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The Power in What We Most Fear

There is fire in the valley and smoke in the mountains. A plague is on the land and danger is afoot.

That may be — maybe — the good news.

Health care is more unstable than it has been at any time in living memory. That’s pretty scary, but that instability may turn out to be its most important asset in this moment, as the whole industry becomes open to profound change.

As long as I can remember, thoughtful analysts have been saying, “We need to do this differently. This is not working.” In this century, the voices became louder and more insistent, and they spread. But health care has been very slow to evolve in any fundamental way. Even health care reform, when it came through extraordinary political pain and maneuver, was more a way to bolster business as usual, a way to shore up revenue streams and patch holes in the fee-for-service business model, than it was any fundamental restructuring.

Now the ground under our feet is liquefying.

The Bad: The Economy

Political rhetoric screaming “Jobs! Jobs! Jobs!” continues to be matched at every level by political action to slash government-dependent jobs, cut funding and limit actions that might actually produce more jobs any time soon. More and more “medically indigent” people are streaming through our doors, and the number and percentage of uninsured still are rising a year after passage of health care reform.

The health care sector of the economy is slowing down. Health care architects and planners are heading to the airport for another trip to Brazil or Dubai or Shanghai, places that are building while capital projects have slowed, suspended and stopped in the United States. The latest job reports show that health care, for the past three years the stable haven of job growth in the troubled economy, has stopped hiring. The looming Medicare cutbacks are troubling executive conference rooms and board meetings across the country.

The worst anxiety is the instability. There is no light yet at the end of this tunnel. No one knows when the economy will turn around, or how much worse it will get before it gets better.

The Ugly: The Politics of the Slowdown

State governments are slashing Medicaid and indigent care budgets, depriving health care institutions of lifelines that help them offset the costs of caring for the poor.

The anti-government and anti-tax mood in the land spills inevitably into health care, which gets so much of its funding through federal, state and local governments.

The ugliest of this is again the instability: It is hard to say when this might get better, whether it might get worse, or how fast, or how bad it might get. It is easy in this atmosphere to write doomsday scenarios.

The Good: A Time to Experiment

Wait, really? Is there something good in this mess? Actually, there is. It is the very instability that is the source of the fear.

Every problem holds the germ of its own solution. We cannot know exactly how health care will change in the coming few years, but we can know that it will change, because it is not possible for it to stay as it is. It is also far more malleable to our attempts to change it for the better than it has ever been.

If we are smart and fast and aggressive and have a clear vision, there is a better chance than ever that we can help it change not chaotically but in ways that will make it better and cheaper for everyone. That’s our job, and this is our chance.

Our Shaky Equilibrium

Systems get stuck. In economic game theory, the technical term for this particular way of getting stuck is a “Nash equilibrium,” named for the mathematician who formulated it, John Nash (portrayed in the 2001 film A Beautiful Mind). Systems consist of a number of different interacting players. In the health care system, for instance, there are hospitals and health systems; doctors and physician groups; and other providers, health plans, employers, government payers, politicians, pharmaceutical companies, various suppliers and manufacturers.

In any system, each player seeks what is best for him-, her- or itself, to survive and grow and do what he, she or it is there to do. But we can’t think about them in isolation, because each player thinks about, and acts on, what he or she thinks the other players’ strategies will be. Each player fights to a position that is the best he or she can do with the information acquired, against the strategies of the other players as they are understood.

Imagine the players in a 3-D landscape, each climbing a peak of fitness, the taller the better. The place that represents “the best they can do” is called their “local optimum,” fitness peaks from which every direction is down. There is no strategy that will take them farther up without first taking them back down into the trough, no way to do better without doing a lot worse for a long time.

But this is not their best possible position. They may well be able to imagine a much better situation for themselves, they may be able to see another peak that is higher, but they have no way to get to it without hurting themselves. So they are doing “good enough” to stay where they are, but they are stuck there. And the players’ local optimum, their stuckness, is locked into the local optima of the other players around them, because each player is watching the others and reacting to their strategies.

So doctors being paid fee-for-service may know that their patients need and deserve more of their time and attention, and the insurance companies less of their time and attention, but if they do this unilaterally, they will make less money and likely be driven out of business. Insurance companies may know that there are less expensive ways to fund health care, but they are paid a percentage of the health care market. If they truly drive their customers to better, cheaper health care, they cost themselves a chunk of their market.

Hospitals are in the same position as doctors: They have to take the “good enough” funding that they can get, and keep begging for more, because to do anything seriously different would so undermine their position that they might have to close their doors, and what good would that do?

This position holds as long as the status quo does, even as it may slowly become less tenable for every player. A Nash equilibrium changes only if something causes the ground under everyone’s feet to shift.

That is what is happening right now.

A Window of Opportunity

For a concatenation of reasons, reasons that neither start nor end with Obamacare, players across health care are feeling the earth move under their feet.

Talk, as I have been talking, to surgeons, hospital executives, health plan administrators, nurses, insurance brokers, employers wrestling with health care costs, health care architects, pharmaceutical companies, device manufacturers, vendors, the people who actually make up this vast rolling chaotic system — and every sector tells the same story: It’s not working for them anymore. They no longer anticipate that the future will resemble the past, or get any better without some big change. Their business models have come loose from their moorings, and the new and safer harbor has not yet been located.

The fact that much of the industry shares this perception is of profound importance. The risk of attempting to stay where they are has come to seem very great, in fact impossibly so: They must change or die. The resistance to change has disappeared — if only they can see what to change to, what course to set that will bring them safely to a new situation.

The health care system is approaching a state of liquefaction. New coalitions of players can form, break and re-form in new relationships, to find better footing for their members. Providers may ally directly with employers, for instance. Broad coalitions of providers may organize ACO-like virtual organizations to offer services to employers or government payers. Health plans may reorganize themselves to directly provide health care services to select covered populations. Disease management organizations may spring up to serve as organizers of services with different incentives.

The resistance to experiment, the defaulting to status quo, is evaporating.

This is temporary. Before too long the system will resolidify in new forms that represent a better solution in one way or another for some or most of its most powerful players. Once it does, it once again will be in a Nash equilibrium, difficult for any player or coalition of players to change.

The time span is short, the speed accelerating. Given the pace of change of a huge, politically embedded system like health care, this is probably a unique opportunity in our professional lives. Once the system re-concretes, it is not likely that we will have another such opportunity any time soon.

We in health care deal in contracts and budgets and programs and percentages, but these numbers and documents represent real life and death, real suffering and poverty. If you hope, in your life, to do good in the world, now’s the time.

With nearly 30 years’ experience, Joe Flower has emerged as a premier observer on the deep forces changing healthcare in the United States and around the world. He has written for a number of healthcare publications including the Healthcare Forum Journal, Physician Executive, and Wired Magazine. You can find more of Joe’s work at his website,, where this post first appeared.

A Computer Teaches Docs the Empathy Thing

The Canadian Cancer Society says this year alone, more than 170,000 Canadians will be diagnosed with the dreaded disease. What those patients want from their doctors is a little kindness along with chemo.  That’s not something all doctors know how to provide. But a recent study has concluded doctors can learn some empathy skills.  And the teacher may surprise you.

The doctors in this study, published last week in the Annals of Internal Medicine, learned empathy – from a computer.  That’s right, a computer.

Researchers at Duke University in the US developed a computer program that teaches what cancer specialists learn when they take courses on empathy.  Researchers audiotaped between four and eight encounters between the cancer doctors and their patients – people with advanced cancer.  Those recorded sessions were submitted throughout the study period to monitor empathic responses and – in the case of the doctors who received special training in the empathic response – provide tips on how to improve.

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Pfizer Pioners New Ways to Frustrate Generics

The best-selling drug in pharmaceutical industry history, Pfizer’s cholesterol-lowering Lipitor, lost its patent protection Thursday. But the huge savings that consumers, insurance companies and the government usually realize when generic versions of a best-selling pill hit the market are still six months away, and, consumer advocates fear, may never come to pass.

The reason is the unprecedented series of side deals that Pfizer has signed in recent months with some insurers and pharmacy benefit managers to offer lower-priced versions of Lipitor, known generically as atorvastatin. They also are offering consumers $4 co-pays – comparable to prices paid at discount outlets like Walmart and Costco – so they’ll continue buying the brand name version of the drug.

Government officials fear the full cost of the drugs might then be passed along to insurers and Medicare, although the companies involved say that won’t happen.

The goal of the maneuvers is to keep as many of the estimated 8 to 10 million Americans who take Lipitor ($7.2 billion in U.S. sales in 2010; $10.7 billion worldwide) on either the branded product or on an “official” generic, which in Lipitor’s case will be marketed by Watson Pharmaceuticals. They will sell for about half the price of the branded product for about six months, when a number of generic makers are expected to hit the market. Their versions of atorvastatin could sell for as low as $50 a month, which is less than a tenth its current price and comparable to other generic statin drugs already on the market.

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The Vital Role of Guideline Narratives

A few weeks ago, I presented Family Medicine Grand Rounds at Georgetown University School of Medicine on resolving conflicts between screening guidelines. During the question and answer session, Department Chair James Welsh, MD asked how evidence from carefully conducted clinical trials can possibly overcome powerful emotional stories of “saved lives.” I answered that evidence-based medicine’s supporters must fight anecdotes with anecdotes. For every person who believes his or her life was extended by a PSA test or a mammogram, statistics show that many more are temporarily or permanently injured as a result – and their stories matter too. As blogger Kevin Pho, MD wrote about the USPSTF’s recent prostate cancer guideline, “Task Force advocates will need to put a human face on the complications stemming from prostate cancer screening” in order to convince physicians and patients that it’s okay to stop. Indeed, news stories about PSA test-related complications such as this one by Associated Press writer Marilynn Marchione will go a long way in balancing the scales.

An insightful commentary published in JAMA last month took this point one step further by asserting that narratives deployed to support evidence-based guidelines should include not only patients’ stories, but the story of the guideline developers themselves:

“Typically, experts present a “clean” version of their findings without any narrative about how they made sense of the data. This fulfills the scientific virtues of objectivity, coherence, and synthesis. When the USPSTF released its report on screening mammography to much controversy, it included no narrative about the process. Only later was the story of the task force deliberations revealed. This narrative, with multiple characters operating within the context of historical precedents, timing mandates, and a messy political milieu, created a substantially more compelling perspective. But the account came too late to engage a confused and angry public with the task force’s conclusions.”

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As Goes the Post Office, So Too Medicare?

With the announcement that the Center for Medicare and Medicaid Services (CMS) will begin auditing 100% of expensive cardiovascular and orthopedic procedures in certain states earlier this week, we see their final transformation from the beneficient health care funding bosom for seniors to health care rationer:

The Center for Medicare and Medicaid Services will require pre-payment audits on hospital stays for cardiac care, joint replacements and spinal fusion procedures, according to the American College of Cardiology in a letter to members. Shares in both industries fell with Tenet Healthcare Corp., the Dallas- based hospital operator, plunging 11 percent to $4.18, the most among Standard & Poor’s 500 stocks. Medtronic Inc., the largest U.S. maker of heart devices, dropped 6 percent to $34.61.

The program means hospitals won’t receive payment for stays that involve cardiac care or orthopedic treatment until auditors have examined the patient records and confirmed that the care was appropriate, Jerold Saef, the reimbursement chair for the Florida chapter of the American College of Cardiology, wrote in a Nov. 21 letter to members. The review process is expected to take 30 days to 60 days, beginning January 1, Saef said.

This is not at all unexpected. In fact, in our field of cardiac electrophysiology, we have known this day would be coming; our expensive, life-saving gadgets and gizmos are easy targets upon which the government can cut its rationing teeth. And so as it will go for us at first, and then for many other areas of health care.

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Using Medicare Data to Rate Physician Quality

Last week, the federal government announced that it would allow Medicare claims data to be used for the purpose of disseminating physician quality information to the public. What’s news is not that there will be attempts at creating so-called quality “report cards”–attempts at those have been around for some time–rather it’s that the Centers for Medicare & Medicaid Services (CMS) has finally agreed to let a wide range of folks access Medicare claims data for the purpose, which hasn’t happened before on this level.

But what are we to make of this new development? Is it a good thing or not? Giving the “consumer” more information on which to base their selection of a physician and their use of health care services seems like a good thing. After all, it’s essentially central to the idea of a well-functioning free market. As any health economist will tell you, the information asymmetry between consumers and providers leads to all sorts of peculiarities that cause the health care market not to behave like the market for other goods and services. This could then conceivably be a step in the direction of correcting some of those peculiarities.

The real question, though, is how good will this information be? Or, said another way, is poor information preferable to no information? Now, that doesn’t mean that there’s not a lot of excellent potential in these Medicare claims data. On the contrary, there’s much to be learned here. Of course, the realization of that potential is a function of the empirical rigor of the analyses researchers like myself undertake. No, the real worry I have is how this translates to the lay public without grossly oversimplifying things.

Let’s say a system is devised that, in true “report card” fashion, assigns physicians a grade ranging from “A” for outstanding to “F” for visit at your own risk. The public would certainly understand such a grading system, and people would be expected to show a clear preference for “A”-rated physicians over “F”-rated ones, but what about the bulk of physicians in the “B” and “C” range? It’s entirely possible, depending on the rating algorithm used, that a physician who excels in one particular area nevertheless gets a “C” rating. Would the public do its homework, or would it avoid doctor “C”? I worry that the latter may be the most likely outcome.

Again, I’m not saying that efforts to monitor quality and report that information publicly are a bad idea. Far from it. I’m merely suggesting that we must be extremely thoughtful in how we engage in such efforts, because the potential for significant unintended consequences is quite real. We must figure out how to approach these data using the most sophisticated of techniques, all the while with an eye on translating what we find in a manner that is accessible to the public without being “watered down” or less than accurate. The risks and the rewards are great.

D. Brad Wright is postdoctoral fellow at Brown University and  holds a PhD in health policy and management from the University of North Carolina.  He has worked as the Assistant Director of Health Policy for the Association of Clinicians for the Underserved. You can follow him at his blog Wright on Health where this post first appeared.

Why Smart People Don’t Learn from Failures

My ICSI colleague Claire Neely recently mentioned that the classic Chris Argyris article “Teaching Smart People How to Learn” had been an “aha” moment in her efforts to learn how to better teach and reach physicians. While I don’t think I have ever read that article, I had been impressed with Chris Argyris, especially his work with Donald Schoen.  Claire emailed me the article, and it really is a classic that needs to be read.

Originally copyrighted by the Harvard Business Review in 1991, Argyris’ article succinctly outlines the challenges we all face in a knowledge economy, and he concludes that learning is imperative for individual and organizational success in such a global marketplace.  People have to master technical skills, work effectively in teams, form productive relationships with clients, and critically reflect on and change their own organizational culture. Managers and leaders have to guide and integrate the autonomous but interconnected work of highly skilled people.

Argyris distinguishes between single loop and double loop learning.  “A thermostat that automatically turns on the heat whenever the temperature in a room drops below 68 degrees is a good example of single loop learning. A thermostat that could ask, ‘Why am I set at 68 degrees?’ and then explore whether or not some other temperature might more economically achieve the goal of heating the room would be engaging in double loop learning.”

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The Joy of Success

As the year ends, I’ve spoken to many CIOs.   2011 was a hard year filled with Meaningful Use (including many upgrades to certified systems or self-certification),  5010 (the deadline for upgrading billing systems is January 1, 2012), accelerating compliance demands,  new security threats, rapidly evolving technologies, and unprecedented demand for new projects driven by the consumerization of IT.

At the same time that CIOs and IT professionals are running marathons, they are being held accountable for events that are not directly under their control.   They are not being congratulated for the miracles they create every day, but are being criticized for not moving faster.

What do I mean?

One CIO received a negative audit report because new generations of viruses are no longer stopped by state of the art anti-virus software.   Interesting.  The CIO cannot control the virus authors, nor the effectiveness of anti-virus software.    No one in the industry has solved the problem, but audit firms revel in creating fear, uncertainty and doubt at the Board level as it enhances the reputation of the auditor.

Another CIO was held accountable for infrastructure demands that were not forecasted, planned, or communicated.   CIOs do their best to be proactive, but in the world of Big Data, past trends may not predict future needs.

Another CIO was was given 10 goals and 5 unplanned urgent projects.   She completed 8 of the planned goals and all the urgent projects, yet was told she only met 80% of expectations.

In a world that expects leaders to continuously perform miracles with constrained resources in limited time,  we all need to step back and take our own steps to stop the madness.

With your own staff, celebrate the joy of success and focus on what really matters.

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Food Safety: It’s Déjà Vu All Over Again

In preparation for the holiday season, Secretary of Health and Human Services Kathleen Sebelius and Agriculture Secretary Thomas Vilsack held a press conference to promote the departments’ efforts on food safety.

They announced release of the administration’s progress report from its Food Safety Working Group.

They also highlighted additional places to get government information about food safety at home:

I didn’t pay much attention to these announcements until I read the slightly snarky account in Food Chemical News (December 22).

The Obama administration patted itself on the back today with a new report that both lists the accomplishments over the past three years of its Food Safety Working Group (FSWG) and identifies the group’s top priorities for the coming year.

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Our Cancer Journey – Week 2

It’s been two weeks since my wife said “I have cancer” to my daughter.

It’s been a week since we described our workup thus far on my blog.

Reaction to our blog post was diverse, ranging from the HISTalk blog to the Boston Globe.

It’s a time of anxiety and unanswered questions.   The diagnosis and staging phase has been described as one of the two major tension points in  cancer.   The other is the time after remission, when the worry about recurrence is a constant burden.  One of our doctors recommended we keep a “family bottle” of anti-anxiety medication ready for those times when the stress exceeds our capacity to cope.   Cancer is truly a family disease and the emotional impact extends from the patient to family caregivers.

Many friends and colleagues have offered prayers and support.   A few have lamented that care coordinated by a physician-husband at a Harvard-associated hospital in Boston lacks equity since every wife/mother/daughter may not receive the same care throughout the US.  Kathy and I agree.   We posted these comments in response to those who speculated that Kathy’s care consumes an asymmetric amount of healthcare resources.

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