It’s time to toss the whole business-as-usual model — for your own good and the good of your customers.
The emerging Default Model of health care — the “consumer-directed” insured fee-for-service model in which health plans compete to lower premiums by bargaining providers into narrow networks — not only does not work for health care’s customers, it cannot work. This is not because we are doing it wrong or being sloppy. By its very nature the Default Model must continually fail to bring our customers what they want and desperately need. Ultimately it cannot bring you, the providers, what you want and need.
Take a dive with me into the real-world game-theory mechanics of the health care economy, and you will see why. It’s time to rebuild the fundamental business models of health care.
The janitor approached my office manager with a very worried expression. “Uh, Brenda…” he said, hesitantly.
“Yes?” she replied, wondering what janitorial emergency was looming in her near future.
“Uh…well…I was cleaning Dr. Lamberts’ office yesterday and I noticed on his computer….” He cleared his throat nervously, “Uh…his computer had something on it.”
“Something on his computer? You mean on top of the computer, or on the screen?” she asked, growing more curious.
“On the screen. It said something about an ‘illegal operation.’ I was worried that he had done something illegal and thought you should know,” he finished rapidly, seeming grateful that this huge weight lifted.
Relieved, Brenda laughed out loud, reassuring him that this “illegal operation” was not the kind of thing that would warrant police intervention.
Unfortunately for me, these “illegal operation” errors weren’t without consequence. It turned out that our system had something wrong at its core, eventually causing our entire computer network to crash, giving us no access to patient records for several days.
The reality of computer errors is that the deeper the error is — the closer it is to the core of the operating system — the wider the consequences when it causes trouble. That’s when the “blue screen of death” or (on a mac) the “beach ball of death” show up on our screens. That’s when the “illegal operation” progresses to a “fatal error.”
The Fatal Error in Health Care
Yeah, this makes me nervous too.
We have such an error in our health care system. It’s absolutely central to nearly all care that is given, at the very heart of the operating system. It’s a problem that increased access to care won’t fix, that repealing the SGR, or forestalling ICD-10 won’t help.
It’s a problem with something that is starts at the very beginning of health care itself.
At HIMSS 2014, the health information technology’s (HIT) largest annual confab, the bestest-best news we heard from a policy perspective, and maybe even an industry perspective, was the Centers for Medicare & Medicaid Services’ (CMS) dual announcement that there will be no further delays for either Meaningful Use Stage 2 (MU-2) or ICD-10.
Perhaps we should have immediately directed our gaze skyward in search of the second shoe preparing to drop.
As it turns out, CMS de facto back-doored an MU-2 delay by issuing broad “hardship” exemptions from scheduled MU-2 penalties. To wit: any provider whose health IT vendor is unprepared to meet MU-2 deadlines, established lo these many months ago, is eligible for a “hardship” exemption.
Few would disagree with the notion that it’s unproductive to criticize policy without offering constructive ideas to fix the underlying problems.
Here, the underlying problem is easy to define: it is in point of irrefutable fact fundamentally unfair to penalize care providers for their vendors’ failings—especially when the very government proposing to penalize them put its seal of approval on the vendors’ foreheads to begin with.
CMS’s move to exempt providers from those penalties is correctly motivated, but it seeks to ease the provider pain without addressing its cause.
Instead of issuing a blanket exemption for use of unprepared vendors, CMS should:
Waive penalties only for those providers who take steps to replace their inferior technologies with systems that can meet the demands of the 21st century’s information economy;
Publish lists of health IT vendors whose systems are the basis for a hardship exemption, along with an accounting of how many of those 21 billion dollars have been paid to subsidize those vendors’ products; and
Immediately initiate a reevaluation of the MU certification of any vendor whose products form the basis for a hardship exemption.
This proposal might seem bold, but if we’re truly looking to advance health care through the application and use of EHR, then what I’ve outlined above simply represents necessary and sound public policy. Current practice rewards vendors whose products are falling short by perpetuating subsidies for those products.
The federal government should stop paying doctors to implement health IT that cannot meet the standards of the program under which the payments are issued. That’s just a no-brainer.
An EHR should not be a federally-subsidized “hardship.”
We argue that a strategy that capitalizes on “small wins” is most effective. This approach allows for the creation of steady momentum by first convincing workers they can improve, and then picking some easily obtainable objectives to provide evidence of improvement.
National Quality Improvement Initiatives
Our qualitative team is participating in two large ongoing national quality improvement initiatives, funded by the Agency for Healthcare Research and Quality (AHRQ). Each initiative targets a single HAC and its reduction in participating hospitals.
We have visited hospital sites across six states in order to understand why QI initiatives achieve their goals in some settings but not others.
To date, we have conducted over 150 interviews with hospital workers ranging from frontline staff in operating rooms and intensive care units to hospital administrators and executive leadership. In interviews for this ethnographic research, one of our interviewees warned us about unrealistic expectations for change: “You cannot go from imperfect to perfect. It’s a slow process.”
Chicago Cubs fans of a certain vintage will never forget broadcaster Harry Carey’s signature line, “Holy cow!” Some have speculated that the exclamation may have originated in Hinduism, one of the world’s major religions, whose adherents worldwide number approximately one billion. Hindus regard cows as maternal, caring figures, symbols of selfless giving in the form of milk, curds, butter, and other important products.
One of the most important figures in the faith, Krishna, is said to have been a cowherd, and one of his names, Govinda, means protector of cows. In short, cows are sacred to Hindus, and their slaughter is banned in virtually all Indian states.
Medicine, too, has its sacred cows, which are well known to physicians, nurses, and patients visited by medical teams on their hospital rounds. In this case, the cow is not an animal but a machine. In particular, it is the computer on wheels, or COW, a contraption that usually consists of a laptop computer mounted on a height-adjustable pole with a rolling base. It is used to enter, store and retrieve medical information, including patients’ diagnoses, vital signs, medications, and laboratory results, as well as to record new orders.
As the team moves from room to room and floor to floor, the COW is pushed right along. The COW is often treated with a degree of deference seemingly bordering on reverence. For one thing, people in hallways and patients’ rooms are constantly making way for the COW. As an expensive and essential piece of equipment, it is handled gingerly. Often only the senior member of the medical team or his or her lieutenant touches the COW.
Others know that they have said something important when they see the chief keyboarding the information into the COW. Sometimes it plays an almost oracular role. When questions arise to which no one knows the answer, such as the date of a patient’s admission or the time course of a fever, they often consult the COW. Just as cows wandering the streets of Indian cities often obstruct traffic, so healthcare’s COWS can and often do get in the way of good medicine. Continue reading…
In a world increasingly dominated by social media, doctors are becoming more concerned about managing their online reputations. Some doctors have even resorted to making their patients sign a gag order before treatment. Despite all the controversy, medical professionals need not fear online reviews: sites like Yahoo! Local and Insider Pages show that the majority of patients rate their doctors 5 out of 5.
About four years ago here in Beantown, survivors of the last big ill-conceived or poorly-executed (depends who you ask) wave of health care management and finance innovation were kicking around for a new approach to aligning payor and provider incentives, focusing on quality and cost containment. To hear Andrew Dreyfus, CEO of Blue Cross Blue Shield of Massachusetts, tell the story, the Blues wanted to address both quality and cost, and therefore (after looking in vain for a model elsewhere that could be transplanted to Massachusetts) developed the Alternative Quality Contract, or AQC, which features a global payment model hybridized with substantial performance incentives, plus design features intended to lower the cost of care over time.
Many of the features put in place under the AQC will allow participating provider networks in Massachsuetts to make the leap to ACO (once the beast is defined by the federales), despite the difference in payment methodology (global cap for AQC vs. FFS for ACO).
I was invited to hear Andrew present the AQC story this week together with Gene Lindsey, CEO of Atrius Health, a Massachusetts multispecialty physician network of some 700 physicians that participates in the AQC. (Atrius’ largest group is Harvard Vanguard Medical Associates, whose docs used to be employed by Harvard Community Health Plan, the pioneering staff model HMO ’round these parts.)Continue reading…