits discover that not enough time was available for training, education, testing, innovation, and workflow redesign? Certainly. The risk of a premature ICD-10 go live will be the disruption of the entire healthcare revenue cycle in the US. The consequences of a delay in enforcing ICD-10 use are minimal.

There have been lots of similar requests to the government to slow this down, but the CMS administrator is holding firm to the latest deadlines:

Providers, payers and claims clearinghouses can look for no relief from the looming, Oct. 1 compliance deadline for the nationwide conversion to the ICD-10 family of diagnostic and procedural codes, the head of the CMS said Thursday.  

Tavenner's comments triggered a quick, and apprehension-filled, response from the American Medical Association.

“The AMA is deeply concerned that Medicare does not have a back-up plan if last minute testing demonstrates anticipated problems with this massive coding transition,” said AMA President Dr. Ardis Dee Hoven.

Many doctors are still awaiting software updates from vendors and risk not having sufficient time to test those updates when they finally do arrive, Dee Hoven pointed out. “Testing is needed to discover problems and resolve them prior to the go live date. The slightest glitch in the ICD-10 rollout could potentially cause a billion dollar back-log of medical claims that jeopardizes physician practices and disrupts patients' access to care,” she said.

So, the training goes on.  Barnes Jewish Hospital in St. Louis, for example, has prepared thousands of "tip" cards like the ones above to help people remember some of the details required under the new coding environment.

Meanwhile, this has become a big business.  Here in Boston, one IT firm is even advertising on public radio (!) that is it available to help health care facilities manage the transition.  (I guess that just shows how many health-care-related NPR listeners live here!)

I guess this is all necessary, but I'm not sure I really understand why.  For example, if the trend in the US really is towards global, or capitated, payments, why do we need record-keeping of such detailed clinical activities?  Also, this new required level of detail creates immense compliance risks for doctors and hospitals and enforcement needs for regulators. It seems to me that the chance of inadvertently coding something wrong has just increased by two or three orders of magnitude.

 The CDC summarizes:

• There are nearly 19 times as many procedure codes in ICD-10-PCS than in ICD-9-CM volume 3
• There are nearly 5 times as many diagnosis codes in ICD-10-CM than in ICD-9-CM
• ICD-10 has alphanumeric categories instead of numeric ones
• The order of some chapters have changed, some titles have been renamed, and conditions have been grouped differently

Given the government's recent focus on enhanced billing compliance, we can expect many more investigations and financial penalties.

I'd prefer that providers be allowed to spend more time calling their patients and talking to them about their conditions rather than coding their illnesses.

Meanwhile, there is some humor in the situation:

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Three wrongs don't make a right, even for Deans

An important comment was submitted on my post below, in which I argued that the service of the University of Illinois Dean of Medicine on the Board of Directors of a medical device and pharmaceutical company was unwise.  Recall that I said:

I seek to present facts and context that, in my mind, again raise the issue of governance and propriety:  How can this person exercise a proper duty of care and loyalty to both institutions, not only in terms of time commitment, but also in terms of the overlapping scientific research and clinical interests of the two organizations?  I raise this issue not to accuse anyone of misbehavior, or engaging in conflicts of interest that result in personal gain, but as a matter of public trust.

The comment was as follows:

The governance rules that allow external leadership positions are not unique to UIC or to the city of Chicago. As examples, the Dean of Weill Cornell Medical College in New York is on the Board of Directors of Bristol-Myers Squibb Pharmaceutical Corporation, and the Dean for the University of North Carolina School of Medicine is on the Board of Directors of Eli Lilly. This is an issue that extends beyond the city limits of Chicago – a city that I call home and I love.

I checked it out.  Laurie Glimcher, the Dean at Weill Cornell, is indeed on the Board of Directors of the Bristol-Myers Squibb Pharmaceutical Corporation. She is an expert in rheumatology, immunology, skeletal biology and translational medicine.  You can understand why BMS would welcome her to their board, as they have a large presence in the immunology field.  She is also on the Board of the Waters Corporation, a laboratory equipment company.

Questions akin to those I have raised about UIC have been raised about Dean Glimcher's dual roles:  This article, for example, was published in 2012 in the Cornell Daily Sun:

In addition to receiving an academic salary from Cornell, WCMC Dean Laurie Glimcher receives six-figure salaries annually from pharmaceutical giant Bristol-Myers Squibb and the Waters Corporation, a laboratory equipment company, according to the companies’ filings with the U.S. Securities and Exchange Commission. There are no allegations that Glimcher has used her position at Weill to do anything illegal or to steer the school to purchase those companies’ products.

But leading research ethicists say such close financial ties to big business can prove harmful in less obviously wrong ways. Having a medical college’s top official personally and financially invested in the profits of the medical industry can stifle academic integrity and stain medical research with a subtle, if perhaps unconscious, corporate bias, they said.

“If medical faculty know they’re basically reporting to Bristol Myers Squibb, does that make them change what they do? Be more afraid to criticize certain priorities?” said Roy Poses, president of the non-profit Foundation for Integrity and Responsibility. “There’s a lot of evidence to [cause] concern [that it does] alter their behavior.”

Poses, who is also a professor of medicine at Brown University, pointed to board directors’ legal obligation to help the companies they work for.

“If you’re sworn to uphold these shareholders and you are good buddies with the management, are their interests always completely aligned with [those of] students and faculty [and] patients of the medical school?” Poses said.

William L. Roper is dean of the School of Medicine and vice chancellor for Medical Affairs at the University of North Carolina at Chapel Hill (UNC) and CEO of the UNC Health Care System.  He is an expert in pediatrics and social medicine.  He is not on the board of Eli Lilly.  But he is on the Board of Directors of DaVita, Inc., which provides a complete range of dialysis treatments and support services for patients.  DaVita reports: "Dr. Roper brings substantial expertise in the medical field, an in-depth understanding of the regulatory aspects of our business as well as clinical, financial and operational experience."  Dr. Roper is also on the Board of Directors of Express Scripts Holding Company, which provides pharmacy benefit management services and clinics healthcare account administration services.

As in the case of the UIC Dean, there is no evidence of any attempt to hide Glimcher's or Roper's relationships.  As you would expect, they are fully disclosed in both university and company documents.

So what's the problem?  It's the same one I mentioned at the start:  How can this person exercise a proper duty of care and loyalty to both institutions, not only in terms of time commitment, but also in terms of the overlapping scientific research and clinical interests of the two organizations?

In a era of diminished public confidence in our health care institutions and in the pharma companies, why introduce additional relationships that have the potential to erode public trust?  There are plenty of ex-Deans with scientific expertise to be tapped by public companies.  And for these three Deans, there will be plenty of commercial board opportunities when they step down some day.

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Jubilee Project presents The Mixtapes

The Jubilee Project continues to provide us all with heartwarming videos.  Check out this one.  Or watch it here:

 

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Addressing Patient Wait Times with Systems Thinking

MIT SDM Systems Thinking Webinar Series

Addressing Patient Wait Times with Systems Thinking

Ali Kamil, SDM '12, MIT SDM and Harvard Kennedy School of Government Graduate Student 

Dmitriy Lyan, SDM '11, Senior Product Manager, Amazon Web Services

Date: March 10, 2014
Time: Noon – 1 p.m. EDT
Free and open to all

Register

About the Presentation

This webinar will present findings from a 12-month study that explores the use of systems thinking to address the prolonged and highly variable patient wait times. The research was conducted at the LV Prasad Eye Institute (LVPEI) in Hyderabad, India, which has provided care for more than 15 million people—over 50 percent of whom were served free of charge.

The presentation will:

• Outline the challenges faced by the LVPEI's outpatient department (OPD) clinics, which serve 65 to 120 patients per day, with patient wait times ranging from 45 minutes to 6 hours;
• Review time and motion studies of 430 patients at four LVEI OPDs;
• Describe how researchers used qualitative and quantitative data to capture the operational structure of LVPEI OPD clinics and simulate daily patient flow;
• Share contributions from key stakeholders;
• Reveal the analysis used to quantify the impact of service demand, patient scheduling, and resource allocation factors on patient wait times and service quality; and
• Summarize outcomes, including identifying the key policy levers that determine LVPEI's effectiveness.

A question and answer session will follow the presentation.

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