Thursday, April 16, 2015

All your labs are back.

Not a new one, but I just saw it.  It made me laugh . . . sort of.

Eric Semelroth is assistant graphics editor for Modern Healthcare.

Wednesday, April 15, 2015

A market shift in Boston

It may or may not be a big deal, but these things don't happen too often.  It appears from a recent "Notice of Material Change" filing that Steward Health Care System is leaving Children's Hospital Boston behind to enter into a deal with Partners Healthcare System to provide pediatric and newborn services.

If you go to the current Steward maternity services website, you find:

Steward maintains a partnership with Children's Hospital Boston, which provides our pediatric patients with access to the most advanced treatment available. Patients have access to in-house Children's Hospital Boston pediatricians around the clock, seven days a week.

The Holy Family hospital site goes into further detail:

Holy Family's partnership with Children's Hospital Boston provides newborns with access to the most advanced treatment available. Children's Hospital neonatologists staff our Special Care Nursery, working closely with community obstetricians, maternal/fetal medicine specialists, community pediatricians and pediatric specialists to ensure optimal coordination of care.

In the event that neonatal patients require the most critical care, they have access to clinical services at the Level III Neonatal Intensive Care Unit at St. Elizabeth's Medical Center in Boston or at Children's Hospital Boston. 

St. Elizabeth's notes in turn:

We can also arrange excellence sub-specialty care for your child through our affiliation with Children's Hospital Boston.

But the NMC says this will change on July 1, as follows:

The NMC says that the new arrangement will, among other things:

Lower total medical spending for newborn medicine and pediatric services without compromising the quality of or access to such services.

There may be more, or less, here than meets the eye. Steward already has deep relationships with Partners for trauma care and adult tertiary and quaternary care.  Those arrangements were signed notwithstanding the higher cost of services provided through Partners compared to all other academic medical centers in Boston.

So, is this latest shift just part of a continuing, gradual absorption by Partners of Steward services?  Or, are we seeing real competition in action, i.e., that Partners has chosen to "lower total medical spending" by underpricing Children's Hospital?

Juggling in the spring!

In honor of spring here in Boston (finally!), I present a quick soccer/football/futbol diversion.  A young man named Shaun McBrien is director of coaching for our girls soccer club, and he provides really helpful advice to those of us who volunteer to coach.  I've learned tons from him, even after coaching for over two decades.  In his latest note, Shaun extols the virtue of juggling:

What is Juggling? Juggling is the act of keeping the ball in the air with all parts of your body with the exception of your hands and arms. Players can use their feet, thighs, chest, head and shoulders to keep the ball elevated, but must not use their hands.

Why Juggle?
  • Improves a players touch on the ball
  • Improves a player’s ability to judge the flight of the ball
  • Improves a players balance (Don’t be a one footed juggler!)
  • There are very few exercises a player can do that provide the repetition and maximize the number of touches one receives by juggling the ball.
For inspiration, he included this YouTube of Indi Cowie from a few years ago. Check it out and work on your skills!

Tuesday, April 14, 2015

Your call: Overdiagnosis or appropriate caution?

In a Medscape article, Kenny Lin (a family physician at Georgetown University School of Medicine) asks, "Can Patients Understand the Concept of Overdiagnosis?" He suggests:

In my opinion, doctors are not doing nearly enough to inform patients about the possibility of overdiagnosis, and we really need to do more. One survey of people aged 50-69 years found that only 9.5% of patients were told about the possibility of overdiagnosis when cancer screening was discussed. Given the results of another survey that shows that patients' tolerance levels for overdiagnosis can vary widely, it is absolutely essential that we include a discussion of overdiagnosis in shared decision-making about cancer screening.

I had an experience that might illustrate the difficulty of discussions about this topic.  A recent CT scan picked up incidental findings in my lung.  The radiologist reported as follows:

New left lower lobe peribronchiolar opacities and right lower lobe 5 mm nodule from 2013, which may relate to aspiration/infection. Since these findings are unable to be visualized on the scout images, follow-up chest CT in 6 weeks is recommended to document resolution.

With the concurrence of my primary care doctor--who is passionate about avoiding over-testing--a follow-up scan occurred a few weeks later, when an aspiration or infection would likely have a chance to clear up. There was good news:

Non-contrast chest CT was performed acquiring sequential axial images from the thoracic inlet through the adrenal glands. Thin section axial, coronal, sagittal and axial MIP's were also obtained. 

There has been substantial interval clearing of previous bilateral lower lobe ground-glass opacities. There are no new ground-glass opacities, consolidations or nodules. No endobronchial lesion or pleural abnormality is identified. 

IMPRESSION: Resolving bilateral lower lobe aspiration or infection. 

Here's the question for my medical experts reading this.  I'm not asking you to second guess my PCP's judgment. I'm asking whether you, in your clinical practice, would have judged the initial findings worthy of the second CT scan, with the added radiation exposure? (Here there was no personal or family history of lung disease.)

More importantly, whichever way you lean on this question, how would you address Dr. Lin's point, i.e., how would you discuss the pro's and con's of the additional diagnostic testing with your patient?

Headline: Massachusetts requires schooling

I'm on a mailing list from the Massachusetts Foundation for the Humanities, which includes "Mass Moments," interesting daily stories from the past.  Here are excerpts from today's:

On this day in 1642, Massachusetts Bay Colony passed the first law in the New World requiring that children be taught to read and write. The English Puritans who founded Massachusetts believed that the well-being of individuals, along with the success of the colony, depended on a people literate enough to read both the Bible and the laws of the land. Concerned that parents were ignoring the first law, in 1647 Massachusetts passed another one requiring that all towns establish and maintain public schools. It would be many years before these schools were open to all children. Only in the mid-nineteenth century was universal free public schooling guaranteed – in time, made compulsory — for Massachusetts children.

Five years later, disturbed by what it perceived as persistent parental negligence, the General Court passed a more comprehensive law, the first to require that towns provide schools (although in practice the law was generally applied only to free, male, white children). All towns with 50 or more families were obligated to hire a schoolmaster to teach children to read and write. In towns of 100 or more families, the schoolmaster (who was usually a recent Harvard College graduate) had to be able to teach Latin as well. Responsibility for education was shifting from the family to the town.

The 1647 law eventually led to the establishment of publicly funded district schools in all Massachusetts towns. The schools were distributed around the town, so that no child had to travel more than a mile or two. The curriculum was basic — reading, writing, and arithmetic. In larger towns, a young man whose family could afford to forego his labor might attend a grammar school and, if he hoped to enter the ministry, Harvard College.

Public did not necessarily mean free. The law did not specify that towns had to pay the full cost. During the colonial period, many Massachusetts towns required students to cover part of the cost by paying tuition, supplying wood for the schoolhouse, or lodging for the schoolmaster.

Nor did public mean universal. At no point in the colonial period were parents required to send their children to school, and many poor children had to be satisfied with whatever education they received at home. Also, not all towns allowed girls to enroll in publicly-supported schools. Girls and very young children whose parents could afford the fees attended what were called "Dame Schools," where a local woman taught reading, writing, and sometimes domestic arts in her home. 

When John Adams drafted the Massachusetts Constitution in 1780, he included provisions that guaranteed public education to all citizens. In 1789 Massachusetts was the first state in the nation to pass a comprehensive education law. In updating the colony's 1647 law, the legislature required all teachers in grammar schools to "provide satisfactory evidence" that they had received a formal education in a college or university and, equally important, were of good moral character. Even women who taught neighborhood dame schools were to be certified by the selectmen.

Monday, April 13, 2015

I trust my doctor

It's seems that there is almost an annual debate on the value of annual physicals. Here's the latest article from Medscape and Kaiser Health News:  "Ritual, Not Science, Keeps the Annual Physical Alive." Excerpts:

92 percent of Americans say it is important to get an annual head-to-toe physical exam . . . and 62 percent of those polled said they went to the doctor every year for their exam.

But the evidence is not on their side. "I would argue that we should move forward with the elimination of the annual physical," says Dr. Ateev Mehrotra, a primary care physician and a professor of health policy at Harvard Medical School.

Mehrotra says patients should really only go to the doctor if something is wrong, or if it's time to have an important preventive test like a colonoscopy. He realizes popular opinion is against this view. "When I, as a doctor, say I do not advocate for the annual physical, I feel like I'm attacking moms and apple pie," Mehrotra says. "It seems so intuitive and straightforward, and [it's] something that's been part of medicine for such a long time."

But he says randomized trials going back to the 1980s just don't support it.

I raised this issue last year with my primary care physician (another faculty member at HMS), and she--one of the more quantitatively astute physicians I know--and one who is compulsive about helping me avoid unnecessary tests--scoffed, saying, "Of course I am going to see you every year."

I know my various posts on this blog have strongly advocated the use of evidence based medicine.  It's all right if you want to call me illogical or inconsistent, but when it comes to this matter, I trust my doctor.

Sunday, April 12, 2015

After the error: Disclosure?

The following letter was included in the "The Ethicists" section of the New York Times Magazine:

I am a pediatric intensive-care physician. Recently, a colleague of mine, a very good doctor, was taking care of an extremely sick child who was expected to survive at the time of admission but who died. The institution conducted a root-cause analysis (R.C.A.), which found that the medical team made mistakes in diagnosis that led to inappropriate treatment and eventual death. The leader of the team resigned. I feel guilty: I was close to the family and took care of the child several times; the mother trusted us. After the R.C.A., I thought our institution had the obligation to tell her the results. I want to tell the family. I think they will pursue litigation if they get the results of the R.C.A. I would sue my hospital as well if I found out they made a mistake and my child died, at least in part because they were not forthright. I think whenever an R.C.A. is conducted, the results, positive or negative, should be shared with the family. Many of my colleagues think a physician’s ethical obligations to a child end when the child dies. I argue that this means that whenever there is a bad, nonfatal outcome because of medical error, logic would mean that the physician should hope for death in order for self-preservation. I am sure that I am conflating many pillars of ethics. I want to advocate for my patient even when she has died. NAME WITHHELD

There were several thoughtful responses from readers.  I thought these four caught the divergence of opinion nicely:

The first

I am a pediatric blood and marrow transplant physician, and am involved in safety and quality improvement, including participation in RCA. The letter writer raises two related but separate ethical questions: should the hospital disclose the results of the RCA, and if the hospital does not, should the writer do so.

The hospital clearly has an ethical obligation to disclose relevant information from the RCA to the family, even if that results in a lawsuit. The death of the child does not end the obligation. Several commenters worry that disclosing the information may further distress the family. However, it is possible to let the family know there is more information in a compassionate way that allows them to decide how much detail they want to hear.

The second question is less a medical ethics question than one of whistleblower ethics. The letter writer is ethically obligated to advocate within the hospital for disclosure. If it is clear that isn't going to happen, she or he needs to weigh the harm from keeping the secret versus the harm caused by disclosure, including harm to the hospital, the RCA process, and to himself or herself. We don't have enough information to judge (details of the mistake and the likelihood of a repetition are particularly important), but should keep in mind that sometimes the result of whistleblower ethical analysis is that disclosure by the whistleblower would be praiseworthy, but not ethically required.

The second

1. No amount of money will ever bring that child back to life. However, the family many incurred a large amount of out-of-pocket costs, and certainly any such costs should be ZERO.
2. There is simply not enough information contained here to make ANY ethical evaluation. What kind of mistakes? Honest mistakes, Careless mistakes, stupid mistakes, gross negligence, failure to follow established protocol, or what? All this has great bearing on what is the appropriate course of action.
3. I am personally very much in agreement with the concept, that forcing disclosure, will result in far fewer RCAs being conducted, and therefore many fewer lessons learned. LEARNING LESSONS for the future is far and away the most important aspect of any RCA.
4. Team leader resigned? Assume that person is an MD, and that they will rather effortlessly find other work. Hard to imagine that the former-team-lead won't be haunted by this experience for the rest of their life. And probably several other people on the 'team' who might have been in a position to alter the outcome.

The third

I wonder if the physician would feel the same obligation if he or she did not know the parents personally? The hospital should tell the parents the results of the RCA, explaining "this is what we're going to do differently from now on". It might actually help ease the parents' grief if they could know that some positive change was going to come out of their child's death.

The fourth

Medical error is now, according to IOM, our third leading cause of death behind cardiac events and cancer, and responsible for 400,000 deaths a year. A patient safety movement, led by Marty Makary and Peter Pronovost of Hopkins and Atul Gawande of Harvard, has gained adherents, and made some hospitals safer, moving toward teamwork, standardization, and greater safety, but unable to reach the laggards in hospital administration and daily practice. Administrators proliferate; staff is cut; contract emergency department personnel staff 65% of our EDs; device companies offer lucrative incentives; hospitals merge, build, and market themselves like toothpaste. Some hospitals seem to have dropped the weekly morbidity and mortality conference, always confidential. Patients and families are often kept in the dark. This physician may wish to find other employment before s/he talks to the family about the RCA and its results. The hospital culture in which he works will bring the hammer down if s/he remains.

Best practices in the delivery of compassionate healthcare

Thanks to Petra Langer and Julie Rosen for this news:

Last year, the Schwartz Center worked with a group of Harvard Business School and Kennedy School alumni to identify best practices in the delivery of compassionate healthcare. They’ve now compiled what they learned into a white paper entitled “Building Compassion into the Bottom Line: The Role of Compassionate Care and Patient Experience in 35 U.S. Hospitals and Health Systems.” They’re in the process of disseminating it to healthcare organizations across the country as well as to senior healthcare and policy leaders.

Below are the major themes that the Harvard team identified from their interviews with more than 75 hospital and health system CEOs and patient experience leaders. The white paper provides much more detail about each of these as well as specific examples.

Employee experience drives patient experience and compassionate care.

Involving patients and families in care improvement efforts is essential.

Hiring and training for compassion are critically important.

Successful organizations have a culture of experimentation; compassionate care champions, often in the middle of the organization; and units that model compassion and share their strategies with others.

Compassionate care requires continuity of care and teamwork.

Transparency of patient experience data is a powerful tool to improve performance.

Simple tactics can make a difference.

Saturday, April 11, 2015

Annual Costs of Care essay contest

It's that time again.  The annual Costs of Care essay contest is accepting entries for $4000 in prizes for anecdotes illustrating the importance of cost-awareness in health care. There are three eminent judges this year:

Leah Binder, President and CEO of the Leapfrog Group
Mark McClellan, Senior Fellow at the Brookings Institution
Sandra Hernandez, President and CEO of the California Healthcare foundation.

Here's the link with all the rules.

And here's a nice blog post from Neel Shah and Jordan Hammon on the context for all this.  An excerpt:

We decided that there are many capable organizations suggesting good policy, and occasionally we are one of them. But someone also needed to shine a light on this other narrative, the day-to-day opportunities that those on the frontlines of healthcare delivery are seeing in every healthcare facility in every corner of the country. So we made a deal. If you send us your story about how knowledge of healthcare costs at the point of care can help us make better decisions, we will commit to publishing it. The most compelling stories will get a $1000 cash prize. It has to be a real story and you have to be willing to put your name on it. That’s it.

Thursday, April 09, 2015

NP in the ambulance?

Thanks to Neville Sarkari, long serving physician executive from Pensacola, Florida, for forwarding this editorial from the Los Angeles Times.

A proposal by Councilman Mitchell Englander could start reordering priorities at the LAFD by diverting the least-urgent medical calls to a team of just two people — a nurse practitioner and a paramedic. They would use an ambulance, but the goal would be to treat people who call with minor medical needs right there at the scene, rather than schlepping them to the hospital — thus saving millions of dollars each year on ambulance rides and hospital admittances. Nurse practitioners are able to do more than paramedics, including writing prescriptions and performing minor procedures.

Between calls, this nurse practitioner unit would reach out to "superusers" — people who call 911 more than 50 times a year — to help them find services and resources before they pick up the phone again.

I know that such proposal can be controversial, and I'm sure there would be logistical things to work through, but it seems really sensible and interesting.  Your thoughts?

Wednesday, April 08, 2015

A Potential Safety Blind Spot

A new article on the Jama Network addresses the issue of credentialing doctors in the use of robotic surgery.  It's worth reading.  Here's the lede: 

This Viewpoint reviews an important legal ruling on robotic surgery that highlights potential safety concerns in hospital credentialing and privileging with regard to new technologies.

Innovative procedures and technologies are regularly introduced into clinical practice. Although the US Food and Drug Administration (FDA) exercises strict regulatory control over new drugs, it exerts minimal oversight for new devices and no oversight for new surgical techniques. When technology such as the da Vinci robot enters the field of surgery, it is less clear who is responsible for ensuring its safe introduction. 

And the authors make this point: 

In recent years, controversey has arisen when manufacturers go beyond their traditional role (i.e., to reasonably design and manufacture a device) and participate in training and credentialing physicians to use their company's product. 

And how much more so when the company also pays for the equipment and training?

Fighting occurrences of C. difficile on WIHI

Madge Kaplan writes:
The next WIHI broadcast — All Hands on Deck to Reduce C. difficile — will take place on Thursday, April 9, from 2 to 3 PM ET, and I hope you'll tune in.

Our guests will include:
  • Dale Gerding, MD, Professor of Medicine, Loyola University Chicago Stritch School of Medicine; Research Physician, Edward Hines Jr. VA Hospital
  • Jason Leitch, National Clinical Director, Healthcare Quality, Scottish Government
  • Alan Whippy, MD, Medical Director of Quality and Patient Safety, Permanente Medical Group, Northern California
  • Don Goldmann, MD, Chief Medical and Scientific Officer, Institute for Healthcare Improvement
What was your reaction when you heard the news that Clostridium difficile (C. diff) infected far more people in 2011 than first reported by the US Centers for Disease Control and Prevention (CDC)? Writing in the New England Journal of Medicine at the end of February, the CDC updated its own prior calculations to report that the burden of infection in 2011 was 80% higher than previously stated. In total an estimated 453,000 people were afflicted with C. diff in 2011; C. diff was a factor in some 29,000 deaths.

Our reaction here at IHI was, among other things, to schedule a WIHI and to touch down with some people who can help us make sense of the numbers and the health care and community settings contributing to them. And, more importantly, to check in on where progress is being made to reduce instances of C. diff and where much more aggressive work needs to be done. While there are indications that hospital-onset C. diff is declining in the US, no one is satisfied with the pace of change.

So, please join us for the April 9 WIHI: All Hands on Deck to Reduce C. difficile. WIHI host Madge Kaplan has assembled a solid panel, starting with Dale Gerding, who will walk us through the latest epidemiological research on C. diff: proven reduction strategies, ongoing challenges with antibiotic stewardship, and where trend lines are moving in the right direction. Jason Leitch is going to give us the view from the UK, and Scotland in particular, where concerted interventions have led to an 82% decline in cases of C. diff in hospitals among people over 65. And Alan Whippy will tell us about important work at Kaiser Permanente, where significant progress has been made, too, and adherence to best practices is crucial so problems can’t creep back in. And, IHI’s Don Goldmann will help us appreciate why it’s important to stay focused on acute-care settings, even as we grow to appreciate the value of prevention and detection of c. diff across the continuum of care and the community.

Please join us on April 9You can enroll for the broadcast here. We'd also appreciate it if you would spread the word about the show via Twitter.

Revisionist history

We can have proper debates about the public policy merits of capitated, or global, payments, but things get dicey when the biggest protagonist of such in Massachusetts tries to restate history.  In this article by Brant Mittler about Blue Cross Blue Shield of Massachusetts, there is this excerpt:

Levy said that others signed because they received "very sweet signing bonuses" -- in the form of front-loaded contracts which would be more palatable to providers.

Dana Safran, DSc, the plan's senior vice president for performance measurement and improvement, calls the idea that contracts were front-loaded "not accurate."

And yet, let's look at the contemporaneous reporting (Spring 2011) from Bruce Mohl at Commonwealth Magazine:

Safran says Blue Cross padded first-year global payment budgets to entice hospitals and doctors to sign on.

There is no indication that BCBS asked for a correction of this quote at the time or any time since.

I also know from personal conversations at the time with early adopters that they received substantial bonus payments from BCBS.  Indeed, at least one major provider organizer received a retroactive payment, going back almost a year--this for a pricing regime that was supposed to influence behavior.  Hard to influence behavior after it's already occurred, no?

If they can't tell the truth about this, how can we believe the other claims?

Those little one-sided news releases pack a big wallop.

Trudy Lieberman offers an entry in the series at on "systematic criteria-driven reviews of health care news releases."  She notes:

This time it’s the long arm of a surgical robot that a healthcare seller hoped would make news. “Midtown Surgery Center Announces First-Ever Use of Robotics During a Total Extra-Peritoneal Hernia Procedure,” the news release said informing us that its “Groundbreaking Use of Robotics Could Change the Face of Inguinal Hernia Repair.” It was that old press release trick I wrote about a couple weeks ago—shout to the world you’re the first, and patients will flock to the door.

While she quotes me, the pertinent quotes are from Dr. Bruce Ramshaw, a Florida hernia surgeon who is the immediate past president of Americas Hernia Society:

Is it better for patients?  That’s the big question news releases don’t answer. But Ramshaw says the real questions are what’s the value to the patient, and where does the robot have value in the context of each patient care process and for each local environment. “The robot is great technology. It’s cool,” he says. But he notes that like all drugs, devices, and screening tests, robotic surgery systems have value in some situations, cause harms in others, and may be wasteful in still others. “Unless we measure the value to patients, we won’t know the actual value of the tool,” he concludes. The country is a long way from measuring the value of such medical interventions. Instead news releases and seller marketing prowess substitute for real information about whether a patient should undergo this procedure or others that have limited or no objective evidence about whether they add value and for whom.

And she concludes:

These kinds of press releases are another form of direct-to-consumer advertising, which does stimulate demand—demand for often unproven technology that threatens to overwhelm the U.S. health system. Such technology may one day be useful and cost effective, but for now it adds mightily to the country’s healthcare tab. Those little one-sided news releases pack a big wallop.

Tuesday, April 07, 2015

App to help traumatized children

I was pleased to get this announcement from Larisa Munsch with the Research & Innovation group at Allegheny Health Network.  It's really fascinating. Some excerpts:

A new mobile game app created by Allegheny Health Network mental health professionals and students at the Entertainment Technology Center at Carnegie Mellon University helps traumatized children by letting them use their tablets or smart phones to practice the life skills they’ve learned in the therapist’s office.

With the tagline “Change how you think; change your life,” the TF-CBT Triangle of Life game is designed to help children age 8-12 better understand their thoughts, feelings and behaviors, and move toward a better quality of life. During this game, the player takes the role of the lion in a jungle story, guiding other animals toward more positive experiences and relationships. 
Children who have experienced traumatic events such as physical or sexual abuse, domestic or community violence, the traumatic death of a parent or other significant person, war or bullying, face significant challenges in childhood and adulthood. In childhood they may suffer from nightmares, anxiety, disordered sleep and behavior problems. Research shows that in adulthood they are at significant risk of developing depression, drug and alcohol problems, and poor physical health.

TF-CBT is used by child mental health professionals throughout the state and nation, and around the world, from Arkansas to Zambia.”

Reducing C-Sections in India

It's good to learn of progress in quality and safety improvement around the world.  Here's an impressive story from India.  Abhishek Bhartia writes:

I want to invite you for a webinar that we are doing for BMJ Quality on April 9 in which we give an overview of the transformation that we are attempting in our hospital--Sitaram Bhartia in Delhi. I will provide an introduction to our work, our general manager will speak about how the quality department has supported improvement across the hospital, and our lead obstetrician will talk about our initiative for achieving a medically justifiable caesarean section rate.

The timing is 11:30AM New York time; 4:30PM London time; and 9:00PM Delhi time.  Here's the link.

Monday, April 06, 2015

LIVE AT MIT! Wearables, Big Data, and Healthcare Innovation

This looks like a fascinating session.  If you'll be in the Boston area, you might want to drop by.

MIT SDM Speaker Series
Todd P. Coleman, M.S., Ph.D., MIT; Associate Professor of Bioengineering, University of California, San Diego; Director, Neural Interaction Laboratory; and Codirector, Center for Perinatal Health
Date: April 10, 2015
Time: 11 a.m. – noon EDT
Location: Wong Auditorium, E51
Free and open to all

In this presentation, MIT alumnus Todd P. Coleman will discuss the complex challenges involved in developing and implementing a suite of tools that transforms "big data" into "small, relevant" data to aid decision-making in perinatal health and chronic disease management. He will: 
  • Describe how flexible, multimodal electronics can be combined with physiologically­ guided analytics algorithms to provide vulnerability profiles that can be efficiently implemented in the cloud;
  • Explain how this suite of human-computer interface applications blurs the line between man and machine, while enabling humans and computers to play to their individual strengths;
  • Offer thoughts on the challenges of interdisciplinary research, using examples involving professionals from electrical engineering, medicine, management, and design; and
  • Discuss the socio-political and legal implications of this work and how they can be addressed.
A Q&A will follow the presentation in a nearby breakout room and lunch will provided on a first-come, first-served basis.

We invite you to join us.

About the Series

The MIT System Design & Management Speaker Series features presentations by leaders who use a systems-based approach to innovation. The series is designed to disseminate information on how to employ systems thinking to address engineering, management, and socio-political components of complex challenges in virtually any domain.

Friday, April 03, 2015

“Your Best Chance For Beating Cancer.”

Those who are concerned about the mixup of science and marketing at America's hospitals will appreciate this comment from Tazia Stagg over at, following a post about Emperor of Maladies:

I’m board-certified in Public Health and General Preventive Medicine. The university I went to for college and medical school has a public radio station and an NCI-designated cancer hospital on its campus. The mission of the hospital is “to contribute to the prevention and cure of cancer.” Its current marketing tagline is “Your Best Chance For Beating Cancer.”

Six weeks ago, I emailed the hospital’s CEO (copied the founder and the marketing director) to ask why he thought it was okay to use the inaccurate slogan. The marketing director replied with “I would love the opportunity to talk with you about this,” and instructed me to call him.

Then I found billboards around my neighborhood advertising a health fair–presented by the cancer hospital–to be held on campus for poor minorities (my neighbors). Five weeks ago, I emailed the marketing director to attempt to prevent the inappropriate testing announced on the event website. Instead of answering, he replied with, “I am more than happy to answer any questions that you have.” and “I am happy to speak with you about this.”

I decided to intervene on the event, which appears to have been designed and organized by the marketing department of the cancer hospital. In one of the prostate cancer screening workshops, I requested a microphone during the Q&A session. I asked the non-clinician who had delivered the inadequate presentation in English to tell us about his qualifications and conflicts of interest. (He hilariously answered, “I work at [cancer center] and I have no conflicts of interest.”) Then I pointed out that screening experts recommend against prostate cancer screening, and asked the non-clinician to tell us about the likelihood that a man who accepted these tests would experience benefit or harm (because this hadn’t been included in the non-clinician’s presentation). This, too, was foreign to him.

(At the conclusion of the workshop, as the poor men were rushing out of the auditorium to claim their tickets to free net-harmful tests, he approached me privately, asked me if I had questions for him, didn’t answer my questions, and recommended that I “never do that again.” He also instructed me to “Be careful.”)

This past weekend, I attended a town hall meeting (Ken Burns documentary screening, radio program taping/panel discussion, public Q&A session) at the hospital. A non-clinician on the panel twice recommended prostate cancer screening.

I wasn’t selected to ask a question, so I later emailed my question to the hospital CEO (copied the founder, others, of course not the marketing director): “I attended this morning’s promotional event and would like to understand the following. Considering the position of the word “prevention” in [cancer hospital's] mission statement: Is there now, or has there ever been, a preventive medicine specialist among [cancer hospital's] leadership or on its staff? If not, why not?"

The marketing director sent a reply. Guess what he wrote!

Thursday, April 02, 2015

In appreciation: David Boyd

There's a reception today on the occasion of David Boyd's retirement from teaching at Northeastern University, celebrating 36 years of service.  Professors come and professors go, but this one is worth noting.

Several years ago, while I was running the hospital, David called and asked if I would address one of his classes.  He teaches leadership to undergraduates, MBA students, and executive MBA students.  This first class had the MBAs.  Well, that was the start of a great relationship.  We both had such a good time, and the students were so engaged, that he kept inviting me back.

David always got exceptional reviews from his students.  Shown above is an outtake from the NU student rating website.  I'm sure I understand the slightly lower grade for "easiness," as he is quite demanding with regard to written assignments, but I not quite sure what one pepper signifies in terms of "hotness!"  In any event, look at these verbatims:

Took his Leadership MBA class and must say he is the best professor I had during the program. He is extremely nice and cares a great deal about his students' well-being. I highly recommend taking him. 

Prof. Boyd is an extremely smart and honest man. I'm a senior and I can honestly say that he is my absolute favorite professor at NU. He's very kind, and will always give you his full attention if you ask him for help or if approach him for any reason. You'll be lucky to have him as a teacher!  

Boyd is a great teacher and a great person. He has a bunch of great stories to tell as well. Try and take one of his classes before you graduate. 

This guy is amazing. I've taken two of his classes, and he inspires me to take more. He is the best teacher that Northeastern has, due to his respect for student opinion, different course work, and easy grading style.  

Prof. knows precisely what he's talking about and is the ABSOLUTE BEST teacher I've had in my 2 1/2 yrs at NU. 

Amazing teacher, really engages his students, and truly loves what he's teaching. DEF take him if you can...  

Professor Boyd was the best professor I have had in my grad school program. He gave nothing but respect to the students and I really learned a lot in his class. 

Professor Boyd was far and away the best teacher I have ever had. He was so excited about teaching and made class extremely interesting, using relevant information to make the material easier to understand.

One of the nicest and most helpful professors I've ever had. Always has a smile on his face and is passionate about what he teaches.  

His insight and genuine concern are evident as this was one of the best classes I have taken. Prof. Boyd is a wonderful professor, and I highly recommend his class. 

There's just not much more that could be said.  I join hundreds of his students in saying that I treasured our times together.

Wednesday, April 01, 2015

Too true for April Fool's Day

Our buddies over at They Said What? have been carefully curating many additions to the claims made by the wellness community.  Worth a look for the updates.

Tuesday, March 31, 2015

Keep 'em in the hospitals!

Well, speaking of twists in the usual story, check out this op-ed by Joseph Doyle, John Graves and Jonathan Gruber in the Boston Globe, suggesting that patients should spend more time in hospitals before going on to post-acute care elsewhere. Excerpts:

[O]ur research shows that a major source of the waste [in health care spending] comes after a patient is released from the hospital. Hospitals that discharge patients to expensive skilled nursing facilities are raising costs and reducing care quality.

We . . .  find that for those patients there is a substantial benefit to receiving higher spending while in the hospital: Being treated at a hospital that provides more aggressive treatments and accrues high levels of spending at the time of the health emergency leads to about a 10 percent reduction in the likelihood of death compared to being treated at a low-spending hospital. 

It turns out that what is really going on is excessive use of skilled nursing facilities post-hospital discharge. Patients who go to hospitals that have a high rate of discharge into SNFs are much more likely to die than those who are transported to hospitals that send their patients home instead. ... [H]ospitals that use SNFs more than average are not providing good enough care to their patients. These findings confirm what has been suspected by many: Coordination of care post hospital discharge is a primary source of waste in the health care system, of both money and lives.

Our findings suggest that, at a minimum, the existing system should also track hospital use of expensive post-acute care and penalize them for it just as they are penalized for a high readmission rate. 

Hospital system seeks risk. Insurers say no thanks.

Well, here's a twist in the usual story, from Modern Healthcare:

Since 2002, Dan Wolterman has served as president and CEO of Houston-based Memorial Hermann Healthcare System, Texas' largest not-for-profit health system, which provides care in southeast Texas through 16 hospitals and has $4.2 billion in net operating revenue.

MH: Do you expect to see Memorial Hermann take on additional financial risk under contracts?

Wolterman: We would love to take risk. The problem is this: Very efficient providers like Memorial Hermann with their doctors have been able to reduce inpatient admissions, hospital-acquired conditions and infections, and ancillary testing like MRIs and CT scans. With our total cost of care so low, we would love to go and take a risk contract. We would be much better off. We saved $58 million in the Medicare ACO. We received 50% of that from Medicare to divvy up between the physicians in our system. If they were all under a risk contract, we would have received all $58 million of that. But carriers simply do not wish to share it with us. They say, “We love how you all are providing care, the quality is outstanding and the cost controls are wonderful. You just keep doing what you're doing. You're making us lots of money. We'll stay under fee-for-service.”

So we felt that we needed to be more aggressive. A couple of years ago, we decided to start our own insurance company. It is a fledgling company today, but we are off the ground and we are now in the commercial and Medicare Advantage programs, and hope that will start the ball moving to where we can take risk.

Monday, March 30, 2015

Crushed between two elephants

Here's a fascinating story about a developing trend. It's by Jordan Shapiro at the St. Louis Post-Dispatch and is presented over at Kaiser Health News. (KHN, by the way, is one of just a few go-to media outlets when you want to know what's really happening in health care.)

Jordan explains:

UnitedHealthcare, which covers approximately one-fourth of Missourians, has changed the way it handles something known as “balance billing” — the difference between the provider’s charge and the amount allowed by the insurer. The insurer’s move this year, designed to force down costs, means the insurer won’t pay the bills of some emergency room physicians and other specialists even though they work for hospitals in the UnitedHealthcare network. That could leave a customer with health insurance coverage stuck with thousands of dollars in unexpected expenses.

UnitedHealthcare previously would pay almost all of the bill from the emergency room doctors who performed services at an in-network hospital. But now UnitedHealthcare says it would scale back how much it would pay. It will now only pay the prevailing out-of-network rate, leaving the remainder of the bill to patients.

UnitedHealthcare blames the hospitals that contract out their emergency care to other providers who may or may not be in the insurer’s network.

It feels like the battle of the titans, with consumers getting crushed in the middle. As KHN's Jay Hancock noted on Twitter:

"What happens when Big Insurance plays the heavy with Big Hospitals? Consumers get screwed."

More than a Hallmark moment

I'm such a cynic about National ** Day (where ** is some profession or other.)  I really believe that most of these "holidays" were created to sell greeting cards, and maybe also roses and candy.  I also think that days like National Secretary's Day, for example, are pretty insulting, in that every day of the year should be cause for appreciation of people and their professions.

So it was with a touch of sarcasm that I posted on Facebook and Twitter the following query:

It's National Doctors Day. How do you plan to celebrate? Kiss your PCP? Send a Hallmark card? Pay your co-pay at time of visit? Adhere to a prescription? File an advance directive?

Who would have thought that this would prompted a cascade of true appreciation?  So very sweet.  Here's a sample:

Say a silent thank you to all the doctors I've worked with over the years and a special thanks to the one who figured out what I needed when I was at my lowest.

Remember what an amazing neurologist and heart surgeon I had at BIDMC.

I have the privilege of working at BIDMC and will say thank you to all the "white coats" and even the residents I come across today as they are the doctors of tomorrow once they pass their Boards!

Simply say, thank you. Most don't hear it enough, especially these days.

Don't kiss your PCP-do a fist bump and a big thank you.

See your doc as a human who also carries a heavy burden. Treat them as such. Offer a hug and encouragement.

And, finally!

First, I'll remind them that nurses have helped get them where they are today, and that our week comes in May! Next, I think I'll schedule my annual mammogram and eye exam to help boost my PCP's quality scores.