An Information Flaneur's Best Blog Posts of 2012

As a self described Information Flaneur who wanders aimlessly around the Internet and my world searching for what I don’t know that I don’t know, I did not expect to find any rhyme or reason to my 2012 blog posts.  And yet when I read them today on New Year’s Eve to select the Best of 2012, I surprised myself by finding six coherent and recurring overarching themes:

·      American physicians have lost their way and need to undergo intense self-scrutiny

·      American health plans need to reinvent themselves or disappear

·      The digital future of medicine is fascinating and largely unknowable

·      There is an urgent need to bridge the gap between the humanities and the sciences

·      The American preoccupation with Happiness is wrongheaded but extremely important

·      Understanding and explaining the Affordable Act takes a lot of time and energy, but it is worth it

American physicians have lost their way and need to undergo intense self-scrutiny

Some of my closest colleagues found it amusing that I of all people wrote passionately about the need for physicians to embrace humility and win the battle for the soul of American Medicine. “Early in life I had to choose between honest arrogance and hypocritical humility. I chose the former and have seen no reason to change” is a Frank Lloyd Wright quotation that I used ironically at the start of one of my diatribes calling for physicians to undergo intense self-scrutiny, and my closest friend said he thought Wright could be speaking for me.

http://www.thedoctorweighsin.com/physicians-humility-and-the-transformation-of-american-healthcare-2/

Nevertheless, there is a battle for the soul of American Medicine; I pontificated about it here http://thehealthcareblog.com/blog/2012/12/20/the-battle-for-the-souls-of-american-doctors/  and in a three part essay inspired by the English Olympics Opening Ceremony, which celebrated the National Health Service http://www.thedoctorweighsin.com/the-olympics-doctors-nhs-transformation-and-heroes-why-the-difference-between-usa-and-uk/, http://www.thedoctorweighsin.com/the-olympics-doctors-the-nhs-transformation-and-heroes-why-the-difference-between-the-usa-and-uk-part-ii/, http://www.thedoctorweighsin.com/the-olympics-doctors-the-nhs-transformation-and-heroes-why-the-difference-between-the-usa-and-uk-part-iii/   These blogs drew the wrath of many practicing physicians, as did my blog post that attributed much of any personal or professional success to luck http://www.thedoctorweighsin.com/does-luck-contribute-to-personal-success-2/.

American health plans need to reinvent themselves or disappear

The survival of Obama’s Affordable Care Act has demolished the traditional business model of the American health insurance company, and it has been fascinating to watch them scramble to reinvent themselves.  Some are buying bankrupt delivery systems and others are investing in providers and smartphone applications, but none of these tactics will work unless they can transform their corporate cultures.  Read about the challenges here http://thehealthcareblog.com/blog/2012/07/22/health-insurers-the-affordable-care-act-extinction-or-reinvention/, here http://www.thedoctorweighsin.com/health-plans-continue-to-struggle-to-reinvent-themselves/, and here http://kentbottles.blogspot.com/2012/03/technology-aetna-itriage-and-future-of.html.

The digital future of medicine is fascinating and largely unknowable

Like everyone else I read Eric Topol’s book and tried to keep track on Twitter of how digitizing a human being will revolutionize medicine.  I reviewed two books on digital medicine http://www.thedoctorweighsin.com/the-future-of-medicine-as-envisioned-by-topol-and-agus/, advised hospital executives to get with it http://www.hospitalimpact.org/index.php/2012/03/06/p4009#more4009, and wrote a summary of an iMedicine conference organized by medical students http://kentbottles.blogspot.com/2012/04/imedicine-influence-of-social-media-on.html.

There is an urgent need to bridge the gap between the humanities and science

Two of my favorite quotations are the 19^th century neurologist Jean Martin Charcot’s “Theory is good, but it doesn’t prevent things from existing” and Albert Einstein’s “In theory, theory and practice are the same. In practice, they are not.”  These two statements summarize the tension between a medical science that thinks it can explain everything and my own experience that an alternative theory of the mind is needed.  I explore these issues in great detail in a five part essay titled Human Understanding, Randomness, Free Will, and Delusions found here http://www.thedoctorweighsin.com/human-understanding-randomness-free-will-and-delusion-part-i/, http://www.thedoctorweighsin.com/human-understanding-randomness-free-will-and-delusion-part-ii/, http://www.thedoctorweighsin.com/human-understanding-randomness-free-will-and-delusion-part-iii/, http://www.thedoctorweighsin.com/human-understanding-randomness-free-will-and-delusion-part-iv/, http://www.thedoctorweighsin.com/human-understanding-randomness-free-will-and-delusion-part-v/ and in a two part essay titled The Humanities vs. Science linked here http://www.thedoctorweighsin.com/the-humanities-vs-science-part-i/ and http://www.thedoctorweighsin.com/the-humanities-vs-science-part-ii/

Siri Hustvedt’s elegant book review of Oliver Sacks’ new book Hallucinations convinces me I need to read more of Sacks and re-read some of Hustvedt’s novels to make better sense of this complex subject. (http://www.nytimes.com/2012/12/30/books/review/hallucinations-by-oliver-sacks.html)

The American preoccupation with Happiness is wrongheaded but extremely important

Even though I have read at last count 19 books on happiness, I am always a little bit skeptical about the whole enterprise.  I do find it fascinating that bronze medal winners are happier than silver medal winners and that winning the lottery often results in misery, but there is something wrongheaded about pursuing happiness as a goal.  Viewing Stefan Sagmeister’s The Happy Show at an art museum at the University of Pennsylvania inspired me to write a four part blog post on happiness: http://www.thedoctorweighsin.com/musings-on-stefan-sagmeisters-the-happy-show/, http://www.thedoctorweighsin.com/musings-on-stefan-sagmeister-the-happy-show-part-ii/, http://www.thedoctorweighsin.com/musings-on-stefan-sagmeister-the-happy-show-part-iii/, http://kentbottles.blogspot.com/2012/05/musings-on-stefan-sagmeister-happy-show_21.html.

My skepticism about the whole subject made me write The Downsides of Trying Too Hard to Be Happy, which can be found here http://www.thedoctorweighsin.com/the-downsides-of-trying-too-hard-to-be-happy-part-i/ and http://www.thedoctorweighsin.com/the-downsides-of-trying-too-hard-to-be-happy-part-ii/. I just finished reading a new book by Oliver Burkeman titled The Antidote:  Happiness for People Who Can’t Stand Positive Thinking, which has reinforced and brought focus to my skepticism.  I recommend it highly.

Understanding and explaining the Affordable Act takes a lot of time and energy, but it is worth

I spent much of 2012 running around the country giving keynotes, retreats, and seminars on the Affordable Care Act.  I also enjoyed teaching another graduate class at the Thomas Jefferson School of Population Health on health policy and the structure of the American delivery system.  My best blogs on this subject were on the demise of fee for service payments http://healthworkscollective.com/kent-bottles/70536/fee-service-really-dead, the Supreme Court decision upholding the individual mandate http://kentbottles.blogspot.com/2012/06/why-did-chief-justice-roberts-do-it.html, and the Medicaid expansion controversy http://www.thedoctorweighsin.com/the-scotus-the-ppaca-the-medicaid-expansion-decision/.

At the end of 2012 I was asked to predict what health care journalists should cover in 2013.  My essay can be read here http://www.reportingonhealth.org/2012/11/15/kent-bottles-new-ideas-covering-health-care-2013.  However, I must warn you that a far better way to understand health care in 2013 is to wander around twitter, read books and newspapers, and go to conferences in fields other than medicine.  Join me in becoming an information flaneur. 

The Battle for the Souls of American Doctors

We physicians like to think that we are really different from other workers.  We physicians, perhaps thinking back to that medical school application essay we all wrote, really believe that we went into this career to simply help others.  We physicians truly believe that we always put our patients first. 

Because we sincerely believe all of the above, we are shocked when someone like Uwe Reinhardt points out that collectively we act just like any other worker in the economy.  The classic 1986 letters between the Princeton professor Reinhardt and former New England Journal of Medicine editor Arnold Relman highlight the tension between how we think of ourselves and how we act.

Relman thinks physicians are special and he asks Reinhardt the following question:

“Do you really see no difference between physicians and hospitals on the one hand, and ‘purveyors of other goods and services,’ on the other?”

Reinhardt is ready with a long answer that should be read in its entirety.  The short answer is that doctors act like any other human beings.   A portion of his answer includes the following:

“Surely you will agree that it has been one of American medicine’s more hallowed tenets that piece-rate compensation is the sine qua non of high quality medical care.  Think about this tenet, We have here a profession that openly professes that its members are unlikely to do their best unless they are rewarded in cold cash for every little ministration rendered their patients.  If an economist made that assertion, one might write it off as one more of that profession’s kooky beliefs.  But physicians are saying it.” (http://content.healthaffairs.org/content/5/2/5.full.pdf+html)

I have recently written about the inevitable transition from fee for service payment to global, value-based payment systems, and I was surprised when a primary care physician whom I admire tweeted that he thought the end of fee for service would be the end of primary care.  (http://thehealthcareblog.com/blog/2012/12/12/is-fee-for-service-really-dead-really/)

This tension between the ideal of medicine and the economic reality of how medicine is practiced in the United States is perhaps best summarized by Atul Gawande in his famous New Yorker article about McAllen, Texas:

“Here, along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community has come to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers." (http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande)

This morning I was reminded of this battle for the soul of American medicine when I read two articles in the New York Times.   On the front page an article titled “Quiet Doctor, Lavish Insider:  A Parallel Life” describes how a well-respected neurologist at the University of Michigan capped off his successful academic career by cooperating with federal prosecutors to avoid charges in a Wall Street insider stock trading scandal. 

“The riddle for Dr. Gilman’s longtime friends and colleagues is why a nationally respected neurologist was pulled into the high-rolling life of a consultant to financiers and how he, by his own admission, crossed the line into criminal behavior.”  (http://www.nytimes.com/2012/12/16/business/sidney-gilmans-shift-led-to-insider-trading-case.html?ref=health)

The other article in the Times published on the same day was the obituary of Dr. William F. House who invented the cochlear implant. 

“Neither the institute nor Dr. House made any money on the implant. He never sought a patent on any of his inventions, he said, because he did not want to restrict other researchers. A nephew, Dr. John House, the current president of the House institute, said his uncle had made the deal to license it to the 3M Company not for profit but simply to get it built by a reputable manufacturer.

Reflecting on his business decisions in his memoir, Dr. House acknowledged, ‘I might be a little richer today.’” (http://www.nytimes.com/2012/12/16/health/dr-william-f-house-inventor-of-cochlear-implant-dies.html?_r=0)

A major challenge for 21^st century American medicine is to cultivate the culture epitomized by Dr. House and avoid the mistakes of Dr. Gilman.

Is Fee-For-Service Really Dead?

The 21^st century challenge for the American health care delivery system is to deliver higher quality care for less money.   Republican and Democratic experts agree that payment reform involving transitioning from fee-for-service to global, value-based systems is necessary for us to achieve that goal.  Accountable care organizations (ACOs) are the new entities that will receive the new global payments and distribute them to the doctors, allied health professionals, hospitals, and post-acute care facilities that care for the patients; Medicare ACOs are being piloted under provisions in the Affordable Care Act (ACA) and Commercial ACOs are being developed by private insurance companies, hospitals, and physician groups. 

The ideal payment system would support the ideal value-driven health care delivery system.  Distinguished expert panels convened by the Commonwealth Fund and the Institute of Medicine have described the attributes of a system that would be far superior to our current delivery system:

·      Care would be patient-centered

·      Care would be safe and effective

·      Care would be timely and accessible

·      Care would be efficient with little waste

·      Care would be coordinated among providers and across facilities

·      Continuity of care and care relationships would be facilitated

·      Collaboration among providers would deliver high quality, low cost care

·      Patients’ clinical information would be efficiently exchanged

·      Caregivers would engage patients in ways that would maximize health

·      Accountability for each aspect and for total care would be clear

·      Continuous innovation, learning, and improvement would occur

                           (http://www.minnesotamedicine.com/tabid/3679/Default.aspx)

Although fee-for-service does not have all of the above ideal attributes, it does have a long history of paying for medical care.  Atul Gawande’s fascinating description of how he negotiated for his first salary as an attending surgeon at Harvard includes a brief history of fee-for-service medicine.  He starts with eighteenth century BC Babylon where surgeons got ten shekels for lifesaving operations on citizens and two shekels for the same operation on slaves and ends up with the standardized fee schedule that was developed in the 1980s to replace the “usual, customary, and reasonable fees” that insurance companies did not always find reasonable.  Gawande’s article is a good place to start understanding the strengths and weaknesses of this a la carte approach to paying doctors with its 600 page master fee schedule that lists what 24 different insurers pay for different services that Harvard physicians bill (http://www.newyorker.com/archive/2005/04/04/050404fa_fact).

Fee-for-service has lasted so long because it does have some advantages.  Conceptually, it is easy to understand because each procedure, service, intervention, or medical device is billed and paid for separately.  Fee-for-service encourages the delivery of care, is flexible enough to work with different sizes and types of physician practices, different types of care such as office visit, operation, procedure, or therapy session, and different sites of care such as office, skilled nursing facility, nursing home, hospital, or out-patient surgery center.  Fee-for-service supports accountability for each separate portion of care, but it falls down in supporting accountability for total clinical care provided by many different providers. (http://www.minnesotamedicine.com/tabid/3679/Default.aspx)

While the concept of fee-for-service is relatively straightforward, the reality can be quite confusing for both patients and providers.  Fee-for-service payments are constrained by CPT and ICD-9 rules that establish what can and cannot be billed for.  Unlike normal consumer markets, the list price for a service is hard to pin down because the amount paid is negotiated between different insurers and providers.  When a health reporter was told by her physician to obtain an expensive MRI to work up her migraine headaches, she experienced frustration trying to establish just how much the test would cost  (http://www.kaiserhealthnews.org/Stories/2012/December/09/mri-cost-price-comparison-health-insurance.aspx).  Her local hospital could not tell her how much it would cost; an academic medical center quoted her a price of $5,315 for an uninsured patient, but could not tell her what the price would be to her insurance company; an independent imaging center told her that the price would be $2,000 to $3,600 for an uninsured patient and about $600 to $1,200 for an insured patient.  She finally got the scan at her local hospital and was surprised to get a bill for $7,468. 

Fee-for-service also makes coordination of care across multiple providers and different settings difficult.  Since the payments are limited to one provider performing one service, this arrangement leads to hospitalized patients receiving different bills from the surgeon, the anesthesiologist, the pathologist, the infectious disease consultant, the radiologist, and the respiratory therapist.

The biggest problem with fee-for-service payments is that it results in overutilization and unnecessary care.  Dr. Gawande’s New Yorker article about McAllen, Texas explained the problem of medical overuse so clearly that President Obama had members of the Senate and the House of Representatives read it during the debate over the Affordable Care Act.  One cardiac surgeon in McAllen said, “Medicine has become a pig trough here.  We took a wrong turn when doctors stopped being doctors and became businessmen.”

“Compared with patients in El Paso and nationwide, patients in McAllen got more of pretty much everything – more diagnostic testing, more hospital treatment, more surgery, more homecare.”  (http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all)

Health care policy experts on both the left and the right agree that ending the fee-for-service payment system will be necessary to control health care costs.  The New England Journal of Medicine recently published back-to-back articles with how the two approaches would bend the health care cost curve.  The Republicans responded with the following proposals:

•Medicare premium support replaces defined benefit to be used to purchase insurance

•Convert tax subsidy for employer insurance to predetermined refundable credit

•Transition from fee for service to bundled payments

•High option plan for Medicare

•Regional Medicare plans to encourage greater entrepreneurship

•Health insurance exchanges without “heavy regulation imposed by ACA” (http://www.nejm.org/doi/full/10.1056/NEJMsb1207996)

Not surprisingly, the Democratic health policy wonks came up with a slightly different list of solutions:

•Model of state self-regulation with spending targets where public & private payers negotiate payment rates with providers

•Replace fee-for-service with bundled and global payments

•Medicare competitive bidding for medical devices, lab tests, X-rays, etc

•Insurers should offer tiered plans with lower copays if patient chooses high value providers

•Payers & providers electronically exchange eligibility, claims, etc

•Single-standardized physician credentialing

•Price transparency

•Non physician providers should practice to full extent of their training

•Stark Law extended to prohibit physician self referrals for services paid by private payers

•FEHBP transition to new payment models

•Safe harbor against malpractice if physician uses HIT & EBM guidelines

•Shifting costs to patients & cuts to provider payments are not good ways to cut costs (http://www.nejm.org/doi/full/10.1056/NEJMsb1205901)

Replacing fee-for-service payments with global, value-based payment methods is the one proposed solution that both liberal and conservative health policy experts agree on.  Ken Kizer, MD spoke for most health care policy experts when he stated at a recent American Society of Clinical Oncology meeting, “Payment reform is inevitable.  Fee for service is dead.”  (http://thehealthcareblog.com/blog/2012/12/10/acos-we’re-not-there-y/#more-55492)  Health care experts are attracted to payment reform because of the estimated $200 to $600 billion savings over ten years (http://capsules.kaiserhealthnews.org/index.php/2012/12/report-payment-reform-leaves-docs-uneasy/).

Practicing physicians have not shown the same level of enthusiasm for the elimination of fee-for-service.

“A survey of doctors by Harris Interactive finds that 59 percent of physicians believe that the fee-for-service system encourages them to provide ‘an appropriate level of care.’ Only 15 percent disagreed. Although 37 percent of doctors thought such a system encourages the use of more care or expensive care, 38 percent also said that a fee-for-service system encourages coordination of care. Not surprisingly, the 400 U.S.-based primary care physicians and 600 U.S.-based specialists surveyed, did not favor the idea of a global capitation payment—or a fixed payment per month for all medical services. Nearly 60 percent of the doctors surveyed said that capitation put too much risk on the provider.”

(http://capsules.kaiserhealthnews.org/index.php/2012/12/report-payment-reform-leaves-docs-uneasy/)

Another problem for health care leaders is managing the transition from fee-for-service to global, value-based payment systems.  Dr. Don Berwick, former head of CMS, describes the transition problem facing leaders who are still paid mostly by fee-for-service arrangements:

They've got one foot on the dock and one foot on the boat and they're drifting apart. One foot is fee-for-service, revenue-driven, grow the volume, do more and more, which is the dock, and the boat is, let's focus on what patients really need and decrease unnecessary care and the liability or harmable (sic) unnecessary care. (http://www.healthleadersmedia.com/content/QUA-287211/QA-Don-Berwick-Reflects-on-Healthcare-Reform-Part-I )

Steve Blumberg has described four types of health care leaders when it comes to dealing with the transition away from fee-for-service:

·      Leaders who are acquiring the necessary tools and shifting the culture to deal with new payment systems.

·      Leaders who understand the problem intellectually but have not embraced any solution.

·      Leaders who are just waiting and hoping the problem goes away.

·      Leaders who are trying to get their organizations acquired by others so they don’t have to deal with the problem.

(http://thehealthcareblog.com/blog/2012/12/10/acos-we’re-not-there-y/#more-55492)

Blumberg’s observations are spot on and match my impressions from talking with health care leaders from all over the country.  I have met executives who belong in each of the four groups, and the smallest number in my experience resides in the proactive first category.

I recently read with interest two reports out of California, which support the uneven preparation of health care to get ready for accountable care organizations that are not paid by fee-for-service.  In San Francisco providers appear to fall into all four categories (http://www.chcf.org/publications/2012/12/regional-market-san-francisco). In Fresno, California physicians appear content to remain in fee-for-service arrangements and appear to land squarely in the third category of waiting and not preparing to respond to federal health care reform. (http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/A/PDF%20AlmanacRegMktBriefFresno12.pdf) 

This gap between the health policy experts and practicing physicians and local health care leaders is worrisome.  Even if Accountable Care Organizations paid by global, value-based payments are inevitable and the best possible solution to the unsustainable cost of American medicine, the reform enterprise will fail or flounder without an enormous cultural change by all the participants in this complicated and important endeavor. 

Health Insurance Reinvention: The Florida Blue Example

One of the perks of giving keynotes all over the country is being able to hear what other health care leaders are saying without having to pay the conference fees.  One of my major keynote themes is that everyone (patients, doctors, hospitals, employers, and health plans) will have to change in order to thrive during the current health care delivery system transformation. 

Recently in Delray Beach, I stayed after my keynote to hear Florida Blue CEO Patrick Geraghty describe his first year of trying to change the Blue Cross/Blue Shield franchise to respond to health care reform.  I have written elsewhere about the health plan response to the changing environment (http://thehealthcareblog.com/blog/2012/07/22/health-insurers-the-affordable-care-act-extinction-or-reinvention/), but Geraghty’s speech highlighted how urgent and how difficult change can be when an industry business model is disrupted by federal legislation and market forces. 

Geraghty has led the Blues effort in Florida to update their name, mission, vision, and values.  Focus groups revealed that the new name Florida Blue was easier to say and communicated a less corporate, more friendly image than the old name Blue Cross Blue Shield which brought to mind adjectives such as corporate, distant, and expensive. 

A four paragraph mission statement was replaced by a single sentence: “To help people and communities achieve better health.”   The vision statement was rewritten to now describe the company as “a leading innovator enabling healthy communities.”   The five corporate values now include the familiar “respect,” “integrity,” and “excellence,” and the more unusual “courage” and “imagination.”

What I found most intriguing and revealing was how these new efforts are being translated into concrete tactics such as opening retail centers and partnering with Disney on a new innovation institute. 

Florida Blue recognizes they must engage consumers in the new world of Affordable Care Act Insurance Exchanges, and they have opened retail stores so that there is a center within 25 minutes of 80% of their membership.   These stores do more than just sell insurance and resolve claims problems.  They also:

• ·           Teach people to use online tools such as iPads and smartphone health apps
• ·          Provide health and wellness services such as health risk assessments
• ·          Engage and educate legislators at the store in the state capital
• ·          Host programs where book donations for school kids are tied to the number of points scored by the Miami Heat and the Orlando Magic
• ·          Act as starting and finishing points for fitness runs

Partnerships with Disney include both a kids’ center at the Disney World’s Epcot  and a new health care innovation institute.  Geraghty said that the kids’ center will feature health and wellness games and exhibits and that 500,000 visits a year can be anticipated.  He was also happy that Disney chose Florida Blue to join GE, Johnson & Johnson, and Cisco as partners in the state of the art innovation center.

Geraghty described how his Accountable Care Organization (ACO) experiment with Baptist Health South Florida differed from the federal Medicare Shared Savings Program.  By reducing the 64 quality metrics in the federal program to 15, he believes they have created a more flexible and workable model.

Florida Blue’s ACO elements of success include:

• ·             Trust between all the parties involved
• ·            Data transparency
• ·            Meaningful quality measures
• ·            All parties having vested interest in success of program
• ·            Shared savings aligns with best interests of the patient

It is still an open question whether health plans can evolve fast enough to be successful in the newly emerging health care world. At least one question to Geraghty in the question and answer session reflected skepticism on the part of hospital leadership to be able to truly trust a health plan.  “They are among the most disliked industries in the United States” according to Harvard professor Regina Herzlinger. Another expert, Fred Karutz of Silverlink Communications, thinks that health care insurance companies have a long way to go because they are new to the retail environment. “As people become consumers, they seek out value. In the group space, health plans could never hear the consumer scream, but in the retail space everybody can hear the consumer scream.”

 (http://www.nytimes.com/2012/06/22/us/politics/insurance-companies-are-trying-to-soften-their-image.html?pagewanted=all)

Florida Blue seems to be responding to this new retail challenge with imagination and focus. Time will tell if they are successful in becoming an effective and trusted partner to patients and providers in a transformed clinical delivery system.  

Health Plans Continue to Struggle to Reinvent Themselves

American health care insurers continue to scramble to try to reinvent themselves and discover a new business model that will be successful during a time of transformation and payment reform.  In previous blogs I have described several different approaches, some of which leave me skeptical. (http://www.thedoctorweighsin.com/health-insurers-the-ppaca-extinction-or-reinvention-part-i/ )

One of the most interesting and controversial attempts to reinvent a health insurance franchise appears to becoming unraveled.  I wondered in print if new Highmark CEO William Winkenwereder would continue to try to implement fired Highmark CEOKenneth Melani’s aggressive merger with the failing West Penn Allegheny Health System.  The new CEO did not have Melani’s historical loyalty to West Penn Allegheny, and many questioned the wisdom of the merger from the start. (http://www.thedoctorweighsin.com/health-insurers-the-ppaca-extinction-or-reinvention-part-ii/)  

Late last week, the West Penn Allegheny board called off the merger because Highmark wanted the health system to declare bankruptcy to get out from under nearly $1billion in debt.  Highmark had already acquired Jefferson Regional Health System, Premier Medical Associates (the largest independent multispecialty physician group), and planned medical malls to supplement West Penn Allegheny in a new integrated delivery system. (http://old.post-gazette.com/pg/12273/1265542-28.stm)  Highmark also tried to acquire Excela Health, partner in its medical mall and gain majority ownership in the Westmoreland county provider network.  When Excela declined the offer, Highmark threatened Excela according to the Excela board chair: “The threat was clear – if Excela did not enter into an acquisition or affiliation with it, Highmark would use its monopoly position to destroy Excela,” said James Breisinger.  (http://www.fiercehealthpayer.com/story/highmark-trying-destroy-health-system-after-failed-alignment/2012-08-02)

Reaction to the failure of the merger included Jan Jennings,  President of American Healthcare Solutions, who said, “It is the dumbest, most recless abandonment of fiduciary responsibility I have ever seen. I don’t think anybody from out of town sees West Penn Allegheny as some kind of crown jewel.  I just think it is a big mistake.” (http://triblive.com/business/2687181-74/penn-west-highmark-allegheny-system-health-agreement-board-officials-community#axzz27sxdlxu9)

Highmark is not the only insurance company that is finding out that reinvention can be difficult.  When Patrick Geraghty left Minnesota Blue Cross and Blue Shield to run the Florida Blues, the Minnesota Board hired Kenneth Burdick largely because he had experience with the highly successful for profit UnitedHealth Group.  After six months on the job Burdick was fired due to “examples of leadership that weren’t optimal.”  Board chairman Vance Opperman was quoted as saying, “’What you have is a difference in culture.  The difference between for-profit and not-for-profit is pretty big…After looking at this for many hours and many meetings, we came to the unfortunate and unhappy realization that Ken couldn’t make the transition and couldn’t bring the leadership team with him.’” (http://www.startribune.com/business/163068436.html?refer=y)

Another health care organization struggling to cope with the new health care environment is  Seattle’s Group Health Cooperative which recently decided to cut $250 million over the next 16 months to better position the organization in the new world. Group Health has already assembled the combination of hospitals, physicians, and health insurance plan that Highmark was trying to emulate in Pittsburgh.  However, CEO Scott Armstrong is facing three years of sharp declines in revenues, and he has arranged for Richard Magnuson, executive vice president and chief financial and administrative officer to leave the $3.5 billion health system.  (http://seattletimes.com/html/localnews/2019204930_grouphealthxml.html)

HealthPartners of Minneapolis is a fourth health plan recently announcing a new direction by merging with Park Nicollet to respond to federal health care reform measures.  If approved by regulators, the new system will become the second largest in Minnesota with 1,500 physicians and two hospitals Regions in St. Paul and Methodist in St. Louis Park.   HealthPartners insurance plan covers 1.4 million people.  Keith Halleland, a health care attorney, states that the merger is part of a national trend to “’provide total cost of care for a variety of populations’” and to create “’one organization that can do everything for basically anyone in the health care environment.’” (http://www.startribune.com/business/168058306.html?refer=y)

These four examples of health plans trying to create new business models for the 21^st century offer a window into the complicated and evolving health care environment that is creating anxiety and opportunity for everyone involved in the industry. 

Sticking to Health & Wellness Goals: These Websites Made Me Do It

My regular readers know how important I think behavioral economics will become in the field of health care.  (http://www.hospitalimpact.org/index.php/2012/05/16/understanding_barriers_to_shared_decisio)  The best place to start thinking about applications of behavioral economics principles to wellness is Nobel Prize Winner Daniel Kahneman’s book Thinking, Fast and Slow  http://kentbottles.blogspot.com/2012/09/8-things-medical-school-failed-to-teach.html

Several start-up companies have created ways for people to apply behavioral economics heuristics to their own individual fitness and wellness programs.  Jordan Goldberg was so intrigued by these possibilities he encountered in undergraduate classes at Yale that he started a company, Stickk, with his professors Dean Karlan and Ian Ayres. 

As Goldberg related in an e-Patients Connections 2012 talk in Philadelphia recently, people say they want to do healthy things, but then life happens, and they don’t follow through on their stated intentions.  Stickk creates clever ways to take advantage of nudges and libertarian paternalism to frame choices so people do what they really want to achieve.

My favorite example of this concept  is their anti-charity option where Stickk takes money away from you to give to a charity you hate if you do not achieve your goal.  If your stated goal is to walk 10,000 steps every day and you slack off, the despised charity you choose gets an automatic contribution.  According to Goldberg the George W. Bush Library is a favorite charity in this program.

By applying the behavioral economics principles of hyperbolic discounts, real time loss aversion, carrot vs. stick, reference points, and power of defaults,  Stickk has created both public and commercial websites that may really get people to stick to their stated health and wellness goals.

Aherk! is another website designing tools for people having difficulty sticking to their weight loss regimen. 

“The user also emails Aherk! An embarrassing photo – referred to as ‘the bomb’ on the site.  When the deadline hits, Facebook friends vote on whether the goal was achieved.  If not, up goes that incriminating pic at the expense of some social media status.”

(http://articles.philly.com/2012-09-26/news/34103610_1_facebook-timeline-website-posts-social-media)

Other start-ups applying behavioral economic heuristics to healthcare include GymPact where smartphones track missed exercise workouts and automatically fine the participant and MetaReal’s Virtual Fridge Lock with its refrigerator device that posts a Facebook notice when one raids the refrigerator when one is not supposed to.

One can find psychology professors who think the above tactics are laudable and those who object to these approaches:

“I would rather see a website that allows a person to define a goal and state a reward the person will give him or herself if the goal is met.”  Erin Way

“Committing to anything in public, something that has been known for a long time in psychology, is a good way to get people to stick to their guns…People don’t like to feel like a fool.” Andrew Ward (http://articles.philly.com/2012-09-26/news/34103610_1_facebook-timeline-website-posts-social-media)

8 Things Medical School Failed to Teach Me About Being a Physician Executive

You Will Have to Move a Lot

I went to medical school in Cleveland and did myj pathology residency in San Francisco at UCSF.  I was on the medical school faculty at UCSF, Iowa, Allegheny University of the Health Sciences, and Michigan State. 

Since leaving academic medicine, I have worked at a bio-tech start up in Cambridge, an educational and research institute in Grand Rapids, a $2 billion integrated delivery system in Iowa, and an evidence-based medicine consortium in Minneapolis.

In my experience physician executive positions do not always last a long time because the environment changes, my career aspirations changed, and getting the job done sometimes means alienating enough people to get in the way of long job tenure.

You Will Have to Reinvent Yourself Over and Over Again

My main professional roles have included: medical school pathology course master, surgical pathologist, division head, vice chair of academic department, chair of academic department, medical director of managed care, corporate operations officer of ambulatory care, special assistant to the president of a big ten university for managed care, search consultant, chief knowledge officer of a genomics bio-tech start up, president and ceo of an educational consortium, chief medical officer of a delivery system, president and ceo of an evidence based medicine institute, and health policy professor at a school of population health.

My only educational credentials are a bachelor’s degree in history and a MD degree.  Although I have taught in MBA programs, I do not have a MBA degree.  Although I headed up a genomics repository of DNA, I had to teach myself genomics and proteomics on my own.  Although I teach health policy and population health, I did formally study these subjects.  I have discovered that if I read a lot, go to conferences in different fields, and talk to smart people, I can pick up what I need to know without going on to obtain lots of graduate degrees.

Everything is in the New York Times and The Wall Street Journal 

I am amazed at how much I am able to keep up with payment reform, federal health care reform, and major trends just by reading these two newspapers every day.  It is also good to see how liberals and conservatives interpret the same story, often with dramatically different conclusions.

The Killer App in Social Media is Community

Twitter has become the most important technology in my career as a physician executive.  I follow about 2000 key opinion leaders in health care, and about 7000 people follow me.

I use twitter to crowdsoure subjects that I need to master in order to give keynotes or consult with health care systems.  For example, Einstein Medical School asked me to come give a presentation on social media and undergraduate medical school education.  In order to prepare for a subject that I had not thought about much, I tweeted the following: “Help; need best practices of social medical and medical school education.”

I received responses from all over the world that formed the basis for my all day seminar that was well received and consisted of concrete examples of medical educators from the Cleveland Clinic to the UK using twitter and facebook in ways I had never imagined.

An important point here is that it is now my obligation to my social media community of practice to provide knowledge to others when they are reaching out for assistance.

If I can’t understand it, I don’t believe it

When I started out in leadership roles, I did not always trust my own judgment.  I sometimes thought I was not smart enough to grasp situations that made no sense to me.

When I was Interim Head of pathology at Iowa, I thought my lack of training in clinical pathology was the reason I could not understand the classification of all the technologists in the hospital labs.  It took a while to grasp that job classifications and titles had multiplied and proliferated in a way that did not serve us well in a changing health care environment.  It was only when I truly understood that the system did not make sense that I could lead a simplification of job titles that made more sense in that time of managed care. 

I will never forget going to a meeting in Palm Springs of venture capitalists.  What made them different from others I had encountered was their skepticism and insistence that they understand how start-up companies would make money.  If they could not understand the business plan, they did not invest. 

You Will Fail; Do it Quickly and Cheaply

A successful entrepreneur in Iowa taught me that failure is inevitable.  The trick is to recognize when you have failed, learn from it, and move on as quickly and cheaply as possible.  When I was helping to raise $36 million dollars for a genomics company, I was amazed to learn from venture capitalists that they do not try to predict winners and losers.  They do not think it is possible.  When they invest in 20 companies, they are hoping that one of them will be a Google or apple.  They fully expect the others to fail. 

I have noticed that health care organizations have a hard time killing programs that are simply not working. 

You Must Become a Life Long Learner

When I graduated from Case Western Reserve School of Medicine in 1980, there was no Internet, no Google, no disease called AIDS, and no smartphones.  You must continue to learn about the world you live in, and the world will continue to change in amazing and confusing ways.

Master the Gartner Hype Cycle and Learn Behavioral Economics

Do yourself a favor.  Master the Gartner Hype Cycle to understand why all those revolutionary disruptive technologies fail and those startup stocks go down (http://www.gartner.com/it/products/research/media_products/book/index.jsp)

Read Nobel Prize winner Daniel Kahneman’s book Thinking, Fast and Slow; you will understand why you and those you work with are often irrational and annoying.

Why Do Academic Medical Centers Do Poorly on Quality Report Cards?

In September 2012, the Joint Commission recognized 620 hospitals (about 18% of the total number of accredited American hospitals) as “top performers,” but many were surprised when some of the biggest names in academic medical centers failed to make the cut.  Johns Hopkins, Massachusetts General Hospital, and the Cleveland Clinic (perennial winners in the US News & World Report best hospital competition) did not qualify when the Joint Commission based their ranking not on reputation but on specific actions that “add up to millions of opportunities ‘to provide the right care to the patients at American hospitals.’” (http://www.washingtonpost.com/national/health-science/holy-cross-2-other-area-hospitals-make-top-performer-list/2012/09/20/5cf2bba2-0334-11e2-9b24-ff730c7f6312_story.html )

The gap between the perceived reputation of America’s “best” hospitals and medical schools and their performance on an evidence-based medicine report card provides an interesting lens through which to understand the role and performance of America’s academic medical centers in the 21^st century.

The most pressing challenge for American medicine has been summarized in the triple aim:  how to cut the per-capita cost of healthcare, how to increase the quality and experience of the care for the patient, and how to improve the health and wellness of specific populations.

Can we expect academic medical centers to lead the country in meeting the challenge?  If history is any guide, the answer may be no.  In a 2001 article titled “Improving the Quality of Health Care:  Who Will Lead?” the authors state

“We see few signs that academic medical leaders are prepared to expend much effect on health care issues outside the realms of biomedical research and medical education.  They exerted little leadership in what may arguably be characterized as the most important health policy debates of the past thirty years:  tobacco control, health care cost containment, and universal access.”  

(http://content.healthaffairs.org/content/20/5/164.abstract)

Having been a professor at several medical schools (UCSF, University of Iowa, Allegheny University of the Health Sciences, and Michigan State), I learned early on that the key to academic advancement was NIH funded basic science research.  While lip service was paid to the ideal triple threat professor (great clinician, superb teacher, and peer reviewed published investigator), the results of the tenure process clearly resulted in a culture where funded research counted far more than teaching and clinical care delivery.

This gap between what the country needs and what medical schools traditionally emphasize was demonstrated when researchers studied more than 60,000 medical school graduates from 1999 to 2001.  As Pauline W. Chen, MD wrote in the New York Times:

“Putting the issues of primary care shortage, underserved communities and workforce diversity under the banner of ‘social mission,’ the researchers found that many of the schools that were traditionally ranked highly were also among those least focused and least successful in addressing the most pressing issues facing the country right now.”

A recent report from the Lucien Institute at the National Patient Safety Foundation describes the kind of culture required to achieve the goals of the triple aim.

            “Achieving safety in the work environment requires much more than

implementing new rules and procedures. It requires developing and sustaining cultures of safety that engender trust and embrace reporting, transparency, and disciplined practices.  It also requires an atmosphere of respect among the health care disciplines and a fundamental ability of all practitioners to work together in teams.” (http://thehealthcareblog.com/blog/2010/03/20/a-culture-of-fear-and-intimidation-reforming-medical-education/)

The Association of American Medical Colleges survey on medical school culture reveals a culture that does little to encourage trust and transparency. From 2004 to 2008, 12.7% to 16.7% of students reported being publicly belittled or humiliated.  The best program for implementing a culture of safety I have seen did not originate in an academic medical center; it was developed and implemented at the Sentara Healthcare System in Virginia.

Academic medical center hospitals often save the lives of patients with complicated conditions who benefit from cutting edge treatments supported by basic science research.  However, it is revealing that the community Holy Cross Hospital in Silver Spring, Maryland made the Joint Commission’s list of  “top performers” and the famed Johns Hopkins did not do as well on the quality scoring report card. 

The Holy Cross vice president of quality and care management cites three factors for the hospital’s excellent quality results: intensive review of patients’ charts, the electronic medical record system, and the leadership focus on quality. (http://www.washingtonpost.com/national/health-science/holy-cross-2-other-area-hospitals-make-top-performer-list/2012/09/20/5cf2bba2-0334-11e2-9b24-ff730c7f6312_story.html )

When it comes to choosing a hospital, patients should take into account quality report cards as well as reputation.