Administrators, Clinicians, and Professionalism

From “Not Running a Hospital” (runningahospital.com) by Paul Levy, today:

“We still find hospital administrators more interested in market dynamics, mergers, and the like than improving the quality and safety of care.  We still find doctors untrained in the use of the scientific method to achieve clinical processes.  We still see medical schools and residency training programs as woefully deficient in such matters.”

And from an article in Kaiser Health News today:

A recent study by researchers at the Yale School of Medicine found that only a third of 400 elderly patients were discharged with a follow-up doctor's appointment and 25 percent were handed instructions written in impenetrable medical jargon.

Right.  When I read about this, I am outraged.  It gets to the core of professionalism.

I learned this in internship.  On rounds at UCSF, I said to my attending pediatrician that the lab was very slow and unresponsive, and that as a result the patient would just have to suffer.  I was being passive aggressive, and I knew, provocative.

He turned to me with heat  He said, "You will not do this!  You will go down to the lab and get those results personally!"  (The attending was Henry Shinefield, a wonderful man and clinician, with whom I developed a very warm relationship.)

Structurally, he was wrong.  I would be enabling the lab's poor service.  A system correction was needed, and all the clinicians should have gone to administration and demand they get the damn lab fixed.

But his doctor's solution was also correct.  The patient, the individual patient, comes first, and the doctor's job is to get it fixed for the patient, right now.

In fact, to be successful, both views are needed, the clinician's impatience to fix the individual situation, and the the administrator's view to fix the system for everyone once and for all.  

In our 10-office practice, I taught our managers, "Patience is not a virtue!  Insist that things go right, right away.  If you don't get a fix on something, call me directly.  That will be my job."  I taught them not to have an "off my plate" mentality.  It's not off your plate if the problem is simply on some else's plate now -- it's only off your plate when the problem is fixed.

How successful was I at Bayside in teaching organizational professionalism?  I truly don’t know.  I think I changed some of the managers’ attitudes, maybe.  I know they admired my point of view, but how much could they adopt it themselves?  Some did.

How successful was I with the clinicians?  I’m pretty sure they were professionally responsible to their patients, one by one.  How much were they responsible for seeing that a system got changed?  Some, but not so much.  This depends a lot on leadership.  I had quarterly meetings in each office with an agenda that featured systemic problems in the office from both the clinician’s and my own (leadership's) point of view.  After each meeting I made sure to effect improvements within a week, demonstrating to the clinicians that it was a responsible system.  But since I sold the practice I understand that the meetings have been sporadic at best and the Medical Director does not attend.  Leadership is key.

It is hard to overstate the importance of responsibility and persistence as ingredients of success.  As an executive, one thinks: who takes the job seriously?  Professionals take it seriously; that’s what is meant by being a professional.  Economics mixes us up by distinguishing an amateur and a professional by accepting money or not.  But the deeper meaning is the degree of responsibility accepted.  A true professional is someone who figures a problem is off his plate only when a problem is solved systemically.

It is so easy to talk about an "uncoordinated system," but within that system are real people, who are taking responsibility or not.  A system will hold the individuals accountable, but a real top-quality professional will hold not only him or herself accountable, but will hold the system accountable as well.  

As in the above hospital example with poor follow-up and undecipherable patient instructions, where are the professional members of the system headed to the offices of the administrator and the chief physician saying, how can you let this happen?  Where is your leadership in fixing this?  Do we only see individuals doing their jobs with their patients, heading down to the lab to get the results that should have been there at morning rounds, enabling a poor system?  Do we see ER docs readmitting patients, knowing they didn't have follow up appointments, knowing their instructions were indecipherable, and not insisting the leadership improve this performance?  I don't think so.  They might being a professional in the narrow sense, but it’s not enough.  

On the other hand, the profession called attention to the problem some 14 years ago (the Institute of Medicine report on safety), professionals conceived of this study and someone gave a grant for it, and a journal published it.  In my view it's too much time and the cumbersomeness reveals a lack of true interior professionalism -- if everyone were professional in the system the research results would have been different -- but at least we're on the right road.  It's just bumpy and meandering while people die and money is wasted, is all.

Budd Shenkin

Kennedy

It is JFK season, but even apart from that, I’ve been reassessing him and the era in the last few years, reading accounts of general history of the era, Eisenhower histories, the Stephen King book, and most importantly the 2007 David Talbot book “Brothers.”  My life-long friend Bob Levin has also been immersing himself, principally in the civil rights literature, I think – Taylor Branch, and a book we both read about the Freedom Riders, which was great.

So here is Bob’s current take on the Kennedy Administration:

Those I know who believe most strongly that a vast conspiracy lay behind the assassination of President Kennedy place great emphasis on his commencement address at American university in June of 1963.  They believe these remarks revealed him to be committed to achieving global peace through agreements with Nikita Khruschev and certainly prefigured his intent to end our involvement in Vietnam and, hence, made the CIA, the military, and others decide to murder him.  Never a great believer in conspiracy theories myself, and not a greater admirer of JFK, I decided to see what went on between the time of this speech and his assassination five months later.  For my admittedly non-exhaustive research I turned to the Stanley Karnow book, my only Vietnam reference on hand, and my conclusion is i don't think Kennedy knew what the fuck he was doing with Vietnam.

Shortly after the speech he sent 3000 troops to Thailand because of unrest in Laos.  In early September, he told Walter Cronkite withdrawing from Vietnam would be a mistake.  He tried to get the New York Times to pull out David Halberstam because his reports were hurting the war effort.  He went back and forth about whether to support the coup against Diem, worrying mainly if it would work, not if it was the moral thing to do, eventually leaving it to his ambassador Henry Cabot Lodge to do as he felt best.  

             

The only support I found for the existence of an anti-war attitude in Kennedy was Larry O'Donnell's recollection of JFK's telling him he would pull out troops once he was re-elected, but couldn't do it before without being tarred as soft on Communism.  But O'Donnell was a Kennedy loyalist likely to paint him in the best light, which, in 1970, when he recounted this conversation, would have been to make him a peacenik.  And even if O'Donnell's memory and account were accurate, it still doesn't mean Kennedy would have acted in line with this sentiment.

   

So I see the Am U speech as just political talk.  I think Kennedy was a pol, playing things for maximum advantage, not out of principle.  (Certainly that's how he acted in the South on civil rights.)  Maybe that was enough to get people in the CIA pissed off enough to want to kill him but he was not the figure this other crowd is trying to make him out to be.

I believe Kennedy was essentially an unprincipled politician, telling audiences what he thought they wanted to hear, always seeking to manage events to his and his party's political advantage.  Certainly, that was how his administration conducted itself with respect to the civil rights movement then raging in the south.  And civil rights, remember, was more of an issue than Vietnam was in 1963.  Freedom Summer was about to launch, whereas hardly anyone knew where Vietnam was, and there was no anti-war movement to even speak of.

Then again, as my friend Richard Weber points out, it isn't necessary to burnish JFK's reputation in order to find motivation for the CIA, for instance, to take him out.  He had already pissed them off by firing Allen Dulles and not giving them carte blanche in Southeast Asia.

I myself have a different view:

I went around for years thinking that I liked Kennedy, his panache, the change from the 50's, but I knew the charges that he was essentially a cold warrior, not so progressive on many things.

Then I read the book by Talbot, who polishes everything to a high sheen, and my images of him reunited: he was indeed great, or at least was getting there!  He was fighting the militarists who predominated, but was severely limited in what he could do.  The Talbot book essentially says that he learned quickly, and was in ascent to the gods of right-thinking.  He takes Bobby's ascent in righteousness in the subsequent years as a surrogate for where JFK was going.

That is a speculative view, but an attractive one to reunite my psyche.  And it can't be disproved by his knowledge of political necessity; you can only do what you can do.  I think I'll stick with it.

Budd Shenkin

Disillusioned with government

 

There are many reasons and ways to distrust government, God knows.  As a card-carrying liberal, I have always thought of the good things government can do.  But the more I get involved in government programs, the less I trust.

Here is a beautiful example.  What could be more important to kids than vaccines?  Aside from clean water supplies, there have arguably been no measures more important for saving lives.  Public health demands that children be vaccinated.

In this country the great preponderance of vaccines are dispensed by private medical offices.  No problem there – in general, they do a good job.  Enter, government!

The government says, why should patients on Medicaid get vaccinations the way all the private patients do?  Let’s do it our way!  Instead of having local offices purchase the vaccines and charge for them (with overhead included in the charge), let’s buy the vaccines ourselves (it’s called the Vaccines For Children program, or VFC), ship them to the doctors, and have them give the vaccines to the Medicaid kids.  And since the offices don’t pay for these vaccines, let’s not pay them anything except for administering the vaccines – let them order, receive, inventory, refrigerate, etc. for free.  In other words, if an office agrees to see Medicaid children, let’s make sure they lose money on the deal, because they will have to pay for their overhead out of their own pockets.  That’s their reward.

But wait, you say you’re not satisfied, you say you want more for your money – tell ya’ what I’m gonna do!  Not only will you get no payment for overhead, but if you somehow drop a dose on the floor, you will have to pay us the cost of that vaccine.

And that’s not all.  In addition, we will dictate how you will store your vaccine; it can only be in approved refrigerators and freezers, which you have to buy out of your own pocket.

And even that’s not all.  Some states (hello, Connecticut) will also supply “free” vaccines for even those kids covered by private insurance, so the practices can lose overhead on those kids also!

And then, let’s regulate some more.  Let’s make sure that if a practice has a shortage of a certain vaccine for the VFC program, you can’t borrow from your private stock to vaccinate a kid and replace it later, or vice-versa, no matter how good your record keeping.

And there’s even more – let’s mandate that all vaccines have to be stored separately according to who purchased it.  Here is what Graham Barden, terrific public spirited pediatrician from North Carolina has to say:

“Just when you thought the CDC's requests could not get crazier.  The CDC thinks it is reasonable to have separate VFC, Private, S-CHIP, 317, State supplied vaccine. Five complete sets of vaccines. The bean counters want to make sure no one can say they are not counting beans!  Paperwork is now the measure of our success.”

As I said, I have always believed in government.  But when I get up close, government doesn’t seem so nice to deal with.

Budd Shenkin

Restrictive Medical Networks

 

We know that insurance companies are cutting costs by narrowing networks for physicians and for hospitals, or “tiered networks.”  Our problem is this conjunction that flows off the tongue, "physicians and hospitals."

To be more concrete, here is how it works for a primary care practice.  You as a primary care practice receive a contract proposal from Blue Shield, say.  You can sign up for network, A, B, C, or D.  If you sign up for Network A, all your charges will be paid for at 70% of the Medicare base price.  Patients who sign up for Network A, which costs the insurance company somewhat less because the fees paid are lower, will pay a lower premium than for other networks.  If you sign up for Network B, you will be paid say 80% of Medicare – a somewhat higher fee – but the only patients who can come to you will be those who sign up for Network B and pay the higher premium.  And so on.

From the patient’s point of view, it will be a juggling act – sign up for a Network and figure out where you can go.  If you already have a primary care doctor, see which Network you can sign up for and not change doctors.  We have seen by experience that many, many patients will sign up for a cheaper plan and make the doctor switch.

I’m not quite sure how it will work for hospitals.  It might be that patients in Network A will need to go to a hospital that signed up for that network, and thus will receive a lower payment from the insurance company.  Or it may be that the plan will be so-called “reference pricing.”  In this approach the patient can go to any hospital, but the insurance will pay the charge given by the lowest (or maybe second lowest) hospital in the wide area, and the patient needs to pony up the rest if he or she chooses a more expensive hospital. 

Now, there is every reason to restrict choice of hospitals.  This is where the money is, this is where the savings will be, and this is exactly where the excessive charges are.  There is plenty of evidence of great variability of charges with no correlation with quality (as far as quality can be measured, but that measurement is pretty good for hospitals as compared to outpatient quality.)  It's hard to narrow this network because of hospital consolidations and local monopolies that have resulted, but it must be done, somehow. 

On the other hand, there would appear to be no reason at all to restrict access to primary care.  Primary care impacts only minimally on the health care budget.  Good primary care, high quality primary care, is generally cost-saving rather than cost-enhancing.  There is no evidence whatsoever of primary care being excessively priced.

In fact, what might happen is the reemergence of so-called Medicaid mills.  One can save money in primary care by having clinics staffed by midlevel professionals – nurse practitioners and physicians assistants – and restricting access to patients by a variety of means.  Decreased quality of care in Medicaid mills is inevitable.  But because of the limited impact of primary care onto the health care budget, virtually nothing will be gained by this approach and much will be lost.  It is well established in health policy that the United States has too little primary care, not too much, and the restricted network approach will only further exacerbate that deficit.

[Note that I have not discussed specialists here, only primary care and hospitals.  Probably the best approach would be to split specialists into proceduralists and non-proceduralists, and treat the proceduralists like the hospitals, and the non-proceduralists like the primary care docs.  There are a lot more imaginative approaches that could be followed, but this might be a simple first step.]

Anyway, that’s my view.  There will doubtless be lots of confusion and some conflict, but if the insurance companies are in charge, as the ACA puts them, there is every reason to expect difficulties and missteps. 

Budd Shenkin

Second Opinions

Paul Levy has another interesting post on the value of second opinions.  He says:

Simon Schurr at Collaborative Medical Technology Corporation suggests in this blog post that current levels of overtreatment and inappropriate care could be reduced by more widespread and judicious use of second opinions.  He points to unnecessary surgeries, overtreatment of back pain, mistreating ovarian cancer, and outdated procedures.

His diagnosis: "The causes of inappropriate care are complex, but often the root is simply lack of knowledge, an honest mistake, or a healthcare provider who simply wants to help a patient when treatment isn’t working. Sometimes, profit-driven decision-making or fear of malpractice claims lead to over-testing and overtreatment."

His solution:  "The best approach may be a combination of well-informed patients asking the right questions and seeking top doctors who stay abreast of the latest research, and rigor in using second opinions."


My response:

Here, here!

Years ago I advocated (in the first ever Sounding Board section in the NEJM) for patient access to medical records, partly reasoning that if medical records got a wider circulation, their quality would improve, because clinicians would know that what they wrote could be seen by others.  Now, EMR serves the same purpose, as does the growth of group practices generally, where you know that your colleagues will sometimes see your patients and read your notes and judge.

Likewise, it's possible that even the knowledge that your patient would likely be seeking a second opinion would be very bracing.  When our pediatric practice seemed to have an excessive number of referrals to specialists for one HMO. I announced that I would be reviewing all referral requests from our group before they went out.  Instantly, the number of requests dropped, just from the knowledge that they would be reviewed.  I then had to send back the referral request for reconsideration by the clinician only rarely; just the existence of the review process did the job -- as expected.

Moreover, if you consider Groopman's How Doctors Think, you immediately are impressed with the desirability of second opinions,  to avoid the cognitive error of anchoring, if nothing else.

Here's another example.  A doctor friend of mine had a father-in-law, I think it was, who was sick for years and years without a diagnosis.  By chance, my friend and his father-in-law were walking around the halls of Dartmouth Medical Center and a doctor friend of my friend saw them, walked up to them, and said to the father-in-law, "You have hemochromatosis!"  He could just tell by the look.  After years without a diagnosis.  A single doctor just can't know everything.

Or, consider this.  Just two days ago I was at our health club and a 76 year old friend came up to me.  He had pneumonia almost a year ago and has never really recovered, he thinks.  For the last few weeks he has felt really, really tired.  He's worried -- as he should be.  He asked me about a second opinion -- from an internist, he specified -- because his regular doctor (who is in fact an internist), who he likes, hasn't pinned down anything.  Is his doctor saying subconsciously to himself that my friend Arthur has just run out his string?  Is he out of ideas?  What?  I don't know.  But I urged Arther to in fact get a set of fresh eyes on him -- take up the case from the beginning!  Why not?  Visits are cheap.

Finally, while we have many specialists in many fields, what we really don't have is a super specialist in internal medicine.  When I did my medical school internal medicine rotation at the Beth Israel we had an attending who was revered for his differential diagnosis acumen (Manny something).  His visits were prized, as various residents sought help, and to stump him.  The Chief Residents sought to emulate him.  But what happened to these Chief Residents when they moved on out of training?  Chief Residency was the best training possible for a job that didn't, and doesn't, exist.  You either go to a recognized specialty, or you go into primary care, which really presents a different set of circumstances than Chief Residency.  (For one thing, primary care puts a premium on prevention, which internists generally do not excel at, nor are they well trained for, etc.)

What we need is an institutional setting for the master internist, someone to turn to, or a set of doctors to turn to, who are really smart.  They wouldn't have to give primary care, and their field would feature breadth, rather than the depth of the recognized specialties.  These would be great for second opinions.

I guess you could do the same thing for surgery, but that's a more complicated issue.

And to reiterate: visits are cheap - it's the procedures that are expensive.

Budd Shenkin

Monopoly and Medical Care

In every industry as a firm gets larger and conglomerates, it explains to regulators that its size will redound to the benefit of consumers, as they will be able to offer new services, etc.  Usually, it is bull-diggy.  Who wouldn't want a monopoly?

Paul Levy writes a very interesting blog called "Not Running a Hospital."  It used to be called "Running a Hospital" when he was CEO of Beth Israel Deaconess, a Harvard hospital, and he renamed it when he left his job.  Before I discovered this blog, I had heard of him from some Teaching Company tapes on Leadership - how he came into a dysfunctional Board at the Beth Israel and laid down the rules and turned the institution around.

Anyway, here is his latest blog and my response:

Self-dealing between a health system and its insurance company

Posted: 13 Sep 2013 06:22 AM PDT

Just when you think you've seen the limits of market power, creativity emerges.  Julie Donnelly at the Boston Business Journal reports:

Partners HealthCare aims to drive new members to its newly acquired health insurer, Neighborhood Health Plan, by cutting off access to some doctors within new health plans offered under ObamaCare.

Neighborhood Health Plan is one of 10 insurers that has been certified to offer subsidized and un-subsidized ObamaCare plans through the state’s Health Connector.

But what Neighborhood Health Plan has is exclusive access to primary-care doctors at Brigham and Women’s Hospital and Massachusetts General Hospital.

Now that Partners, the parent organization of the Brigham and Mass General, owns a piece of the insurance pie, they have decided to offer access to their primary care doctors only to those members who choose Neighborhood Health Plan.

This is likely to drive new business to Neighborhood Health Plan from Boston-area patients who want to keep or begin a relationship with a primary-care doctor at one of the two most prestigious hospitals in the state.
 
This is a departure from Partners’ strategy in the past. Before its purchase of Neighborhood Health Plan, Partners’ offered access to its doctors to all of the health plans within the state-subsidized health plans that were launched under Massachusetts' own statewide health reform.

And I wrote in rsponse:

Paul, this new thrust by Partners' seems really important. 

I get how pissed off you are at them, probably buttressed by a holier-than-thou sanctimonious and hypocritical attitude -- I was at HMS, so I get that.  

But I'm wondering how this fits in with Kaiser?  And maybe Apple -- closed networks, both. And ACO's.  All talk about the importance of integration - the Oliver Williamson (Nobel Prize, economics) idea that incorporating functions within one company can be more efficient than a market.  Don't get me wrong, I'm with you in smelling monopoly, and as a former primary care doctor with an independent company, I never wanted to be incorporated and thus controlled by an exclusive relationship with a single payer.  I thought it was better for patients, and better for our practice, for us to be independent and have multiple avenues of ingress for patients.  And I had no question that an exclusive relationship would spell decreased payments for us in primary care.

But the ultimate problem with our current medical care system is hospitals and hospital costs.  Kaiser cuts them down because everyone there benefits from decreased hospital costs.  Although they are unionized, and that's a problem.  (Interestingly, when you go into an exam room, the medical assistant is wearing a large, prominent pin that says SEIU!!)  So one could say that to get control of the system they need a completely integrated company.  In this case, of course, one could say that it is not a small upstart company competing with the behemoths, but the latter solidifying their position.  In that case, we rely on government and anti-trust, but we know that's not going to work at this stage of the game. 

Anyway, I would encourage you to keep writing about this, as deep as possible.

Budd Shenkin

Obama and Putin - Let's Be Optimists!

So, Obama has waged a “feckless” (my word) and confused foreign policy, Putin has “bested him,” and the US looks inward, the world has no cop, the Russians are back in play in the Middle East where they have been aching to arrive again as a Big Power, they say.

As my roommate Peter Kelley from Aroostook County, Maine, used to say, “Bull-diggy.”  Instead, it is time for optimism.

Let’s get away from American “primacy.”  We’re big, we’re powerful – but we’re not the only ones in the world.  We are a settled country, where the government has a monopoly on violence, which is what a non-failed state is.  OK.  We think we have the best government there has ever been – OK, that’s defensible, although not airtight, and as far as I know, it’s true.  Putin is ridiculous when he talks about democracy, and about everyone’s not having achieved it fully, implying that he and Russia have, I guess, although that’s not certain from his editorial.

The Russian government wanted to come over and lobby the House of Representatives!!  How hard to believe is that??  Why isn’t anyone saying anything about that, I wonder?  Putin publishes in the New York Times – lots of holes in his argument, but still!

The fact is, and has long been, that settled governments have a lot of common interests, overwhelming common interests, against disruptive forces like terrorism (did Putin chuckle an “I told you so” when the Chechens hit Boston?), and against their combined assault on the commons of the earth’s environment.

We have to pay attention to human rights, OK – but it’s better than it used to be.  Jews can still emigrate, can’t they?  China has lifted tens of millions out of poverty.  But still – we have a lot in common, and if we don’t get all absolutist on the human rights thing, the civil liberties (which I treasure), if we concentrate on a more public health point of view, a collective good point of view, we can celebrate a coming together, ice-flow breaking up of American-Russian cooperation.

I get pissed off at Obama, true.  But along with millions of others I got pissed off at Nixon, but in retrospect, policy-wise, he was very good in so many ways.  He relied on Pat Moynihan domestically, and although he was terrible on Chile – thanks, Henry – if he had just had a different personality, he would have been pretty good overall.  And my being pissed off at Obama isn’t even near the ballpark of being pissed off at Nixon, not even at the hotdog stand outside the stadium, or even paying off some kid to watch my car when I’m a few blocks away at the game, not near.  So, let’s just call it a general disappointment that will fade with time and with appreciation of the real achievements of the Obama Administration (excepting Eric Holder and his outlawing of investigative journalism when it concerns the Feds.)  But that’s just personal, not business.

Why not let Putin into the game and work together?  It’s not like we’re doing so great on our own.  Why not let him keep Syria in his pocket (do we really have much of a choice, really?)  Does it really hurt us?  What’s Putin’s position on Israel?  I don’t think he’s against it; I bet he is willing to see a successful so-called Peace Process.  Does he want to construct a new Warsaw Pact in the Middle East?  Don’t think so.  Does he want Iran to have the Bomb?  Don’t think so.  Does he want countries to adopt a Communist form or government?  Don’t think so.  I mean really, even if Russians are mean sons of bitches, where is the threat?  Am I just so blind?  Will the Russians construct a new operating system and outlaw Microsoft?  Will they overtake Google?  Where is the competition?  Oil?  Oil?  We’re all on our way to conservation and home-brewing from shale.  Maybe I’m blind.

So, I’ve thought from the start that Kerry will go down as a remarkable Secretary of State, far surpassing Hillary, who really was a competent presence, but nothing remarkable.  Smart, but not innovative, nor probably very flexible.  Could it still be Kerry for President?  I think that ship has sailed and hit the rocks.  But, could it be a new era, and a Nobel?  Could be.

I’m going far, far into euphoric optimism here, buying a stock as it emerges shakily from a very long base.  It’s really too early to tell.  That’s why this essay will simply stay on the blog, not read by many, and if it really becomes true bulldiggy, who will remember?

But I say, let them work together.  Let’s not forget that Fox News and the war-mongers of the Right, always there, will yell and scream.  David Talbot thinks that it was Kennedy’s opposition to the war-mongers that got him killed (Brothers, 2007, Free Press).  Eisenhower identified the Military-Industrial Complex, and it was only in late drafts of the speech that he amended that term from his initial one, “Military-Industrial-Congressional Complex.”  So, we will hear a lot from the House, whose members’ districts still thrive on the military, dispersed strategically throughout the US.  There are interests, there are viewpoints, there is violence always as a threat.  Personally, I would double Obama’s security detail.

But I’m optimistic.

Budd Shenkin