Some years back I was mortified to realize that it would be all-but-impossible to fix health care without first fixing America’s patronage system, that puts virtually all policy up for sale to the highest bidder. In 2006, American corporations spent $2.5 billion lobbying Congress, nearly $5 million per Senator and Congressional representative. More than $350 million of that figure came from the health care sector, and half of that ($180 million) came came from the drug, device and supply industries. All this information is handily cataloged at the excellent site, www.opensecrets.org.
A couple weeks ago I published a letter in the New York Times – yes, I was astounded too – arguing that we won’t have health care reform until the leaders of the non-health care business community come together and roll over the health care industry.
Now, the always astute Greg Pawelski brought my attention to a superb Bill Moyers presentation, describing a parallel problem. America’s financial sector leverages its strength to take huge amounts of capital out of the system, without providing much in the way of value. The message is delivered by John Bogle, who created The Vanguard Group. Here’s the background:John Bogle, 77, created The Vanguard Group, Inc., in 1974, which today
is one of the two largest mutual fund organizations in the world, and
was was the first index mutual fund. He retired as Chairman and Chief
Executive Officer of the fund in 1996, yet remained Senior Chairman
Bogle explains the broader implications of The Carlyle Group’s buyout of Manor Care Nursing Homes. More and more, Wall Street is taking control of corporations, making Main Street pay the price, and making health care less attainable. The financial sector – banks, money managers, insurance companies, and certainly annuity providers – takes $560 billion a year out of society. They all subtract value from the economy.
Read Mr. Bogle’s recent article in DAEDALUS, "Democracy in Corporate America."
Take the time to watch this worthwhile piece and possibly to read Mr. Bogle’s lucid article. All the stuff we talk about on this and related sites are moot unless we understand and ultimately address these deep cancers on our system.
Last week, Jeff Goldsmith, who enjoys a reputation as one of health care’s more thoughtful commentators and advisors, wrote a curious post on this site. He puzzled over Kaiser Family Foundation Chairman Drew Altman’s failure to gush that the 2007 health care inflation rate had moderated to 6.1%, down from 13.9% in 2003. While acknowledging that, yes, the drop in inflation is likely a low point in a larger cycle, he noted that, on an $800 billion base, the drop in premium growth freed up some $62 billion in capital for American business, funds that might be applied to better purpose.
Jeff theorizes that
cost sharing has, over a number of years, compelled families to be more
careful about their use of health services."
And he points to other influences that might have contributed to cost declines, including
"soggy admissions growth for hospitals, the
plummeting demand for expensive heart care (and the reduction in heart
attack admissions to hospitals), record low rates of prescription
drug cost growth, which stem from the explosion in generic drug options," and declines in nursing home census [on the public financing side].
He chides the health care community’s Chicken Littles who, presumably, live in an alternative reality, sit around hand-wringing, repeating "Ain’t it awful," but don’t get that this drop in explosive cost growth is really a sign of how many improvements there are in the system’s function. He says, as though confident that he’s dispensing wisdom,
"Sometimes it seems like it’s the only
game in town. If you want to see moderating health
costs as a problem, and are creative enough, you can think of reasons
why this is bad. And how helpful is that?"
I’m sure I don’t really get the deeper issues involved here, but sometimes its hard to not have your breath taken away by some people’s notion of a good idea. Maybe its because I’m not a true geek, but what I’m about to describe strikes me about the same way I feel as when I see a young adult with multiple facial piercings and hear her/him say "Aren’t these great!?"
Modern Healthcare has an interesting piece on a report that was developed by RTI, a contractor to HHS’ Office of the National Coordinator for Health Information Technology (ONCHIT). The report urges revising Electronic Medical Records (EMR) standards to make it easier for payers and the feds to access the records and spot fraud.
Now I’m as big a transparency advocate as the next guy, and I routinely explain to doctors how claims or clinical encounter data can be used to accurately rate their pricing and performance relative to peers within specialty. I believe we should use performance ratings to reward the high performers and to incent the poor ones to do better.
But to really get to the system we need, doctors first have to implement and use EMRs. They’re key to making the health system as a whole work better. Fewer than a quarter of physicians currently use them at this point. While there are still some buggy whip advocates out there, a large and growing number of doctors get that. Young physicians take it for granted.
Still, there are a lot of hurdles to installing an EMR system. They’re expensive. They force you to change your practice’s work flows. Some of the designs aren’t all that friendly. They’re complicated. And who wants to learn a new system. Heck, I know I’d like what it can do for me, but I haven’t gotten up the nerve to tackle iMovie yet on my Mac, and that’s about a tenth as complicated as an EMR with embedded practice guidelines.
We KNOW EMRs are a good idea but there are lots of reasons for doctors to say NOT YET. This Administration, to its credit (he said, grudgingly) has gloried in their advocacy for these new
technologies, what they can do, and how they can help improve quality and cost. (Remember Newt’s
line, "Paper Kills?")
So WHY would the guys leading the charge on EMRs announce that one of the really great things to use EMRs for when doctors finally bring them online is to WATCH AND CONTROL THEM MORE EFFECTIVELY.
Dumb, dumb, dumb.
But I’m sure I don’t see the big picture here.
Thomas Wilson PhD is on a mission that’s important to health care. Tom, a respected epidemiologist particularly well-known in disease management circles, founded the Population Health Impact Institute (PHII), a not-for-profit devoted to establishing clear, objective rules to evaluate claims of financial and clinical improvement associated with health management programs.
In an August 16th press release, PHII announced its intention to develop a new accreditation program that
“will focus on the methods behind the claims. It will be based on the established evaluation principles of transparency and scientific validity successfully used by the PHII since its founding in 2004:
- Transparency of metrics,
- Equivalence of populations,
- Statistical significance of measures,
- Plausibility of hypotheses, and
- Disclosures of potential conflicts-of-interest.”
This isn’t a lightweight effort. To oversee the development of their "Quality Evaluation Process” (QEP) standards will be developed by a volunteer panel of national experts, and chaired by former URAC President and CEO Garry Carneal, who oversaw the development of 16 new accreditation programs during his tenure with that quality accreditation organization.
PHII also boasts the participation and support of Sean Sullivan, the CEO of the not-for-profit large employer group, The Institute for Health and Productivity Management. Sean has been an extremely balanced and important voice on health care reform. His group argues that it is in employers’ interests to stabilize and improve health care quality and costs, because employees and families with good health care produce are far more productive. The opposite is true as well.
PHII is looking for expert volunteers for its standards panel. Visit the site of this important effort and consider whether you or your organization might have a way to contribute expertise, financial resources or both.
By way of disclosure, I sit on PHII’s Steering Committee.
I sit on the Dean’s Advisory Councils of the Colleges of Health at two public universities in Florida. Both Colleges are led by extremely capable PhD nurses, and have a variety of programs that train students to be health professionals, including nurses.
A few months ago, I was startled when one of the Deans mentioned that
her Nursing program had 500 qualified applicants for 132 student slots.
In other words, at a time when the market wants her to gear up, she
turns away 3 qualified applicants for each one she accepts. As it turns
out, it’s a national problem. In 2006, Colleges of Nursing turned away 43,000 qualified applicants.
It’s not news that health care institutions face a critical nursing shortage. An April 2006 AHA report estimated that American hospitals currently need 118,000 RNs to fill vacancies. That number is expected to triple by 2020, to 340,000 vacancies.
An innovative Ft. Worth consulting firm comprised of experienced oncology professionals, Oncology Metrics, has linked private oncology practices throughout the country in a collaborative, knowledge-sharing enterprise, called the Oncology Circle. The first round of information brought together 22 practices containing 167 medical oncologists. Combined, the practices treated almost 63,000 patients annually, had $600 million in revenues and spent $375 million on drugs.
In a separate but related effort, Oncology Metrics has established a new national data aggregation effort, The Oncology Metrics National Index (OMNI), which brings together data from practices using electronic medical records (EMRs), mapping the data in each EMR to a standard template. Then those data are aggregated and mined to produce different cancer care-related clinical measures associated with procedures and processes: e.g., the administration of erythropoietin (anemia drugs), hemoglobin (Hgb) testing, and patient staging. A primary goal is to create a data mine that can allow each practice to see how it compares to others, and how they might improve. But a secondary and also very important objective is the development of transparency information that can help rationalize the practices and costs that have dominated oncology.
This is a leading edge project that leverages the data that is newly available through EMRs, and that is indicative of the kind of progress that we can anticipate throughout health care in the next few years. Clearly a company to watch.
Over at The Doctor Weighs In, Bill Bestermann literally grabs our attention and forces feeds us a highly informative, and, dare I say, USEFUL physiology lesson in If You Want To Get It Up – You’ve Got To Get It Down. The subject is the one topic that men (and the women who care about men) really care about: erections. That’s right. Ever thought that even you (or your male partner), burly, strapping man among men, could be afflicted with erectile dysfunction? Get the skinny on the why, what it means and what to do about it from Dr. B. In the process, you’ll get a glimpse of the Marlboro Man and learn some fascinating background on how Viagra came about.
In the comment section of my post on broker compensation, KWeller properly points out that 1) some states regulate broker commissions more stringently than Florida does and 2) I do a disservice to brokers who practice without financial conflict. He is right, and I apologize to anyone whose practice is at odds with my description.
On the other hand, as several other commenters noted, the practices I described are well-known and widespread, and they occur because the brokerage profession does not self-regulate very effectively. (If it makes anybody feel better – it shouldn’t – neither do many other groups of health care professionals.)
So if you’re not one of the broker’s I was referring to, please excuse me then for pointing to the poor behavior of your colleagues. I wouldn’t have tarred you with the same brush if you had held your fellow brokers to a higher standard of practice.
We must view and treat the community as the "owner" to whom we are fully accountable. Aggregate financial performance data, aggregate productivity performance and aggregate quality and patient satisfaction data belong in the public realm. How else can consumers make a decision to…support us?
— Rich Umbdenstock, President and CEOAmerican Hospital AssociationInterview in Hospitals and Health Networks, 10/18/04
Most health care professionals sincerely believe in performance transparency, especially if it applies to someone else. Three years after the encouragement of Mr. Umbdenstock and similar pronouncements by colleagues throughout the industry, many physicians, health plan executives and hospitals executives remain extremely resistant to public reporting of pricing and performance.
Norton Healthcare in Louisville KY has developed one of the most progressive and forthright quality reporting efforts in the country. On their site, they provide their performance figures on a range of indices, indicating where they fall above or below national benchmarks. (You can just imagine how thrilled their staffs were with this decision to "bare all." ) The home page for their quality section lists six principals that drive their reporting.
1. We do not decide what to make public based on how it makes us look.
2. We give equal prominence to good and bad results.
3. We do not choose which indicators to display.
4. We are not the indicator owner.
5. We display results even when we disagree with the indicator definition.
6. We believe unused data never become valid.
Norton sets a fine example for hospitals. But now, as demands for transparency become more compelling, the mega-consulting firms, always quick to lead the way and claim credit once a trend has been firmly established, are throwing their hats into the ring as well, hoping to provide guidance for tidy if exorbitant sums.
And so it is not surprising that the consulting firm Grant Thornton, in its spring newsletter Health Care Rx, has a thoughtful, pragmatic article urging hospitals to review and potentially change their pricing, document justifications when necessary, and generally take steps to ensure that they’re prepared as transparency efforts become irresistible. Its a good piece and, for hospital execs, well worth a few minutes time.
Professor Michele Mello, an expert on the health care justice system at the Harvard School of Public Health, has an interesting 9.5 minute audio podcast on why health courts would be an improvement over the current medical liability system. The development of her health court proposal was funded jointly by The Robert Wood Johnson Foundation and Common Good.