Friday, July 18, 2014

Innovation in American Medicine: the Case of RBCs

I was asked to do a review of this paper: Parents’ Experiences With Pediatric Care at Retail Clinics: Garbutt JM, Mandrell KM, Allen M, Sterkel R, Epstein J, Kreusser K, O'Neil J, Sayre B, Sitrin H, Stahl K, Strunk RC. JAMA Pediatr. 2013 Sep;167(9):845-50.
Retail Based Clinics (RBCs) are a great example of innovation in our system, and thus worth examining not only in themselves, but for what they illustrate.  Here's what I came up with.

American health care is clearly in a state of profound organizational transition. In contrast to countries with socialized medicine, organizational innovation in our private system should in theory be more dynamic, with many innovators trying many new things (some of which fail,) and more attuned to the wishes of the public. On the other hand, individual initiatives and the profit motive can lead to innovations that do not necessarily integrate with other parts of the system, and which may not improve quality in those aspects of care that cannot be evaluated by the patient. In addition, since the American system has very large vested interests in the hospital, insurance, and pharmacy sectors, it is possible that profit-seeking oligopolistic behaviors will predominate. It is obvious that many current innovations are both vertical and horizontal conglomerations. In a quest to improve true value, it is not clear whether the American or the more socialized systems will prove superior.

Retail Based Clinics (RBCs) are one of the most recent American organizational innovations. Ready access to acute care, especially during evenings and weekends, has long been neglected by our health care system. Large pharmacy companies have taken advantage of their access to capital and their high visibility in communities to establish RBCs on their premises to fill that access gap. While they appear to have become financially successful, serious questions surround RBCs. Do they further fragment an already fragmented system? Do they provide high-quality care? Do they succumb to the temptation to drive further profits by prescribing too many medicines to be bought at the parent company's store where they are located?

This simple but wonderfully direct study looks at some of these questions in the St. Louis area by simply asking patients who they find in the waiting rooms of 19 private practices about their RBC visits. They find that an amazing percentage of patients have been seen in RBCs – 25%. They find that they use them because of “convenience,” although almost half the visits were at times the private offices were open. There were virtually no efforts made to integrate with the medical home, by either the RBCs or the patients. And perhaps most strikingly, there is prima facie evidence that the quality of care appears to be quite poor, although presumably profitable to the sponsoring company.

The high utilization of the RBCs should be a wake up call for pediatricians in practice. In areas of the country where competition among practices is high, many practices have established extended office hours on evenings and weekends, and many practices have instituted drop-in times to avoid the hassle of appointment-making. These innovations have apparently not been seen in the St. Louis practices – perhaps the offices are full already and they see no need to please patients with more convenience.

The RBCs lack of integration into the system is dismaying but not surprising. Beyond their fragmenting effect, RBCs also undercut the viability of primary care practices by siphoning off the most profitable segment of their business (not that the practices do not contribute to their own difficulties by not being adaptable to consumer needs.) Thus, when primary care is under such pressure that few graduates are choosing that pursuit, RBCs exacerbate that problem.

Most dismaying, however, is the finding of how many antibiotics were prescribed in clearly inappropriate clinical situations, if the parents' accounts can be believed. 67.7% of patients with colds or flu were treated with antibiotics! 28.6% of patients with a negative rapid strep test were treated with antibiotics! This is clearly not a definitive study, but informal reports nationwide make this finding disturbingly not unexpected.

In a system that is so entrepreneurial, defining the role for government is especially difficult and crucial. Gathering and evaluating information would seem to be very important to help people make individual choices, and to help policy makers choose wisely. In the case of RBCs, government should stimulate studies that further explore the provocative findings of this study to see to what extent it reflects nationwide conditions. Deciding what to do about it can be a joint concern of the profession of pediatrics, federal and state governments, and the larger entities that are so powerful in our system.

Budd Shenkin

Saturday, July 12, 2014

Oligopoly in Massachusetts

Some years ago – OK, many years ago – Ann and I attended my Harvard College 25th Reunion. The highlight was an Evening at the Pops, when we were escorted to Boston Symphony Hall en masse by the police with all roads blocked off on the way. Wow. I couldn't believe it. It was great to be among the chosen. I doubted the same treatment was extended to Boston University, nor to Brandeis. Wow.

I never liked New England much. It was the kind of place that would block off streets from ordinary citizens to honor Harvard alumni. For all the hard scrabble George Higgins books and Matt Damon movies, there was the other side of small time squalor. Big time squalor, perhaps. I did admire Boston medicine, even more so since I have left Boston, and in probably no other city would victims of a marathon bombing receive such unbelievably well thought out and well executed care. But still.

Now I have been following Paul Levy's excellent and thought provoking blog at Paul is the former CEO of the Beth Israel Deaconess Medical Center, and has a strong ethical, idealistic bent and a firm intelligence. He regularly calls attention to the ethical lapses among medical officials as they extoll the virtues of robotic surgery with their right hand and receive various favors from Intuitive Surgical Inc. with their left hand. The University of Illinois had an incredible run their in Paul's blog for a while – in the end, of course, the ensconced vested interests didn't move much, which is what happens with ensconced vested interests most of the time.

Now Paul has turned his attention to Partners Healthcare of Massachusetts, founded by Mass General and Peter Bent Brigham Hospital (whose president years ago was my good friend Jim Mongan.) Partners has been more than successful. They have formed an oligopoly of health care. There are many other providers in Massachusetts but I guess none who had the great ability to run a corporation the was Partners has done it. As a result of their success, they get terrific rates from their insurance plans – Blue Cross is predominant in Massachusetts, I think. With lots in the kitty, they are trying to expand, which is what successful companies do. They want to pick up some hospitals on the South Shore. But to do so, they need the blessing of the Massachusetts Attorney General – there is such a thing as anti-trust in Massachusetts law, and apparently the responsibility for enforcement is lodged in the office of the AG.

Unfortunately, the current AG is the redoubtable Martha Coakley, last heard from nationally as she ingloriously handed over the Kennedy senate seat to Scott Brown – that Martha Coakley, who took a vacation during the campaign, didn't she, and didn't see the point of going out and greeting workers. Now she has given Partners a free pass to expand. It was even freer until there was a tiny little outcry and she got a tiny amount of money from them to do something or other as the price of her acquiescence. Tiny. She's that kind of AG, running for Governor, God help Massachusetts. I hold a grudge, Dear Reader.

The powers that be – think police escort to the Pops – have declared that big is good. It leads to cooperation within the firm, care coordination, higher quality. They don't say it leads to lower prices, note. They say that this is just what national policy is calling for, more firms like Kaiser, Geisinger, Rocky Mountain Healthcare. One of their chiefs, arrogant as always, has declared in the past that “this is what quality costs.” He could be in the first limo headed to the Pops, I guess.

Maybe Partners does have very high quality health care, although there is no evidence that they give better care than other organizations.  Maybe they do.  But it looks much more like simple oligopoly rents.  

Government, however, can't take self-declaration as fact.  The role of government needs to be to lay out the playing field so that it is fair, and referee the game so that it is in the public interest – not like the referee in Brazil vs. Colombia, for instance, who let Brazil intimidate without correction, and look where it led. It is a hard role, because being a referee is hard. After all, your role is not to be the star, and the stars are more popular than you are. But good referees are the key to good and fair conduct. If Partners really does have something better to sell, it has to be a case that can be made for all to see and agree on, and for buyers to agree to buy what they are selling.  This case looks more like a wink and a nod among the passanoventi. (That's as close as I can spell it without a copy of The Godfather to look at.)

Unfortunately, in health care the anti-trust referees have been extremely negligent, letting hospitals merge as they will until they can price themselves as oligopolies will. It is this current tradition, and the evidence of the Coakley decision simply extends this tradition, that makes me very fearful that Accountable Care Organizations – ACOs – sponsored by Obamacare, will lead to big organizations that price-fix and don't add much quality.

Here is the link to one of the Not Running a Hospital posts that quotes yours truly:

And a later post by Paul, on the subject of quality of care at Partners:

Posted: 11 Jul 2014 02:08 PM PDT
Well, we could scarcely expect him to say something else, but the CEO of Partners Healthcare System really went out on a limb when he told the Boston Globe:

“The formation of Partners has been a great thing. Care has gotten so much better.”

Well, no, it has not.  Here's a more accurate description from Dr. Eugene Lindsey, the former head of the state's largest multi-specialty group, which has referred patients to Partners for two decades:

If the motivation of Partners over the last twenty years has been to use its market power to really integrate care and lower the cost of care, they have failed monumentally. The care within Partners is no more integrated, and certainly much more costly than in any other healthcare system in the state, the nation, on this planet, and therefore presumably anywhere in the universe. Partners offers spectacular care in specific areas at a high cost.

Partners’ performance on some of the metrics of care that is routine in the community arguably falls short from being unequivocally “the best,” although its price never reflects that reality. What it does succeed at is finance, marketing, government relations and intimidation of other members of the healthcare industry. There has never been a credible analysis that shows that Partners' care significantly exceeds in technical quality, access, patient satisfaction, patient-centeredness, or safety when compared with the other less generously paid academic medical centers in Massachusetts.

Referring to a New York Times editorial, he adds:

Given this reality and the reality that it is the most expensive provider of care in the Massachusetts healthcare market, the Times has made an egregious error to suggest that Partners has been a leader in collaborating to control costs and improve care.

Gotta be suspicious of situations where the cops are on your side, I guess.

Budd Shenkin

Monday, July 7, 2014

Budd Joins NIMBY Nation

OK, I admit, the real villain is United Airlines, which puts the seats so close together even in business class. It's the situation.

But still. Let me tell you what happened yesterday.

As background, I have to say that I haven't been very sympathetic with San Franciscans railing against the influx of the techies. Yes, the rents have gone way up, and my cousin Allison and her roommate found it very hard to buy a house because the selling price kept being so far above the asking price. I didn't quite get the protest against the Google Bus, because I figured that UCSF has dedicated busses, and there are other shuttles, and I figured that having a dedicated bus just made other transportation less congested. And after all, tech was what has been powering the Bay Area forward all these years, what makes us prosperous.

In these unsympathetic thoughts, I erred, as I found out yesterday in row 4 of the United Airlines Business Class flight back from Philadelphia. In row 3 in front of us were two of the above-mentioned techies, I have to think. The Asian girl was in front of me, the white boy with stubby beard in front of Ann. As soon as we took off, poof! Their seat backs went back as far as they could almost in our laps, even in Business Class. Other people in other rows seemed to understand the predicament that UA had placed us in, and moderated their recline, with the exception of one heavy blond lady with too much makeup in row 3 on the other side. But most people understood.

In this situation I naturally paid some increased attention to the young people in row 3. My little lady had her legs crossed yoga style with her laptop resting on everted knee to everted knee. Her back and the back of her seat made a 45 degree angle, so it wasn't completely clear how necessary her intrusion into my knee space really was. Although she had on a dirty sweatshirt that read “California girl” - not clear who would wear such a sweatshirt – and some nondescript jeans, I think I remember, I did notice a very big rock on the ring finger of her left hand, very big. Very big. Quite a sartorial combination.

She went through her email for hours and made a phone call or two. She looked about 17 years old, so she was probably 26.

Her husband looked about 28 years old, and looked pretty much as you would expect. He lounged with legs akimbo much of the time, and actually read a book, but I couldn't see what it was. Then he attacked his cell phone for a long while. As he climbed over his wife to go to the bathroom he bestowed a quick kiss on her, although it looked like something he was just trying to learn to do casually.

It doesn't help that United Airlines sucks so bad. Crappy movies on offer, and they all run on their own schedules, not yours. When Ann had to get out from her window seat, I was happy to grab the seat in front of me and shake it a little, but Little Miss Big Rock didn't deign to notice that we couldn't get out with her rearward seat back thrust. She was too happy sitting like a little fucking princess.

So, now I think the techies are like Euro-trash. Or maybe like the princes and princesses of a conquering army. I say, fuck them, and let's trash the Google Bus. Tax the hell out of Twitter. Little shits.

OK, call me NIMBY.

Also, fuck United Airlines.

Budd Shenkin

Tuesday, June 24, 2014

Will Obama Qualify as a Profile in Courage?

This from the NYT:

Disapproval of Obama’s Foreign Policy Rises

OK, yesterday I opined that Obama was pursuing a very brave path in risking the unknown and defying a repellant "ally" in whom we had invested tons of money and people and prestige and you name it.  Now we see even more headwinds, political unpopularity.  In politics, popularity is power, so losing it is not nothing, especially as midterm elections loom.  I don't know whether or not they foresaw this, but here it is.

Let's get it straight -- we remember FDR's statement about Somoza, "He's a son of a bitch, but he's our son of a bitch."  Part of what Obama is saying is, "No more Somozas."  That's quite a statement, quite a change, a very important departure from short term to long term, an enlightened view of garnering soft power.  With change comes risk and sometimes opprobrium.

Let's also remember that Obama is doing a lot on the environment on his own, and pushing very hard for public recognition and acceptance of the necessity to lead on climate change.  They say you can't do too much at once, and that as you progress in second terms you get less and less done. But he's trying, and trying hard.  He's picking up the pace.

"Profiles in Courage" was a terrific book that emphasized the heroic individual.  Is Obama possibly becoming a new candidate for the ongoing list?

budd shenkin

Sunday, June 22, 2014

Obama's Foreign Policy: The Tail Shouldn't Wag The Dog

I have been quite critical of Obama through the years, mostly about his performance rather than his ideas. He spent the whole first term domestically negotiating with himself, trying to figure out what proposals would have a chance of acceptance from the Republicans, and then being surprised when they upped the ante as he proposed what he thought they might accept. Or that's the way it seemed.

So it is with some sense of ruminative perplexity that I see I am agreeing with him pretty much across the board these days. Of course, now that he has screwed up the public relations and perceptions for so long, his chances are diminished, but maybe he's at his best coming from behind. Who knows.

Strangely, since he is taking his time and making sure he thinks clearly and doesn't just react, I think he is acting very bravely on Iraq. I also think he is acting in a way that my policy ideal at the Goldman School of Public Policy, Aaron Wildavsky, would approve, if he were still alive.

First, bravery in action and negotiation. Obama is getting pilloried for not keeping forces in Iraq. “They say” that if he had done that, somehow the ISIS forces would not be sweeping in from the northeast. Somehow the divisions of troops in the Iraq Army would not be melting away, abandoning their equipment and their uniforms. “They” are various, amazingly including the should-be discredited voices of the past – Cheney for God's sake, Wolfowitz, Bolton, everyone except Rumsfeld. But even the sober voices somehow allege that Obama was ball-less, and should have insisted on keeping troops there, although they don't say how he could have left troops there given the poor deal Maliki was offering for status of forces.

Now, maybe it's true that there was nothing Obama could have done to leave some forces in place, that Iran dictated that end result. Maybe that's the truth. But the way I look at it, the question is, how much is the US willing to give up in order to keep forces in place, which costs the US a lot, but which is nominally for the benefit of the host country? Are we begging to be of help to them? Certainly to ourselves as well, blocs not having been abolished in the world, and terrorism being exportable, but most directly, isn't it being helpful to them, the recipient countries? Are they children that we care for so much that we are begging to let us do something for them? Isn't this the tail wagging the US dog??

So, it's a negotiation. Obama says, this is our last, best offer. They say no. What should we do, revise the offer? Or should we say, OK, we both lose by not doing things together, but so be it. We'll see what happens. We think it will hurt both of us, but we can't accept your terms. What is wrong with that?

“Stay the course” was heard in Vietnam, and it has been heard here in Iraq, too. “They” say that if we don't stay the course, America will not be trusted in the future. What will it do to our “credibility?” Well, I think that's crap. It's more important for our credibility that we be seen as a country that has a decent negotiating position, a country that will help ourselves by helping others, but up to a point. That is the kind of credibility Obama is forging for us. He is being politically brave to do so, and being canny in not announcing it publicly. And he is being very brave in risking “failure.”

Now, about that “policy” business. There are the “planners,” and there are others, perhaps called those who “muddle through” (Lindblom's term.) “Planners” have to have everything set from the start. If this, then that; if something else, then another “that.” It is in some ways a very defensive strategy that seeks to eliminate risk by thinking of every contingency beforehand. “Muddlers,” on the other hand, take it one step at a time. They realize that the world is complex and that everything cannot be foreseen. So they take a step that seems to provide a good prospect for the future, understanding that assessments and decisions will have to be made. They have confidence in their future intelligence and capacity.

In a way, the “invade with overwhelming force” crowd is like the planners. In seeking to dominate, they are seeking to get their way, whatever it is, and not let the voice of others be heard, not let the choices of others intrude, and have it set up from the start. I think it was Crash Davis who said, “Strikeouts are fascist.” Our neocons are quite fascistic, in case no one noticed.

So I think Obama is being brave in saying, OK, the negotiation fell through, I think we're still in a good position, let's see what happens. I have confidence that we will find good options to take in the future, and that the wrongheadedness of Maliki will run its course, and we will find a way to ally with more enlightened forces. We'll find allies willing to make sure terrorists don't find a haven. It's brave.

I think Obama is pissed he's getting such a bad rap, and I think he's great at coming from behind. So I am belatedly rallying to him. I think he is pretty admirable right now.

Budd Shenkin

Friday, June 13, 2014

Medicare, Hospital Readmissions, and LUC

The reader might remember how my step-daughter's father was sorely neglected when he had to return to UCSF after an operation for esophageal cancer. (see He was poorly treated in the ER where he was delayed for hours and then poorly treated by the resident team on the floor. The attending was in Hong Kong where he responded admirably by telephone to an email from Sara, who is a physician, who was advocating for better care and attention for her father.

I didn't think much more about it, other than to blog about the faults of teaching hospitals. But Sara has brought up another interesting view about the Law Of Unintended Consequences (LUC).

Medicare has tried to incentivize hospitals to do a good job with patients the first time around. In particular, Medicare has wanted them not to neglect patient discharge instructions and coordination, which hospitals have traditionally neglected partially because there has been no money to be made in doing so, and partially because there is no dramatic consequence, either, for the staff and doctors involved. “Out the door and off my plate” has been the traditional attitude. If the patient bounced back, why then, it was another admission that could be charged to Medicare.

The solution Medicare came up with was to inform hospitals that it would refuse payment for a patient readmission within 30 days after discharge. It seems like a simple enough solution, one that would incentivize good and definitive hospital care with an appropriate coda. But Sara observes that while hospitals might save themselves money by doing good discharge planning, if the patient does bounce back to the hospital, the hospital has no incentive to bill for the services delivered, because they won't be paid for. Yes, minimizing the extent of services and discharging the patient as fast as possible is still in the hospital's financial interest, but – importantly in this case where the residents were overloaded with work and Sara's father was neglected – it doesn't matter to the hospital if a staff physician sends in a bill or not, because the hospital won't get paid. It can just be a “resident case.”

Background – for many years teaching hospitals billed for attending physician services whether or not the attending physician actually saw the patient, which was illegal – but if you're a teaching hospital, who cares? Who could or should challenge an institution with such prestige? Well, the US government did so, fined Penn many millions of dollars, and from then on, all the teaching hospitals made sure they had the signature and a note from an attending physician on every patient every day.

But now, with readmissions, all bets are off. They're not going to get paid anyway! So if the attending is in Hong Kong, why get a substitute attending to look at the patient, and to actually care that his sodium is at 128 and plunging? The hospital doesn't really care since payment is not involved. And residents? Ah, residents, our future stars. For now, they're just trying to get through the day, their hours are curtailed by law, and they probably operate in a blame culture, which means that the ultimate bureaucratic virtue is not to be blamed for anything, and the ultimate blame would be to ask an attending to actually help out with patient care, when the attending's priorities are in research and travel, not patient care.

LUC, you are everywhere. Good catch, Sara. She is getting real smart.

budd shenkin

Thursday, June 12, 2014

Fear of Health Care Rationing

A quick note on something that the reader will have understood from the start, but which has just become apparent to me. Sometimes I'm slow.

Rationing of health care has long been a huge bugaboo. I remember that my father said, “Why are people so stupid to talk about the evils of rationing? We already have rationing, we have to!” He thought people were just being stupid.

Well, they weren't being stupid, just a bit disingenuous. Yes, of course we have rationing. My Dad was thinking about what doctors do in guiding patients to one path or another. They ration. But much more importantly, as long as there is any element of the market in health care, we ration care as we do any other good or service, by price. It's clear that the poor get less than the rich, and the in-between – the working poor, those just above the Medicaid eligibility line – get less than anyone.

So, when someone says, “We don't want rationing!” (think, Sarah Palin), what are they really saying? What they are saying is that they don't want to get less than they are already getting. Don't take something away from me and give it to the poor or anyone else – that's the real message. They can't say that directly most of the time, but “don't ration” is code for “don't take it away from me.” And don't give it away to my most feared competitor, those right under me.

As always, those most threatened are those just above the poor, or those just above the working poor. They are the most conservative elements, usually, except for the superrich. (And what is it with them? Are they really just selfish pigs, or do they unconsciously believe that they have no right to what they have, and so are all the more and very insistent on their right to have what they have and more, in a kind of reaction formation?) “What's the Matter with Kansas” investigated why that group of working class voted against their own economic interests, and found that they were diverted toward social conservative ideas by the class above them that really stood to benefit from the conservative economic policies pursued by conservative politicians. But I think the key is, don't take away from me what I already have and give it to those below.

I remember a staff member at Bayside who came from a labor union family. We asked her why she wasn't for the Clinton health plan. She said that everyone having the same plan would mean that she, and everyone else, would have the equivalent of Medicaid. In other words, her take would be downgraded. We were amazed she didn't have our optimistic outlook, but in looking back, I can't blame her. Maybe she actually had it right. After all, even strictly socialistic health care systems have parallel private systems. So, even if you even things up, the upper wealth sectors will have private systems available. It will be the currently strongly insured who have their resources diluted, because they will have to share strictly with the newly enfranchised, while they upper crust won't.

So, as I said, I bet 90% of people understand this, but I didn't really, and now I think I do.

budd shenkin