As Chair of the Walden University Dissertation Committee for Sara Geale, Ph.D..I am pleased to share this very brief SUMMARY prepared by Dr. Geale that describes her timely research. My thanks to her for sharing this Summary. Questions or comments may be directed to her at sara.geale@waldenu.edu or sara.geale@aramco.com
Robert E. Hoye, Ph.D.
Summary
A Case Study of a Modular Logistical Systems Approach to
Community Disaster Response
Background
One of the most basic problems with disaster management is the organization and distribution of supplies (Hogan & Burstein, 2007). The shortage of supplies may lead to a situation in which the emergency response is ineffective, and the result is increased human suffering, morbidity, and mortality. Emergency responders agree that it is important to develop strategies to accelerate supply response to deal with unpredictability of demand (Ergun, Karkus, Keskinoca, Swann, & Villarreal, 2010). Supply needs in a disaster situation change significantly according to the type and the phase of the disaster. The supply and demand structure is both complicated and challenging because of the highly unpredictable nature of the time, location, and magnitude. Logistics planning in emergency medical situations involves dispatching needed commodities to the affected areas in a manner that ensures the right resources get to the right places at the right time.
Problem Statement
The problem addressed was how an emergency medical services (EMS) division of a health care organization can best use a logistical or supply management system to meet the changing response needs of multiple-victim emergencies and disasters.
Methodology
A case study was conducted to describe the development of a modular systems approach to community disaster response. Emergency medical responders who were participants in this study identified and discussed a problem in the supply of and dispatch of disaster medical supplies to the scene of an event in a timely, cost-effective manner. A list of likely supplies was compiled and a trial-and-error process used to determine how many patients could be treated with the supplies in a bag that could be easily pulled by one person and lifted into and out of the back of an emergency vehicle. Descriptive case study methodology was used to evaluate the system and consider its effectiveness in the realm within which it operates. The study also considered generalizability of the system to other emergency medical responders.
Results
The results of this case study illustrated that victims of disaster, as well as the responding medical team, benefit from the significantly increased efficiency of the preparedness of the system. Responses can address nearly every contingency and treat a variety of medical emergencies. The system can meet the needs of trauma caused by a variety of disasters and can be scaled up or down to meet the changing needs of the scenario. The system enables greater efficiency for addressing human needs and is structured to efficiently accommodate ongoing refinements.
Conclusion
With disasters on the increase globally, it is important that communities everywhere prepare for them. EMS has long recognized systems in place to deal with day to day emergencies. Disasters, however, overwhelm those established systems. Disaster from a medical perspective is an imbalance of supply and demand. EMS must have systems and process in place that can deal with this imbalance (Auf Der Heide, 2007; Hogan & Burstein, 2007; Perry & Quarantelli, 2005). The modular color-coded bag system is part of planning and preparation for disasters. It is part of the system approach to the management of disasters. Findings showed that prepacking of medical supplies in modular containers for rapid transfer to multiple victim emergencies could increase the effectiveness of the EMS. The implications for positive social change are that a systems approach to disaster management has the potential to reduce morbidity and mortality through effective disaster response at the community level.
References
Auf Der Heide, E. (2007). Disaster response planning and coordination. In D. E. Hogan & J. L. Burstein (Eds.), Disaster Medicine (pp. 95-126). Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins.
Ergun, O., Karkus, G., Keskinoca, P., Swann, J., & Villarreal, M. (2010). Operations research to improve disaster supply chain management. Retrieved from http://eu.wiley.com
Hogan, D. E., & Burstein, J. L. (2007). Basic perspectives on disaster. In D. E. Hogan & J. L. Burstein (Eds.), Disaster medicine (pp. 1-11). Philadelphia, PA: Lippincott, Williams & Wilkins.
Perry, R. W., & Quarantelli, E. L. (2005). Foreword. In R. W. Perry & E. L. Quarantelli (Eds.). What is a disaster? New answers to old questions (pp. 13-18). Bloomington, IN: Xlibris.
Sunday, December 19, 2010
Monday, December 6, 2010
Principles & Practices of Home Health, Edited by John S. Spratt, MD, Robert E. Hoye, Ph.D. & Rhonda Hawley
Home Health Care: Principles and Practices (CRC Press), Hardcover (1996)
by John Spratt, Robert Hoye, Rhonda Hawley
Hardcover, CRC Press
1996
English
ISBN: 188401593X
ISBN-13: 9781884015939
Twenty-nine practitioners combine their expertise to bring clarity to an issue that is at the forefront of discussion-home health care.The field is emerging and is growing faster than most professionals and their patients can keep up with. Here is a text in which the authors make every effort to provide readers with the latest thinking and technology that can better the home health care field. Spiraling costs have forced all aspects of illnesses to be closely scrutinized for possible home care applications and financial savings.The industry is growing rapidly, fueled by increasing service and constant technological breakthroughs, but the overriding philosophy must be focused on cost containment with maintenance of high quality care. This book is directed at providing highly practical, up-to-date information that health care professionals can use in their daily practices.
by John Spratt, Robert Hoye, Rhonda Hawley
Hardcover, CRC Press
1996
English
ISBN: 188401593X
ISBN-13: 9781884015939
Twenty-nine practitioners combine their expertise to bring clarity to an issue that is at the forefront of discussion-home health care.The field is emerging and is growing faster than most professionals and their patients can keep up with. Here is a text in which the authors make every effort to provide readers with the latest thinking and technology that can better the home health care field. Spiraling costs have forced all aspects of illnesses to be closely scrutinized for possible home care applications and financial savings.The industry is growing rapidly, fueled by increasing service and constant technological breakthroughs, but the overriding philosophy must be focused on cost containment with maintenance of high quality care. This book is directed at providing highly practical, up-to-date information that health care professionals can use in their daily practices.
Sunday, December 5, 2010
Number of U.S. residents without health insurance at new high
FOR YOUR RESEARCH... From the Kaiser Health News: September 16, 2010
Number of U.S. residents without health insurance at new high
A reflection of the weak economy, experts say
By Phil Galewitz, Andrew Villegas
Thursday, September 16, 2010
WASHINGTON, D.C. — In a reflection of the battered economy, the number of people without health insurance rose sharply last year to 50.7 million — an all time high — according to data released Thursday by the Census Bureau.
That pushed the rate of uninsured Americans to 16.7 percent last year from 15.4 percent in 2008, when there were 46.3 million uninsured. It was one of the largest single year increases since the Census starting tracking the figure in 1987.
Nearly every demographic and geographic group posted a rise in the uninsured rate — with the exception of children, who remained stable at about 10 percent. The sharpest jumps were in the Midwest and South, although all areas of the country saw increases.
Jim McLean’s KPR report on the increase in uninsured Kansans
"In a word this is devastating," said Jonathan Oberlander, professor of social medicine and health policy at the University of North Carolina-Chapel Hill.
Both Democrats and Republicans hoped to gain public support from the new figures. The surge in the uninsured could help Democrats gain more support for the new health overhaul law because it underscores the need for dramatically changing the health system. But at the same time, Republicans calling for repeal of that law can use the report to blame Democrats for failing to fix the economy.
"Though not surprising, the uninsured numbers do indicate the role of the dismal economy," said Joseph Antos, a health policy expert from the conservative American Enterprise Institute. "Health insurance is really secondary to the economy."
Although in the short term the report could hurt Democrats, the higher number of uninsured should make it harder for Republicans to talk about repealing the health law, said Oberlander.
"From a political standpoint," he said, "the report makes the administration's and Democrats' point that the status quo is not sustainable and underscores why you needed to do something to stabilize insurance."
The health law approved in March mandates that nearly all Americans have health insurance. It would provide coverage to 32 million more Americans starting in 2014 as the state-federal Medicaid program is expanded and lower-income people get government subsidies to buy coverage through new insurance exchanges or marketplaces.
The jump in uninsured last year reflects the worsening recession, which started in 2008 but ravaged the economy in 2009. The unemployment rate rose to 9.3 percent in 2009 from 5.8 percent in 2008.
"A lot of it is due to changes in people's employment status as people moved from full time to part time and from working to not working," said David Johnson, chief of the housing and household economic statistics division at the Census Bureau.
Analysts said they were not surprised by the big increase in uninsured.
"We've reached yet another milestone in the number of uninsured," said Peter Cunningham, senior fellow at the Center for Studying Health System Change, an independent, nonpartisan think tank. "It's not surprising because it's being driven almost entirely by a big drop in people with private coverage and employer-sponsored coverage."
The percentage of people covered by employer-sponsored coverage dropped to 55.8 percent last year from 58.5 percent in 2008.
The Census report showed there were 43.6 million people in poverty in 2009, up from 39.8 million in 2008 — the third consecutive annual increase.
"The numbers are heartbreaking," said Sara Rosenbaum, a professor of health law and policy at George Washington University. "If we needed any more evidence of the absolute imperative of health reform, this is it."
Indeed, the reliance in America on an employer-based delivery system for health coverage means that the population is susceptible to such explosions of the number of uninsured when unemployment increases, Rosenbaum added. Often, Medicaid — meant to provide coverage for the nation's poor — can't cover many of these newly uninsured, she explained, because strict qualifications exclude many middle class families who lose their jobs and take unemployment benefits.
And it may not get better anytime soon. Rosenbaum said that there will probably be at least one more year with "terrible" health insurance numbers as the economy lags and employers continue to lay workers off.
The report also found that nearly a third of Americans — about 93 million — are now covered by government insurance, mainly Medicare and Medicaid. While the numbers of people on Medicare remains stable, the percentage of people covered by Medicaid, the federal-state program for people with low incomes, rose from to 15.7 percent of Americans from 14.1 percent. Nearly 48 million Americans are in Medicaid programs.
Given the sharp divide in public opinion of the new health law, many Democrats have been reluctant to talk about the health law on the campaign trail. That probably won't change, even with these new figures, said Ross Baker, a professor of political science at Rutgers University.
"They're not going to go back to it. If they've run [from the new law in their campaigns] they're not going to pull a U-turn and embrace it." And voters, Baker said, are unlikely to be more receptive to health reform now because they still simply don't understand what it means for them.
Indeed, the other danger for Democrats going into November's midterm elections is that "any bad stat is going to reflect poorly on the incumbent," Baker said.
Amber Hergen, 34, of Los Angeles, is one of those Americans who lost coverage last year. She left her publicity job at a marketing company, where she had insurance, to pursue her dream of becoming an actress. She's been unable to find affordable individual coverage.
She learned the risk of being uninsured last month when she went to the emergency room after accidentally ingesting a household cleaner. Though she was at the hospital less than an hour, her bill was $2,500.
"Being without insurance is kind of like walking on a tightrope without a net," she said. "It's scary."
Kaiser Health News (KHN) is a nonprofit news organization committed to in-depth coverage of health care policy and politics. The Washington, D.C.-based news service is a partner of KHI News Service.
Number of U.S. residents without health insurance at new high
A reflection of the weak economy, experts say
By Phil Galewitz, Andrew Villegas
Thursday, September 16, 2010
WASHINGTON, D.C. — In a reflection of the battered economy, the number of people without health insurance rose sharply last year to 50.7 million — an all time high — according to data released Thursday by the Census Bureau.
That pushed the rate of uninsured Americans to 16.7 percent last year from 15.4 percent in 2008, when there were 46.3 million uninsured. It was one of the largest single year increases since the Census starting tracking the figure in 1987.
Nearly every demographic and geographic group posted a rise in the uninsured rate — with the exception of children, who remained stable at about 10 percent. The sharpest jumps were in the Midwest and South, although all areas of the country saw increases.
Jim McLean’s KPR report on the increase in uninsured Kansans
"In a word this is devastating," said Jonathan Oberlander, professor of social medicine and health policy at the University of North Carolina-Chapel Hill.
Both Democrats and Republicans hoped to gain public support from the new figures. The surge in the uninsured could help Democrats gain more support for the new health overhaul law because it underscores the need for dramatically changing the health system. But at the same time, Republicans calling for repeal of that law can use the report to blame Democrats for failing to fix the economy.
"Though not surprising, the uninsured numbers do indicate the role of the dismal economy," said Joseph Antos, a health policy expert from the conservative American Enterprise Institute. "Health insurance is really secondary to the economy."
Although in the short term the report could hurt Democrats, the higher number of uninsured should make it harder for Republicans to talk about repealing the health law, said Oberlander.
"From a political standpoint," he said, "the report makes the administration's and Democrats' point that the status quo is not sustainable and underscores why you needed to do something to stabilize insurance."
The health law approved in March mandates that nearly all Americans have health insurance. It would provide coverage to 32 million more Americans starting in 2014 as the state-federal Medicaid program is expanded and lower-income people get government subsidies to buy coverage through new insurance exchanges or marketplaces.
The jump in uninsured last year reflects the worsening recession, which started in 2008 but ravaged the economy in 2009. The unemployment rate rose to 9.3 percent in 2009 from 5.8 percent in 2008.
"A lot of it is due to changes in people's employment status as people moved from full time to part time and from working to not working," said David Johnson, chief of the housing and household economic statistics division at the Census Bureau.
Analysts said they were not surprised by the big increase in uninsured.
"We've reached yet another milestone in the number of uninsured," said Peter Cunningham, senior fellow at the Center for Studying Health System Change, an independent, nonpartisan think tank. "It's not surprising because it's being driven almost entirely by a big drop in people with private coverage and employer-sponsored coverage."
The percentage of people covered by employer-sponsored coverage dropped to 55.8 percent last year from 58.5 percent in 2008.
The Census report showed there were 43.6 million people in poverty in 2009, up from 39.8 million in 2008 — the third consecutive annual increase.
"The numbers are heartbreaking," said Sara Rosenbaum, a professor of health law and policy at George Washington University. "If we needed any more evidence of the absolute imperative of health reform, this is it."
Indeed, the reliance in America on an employer-based delivery system for health coverage means that the population is susceptible to such explosions of the number of uninsured when unemployment increases, Rosenbaum added. Often, Medicaid — meant to provide coverage for the nation's poor — can't cover many of these newly uninsured, she explained, because strict qualifications exclude many middle class families who lose their jobs and take unemployment benefits.
And it may not get better anytime soon. Rosenbaum said that there will probably be at least one more year with "terrible" health insurance numbers as the economy lags and employers continue to lay workers off.
The report also found that nearly a third of Americans — about 93 million — are now covered by government insurance, mainly Medicare and Medicaid. While the numbers of people on Medicare remains stable, the percentage of people covered by Medicaid, the federal-state program for people with low incomes, rose from to 15.7 percent of Americans from 14.1 percent. Nearly 48 million Americans are in Medicaid programs.
Given the sharp divide in public opinion of the new health law, many Democrats have been reluctant to talk about the health law on the campaign trail. That probably won't change, even with these new figures, said Ross Baker, a professor of political science at Rutgers University.
"They're not going to go back to it. If they've run [from the new law in their campaigns] they're not going to pull a U-turn and embrace it." And voters, Baker said, are unlikely to be more receptive to health reform now because they still simply don't understand what it means for them.
Indeed, the other danger for Democrats going into November's midterm elections is that "any bad stat is going to reflect poorly on the incumbent," Baker said.
Amber Hergen, 34, of Los Angeles, is one of those Americans who lost coverage last year. She left her publicity job at a marketing company, where she had insurance, to pursue her dream of becoming an actress. She's been unable to find affordable individual coverage.
She learned the risk of being uninsured last month when she went to the emergency room after accidentally ingesting a household cleaner. Though she was at the hospital less than an hour, her bill was $2,500.
"Being without insurance is kind of like walking on a tightrope without a net," she said. "It's scary."
Kaiser Health News (KHN) is a nonprofit news organization committed to in-depth coverage of health care policy and politics. The Washington, D.C.-based news service is a partner of KHI News Service.
Tuesday, November 30, 2010
The Problem with Free Market Health Care
The Problem with Free Market Health Care
By Joe Flower
The right payment structure keeps patients healthy while saving money.
Complete credit is given to the author... Joe Flower... for this insightful article.
Joe Flower is a health care futurist, speaker and founder of Imagine What If, a service of the education firm The Change Project Inc. Flower is also a regular contributor to H&HN Weekly and a member of Health Forum's Forum Faculty Speaker Service.
This article 1st appeared on November 29, 2010 in HHN Magazine online site.
We want health care to be abundant, effective, easy and cheap; for too many of us, too much of the time, it is scarce, ineffective and maddeningly difficult. For all of us, it is far too expensive. Why? How did we get in this mess? How do we end up paying so much for health care and not getting what we want?
It's a big question, and it's at the core of the mess we are in. The convoluted way we pay for health care in the United States gives too many patients treatments they don't need, or treats them for conditions that could have been prevented with much cheaper care, or denies patients services they need. How does this happen?
To answer this question, we have to dig into the actual structures of health care and some of the basics of economics. And in that answer we can begin to see how we need to rebuild those very structures to survive and thrive beyond reform.
Why Doesn't Competition Seem to Work in Health Care?
There certainly seems to be plenty of competition. For example, there are:
thousands of hospitals of different types (for-profit and nonprofit, freestanding and chain, general and specialty, teaching, children's, public and private, military and veterans);
hundreds of thousands of doctors in specialties organized every way you could imagine (solo practice, small practice, large multispecialty practice, working for hospitals and health systems, running their own centers, in cooperatives like Group Health of Puget Sound and staff-model HMOs like Kaiser);
hundreds of health insurers;
scores of pharmaceutical companies, device manufacturers and other health care vendors supplying bed pans, gurneys and ambulances; and
thousands of pharmacy benefit managers, vendor certification companies, disease management agencies, consultants and other companies providing bits of outsourced management expertise.
Though there is plenty of regulation, on most levels of the system there is no central Soviet-style commission allocating resources and deciding who gets which customers. All these organizations are free to compete for the customers' dollars.
Why, with all that competition, can't most of us seem to get the health care we need when we need it, where we need it, at a reasonable price? For most Americans, though we can see that modern medicine offers a nearly miraculous plethora of cures and therapies, our access to it through the health care industry is often arbitrary, sometimes so arbitrary as to be cruel. For those younger than 65, the price is often so high that even insured people can be one serious disease or traffic accident away from permanent poverty. And even when it works, it can be mind-blowingly inconvenient.
How can that be? How can a "free-market" system so blatantly fail to serve its customers? Until we find the answer, we will never be able to find our way out of this mess. Let's do a little basic analysis, a little Health Care Economics 101.
What Does the Customer Want?
What do I really want, as a customer of health care? Realistically, four things:
When I'm sick, fix me.
If you can't fix it, help me manage it.
When I am well, help me stay well.
Be there when I really need you.
Why is it so hard for me to get those four things? Because—here's the big key—I'm not really the customer. In fact, in most of health care, it can be hard to tell who really is the customer.
Who Is the Customer?
What's a customer? Customers decide that they want something, choose it and pay for it. You decide that a new TV would be nice. You look online or go to a big box store, maybe check out a local independent store. You find what seems a reasonable value for your money and you plunk down a credit card. You're a customer.
The customer is the key regulating part of any free-market system. The customer is the reason you never see a plate of scrambled eggs or a new car advertised for $1,000. It's the customer that enforces all sense of value.
So what's different between classic economics and health care economics? Classic economics pictures a buyer and a seller. There is a constant, dynamic feedback loop between the many buyers and sellers in a market that establishes not only what things cost, but even what's offered for sale, and on what kind of terms.
The core driver of all health care economics is the utilization decision, that is, people deciding to make use of some health care service. They get a new hip, take a new drug, get an exam, go in for a mammogram. The great majority of health care is insurance-supported, whether through government insurance, such as Medicare, or through employers' private insurance. And the great majority of health care is provided fee-for-service, that is, the health care provider (the doctor or hospital) bills the insurance payer for each separate test, procedure or prescription.
So what happens to that feedback loop in health care? First of all, the buyer is split in two—into a chooser and a payer. The organization that pays the bill does not make the decision to use that particular service. So the feedback loop between buyer and seller is obscured. And the chooser and the payer have quite different agendas. If the payer is just there to pay, it can have only one goal: to pay as little as it can get away with. It might set rules and payment schedules, but can never quite get it right, since it is really not there in the transaction, making the choice.
It begins to get cloudy: Who is the chooser? Who is deciding to use the service? Again there's a split. The chooser is not the patient alone, but the patient (or the patient's family) in consultation with the provider (usually the doctor). So again, and in a different way, the buyer is split. And the patient and the provider have different stances. The patient has enormous "skin in the game"—great incentive to use whatever services might seem to help, since it's the patient's body, his pain, indeed, often his life or death that is on the line. The provider, on the other hand, has almost all the resources: the knowledge, expertise, equipment and access to drugs and therapies. In any given transaction, the provider has far less skin in the game—the patient is one of hundreds or thousands, so the feedback loop gets even more obscured and tortuous.
It grows murkier: Who is the "seller?" Who is providing the service being sold? In most instances, it is the provider. The doctor who is advising the patient on buying the service is often either providing the service or working for the organization that will provide the service—or even owns it. You need a new knee, but you're in luck. You've come to the right place, because I am an expert knee installer. And the seller, of course, has a completely different agenda from the buyer. The seller's agenda is simply to sell as much as possible. So the feedback loop between buyer and seller becomes so tortuous and knotted as to be useless, and the system skews, as a normal part of doing business, toward selling the services that make the most money.
It is inescapable; you will serve somebody. If it is not the patient, it will be somebody else.
Out of this we get markets in which, for instance, it can be very hard for a Medicaid recipient with diabetes to get (or even hear about) the nutritional counseling that might help her save her feet, but quite easy to get a surgeon to amputate her feet when her diabetes destroys them.
What Are Health Care Providers Paid to Do?
This may sound overly cynical. Many doctors would protest that they never offer a service just because it would make them more money. But, as one neurologist put it to me, "The more I care about my work, the less money I make. The way for me to make more money is to serve my patients less—give them less time and attention and cut them loose as soon as possible." That's a terrible bind in which to put our best medical minds. Many doctors doubtless choose the path this doctor does: Do better work and make less money. But many doctors feel forced to make the other choice: Do poorer work and make more money.
It is important to remember the two core rules of economics:
People do what they are paid to do.
People do exactly what they are paid to do.
People notice in exquisite detail what makes them money and brings them success. As a normal practice, they will not do things that cost them money or risk getting them into trouble. In health care, what brings a provider money and success is doing more of the procedures and tests that are well-compensated by payers, and doing fewer or none of those that are not well-compensated—and certainly never failing to do a test or procedure that might keep them out of a malpractice suit, whether the patient really needs it or not. And those well-compensated and malpractice-safe procedures and tests are only indirectly related to the four things we really want when we think we are the customer. Almost no one in health care is directly paid to give us what we actually want.
What's the Structure?
It's important to notice that this confusion is structural. The ordinary structures of health care, with doctors, clinics and hospitals in strict fee-for-service relationships with payers, have great difficulty acting as if the patient is a customer.
If we are to get out of this mess, we need to tweak those old structures and build new ones. That's why we are seeing fascinating, weird experimental structures arising across health care—"extended medical home" physician-hospital organizations, "virtual accountable care organizations" like those I cited in my last column. And that is why almost all of these are new forms of partnerships, ad hoc contractual relationships that cut across the traditional structural lines to deal with the health of particular populations. The contracts set up incentive relationships that guarantee someone makes a profit specifically by tending to the real needs of the patient, not just by providing services to the patient. And they are all over the place, taking different shapes to fill niches in the vast ecology of health care.
Let me give you one example. If you were to look around, as an entrepreneur, for a way to make money by helping some population be healthier, what populations would seem like the "low-hanging fruit"? Would you think, "Ah, yes! Frail, elderly people on Medicaid in state-supported convalescent homes! And kids with disabilities on Medicaid!" Probably not. And yet that is exactly what happened in Illinois. McKesson's disease management subsidiary contracted with the state to provide its Your Healthcare Plus services to just such populations. Teams of doctors, nurses and case managers, many of them on-site across the state, working with the patients' existing providers, measurably improved the health of these patients. Counting the costs and fees for running the program, McKesson saved the state of Illinois $307 million in the first three years of the program by giving people more services of the right kind of care and attention, not less.
Hospitals can form these OWAs ("other weird arrangements") in all kinds of shapes, from at-risk contracts with insurers or CMS, to shared-risk, medical-home arrangements with physician-hospital organizations, to disease-management contracts with government agencies. And increasingly they are, across the country, because in the new environment the overburden of high cost and low capacity is killing us. We simply must find more efficient and more effective ways of serving our customers.
Structure matters. With the right structure, you make money by saving money. You help the customers meet their objectives, and you get paid for it.
Joe Flower is a health care futurist, speaker and founder of Imagine What If, a service of the education firm The Change Project Inc. Flower is also a regular contributor to H&HN Weekly and a member of Health Forum's Forum Faculty Speaker Service.
This article 1st appeared on November 29, 2010 in HHN Magazine online site.
By Joe Flower
The right payment structure keeps patients healthy while saving money.
Complete credit is given to the author... Joe Flower... for this insightful article.
Joe Flower is a health care futurist, speaker and founder of Imagine What If, a service of the education firm The Change Project Inc. Flower is also a regular contributor to H&HN Weekly and a member of Health Forum's Forum Faculty Speaker Service.
This article 1st appeared on November 29, 2010 in HHN Magazine online site.
We want health care to be abundant, effective, easy and cheap; for too many of us, too much of the time, it is scarce, ineffective and maddeningly difficult. For all of us, it is far too expensive. Why? How did we get in this mess? How do we end up paying so much for health care and not getting what we want?
It's a big question, and it's at the core of the mess we are in. The convoluted way we pay for health care in the United States gives too many patients treatments they don't need, or treats them for conditions that could have been prevented with much cheaper care, or denies patients services they need. How does this happen?
To answer this question, we have to dig into the actual structures of health care and some of the basics of economics. And in that answer we can begin to see how we need to rebuild those very structures to survive and thrive beyond reform.
Why Doesn't Competition Seem to Work in Health Care?
There certainly seems to be plenty of competition. For example, there are:
thousands of hospitals of different types (for-profit and nonprofit, freestanding and chain, general and specialty, teaching, children's, public and private, military and veterans);
hundreds of thousands of doctors in specialties organized every way you could imagine (solo practice, small practice, large multispecialty practice, working for hospitals and health systems, running their own centers, in cooperatives like Group Health of Puget Sound and staff-model HMOs like Kaiser);
hundreds of health insurers;
scores of pharmaceutical companies, device manufacturers and other health care vendors supplying bed pans, gurneys and ambulances; and
thousands of pharmacy benefit managers, vendor certification companies, disease management agencies, consultants and other companies providing bits of outsourced management expertise.
Though there is plenty of regulation, on most levels of the system there is no central Soviet-style commission allocating resources and deciding who gets which customers. All these organizations are free to compete for the customers' dollars.
Why, with all that competition, can't most of us seem to get the health care we need when we need it, where we need it, at a reasonable price? For most Americans, though we can see that modern medicine offers a nearly miraculous plethora of cures and therapies, our access to it through the health care industry is often arbitrary, sometimes so arbitrary as to be cruel. For those younger than 65, the price is often so high that even insured people can be one serious disease or traffic accident away from permanent poverty. And even when it works, it can be mind-blowingly inconvenient.
How can that be? How can a "free-market" system so blatantly fail to serve its customers? Until we find the answer, we will never be able to find our way out of this mess. Let's do a little basic analysis, a little Health Care Economics 101.
What Does the Customer Want?
What do I really want, as a customer of health care? Realistically, four things:
When I'm sick, fix me.
If you can't fix it, help me manage it.
When I am well, help me stay well.
Be there when I really need you.
Why is it so hard for me to get those four things? Because—here's the big key—I'm not really the customer. In fact, in most of health care, it can be hard to tell who really is the customer.
Who Is the Customer?
What's a customer? Customers decide that they want something, choose it and pay for it. You decide that a new TV would be nice. You look online or go to a big box store, maybe check out a local independent store. You find what seems a reasonable value for your money and you plunk down a credit card. You're a customer.
The customer is the key regulating part of any free-market system. The customer is the reason you never see a plate of scrambled eggs or a new car advertised for $1,000. It's the customer that enforces all sense of value.
So what's different between classic economics and health care economics? Classic economics pictures a buyer and a seller. There is a constant, dynamic feedback loop between the many buyers and sellers in a market that establishes not only what things cost, but even what's offered for sale, and on what kind of terms.
The core driver of all health care economics is the utilization decision, that is, people deciding to make use of some health care service. They get a new hip, take a new drug, get an exam, go in for a mammogram. The great majority of health care is insurance-supported, whether through government insurance, such as Medicare, or through employers' private insurance. And the great majority of health care is provided fee-for-service, that is, the health care provider (the doctor or hospital) bills the insurance payer for each separate test, procedure or prescription.
So what happens to that feedback loop in health care? First of all, the buyer is split in two—into a chooser and a payer. The organization that pays the bill does not make the decision to use that particular service. So the feedback loop between buyer and seller is obscured. And the chooser and the payer have quite different agendas. If the payer is just there to pay, it can have only one goal: to pay as little as it can get away with. It might set rules and payment schedules, but can never quite get it right, since it is really not there in the transaction, making the choice.
It begins to get cloudy: Who is the chooser? Who is deciding to use the service? Again there's a split. The chooser is not the patient alone, but the patient (or the patient's family) in consultation with the provider (usually the doctor). So again, and in a different way, the buyer is split. And the patient and the provider have different stances. The patient has enormous "skin in the game"—great incentive to use whatever services might seem to help, since it's the patient's body, his pain, indeed, often his life or death that is on the line. The provider, on the other hand, has almost all the resources: the knowledge, expertise, equipment and access to drugs and therapies. In any given transaction, the provider has far less skin in the game—the patient is one of hundreds or thousands, so the feedback loop gets even more obscured and tortuous.
It grows murkier: Who is the "seller?" Who is providing the service being sold? In most instances, it is the provider. The doctor who is advising the patient on buying the service is often either providing the service or working for the organization that will provide the service—or even owns it. You need a new knee, but you're in luck. You've come to the right place, because I am an expert knee installer. And the seller, of course, has a completely different agenda from the buyer. The seller's agenda is simply to sell as much as possible. So the feedback loop between buyer and seller becomes so tortuous and knotted as to be useless, and the system skews, as a normal part of doing business, toward selling the services that make the most money.
It is inescapable; you will serve somebody. If it is not the patient, it will be somebody else.
Out of this we get markets in which, for instance, it can be very hard for a Medicaid recipient with diabetes to get (or even hear about) the nutritional counseling that might help her save her feet, but quite easy to get a surgeon to amputate her feet when her diabetes destroys them.
What Are Health Care Providers Paid to Do?
This may sound overly cynical. Many doctors would protest that they never offer a service just because it would make them more money. But, as one neurologist put it to me, "The more I care about my work, the less money I make. The way for me to make more money is to serve my patients less—give them less time and attention and cut them loose as soon as possible." That's a terrible bind in which to put our best medical minds. Many doctors doubtless choose the path this doctor does: Do better work and make less money. But many doctors feel forced to make the other choice: Do poorer work and make more money.
It is important to remember the two core rules of economics:
People do what they are paid to do.
People do exactly what they are paid to do.
People notice in exquisite detail what makes them money and brings them success. As a normal practice, they will not do things that cost them money or risk getting them into trouble. In health care, what brings a provider money and success is doing more of the procedures and tests that are well-compensated by payers, and doing fewer or none of those that are not well-compensated—and certainly never failing to do a test or procedure that might keep them out of a malpractice suit, whether the patient really needs it or not. And those well-compensated and malpractice-safe procedures and tests are only indirectly related to the four things we really want when we think we are the customer. Almost no one in health care is directly paid to give us what we actually want.
What's the Structure?
It's important to notice that this confusion is structural. The ordinary structures of health care, with doctors, clinics and hospitals in strict fee-for-service relationships with payers, have great difficulty acting as if the patient is a customer.
If we are to get out of this mess, we need to tweak those old structures and build new ones. That's why we are seeing fascinating, weird experimental structures arising across health care—"extended medical home" physician-hospital organizations, "virtual accountable care organizations" like those I cited in my last column. And that is why almost all of these are new forms of partnerships, ad hoc contractual relationships that cut across the traditional structural lines to deal with the health of particular populations. The contracts set up incentive relationships that guarantee someone makes a profit specifically by tending to the real needs of the patient, not just by providing services to the patient. And they are all over the place, taking different shapes to fill niches in the vast ecology of health care.
Let me give you one example. If you were to look around, as an entrepreneur, for a way to make money by helping some population be healthier, what populations would seem like the "low-hanging fruit"? Would you think, "Ah, yes! Frail, elderly people on Medicaid in state-supported convalescent homes! And kids with disabilities on Medicaid!" Probably not. And yet that is exactly what happened in Illinois. McKesson's disease management subsidiary contracted with the state to provide its Your Healthcare Plus services to just such populations. Teams of doctors, nurses and case managers, many of them on-site across the state, working with the patients' existing providers, measurably improved the health of these patients. Counting the costs and fees for running the program, McKesson saved the state of Illinois $307 million in the first three years of the program by giving people more services of the right kind of care and attention, not less.
Hospitals can form these OWAs ("other weird arrangements") in all kinds of shapes, from at-risk contracts with insurers or CMS, to shared-risk, medical-home arrangements with physician-hospital organizations, to disease-management contracts with government agencies. And increasingly they are, across the country, because in the new environment the overburden of high cost and low capacity is killing us. We simply must find more efficient and more effective ways of serving our customers.
Structure matters. With the right structure, you make money by saving money. You help the customers meet their objectives, and you get paid for it.
Joe Flower is a health care futurist, speaker and founder of Imagine What If, a service of the education firm The Change Project Inc. Flower is also a regular contributor to H&HN Weekly and a member of Health Forum's Forum Faculty Speaker Service.
This article 1st appeared on November 29, 2010 in HHN Magazine online site.
Friday, October 15, 2010
ISSUES FACING HEALTHCARE
Source: HHN Magazine, Sept. 2009... Credit to Mary Grayson
The Root of the Problem
The issues facing health care are immense, but AHA Chair-Elect John Bluford believes that common sense will prevail in the end.
as told to Mary Grayson
Many of our systemic health care delivery system ills cannot be cured by legislation. The real revolution will come to health care when we reach a culture of wellness and prevention, says John Bluford, president and CEO of Truman Medical Centers, Kansas City, Mo., and the new chair-elect of the American Hospital Association.
Health care service is a family affair for me. I had many uncles in health care and my grandfather was a dentist. I went to Fisk University in Nashville majoring in pre-med and I was on my way to Meharry Medical School when a recruiter for Northwestern University's business program interviewed me. The gentleman tried to convince me that I ought to go into business because of my orientation toward extracurricular activities and leadership roles with my fraternity, student government and the basketball team at Fisk. I told him I knew nothing about business administration, but I passed the graduate school test and received a full two-year scholarship at Northwestern sponsored by what was then the United Insurance Company in Chicago, plus a $250 monthly stipend. In 1971, that was good spending money. So I enrolled in the business school with a hospital and health services major. The real hook was when I realized that you don't have to be a doctor to work in a hospital. You can lead a variety of activities that help support many doctors and their patients in an administrative role.
My first job in graduate school was at the 3,000-bed Cook County Hospital. As an administrative resident, I was the weekend administrator under Bill Silverman and Bob Shakno, both of whom came from Michael Reese Medical Center to help turn around Cook County Hospital in the early '70s. This was a very turbulent time at that county hospital, following much-publicized strikes by residents and nurses. After graduating from Northwestern, I took over as the night administrator. It was training under fire, but the beauty of it for me was that on weekends and nights, I had overall administrative responsibility for the hospital.
I have many stories after being the night administrator at Cook County. My favorite is the night I was looking at the surveillance television monitor and saw one of our buildings on fire. About 16 buildings comprised the Cook County campus and the psych hospital was on fire. I had Bob Shakno's home phone number. He always said, "If there are any problems, just call me." Well tonight was the night. His response: "Step No. 1: Call the fire department."
Today's Non-System
The business we're in today is very complex and often contradictory. We're rewarded for sickness but not wellness and prevention. So many component parts create this non-system—insurers, physicians, hospitals, pharma, device manufacturers—and each component part represents a competing interest that resists change. The cost of health care is a big issue and we all want to reduce cost. But someone's cost is someone else's revenue. Therein lies the root of many of the health care reform political battles inherent in moving the system forward. That is why I am so pleased with AHA's Health for Life platform (coverage, wellness, efficiency, highest quality and best information) as it takes a comprehensive look at the total system(s) for reform.
Today, many uninsured people lack access to appropriate care, at the appropriate time and the appropriate place. One way of thinking is that sick people don't need insurance; what they need is appropriate access to health care. Today, they often access health care through safety-net hospitals and emergency departments, where ongoing continuity of care may suffer. Appropriate health care reform, which increases appropriate access to services, may not be cheaper in the short run, but we might have a healthier society and other benefits to the common good.
The long-term key to success is the prevention of illness and managing the costs associated with sickness. A rallying cry around the country in support of lifestyle enhancement, physical fitness and good nutrition would be the biggest enhancement to health care reform that we could achieve from a quality-of-life perspective.
End-of-life care counseling can also have long-term results. Evidence already exists that a 90-year-old with multiple system failure can either stay in a highly intensified, technological ICU environment and have dozens, if not hundreds, of tests done by high-profile professionals for weeks or that person can go home and be treated with dignity and surrounded by loved ones. The irony is that the length of life is the same in either situation. But the choice for quality of life is a no-brainer. We are often incentivized to do more expensive yet less effective modalities. Unfortunately, end-of-life care issues were avoided in the current reform legislation, but eventually the collective American community must discuss it.
Societal Disparities
My 30-plus years in health care have been in the public or safety-net hospital environments that, on the whole, cater to a vulnerable patient population with a high degree of health care disparity. Their condition often represents social disparities—not just health care disparities. Ethnic and racial disparities come into play as well; but broadly speaking it encompasses the people with fewer employment opportunities, sometimes with poor family support, inadequate housing, and this aggregate population crosses all racial and ethnic boundaries. Much of the reform debate in terms of access and cost is really about this vulnerable patient population. If we focused our attention here and society provided resources to solve the underlying problems, we could carry health care reform further than any legislation.
The focus on continuity of care, medical home experiments and advocacy issues play neatly into helping us get our arms around the problem. Many of our clientele have chronic diseases that are not managed well, and they don't have system navigators to get patients from point A to point B to make sure they keep their appointments, manage medications, and so on. And in many cases, the people who treat them can't associate or identify with them to the extent that it takes to overcome or break through the social disparity aspects of their lives.
Research comes into play, but so does common sense. I get frustrated with "process" versus common sense and the prompt execution of good ideas. There sometimes needs to be a greater sense of urgency and balance between research, process and action. If we know that asthma is a problem for a pediatric patient who repeatedly comes to the emergency room, then someone needs to go to the home and find out what's going on in that environment that is creating the problem.
We are about to start a program at Truman Medical Centers that we call Passport to Wellness, which is targeted at our "frequent flyers"—those people who are constantly readmitted, who make a dozen or more visits a month to our emergency room, and have chronic diseases such as diabetes, hypertension, asthma, chronic heart failure. We want to identify about 100 of these patients and provide as much intense case management attention as possible to see if we can solve their issues.
Sometimes we need to think about different types of interventions in dealing with vulnerable patient populations. I was talking with the head of our EMS system about Passport to Wellness and he said, "I see some of these patients 20 to 25 times a month. Many are diabetic and they need medications and some basic assessment. They call us because they know that if they come in by ambulance they will come through the emergency entrance and won't have to wait two or three hours in the waiting room." Bingo. Why not use these talented, skilled emergency medicine service workers? They are at the house, they can administer the medicine, and in many cases they know the patient better than the rest of the health care system. Perversely, we would lose Medicare payment for a full run to the hospital, but the economical, simple thing to do may be to let the EMS workers meet the needs of the patient on the spot.
The whole mental health sector needs to be brought into play as well. A great proportion of the vulnerable patient population has either mental health or addictive behavioral problems. Also, many people who are incarcerated should probably be in a mental health institution, as should many of our homeless. Our society has not opened our eyes to those realities yet.
All of the significant mental health, psychological-related issues and clinical issues associated with behavioral health are upon us. It is a slightly different business than running an acute care hospital. It is often not a money-making proposition. The capacity is woefully low. But it needs to be addressed.
Safety-net hospitals are critical to the communities they serve, not just because they tend to serve the vulnerable and disadvantaged population; safety nets are not merely for the downtrodden. Safety-net hospitals provide services such as Level 1 trauma units, high-risk neonatal units, burn units, oral health, and teaching and training programs that are vitally important to the entire community and may not be available in other parts of that community's delivery system.
They are also major business entities. We hire a lot of people. Safety nets pay lots of payroll tax and contribute significantly to the local economy through the acquisition of supplies, commodities, construction projects and so on. And because most safety-net hospitals are in the urban core, it is even more critical that they continue to be one of the major engines fueling that inner-city economy.
The maintenance and survival of these institutions is an economic issue as much as it is a health care issue.
Unintended Consequences
There is no question that there will be unintended consequences all over the map as the reform process runs its course over many years. It took more than a generation for us to get into our current circumstance in regards to cost, value and quality, and it is going to take some time for us to find our way out. Whatever happens with health care reform legislation today, it will be constantly modified over the next 10 years until we have a system that is more resourceful and meets more needs than the system does today, at a reasonable and affordable cost.
A theme in this year's discussions is that hospital environments with employed physicians, such as Mayo and the Cleveland Clinic, have better continuity of care, better results and run more efficiently and effectively. The physicians and the hospital are not working at cross purposes with cross incentives. In most institutions, the hospital and the physicians are legally independent organizations, but they are connected at the hip financially; one can't move successfully without the other. The new world order through health care reform with strong disease management, bundled payments and gainsharing arrangements should lead us in more unified alignment.
There are two things that create problems for chief executive officers. One is ineffective relationships with physicians and the other involves poor decisions or implementation of major IT projects. Today, the electronic health record is top of mind. And it will benefit the system, patients and clinicians, but it is not the silver bullet. Migrating from paper records to electronic documentation is very difficult and expensive. Without a thorough operational audit of user requirements and fixing the problems in the manual process before automating simply means that you get bad processes faster.
Another element that is critical to hospitals' long-term success is high-performance governance. Qualified trustees who are engaged and buy into the mission of the institution will advocate for that mission throughout the community at large. One of management's responsibilities with the board is not merely answering the questions that they ask as truthfully and honestly as you can but also, in some cases, showing them what questions to ask because often they don't know. That kind of openness and transparency in governance makes for a much stronger institution and across the nation will lead to a much stronger health care delivery system.
This article 1st appeared in the December 2009 issue of HHN Magazine.
The Root of the Problem
The issues facing health care are immense, but AHA Chair-Elect John Bluford believes that common sense will prevail in the end.
as told to Mary Grayson
Many of our systemic health care delivery system ills cannot be cured by legislation. The real revolution will come to health care when we reach a culture of wellness and prevention, says John Bluford, president and CEO of Truman Medical Centers, Kansas City, Mo., and the new chair-elect of the American Hospital Association.
Health care service is a family affair for me. I had many uncles in health care and my grandfather was a dentist. I went to Fisk University in Nashville majoring in pre-med and I was on my way to Meharry Medical School when a recruiter for Northwestern University's business program interviewed me. The gentleman tried to convince me that I ought to go into business because of my orientation toward extracurricular activities and leadership roles with my fraternity, student government and the basketball team at Fisk. I told him I knew nothing about business administration, but I passed the graduate school test and received a full two-year scholarship at Northwestern sponsored by what was then the United Insurance Company in Chicago, plus a $250 monthly stipend. In 1971, that was good spending money. So I enrolled in the business school with a hospital and health services major. The real hook was when I realized that you don't have to be a doctor to work in a hospital. You can lead a variety of activities that help support many doctors and their patients in an administrative role.
My first job in graduate school was at the 3,000-bed Cook County Hospital. As an administrative resident, I was the weekend administrator under Bill Silverman and Bob Shakno, both of whom came from Michael Reese Medical Center to help turn around Cook County Hospital in the early '70s. This was a very turbulent time at that county hospital, following much-publicized strikes by residents and nurses. After graduating from Northwestern, I took over as the night administrator. It was training under fire, but the beauty of it for me was that on weekends and nights, I had overall administrative responsibility for the hospital.
I have many stories after being the night administrator at Cook County. My favorite is the night I was looking at the surveillance television monitor and saw one of our buildings on fire. About 16 buildings comprised the Cook County campus and the psych hospital was on fire. I had Bob Shakno's home phone number. He always said, "If there are any problems, just call me." Well tonight was the night. His response: "Step No. 1: Call the fire department."
Today's Non-System
The business we're in today is very complex and often contradictory. We're rewarded for sickness but not wellness and prevention. So many component parts create this non-system—insurers, physicians, hospitals, pharma, device manufacturers—and each component part represents a competing interest that resists change. The cost of health care is a big issue and we all want to reduce cost. But someone's cost is someone else's revenue. Therein lies the root of many of the health care reform political battles inherent in moving the system forward. That is why I am so pleased with AHA's Health for Life platform (coverage, wellness, efficiency, highest quality and best information) as it takes a comprehensive look at the total system(s) for reform.
Today, many uninsured people lack access to appropriate care, at the appropriate time and the appropriate place. One way of thinking is that sick people don't need insurance; what they need is appropriate access to health care. Today, they often access health care through safety-net hospitals and emergency departments, where ongoing continuity of care may suffer. Appropriate health care reform, which increases appropriate access to services, may not be cheaper in the short run, but we might have a healthier society and other benefits to the common good.
The long-term key to success is the prevention of illness and managing the costs associated with sickness. A rallying cry around the country in support of lifestyle enhancement, physical fitness and good nutrition would be the biggest enhancement to health care reform that we could achieve from a quality-of-life perspective.
End-of-life care counseling can also have long-term results. Evidence already exists that a 90-year-old with multiple system failure can either stay in a highly intensified, technological ICU environment and have dozens, if not hundreds, of tests done by high-profile professionals for weeks or that person can go home and be treated with dignity and surrounded by loved ones. The irony is that the length of life is the same in either situation. But the choice for quality of life is a no-brainer. We are often incentivized to do more expensive yet less effective modalities. Unfortunately, end-of-life care issues were avoided in the current reform legislation, but eventually the collective American community must discuss it.
Societal Disparities
My 30-plus years in health care have been in the public or safety-net hospital environments that, on the whole, cater to a vulnerable patient population with a high degree of health care disparity. Their condition often represents social disparities—not just health care disparities. Ethnic and racial disparities come into play as well; but broadly speaking it encompasses the people with fewer employment opportunities, sometimes with poor family support, inadequate housing, and this aggregate population crosses all racial and ethnic boundaries. Much of the reform debate in terms of access and cost is really about this vulnerable patient population. If we focused our attention here and society provided resources to solve the underlying problems, we could carry health care reform further than any legislation.
The focus on continuity of care, medical home experiments and advocacy issues play neatly into helping us get our arms around the problem. Many of our clientele have chronic diseases that are not managed well, and they don't have system navigators to get patients from point A to point B to make sure they keep their appointments, manage medications, and so on. And in many cases, the people who treat them can't associate or identify with them to the extent that it takes to overcome or break through the social disparity aspects of their lives.
Research comes into play, but so does common sense. I get frustrated with "process" versus common sense and the prompt execution of good ideas. There sometimes needs to be a greater sense of urgency and balance between research, process and action. If we know that asthma is a problem for a pediatric patient who repeatedly comes to the emergency room, then someone needs to go to the home and find out what's going on in that environment that is creating the problem.
We are about to start a program at Truman Medical Centers that we call Passport to Wellness, which is targeted at our "frequent flyers"—those people who are constantly readmitted, who make a dozen or more visits a month to our emergency room, and have chronic diseases such as diabetes, hypertension, asthma, chronic heart failure. We want to identify about 100 of these patients and provide as much intense case management attention as possible to see if we can solve their issues.
Sometimes we need to think about different types of interventions in dealing with vulnerable patient populations. I was talking with the head of our EMS system about Passport to Wellness and he said, "I see some of these patients 20 to 25 times a month. Many are diabetic and they need medications and some basic assessment. They call us because they know that if they come in by ambulance they will come through the emergency entrance and won't have to wait two or three hours in the waiting room." Bingo. Why not use these talented, skilled emergency medicine service workers? They are at the house, they can administer the medicine, and in many cases they know the patient better than the rest of the health care system. Perversely, we would lose Medicare payment for a full run to the hospital, but the economical, simple thing to do may be to let the EMS workers meet the needs of the patient on the spot.
The whole mental health sector needs to be brought into play as well. A great proportion of the vulnerable patient population has either mental health or addictive behavioral problems. Also, many people who are incarcerated should probably be in a mental health institution, as should many of our homeless. Our society has not opened our eyes to those realities yet.
All of the significant mental health, psychological-related issues and clinical issues associated with behavioral health are upon us. It is a slightly different business than running an acute care hospital. It is often not a money-making proposition. The capacity is woefully low. But it needs to be addressed.
Safety-net hospitals are critical to the communities they serve, not just because they tend to serve the vulnerable and disadvantaged population; safety nets are not merely for the downtrodden. Safety-net hospitals provide services such as Level 1 trauma units, high-risk neonatal units, burn units, oral health, and teaching and training programs that are vitally important to the entire community and may not be available in other parts of that community's delivery system.
They are also major business entities. We hire a lot of people. Safety nets pay lots of payroll tax and contribute significantly to the local economy through the acquisition of supplies, commodities, construction projects and so on. And because most safety-net hospitals are in the urban core, it is even more critical that they continue to be one of the major engines fueling that inner-city economy.
The maintenance and survival of these institutions is an economic issue as much as it is a health care issue.
Unintended Consequences
There is no question that there will be unintended consequences all over the map as the reform process runs its course over many years. It took more than a generation for us to get into our current circumstance in regards to cost, value and quality, and it is going to take some time for us to find our way out. Whatever happens with health care reform legislation today, it will be constantly modified over the next 10 years until we have a system that is more resourceful and meets more needs than the system does today, at a reasonable and affordable cost.
A theme in this year's discussions is that hospital environments with employed physicians, such as Mayo and the Cleveland Clinic, have better continuity of care, better results and run more efficiently and effectively. The physicians and the hospital are not working at cross purposes with cross incentives. In most institutions, the hospital and the physicians are legally independent organizations, but they are connected at the hip financially; one can't move successfully without the other. The new world order through health care reform with strong disease management, bundled payments and gainsharing arrangements should lead us in more unified alignment.
There are two things that create problems for chief executive officers. One is ineffective relationships with physicians and the other involves poor decisions or implementation of major IT projects. Today, the electronic health record is top of mind. And it will benefit the system, patients and clinicians, but it is not the silver bullet. Migrating from paper records to electronic documentation is very difficult and expensive. Without a thorough operational audit of user requirements and fixing the problems in the manual process before automating simply means that you get bad processes faster.
Another element that is critical to hospitals' long-term success is high-performance governance. Qualified trustees who are engaged and buy into the mission of the institution will advocate for that mission throughout the community at large. One of management's responsibilities with the board is not merely answering the questions that they ask as truthfully and honestly as you can but also, in some cases, showing them what questions to ask because often they don't know. That kind of openness and transparency in governance makes for a much stronger institution and across the nation will lead to a much stronger health care delivery system.
This article 1st appeared in the December 2009 issue of HHN Magazine.
Thursday, June 10, 2010
Identifying At Risk Patients
Journal of Ambulatory Care Management:
October/December 2009 - Volume 32 - Issue 4 - p 320-327
doi: 10.1097/JAC.0b013e3181ba6e77
Article
Is Patient Activation Associated With Future Health Outcomes and Healthcare Utilization Among Patients With Diabetes?
Remmers, Carol PhD; Hibbard, Judith DrPH; Mosen, David M. PhD; Wagenfield, Morton PhD; Hoye, Robert E. PhD; Jones, Ches PhD
Abstract
We examined the relationship between the patient activation measure (PAM) and future diabetes-related health outcomes through retrospective analysis of secondary data using multivariate logistic regression. PAM scores from a 2004 survey on 1180 randomly sampled adults with diabetes and health information from a 2006 diabetes registry were the data sources used. The PAM was predictive for hemoglobin A1c (HgA1c) testing (P < .008), low-density lipoprotein cholesterol (LDL-C) testing (P < .005), HgA1c control (P < .01), and all-cause discharges (P < .03), but not for lipid-lowering drug use, LDL-C control, or acute myocardial infarction discharges. These results suggest that PAM scores can be used to identify patients at risk for poorer health outcomes.
October/December 2009 - Volume 32 - Issue 4 - p 320-327
doi: 10.1097/JAC.0b013e3181ba6e77
Article
Is Patient Activation Associated With Future Health Outcomes and Healthcare Utilization Among Patients With Diabetes?
Remmers, Carol PhD; Hibbard, Judith DrPH; Mosen, David M. PhD; Wagenfield, Morton PhD; Hoye, Robert E. PhD; Jones, Ches PhD
Abstract
We examined the relationship between the patient activation measure (PAM) and future diabetes-related health outcomes through retrospective analysis of secondary data using multivariate logistic regression. PAM scores from a 2004 survey on 1180 randomly sampled adults with diabetes and health information from a 2006 diabetes registry were the data sources used. The PAM was predictive for hemoglobin A1c (HgA1c) testing (P < .008), low-density lipoprotein cholesterol (LDL-C) testing (P < .005), HgA1c control (P < .01), and all-cause discharges (P < .03), but not for lipid-lowering drug use, LDL-C control, or acute myocardial infarction discharges. These results suggest that PAM scores can be used to identify patients at risk for poorer health outcomes.
Thursday, May 20, 2010
Healthcare Options for the Elderly
by: William Deskin, Ph.D., and Robert E. Hoye, Ph.D., Faculty, Walden University
As published in the American Academy of Medical Administrators, EXECUTIVE, May/June 2010
The health care policy discussions continue across the country, many asking what we should do with the elderly. There isn’t enough health care to go around, it is said, and we can’t sustain what we’re doing – spending lots of money and not getting the return we’d anticipated. We’ve got to figure out who’s spending the most money, it would seem, and tell them to stop it. The question seems to be what to do with grandpa and grandma. As grandpa’s, this is quite disconcerting. There are many unanswered questions regarding health care for the elderly including who should be covered, for how long they should be covered, for what kinds of illnesses, who should pay for these services, and on what basis should decisions regarding their care be made. Some might question whether the decision should be made on some random or arbitrary basis or should some ethical base be used to help assure a modicum of fairness or equity. Others might question whether fairness is possible with scarce resources, or whether equity applies, or could be applied. While a discussion regarding the elderly may center on the most elderly, the old-old over 85 years of age, policy decisions seem to start around the age of graduating to Medicare with the young–old at 65 years of age.
Some would suggest that the idea of aging is an antiquated idea itself, that the scientific and biotechnological era heralds a new age of defeating chronic pain, illness, and aging as it moves forward (Mykytyn, 2006). With this perspective the emphasis is not on rationing, rather it is on eliminating chronic conditions and reducing the time a person is aged. There are those who disagree. They suggest that a certain amount of illness, wear and tear on the body and mind, goes along with the process of aging; that “the price we pay for long life is debility” (Lachs, 2004, p. 176). Within this last idea is a suggestion that many [perhaps all?] of us both earn and wear our debilities through aging as mementos of an earlier age and afflictions.
The aging or aged body is different from the young or youthful body and the health care resources needed to sustain/maintain it are also different. A natural law perspective suggests that after using our bodies for a prolonged period, the elderly should be required to relinquish any remaining or retained youthfulness (Post, 2004), and with that relinquishing, prepare themselves for a so-called natural end; without prolonging the aging process or altering it. Viewed from a different vantage, others suggest that human nature is an obstacle to be overcome (Hook, C.C. as cited in Post, 2004, p. 535) and that nature is what is unnatural in considering the elderly. What was natural in 1900 is markedly different than 2000. We had less sanitation, no antibiotics, pasteurization, we died earlier, and that was natural.
Much of the discussion regarding scarce resources in health care focuses on how to allocate those resources. After all, “in 2006, the median annual health care expenditure for persons age 65 and over was $4,032,with about one-quarter of the elderly having no expenses or expenses under $1,752 (25th percentile) and one-quarter having expenses over $9,289 (75th percentile) (Machlin, 2009). Maybe all that we need to do to save money is find those in the 75th percentile and tell them to stop being sick! Or stop them from using scarce resources.
Recognizing that nothing is free, “costless benefits are not only unattainable, [but that is] a misleading ideal (Lachs, 2004, p. 175), we also recognize that age is not simply about health, we must have usefulness as well or it becomes empty. Usefulness does not necessarily mean productivity. We can mechanize the process of determining who gets what health care by calculating quality-adjusted life years (QALYs) and comparing perfect health and then reducing debilities to arrive at a score. Comparing QALYs against perfect health (Persad, Wertheimer & Emanual, 2009, p. 427) is inherently ageist. To do the calculation requires value judgment at the beginning and value cannot adequately be determined from outside the individual dispassionately or without bias. So how do we decide about how much we’ll allow for the elderly, call it what it really is - rationing or limiting health care to the elderly – if there is an unequal allocation based on something other than illness or disease. Rationing can occur by allowing payment for certain medical procedures based on age or disallowing them using the same rationale.
Another method of calculation is to view the person, and whatever their illness or debility, and to make a determination of how long they might live, considering all that. If they have less than a certain number of years, they aren’t allowed more than palliative care. Or, in an actuarially determined mode, an elderly person could be given an average determination of expected longevity based on their prognosis and after their cohort average has been attained, no additional health care would be given. This method might even parallel the quality adjusted life years mode. Do we really want to give determination for health care services to the accountants?
A variation might be to provide health care only to those who could benefit, that is, extend their actuarially determined life span by treatment. If one has a genetic predisposition to be sicker than the actuarial tables might suggest or recommend, they might receive services until they attain their cohort average and then services would stop. If one has the genetic predisposition to live less sick they would be allowed to continue without healthcare services because they wouldn’t be needed. After surpassing the average for their cohort, however, they would not be able to receive additional services. This method of deciding when to allow and when to withhold health care assumes that age, by itself, can determine the value of an individual – beyond a certain age point the value is not worth maintaining.
Others have put together combinations of ethical or allocation principles in order to suggest a “complete lives system” (Persad, Werthiemer & Emanuel, 2009, p. 428). This system, very well presented, also “produces a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial change, whereas the youngest and oldest people get chances that are attenuated” (p. 428). Part of the argument is that those younger than 15 haven’t had enough “personal investment that people are morally entitled to have received at a particular age” (p. 428). This recommends, in part, that health care services should be less for the young and elderly – or in this case, those over 40 years old.
A fiscally responsible method of determining which elderly should receive health care might be based on the potential outcome. If risk of medical success is below a particular percent or probability, then care would be withheld. It is not in society’s interest to waste health care resources, and that top 25th percent are very expensive. But perhaps it is best to provide health care only to those who are the sickest and leave those who only have chronic illness alone, after all, natural law will take care of them in due time.
Perhaps one of the most easily determined methods to select who obtains health care’s scarce resources is simply to draw a line in the aging sand – beyond a particular age, no additional health care is provided. While it may seem harsh, it may have merit on the basis of equity. Since everyone is checked into Medicare at the same age, why not have everyone begin the process of checking out using the same logic. It might make for an uneven playing field if those with wealth could obtain care while those without couldn’t, much like inclusion in Medicare without a means test, but it’s an idea. Another method might be to allow those who have access to health care through insurance to obtain it, however, that also seems to favor the wealthy over the less wealthy and the employed or retired with benefits over those without. That seems to be without merit on the basis of equity. It also seems to be one of the main sources of discrimination that politicians seek to remedy at the moment. An alternative is to increase taxes for those that have in order to distribute them to those who have much less. A major issue down the road is when the haves and have not’s arrive at the same point.
What’s fair in the mix? There is health care rationing in the U.K. (Giordano, 2005) and a call for governmental rationing in Australia as well (Johnstone & Kanitsaki, 2009) and a feeling that without rationing that “public services will ultimately collapse under the strain of the ever increasing demands placed on these services” (p. 86). The discussion, it seems, may be mostly about how much a society wishes to pay for the health care services for their elderly, rather than whether it should feel obligated to do so. After all, some may say, the elderly are the ones to blame for the world’s ills anyway. While the percent of gross domestic product that health care represents is considered high, no central planning has determined how much, what percent, is appropriate to meet the needs of citizens, only that what we’re experiencing is too much. What to cover, what to pay for with collected taxes, has not been determined either. As single illness support groups have approached Congress, the elected representatives have repeatedly sought to include everything and everyone. Perhaps that is admirable. Indeed, discussions regarding health care seem to include non-citizens within the same moral stance. The EMTALA laws don’t allow an emergency room to turn away patients or to ask for their legal status before treatment. Fair, in that case, is certainly in the eyes of the beholder.
The so-called fair innings argument suggests that those who have lived beyond a particular point have a responsibility to those who haven’t yet lived equal innings to step aside; to assure that those younger have the opportunity to complete at least a minimum number of innings. This argument suggests that “the value of life can be measured in units of lifetime” (Harris, 2005, p. 95). It also assumes that each measure is the same for each person, that age is the only pertinent discriminating factor, more so than experience or education or genetic make-up, or relative success or failure or illness. To continue the metaphor, once someone has the bases loaded and has done well with their life, up to a point, we bring in a rookie because the rookie needs playing time. Whose game is it, anyway? What is a fair inning?
Normal is a word with various meanings that can be applied when ever advantageous for the sake of an argument. Here, the normal death for animals and plants can be used to suggest that there is a normal life span, and normal does not include extensions to that life span (Mykytyn, 2006). Life happens, death happens – it’s all normal. But is it considered normal to take beta-blockers and ace inhibitors, as an example, or is it a subversive act or implicit support for prolongevity? Certainly, many individuals would have died much earlier and with great health care savings had they not taken anti-aging pharmaceuticals or, perhaps, not acquiesced to by-pass surgeries and used so many resources. Is that prolongevity or is it bad social policy to consider it is anti-aging? There are those who suggest that if only we prevent chronic disease we save health care expenses, however, that appears to be an incorrect assumption since, “less than 20 percent of the preventive options (and a similar percentage for treatment) fall in the cost-saving category-80 percent add more to medical costs than they save” (Russell, 2009, p. 45). The cost of chronic disease causes such a “disproportionate burden” that it may “discourage adherence to drugs that prevent disease progression” (Paez, Zhao, & Hwang, 2009, p. 15). “In 2005, 133 million Americans were living with at least one chronic condition” (Bodenheimer, Chen & Bennett, 2009, p. 64).
Aging, by itself, isn’t the problem, but the pain and suffering from illnesses is the problem. The whole notion of anti-aging medicine challenges the notion of aging as a disease. It certainly makes sense that “what is costly is not “old age” but disability and poor health” (Giordano, 2005, p. 88). If only we, through science and technology, can find remedies or cures for the ailments that align with aging, once they are eliminated or greatly diminished then aging can be a period of time to be desired and enjoyed. Nonsense, suggests others, the idea shouldn’t be about eradicating disease and illnesses for the purpose of extending the human lifespan (Chapman, 2004). Instead, society should use money otherwise spent for the purpose of “providing basic medical services to everyone in our own country and ameliorating basic health needs elsewhere in the world” (Chapman, 2004, p. 488). Without basic health care for all, prolonging the life span or curing chronic ailments is viewed, from this vantage, as inappropriate. Just as convinced are those who feel there is an obligation to eliminate illness and extend the natural life span.
Distributive justice requires a fair distribution of life-years (Persad, 2009), the idea being that young people have a right to a particular number of years of life, very similar to the fair innings argument, although few suggest what the number of years or length of the innings might be. Distributive justice is based on equality; however, equality is not possible if the playing field is uneven to begin with. Consider the person who is born with medical maladies, Does equality suggest that they forego health care since their age cohorts don’t need that same, or similar, health care? Suggesting the use of age as a basis for rationing is discriminatory and yet it is that very discrimination that is encouraged in the elderly through distributive justice, and rationing. Through this consideration of equality rests an assumption that every person is born with an innate ability, provided in some utilitarian sense. What do we do with the less than perfect individuals who, early in life, require life-sustaining support because of illness or accident or genetic disposition? If we eliminate health care for these because of their supposed lack of ability to contribute to society in the same manner or level as those who have not yet been ill or had an accident, money is saved but at a terrible cost. Does it apply to the premature infant, the spina bifida, the one with a hole in their just born heart – fixable, but at a cost? Which illness do we suggest is not worth saving, for whom, and at what cost? Which of the many illnesses, diseases, chronic maladies, or accidents will we consider to lessen the value of the individual to the point that their continued care is not worth the price? This does not consider those who are in a vegetative state, only those who are “less” than those around them. Maybe you’re one of them.
Priority must be given to younger people for health care based on their years, or lack of years, and the potential they have, it has been suggested. If the elderly don’t get out of the way, the natural balance of things will be upset. In other words, the limits on longevity are natural and therefore should be respected. People should only live a fixed period of life. If you’ve lived a period of time, say 65 years, then you owe it to someone who has lived, say 25 years, to let go, get out of the way, don’t use costly health care that should be saved for or used on them. It is an argument for the oldest to step aside and let the younger come forward. One problem is that “once the old, however defined, had been ruled out of account; the middle-aged would become the old. They would after all have the greater elapsed time “in the bank” and shorter life expectancy ahead than the rest of society and the cycle of argument and discrimination would have a tendency to extend indefinitely, a tendency moreover that would be difficult to restrain” (Harris, 2005, p. 97). At some point the young and the old merge and there are no older to be rid of. This also assumes that all elderly have the same conditions and lack potential and all young lack health problems and have potential. There is little room for variation, although variation is evident everywhere.
Consider the story of the elderly person who lives in the frozen tundra and finds that there is not enough food for the extended family to make it through the winter. Dutifully, so the story goes, the person walks into the extreme cold to die, thus saving their portion of food for the younger people in the family. So, is it really the responsibility of the elderly to give up their seat and move towards the exit sign at a particular point? Intergenerational equity suggests that an elderly person should do exactly that, after all, “human societies currently are built around expectations of a lifecycle of more limited durations” (Chapman, 2004, p. 479) and the elderly must abide by them. What if they don’t want to? Can it be argued that a utilitarian approach might be more equitable or that Rawlsian ethics (Lebacqz, 1986) will find a different distribution that will “improve the position of the least advantaged in society” (p. 37) by reducing health care to the elderly? If we consider “anti-aging technologies will disrupt all the delicate demographic balanced between the young and the old, and exacerbate the gap between the haves and the have not’s” (Post, 2004, p. 536), we know that historically there have been different expectations in the role of the elderly to the young. The elderly train, provide cultural knowledge, help financially, yet the change in average expected life from less than 50 years in 1900 to almost 80 years in 2000 hasn’t seemed to disrupt this supposedly delicate balance. Can’t the same thing be said about the difference between almost any two periods of time? In 1900 everyone aged along with their cohorts, at the same rate. It can be argued that if science and technology allow for an expanded life expectancy that it will not be in parallel but will widen the gap between those who can afford cutting edge technology and those who can’t. That can’t be fair even though it has been that way for millennia that those with money and influence can purchase more than those with less. But problems are to fix and if “aging is a problem for us, so fixing aging is natural” (Kennedy, 2009, p. 28).
The argument that the elderly should get out of the way and allow younger people to take their place may be an argument spawned, in part, because of the potential tsunami effect that Baby Boomers might have on health care. What is of concern is the consideration that “youth will be displaced rather than elevated” (Post, 2004, p. 536) and that the many Baby Boomers will hold onto jobs and work positions much longer than they might have. Certainly the recent economic times would suggest this is probable anyway. As Baby Boomer retirement savings were reduced with the strong economic downturn, they found a financial need to remain in jobs longer than they might have otherwise. But within this argument is the contention that the elderly owe intergenerational equity to those younger, and it is paid by leaving. Perhaps this notion is not totally incorrect, but it also has a reverse perspective as well. The younger generations owe to the older generations what exists when the younger generation steps into the job market, and into society. The platform has been built even though a younger generation might have built it differently. Don’t all younger generations say that? The older generations have made choices, some of which may have elevated them to positions of power or authority – some of which have relegated them to losing those same positions. Their choices were economic, familial, political, educational, religious, and many others. They have built the businesses that the young wish to step into. To simply say that they should step aside because someone else wants their position is not founded in equity. It may be founded, in part, in a history where some had the audacity to die at an early age and thus leave vacant positions they had previously held, but science and technology, public health and medical care have lengthened the life span so that the average life expectancy is has been greatly extended. Using this same logic of too many people and too few positions, younger Baby Boomers should have been able to kill-off many of their older cohorts simply because there were too many of them to allow each of the younger to climb the ladder of success. This argument screams with unbridled egoism. To each, it may be that we owe equity in terms of making whatever opportunities available to all in a fair manner. This is hard to argue. Added to this, though, is the pretense that there are no cultural barriers or economic status issues that make some more able to succeed than others. Working to eliminate this imbalance is certainly morally honorable.
Science and technology have made the idea of the compression of morbidity a reality, where chronic or acute illnesses are minimized until life is finally taken quickly by some terminal illness. At what age should this illness not be treated because of age or infirmity because the individual is perceived as less valuable to society? Which method of understanding should we make health care policy, knowing that someone will not receive health care? To what do we owe the young, or the elderly, and what do we wish to preserve of each? Those who wish to prolong life may feel that it is a natural wish to do so. Those who wish to maintain a natural life may also feel that it is natural to do so. Spending health care is not like building interest in a bank account. We do not know when our health will be drawn upon and reduced by illness. The amount replenished to society cannot be considered equitable or even between the participants. What genetic make-up we are born with, what choices we make along the way, and what accidents we are lucky enough to avoid all help to determine how long we live.
So what do we do with grandpa and grandma? It’s probable that they’ve lived long enough that they may be in extra innings. The value to their family is extreme. They know the history of the clan, the names that go with pictures, maybe how to wire the house, plumb the water lines, replace the roof, change diapers, calm wounded emotions. They’ve has abided by the rules for decades, paid taxes, scooped snow, raised kids, washed clothes and kids. What does society require of them that they haven’t paid? To encourage them to step aside is to suggest that they owe more to the next generation and the next, when it can also be argued that the next generations owe them. Although it is easy to pit one generation against another, it serves no purpose (Sawhill & Monea, 2008). Entitlements of the type and at the level they now are cannot sustain themselves. The nation has to make some decisions regarding what to allow into the large governmental pot of self-insufficiency, and determine what is reasonable rather than what is politically advantageous. Every illness, every malady, cannot be cured. We should try. If there is evidence-based medicine, there is evidence of what can be done and what can’t. We have no nationally centralized planning process to determine the boundaries of what we, as a nation, can provide. Loy & Chi (2005) are correct to point out that “the present generation has mastered the art of pushing the costs of shortsighted decisions onto future generations” (p. 458) when they include Social Security, the National Debt, and Global Warming and to that add Medicare and Medicaid. But the present generation didn’t begin or significantly alter Social Security. The National Debt has grown, in part, because of continued war around the globe that has not been put to a litmus test through voting by this or any other generation. The idea of Medicare as a cushion for the elderly has never bended to the politically difficult position of including a means test even though most recognize the inherent fairness of doing so. Politicians have bent over backwards to accommodate expanding Medicare beyond its beginning boundaries to include any health care issues that can be seen on the open horizon. National health policies do not address what is fair or equitable or honorable. It has been suggested that once Congress has to find health care insurance coverage in the open market like their constituents that perhaps something new will happen. We should find out; “the test of every institution or policy is whether it enhances or threatens human life and dignity” (U.S. Catholic Conference, 1990).
Giordano (2005) declared, “no age-based rationing may be considered coherent with universal ethical principles and that there is no valid reason, either theoretical or empirical, to deny the elderly full membership to the human family” (p. 90). Full membership includes those younger than 15 and older than 40. Let the debate continue, trying to find an ethical base that supports the people being harmed or helped – an ethical base of fair distribution suggests a supply chain rather than medical care. To determine what health care can be provided based on age – too young or too old - is wrong.
References
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©2010 American Academy of Medical Administrators - All Rights Reserved.
As published in the American Academy of Medical Administrators, EXECUTIVE, May/June 2010
The health care policy discussions continue across the country, many asking what we should do with the elderly. There isn’t enough health care to go around, it is said, and we can’t sustain what we’re doing – spending lots of money and not getting the return we’d anticipated. We’ve got to figure out who’s spending the most money, it would seem, and tell them to stop it. The question seems to be what to do with grandpa and grandma. As grandpa’s, this is quite disconcerting. There are many unanswered questions regarding health care for the elderly including who should be covered, for how long they should be covered, for what kinds of illnesses, who should pay for these services, and on what basis should decisions regarding their care be made. Some might question whether the decision should be made on some random or arbitrary basis or should some ethical base be used to help assure a modicum of fairness or equity. Others might question whether fairness is possible with scarce resources, or whether equity applies, or could be applied. While a discussion regarding the elderly may center on the most elderly, the old-old over 85 years of age, policy decisions seem to start around the age of graduating to Medicare with the young–old at 65 years of age.
Some would suggest that the idea of aging is an antiquated idea itself, that the scientific and biotechnological era heralds a new age of defeating chronic pain, illness, and aging as it moves forward (Mykytyn, 2006). With this perspective the emphasis is not on rationing, rather it is on eliminating chronic conditions and reducing the time a person is aged. There are those who disagree. They suggest that a certain amount of illness, wear and tear on the body and mind, goes along with the process of aging; that “the price we pay for long life is debility” (Lachs, 2004, p. 176). Within this last idea is a suggestion that many [perhaps all?] of us both earn and wear our debilities through aging as mementos of an earlier age and afflictions.
The aging or aged body is different from the young or youthful body and the health care resources needed to sustain/maintain it are also different. A natural law perspective suggests that after using our bodies for a prolonged period, the elderly should be required to relinquish any remaining or retained youthfulness (Post, 2004), and with that relinquishing, prepare themselves for a so-called natural end; without prolonging the aging process or altering it. Viewed from a different vantage, others suggest that human nature is an obstacle to be overcome (Hook, C.C. as cited in Post, 2004, p. 535) and that nature is what is unnatural in considering the elderly. What was natural in 1900 is markedly different than 2000. We had less sanitation, no antibiotics, pasteurization, we died earlier, and that was natural.
Much of the discussion regarding scarce resources in health care focuses on how to allocate those resources. After all, “in 2006, the median annual health care expenditure for persons age 65 and over was $4,032,with about one-quarter of the elderly having no expenses or expenses under $1,752 (25th percentile) and one-quarter having expenses over $9,289 (75th percentile) (Machlin, 2009). Maybe all that we need to do to save money is find those in the 75th percentile and tell them to stop being sick! Or stop them from using scarce resources.
Recognizing that nothing is free, “costless benefits are not only unattainable, [but that is] a misleading ideal (Lachs, 2004, p. 175), we also recognize that age is not simply about health, we must have usefulness as well or it becomes empty. Usefulness does not necessarily mean productivity. We can mechanize the process of determining who gets what health care by calculating quality-adjusted life years (QALYs) and comparing perfect health and then reducing debilities to arrive at a score. Comparing QALYs against perfect health (Persad, Wertheimer & Emanual, 2009, p. 427) is inherently ageist. To do the calculation requires value judgment at the beginning and value cannot adequately be determined from outside the individual dispassionately or without bias. So how do we decide about how much we’ll allow for the elderly, call it what it really is - rationing or limiting health care to the elderly – if there is an unequal allocation based on something other than illness or disease. Rationing can occur by allowing payment for certain medical procedures based on age or disallowing them using the same rationale.
Another method of calculation is to view the person, and whatever their illness or debility, and to make a determination of how long they might live, considering all that. If they have less than a certain number of years, they aren’t allowed more than palliative care. Or, in an actuarially determined mode, an elderly person could be given an average determination of expected longevity based on their prognosis and after their cohort average has been attained, no additional health care would be given. This method might even parallel the quality adjusted life years mode. Do we really want to give determination for health care services to the accountants?
A variation might be to provide health care only to those who could benefit, that is, extend their actuarially determined life span by treatment. If one has a genetic predisposition to be sicker than the actuarial tables might suggest or recommend, they might receive services until they attain their cohort average and then services would stop. If one has the genetic predisposition to live less sick they would be allowed to continue without healthcare services because they wouldn’t be needed. After surpassing the average for their cohort, however, they would not be able to receive additional services. This method of deciding when to allow and when to withhold health care assumes that age, by itself, can determine the value of an individual – beyond a certain age point the value is not worth maintaining.
Others have put together combinations of ethical or allocation principles in order to suggest a “complete lives system” (Persad, Werthiemer & Emanuel, 2009, p. 428). This system, very well presented, also “produces a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial change, whereas the youngest and oldest people get chances that are attenuated” (p. 428). Part of the argument is that those younger than 15 haven’t had enough “personal investment that people are morally entitled to have received at a particular age” (p. 428). This recommends, in part, that health care services should be less for the young and elderly – or in this case, those over 40 years old.
A fiscally responsible method of determining which elderly should receive health care might be based on the potential outcome. If risk of medical success is below a particular percent or probability, then care would be withheld. It is not in society’s interest to waste health care resources, and that top 25th percent are very expensive. But perhaps it is best to provide health care only to those who are the sickest and leave those who only have chronic illness alone, after all, natural law will take care of them in due time.
Perhaps one of the most easily determined methods to select who obtains health care’s scarce resources is simply to draw a line in the aging sand – beyond a particular age, no additional health care is provided. While it may seem harsh, it may have merit on the basis of equity. Since everyone is checked into Medicare at the same age, why not have everyone begin the process of checking out using the same logic. It might make for an uneven playing field if those with wealth could obtain care while those without couldn’t, much like inclusion in Medicare without a means test, but it’s an idea. Another method might be to allow those who have access to health care through insurance to obtain it, however, that also seems to favor the wealthy over the less wealthy and the employed or retired with benefits over those without. That seems to be without merit on the basis of equity. It also seems to be one of the main sources of discrimination that politicians seek to remedy at the moment. An alternative is to increase taxes for those that have in order to distribute them to those who have much less. A major issue down the road is when the haves and have not’s arrive at the same point.
What’s fair in the mix? There is health care rationing in the U.K. (Giordano, 2005) and a call for governmental rationing in Australia as well (Johnstone & Kanitsaki, 2009) and a feeling that without rationing that “public services will ultimately collapse under the strain of the ever increasing demands placed on these services” (p. 86). The discussion, it seems, may be mostly about how much a society wishes to pay for the health care services for their elderly, rather than whether it should feel obligated to do so. After all, some may say, the elderly are the ones to blame for the world’s ills anyway. While the percent of gross domestic product that health care represents is considered high, no central planning has determined how much, what percent, is appropriate to meet the needs of citizens, only that what we’re experiencing is too much. What to cover, what to pay for with collected taxes, has not been determined either. As single illness support groups have approached Congress, the elected representatives have repeatedly sought to include everything and everyone. Perhaps that is admirable. Indeed, discussions regarding health care seem to include non-citizens within the same moral stance. The EMTALA laws don’t allow an emergency room to turn away patients or to ask for their legal status before treatment. Fair, in that case, is certainly in the eyes of the beholder.
The so-called fair innings argument suggests that those who have lived beyond a particular point have a responsibility to those who haven’t yet lived equal innings to step aside; to assure that those younger have the opportunity to complete at least a minimum number of innings. This argument suggests that “the value of life can be measured in units of lifetime” (Harris, 2005, p. 95). It also assumes that each measure is the same for each person, that age is the only pertinent discriminating factor, more so than experience or education or genetic make-up, or relative success or failure or illness. To continue the metaphor, once someone has the bases loaded and has done well with their life, up to a point, we bring in a rookie because the rookie needs playing time. Whose game is it, anyway? What is a fair inning?
Normal is a word with various meanings that can be applied when ever advantageous for the sake of an argument. Here, the normal death for animals and plants can be used to suggest that there is a normal life span, and normal does not include extensions to that life span (Mykytyn, 2006). Life happens, death happens – it’s all normal. But is it considered normal to take beta-blockers and ace inhibitors, as an example, or is it a subversive act or implicit support for prolongevity? Certainly, many individuals would have died much earlier and with great health care savings had they not taken anti-aging pharmaceuticals or, perhaps, not acquiesced to by-pass surgeries and used so many resources. Is that prolongevity or is it bad social policy to consider it is anti-aging? There are those who suggest that if only we prevent chronic disease we save health care expenses, however, that appears to be an incorrect assumption since, “less than 20 percent of the preventive options (and a similar percentage for treatment) fall in the cost-saving category-80 percent add more to medical costs than they save” (Russell, 2009, p. 45). The cost of chronic disease causes such a “disproportionate burden” that it may “discourage adherence to drugs that prevent disease progression” (Paez, Zhao, & Hwang, 2009, p. 15). “In 2005, 133 million Americans were living with at least one chronic condition” (Bodenheimer, Chen & Bennett, 2009, p. 64).
Aging, by itself, isn’t the problem, but the pain and suffering from illnesses is the problem. The whole notion of anti-aging medicine challenges the notion of aging as a disease. It certainly makes sense that “what is costly is not “old age” but disability and poor health” (Giordano, 2005, p. 88). If only we, through science and technology, can find remedies or cures for the ailments that align with aging, once they are eliminated or greatly diminished then aging can be a period of time to be desired and enjoyed. Nonsense, suggests others, the idea shouldn’t be about eradicating disease and illnesses for the purpose of extending the human lifespan (Chapman, 2004). Instead, society should use money otherwise spent for the purpose of “providing basic medical services to everyone in our own country and ameliorating basic health needs elsewhere in the world” (Chapman, 2004, p. 488). Without basic health care for all, prolonging the life span or curing chronic ailments is viewed, from this vantage, as inappropriate. Just as convinced are those who feel there is an obligation to eliminate illness and extend the natural life span.
Distributive justice requires a fair distribution of life-years (Persad, 2009), the idea being that young people have a right to a particular number of years of life, very similar to the fair innings argument, although few suggest what the number of years or length of the innings might be. Distributive justice is based on equality; however, equality is not possible if the playing field is uneven to begin with. Consider the person who is born with medical maladies, Does equality suggest that they forego health care since their age cohorts don’t need that same, or similar, health care? Suggesting the use of age as a basis for rationing is discriminatory and yet it is that very discrimination that is encouraged in the elderly through distributive justice, and rationing. Through this consideration of equality rests an assumption that every person is born with an innate ability, provided in some utilitarian sense. What do we do with the less than perfect individuals who, early in life, require life-sustaining support because of illness or accident or genetic disposition? If we eliminate health care for these because of their supposed lack of ability to contribute to society in the same manner or level as those who have not yet been ill or had an accident, money is saved but at a terrible cost. Does it apply to the premature infant, the spina bifida, the one with a hole in their just born heart – fixable, but at a cost? Which illness do we suggest is not worth saving, for whom, and at what cost? Which of the many illnesses, diseases, chronic maladies, or accidents will we consider to lessen the value of the individual to the point that their continued care is not worth the price? This does not consider those who are in a vegetative state, only those who are “less” than those around them. Maybe you’re one of them.
Priority must be given to younger people for health care based on their years, or lack of years, and the potential they have, it has been suggested. If the elderly don’t get out of the way, the natural balance of things will be upset. In other words, the limits on longevity are natural and therefore should be respected. People should only live a fixed period of life. If you’ve lived a period of time, say 65 years, then you owe it to someone who has lived, say 25 years, to let go, get out of the way, don’t use costly health care that should be saved for or used on them. It is an argument for the oldest to step aside and let the younger come forward. One problem is that “once the old, however defined, had been ruled out of account; the middle-aged would become the old. They would after all have the greater elapsed time “in the bank” and shorter life expectancy ahead than the rest of society and the cycle of argument and discrimination would have a tendency to extend indefinitely, a tendency moreover that would be difficult to restrain” (Harris, 2005, p. 97). At some point the young and the old merge and there are no older to be rid of. This also assumes that all elderly have the same conditions and lack potential and all young lack health problems and have potential. There is little room for variation, although variation is evident everywhere.
Consider the story of the elderly person who lives in the frozen tundra and finds that there is not enough food for the extended family to make it through the winter. Dutifully, so the story goes, the person walks into the extreme cold to die, thus saving their portion of food for the younger people in the family. So, is it really the responsibility of the elderly to give up their seat and move towards the exit sign at a particular point? Intergenerational equity suggests that an elderly person should do exactly that, after all, “human societies currently are built around expectations of a lifecycle of more limited durations” (Chapman, 2004, p. 479) and the elderly must abide by them. What if they don’t want to? Can it be argued that a utilitarian approach might be more equitable or that Rawlsian ethics (Lebacqz, 1986) will find a different distribution that will “improve the position of the least advantaged in society” (p. 37) by reducing health care to the elderly? If we consider “anti-aging technologies will disrupt all the delicate demographic balanced between the young and the old, and exacerbate the gap between the haves and the have not’s” (Post, 2004, p. 536), we know that historically there have been different expectations in the role of the elderly to the young. The elderly train, provide cultural knowledge, help financially, yet the change in average expected life from less than 50 years in 1900 to almost 80 years in 2000 hasn’t seemed to disrupt this supposedly delicate balance. Can’t the same thing be said about the difference between almost any two periods of time? In 1900 everyone aged along with their cohorts, at the same rate. It can be argued that if science and technology allow for an expanded life expectancy that it will not be in parallel but will widen the gap between those who can afford cutting edge technology and those who can’t. That can’t be fair even though it has been that way for millennia that those with money and influence can purchase more than those with less. But problems are to fix and if “aging is a problem for us, so fixing aging is natural” (Kennedy, 2009, p. 28).
The argument that the elderly should get out of the way and allow younger people to take their place may be an argument spawned, in part, because of the potential tsunami effect that Baby Boomers might have on health care. What is of concern is the consideration that “youth will be displaced rather than elevated” (Post, 2004, p. 536) and that the many Baby Boomers will hold onto jobs and work positions much longer than they might have. Certainly the recent economic times would suggest this is probable anyway. As Baby Boomer retirement savings were reduced with the strong economic downturn, they found a financial need to remain in jobs longer than they might have otherwise. But within this argument is the contention that the elderly owe intergenerational equity to those younger, and it is paid by leaving. Perhaps this notion is not totally incorrect, but it also has a reverse perspective as well. The younger generations owe to the older generations what exists when the younger generation steps into the job market, and into society. The platform has been built even though a younger generation might have built it differently. Don’t all younger generations say that? The older generations have made choices, some of which may have elevated them to positions of power or authority – some of which have relegated them to losing those same positions. Their choices were economic, familial, political, educational, religious, and many others. They have built the businesses that the young wish to step into. To simply say that they should step aside because someone else wants their position is not founded in equity. It may be founded, in part, in a history where some had the audacity to die at an early age and thus leave vacant positions they had previously held, but science and technology, public health and medical care have lengthened the life span so that the average life expectancy is has been greatly extended. Using this same logic of too many people and too few positions, younger Baby Boomers should have been able to kill-off many of their older cohorts simply because there were too many of them to allow each of the younger to climb the ladder of success. This argument screams with unbridled egoism. To each, it may be that we owe equity in terms of making whatever opportunities available to all in a fair manner. This is hard to argue. Added to this, though, is the pretense that there are no cultural barriers or economic status issues that make some more able to succeed than others. Working to eliminate this imbalance is certainly morally honorable.
Science and technology have made the idea of the compression of morbidity a reality, where chronic or acute illnesses are minimized until life is finally taken quickly by some terminal illness. At what age should this illness not be treated because of age or infirmity because the individual is perceived as less valuable to society? Which method of understanding should we make health care policy, knowing that someone will not receive health care? To what do we owe the young, or the elderly, and what do we wish to preserve of each? Those who wish to prolong life may feel that it is a natural wish to do so. Those who wish to maintain a natural life may also feel that it is natural to do so. Spending health care is not like building interest in a bank account. We do not know when our health will be drawn upon and reduced by illness. The amount replenished to society cannot be considered equitable or even between the participants. What genetic make-up we are born with, what choices we make along the way, and what accidents we are lucky enough to avoid all help to determine how long we live.
So what do we do with grandpa and grandma? It’s probable that they’ve lived long enough that they may be in extra innings. The value to their family is extreme. They know the history of the clan, the names that go with pictures, maybe how to wire the house, plumb the water lines, replace the roof, change diapers, calm wounded emotions. They’ve has abided by the rules for decades, paid taxes, scooped snow, raised kids, washed clothes and kids. What does society require of them that they haven’t paid? To encourage them to step aside is to suggest that they owe more to the next generation and the next, when it can also be argued that the next generations owe them. Although it is easy to pit one generation against another, it serves no purpose (Sawhill & Monea, 2008). Entitlements of the type and at the level they now are cannot sustain themselves. The nation has to make some decisions regarding what to allow into the large governmental pot of self-insufficiency, and determine what is reasonable rather than what is politically advantageous. Every illness, every malady, cannot be cured. We should try. If there is evidence-based medicine, there is evidence of what can be done and what can’t. We have no nationally centralized planning process to determine the boundaries of what we, as a nation, can provide. Loy & Chi (2005) are correct to point out that “the present generation has mastered the art of pushing the costs of shortsighted decisions onto future generations” (p. 458) when they include Social Security, the National Debt, and Global Warming and to that add Medicare and Medicaid. But the present generation didn’t begin or significantly alter Social Security. The National Debt has grown, in part, because of continued war around the globe that has not been put to a litmus test through voting by this or any other generation. The idea of Medicare as a cushion for the elderly has never bended to the politically difficult position of including a means test even though most recognize the inherent fairness of doing so. Politicians have bent over backwards to accommodate expanding Medicare beyond its beginning boundaries to include any health care issues that can be seen on the open horizon. National health policies do not address what is fair or equitable or honorable. It has been suggested that once Congress has to find health care insurance coverage in the open market like their constituents that perhaps something new will happen. We should find out; “the test of every institution or policy is whether it enhances or threatens human life and dignity” (U.S. Catholic Conference, 1990).
Giordano (2005) declared, “no age-based rationing may be considered coherent with universal ethical principles and that there is no valid reason, either theoretical or empirical, to deny the elderly full membership to the human family” (p. 90). Full membership includes those younger than 15 and older than 40. Let the debate continue, trying to find an ethical base that supports the people being harmed or helped – an ethical base of fair distribution suggests a supply chain rather than medical care. To determine what health care can be provided based on age – too young or too old - is wrong.
References
Bodenheimer, T., Chen, E. & Bennett, H.D. (2009). Confronting the growing burden of chronic
disease: Can the U.S. health care workforce do the job? Health Affairs, 28(1), p. 64-74.
doi: 1628336011
Chapman, A.R. (2004). Ethical implications for prolonged lives, Theology Today, 60, 479-496.
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Frischmann, B.M. (2005). Some thoughts on shortsightedness and intergenerational equity,
Loyola University Chicago Law Journal, 36, 457-467. Retrieved from
http://www.lexisnexis.com.ezp.waldenulibrary.org/us/lnacademic/search/homesubmitForm.do
Giordano, S. (2005). Respect for equality and the treatment of the elderly: Declarations of human
rights and age-based rationing, Cambridge Quarterly of Healthcare Ethics, 14(1), 83-92.
Doi: 788794571
Harris, J. (2005). The age-indifference principle and equality, Cambridge Quarterly of
Healthcare Ethics, 14, 93-99. doi: 788794581
Johnstone, M. & Kanitsaki, O. (2009). Population ageing and the politics of demographic
alarmism: Implications for the nursing profession, Australian Journal of Advanced Nursing
26(3), 86-92. doi: 2010317876
Kennedy, T. D. (2009). Anti-aging, rights and human nature, Ethics & Medicine, 25(1), p 21-29.
Doi: 1627013541
Lachs, J. (2004). Is Aging a Disease? HEC Forum, 16(3) 173-181. Doi: 735224031
Lebacqz, K. (1986). Six theories of justice: Perspectives from philosophical and theological
ethics, Minneapolis, MN: Augsburg Publishing Home
Machlin, S. (2009). Trends in health care expenditures for the elderly age 65 and over: 2006
versus 1996. Statistical Brief #256, Agency for Healthcare Research and Quality, 1-7.
Mykytyn, C.E., (2006). Anti-aging medicine: Predictions, moral obligations, and biomedical
intervention, Anthropological Quarterly, 79(1), 5-31. Doi: 20399826
Paez, K. A., Zhao, L. & Hwang, W. (2009). Rising out-of-pocket spending for chronic
conditions: A ten-year trend, Health Affairs, 28(1), 15-25. Doi: 1628335951
Persad, G., Wortheimer, A. & Emanuel, E. (2009). Principles for allocation of scarce medical
interventions, Lancet, 373(9661), 423-31. Doi: 1662930511
Post, G. (2004). Establishing an appropriate ethical framework: the moral conversation around
the goal of prolongevity, The Journals of Gerontology, 59A( 6), 534-539. Doi: 665442221
Russell, L.B.(2009). Preventing chronic disease: An important investment, but don’t count on
cost savings. Health Affairs, 28(1), 42-45. Doi: 1628335971
Sawhill, I. & Monea, E. (2008). Old news. Democracy: A journal of ideas, 9, 20-31. Doi: 1560006271
United States Catholic Conference, (1990). A century of social teaching: A continuing challenge.
©2010 American Academy of Medical Administrators - All Rights Reserved.
Sunday, May 9, 2010
Government Run Health Care
With complete credit to author and futurist, Ian Morrison, I recommend this thoughtful article.
Government Run Health Care
By Ian Morrison
Powerful forces will expand public funding of health care no matter what.
About the time you read this column we will have Government Run Health Care. No, it's not what you think. While Obamacare has just passed in Congress, the full effect of the legislation will not be felt until 2014 and beyond. No, what I mean is that even if health care reform is repealed, or blocked in implementation, the public sector share of health spending will exceed 50 percent in 2010 for the first time.
Wait, you wonks say, the recent official CMS projections say that doesn't happen until 2012. (See "Health Spending Projections Through 2019: The Recession's Impact Continues," by Christopher J. Truffer, Sean Keehan, Sheila Smith, Jonathan Cylus, Andrea Sisko, John A. Poisal, Joseph Lizonitz and M. Kent Clemens, in Health Affairs, vol. 29, no. 3 [March/April 2010], http://content.healthaffairs.org/cgi/reprint/29/3/522.pdf.) True, but read the fine print. That forecast assumes that Medicare follows current law and cuts Medicare physicians' fees by 20 percent in March because of the sustainable growth rate (SGR) provisions. Since SGR is set to get its annual stay of execution extended for another year, if you follow the authors' own math, then sometime in mid-2010 public payment will exceed private payment in American health care for the first time.
Demography and Recession
As the CMS projections show, this is a result of relentless demographic change, coupled to the lingering effects of the massive economic downturn, which raised Medicaid burdens by a record annual increase of 3.3 million eligibles (to a total of 46.3 million), swollen the ranks of the COBRA-subsidized, and reduced the total number of privately insured by 1.2 percent. But, this is no short-term phenomenon. CMS' current law projection has the public sector growing more than the private sector as far as its eye can see (which is up until 2019). Beyond that, you don't need to be an actuary or futurist to realize that the private sector is unlikely to make a late-breaking comeback in the fourth quarter because of the aging of the baby boom. (By the way, one of my working definitions of a futurist is an actuary who doesn't like numbers.)
Remember, the baby boomers have just started to become Medicare eligible. We are on our way! We boomers can't wait to convert from the uncertainty and capriciousness of private-sector health insurance coverage—especially those of us buying individual coverage from Anthem in California (as my family does)—and get our hands on one of those Magic Kingdom cards that is Medicare, which guarantee we can see pretty much any doctor and that Medicare will at least pay them something. Sounds pretty good to me, even though the benefit consultants and financial planners tell us we also will each need to save $500,000 for our lifetime out-of-pocket medical costs not covered by Medicare. That still may be a better deal than a lifelong relationship with Anthem, trust me.
Higher Taxes Are Inevitable
Republicans are not the mean-spirited rubes that so many sneering progressive intellectuals make them out to be. They understand this math perfectly, and they do not want any part of the massive tax increases that this inexorable, demographically induced march implies.
Republicans were therefore not exactly big fans of the Obama administration wanting to expand coverage to the poor and middle class through government subsidies (albeit that the administration plans are in part financed by provider rate cuts in Medicare). Plus, all of the Democratic legislation expands Medicaid by 16 million enrollees. Medicaid is another publicly financed program, not particularly near and dear to the core Republican voter (or, as the polls show, it is not particularly popular with Independents).
The Republican Plan
So the demographic inevitability of higher taxes for health care motivates Republicans to fight any health care coverage expansion that is funded through public financing.
This partly explains what happened at the exquisite Kabuki Theater of the Health Care Summit at Blair House. The Republicans' goal was to stop this rollercoaster; better yet, reverse it. Step 1 was to stop Obamacare. The Republicans had exactly the same cue cards—some Republican leaders read them better than others—but they all said, "Start over, clean sheet of paper, step by step." It could be a top-40 electro-pop lyric that would make the Black-Eyed Peas proud.
Step 2 is to propose sensible, reasonable, American alternatives. (By the way, clue me in here, who gets to decide what are sensible, reasonable, American alternatives?)
The Republican plan was estimated to reduce the uninsured by 3 million and this was achieved, as follows:
Say "free market" a lot. Government health care is bad, free market health care is good. (I graduated from Edinburgh University 200 years to the day after Adam Smith went there to write The Wealth of Nations, and we still see each other at alumni meetings. He would be appalled that the term free market was applied to anything in American health care. Even private-sector health care bears little resemblance to a free market.)
Create high-risk pools at the state level so you can turbo-charge the death spiral in the insurance market. A high-risk pool makes health insurance cheaper for healthy people and more expensive for sick people. Whenever high-risk pools have been established at the state level, they rapidly death-spiral out of control.
Provide tiny wee tax credits for "affordable insurance." The polls show Americans like tax credits, particularly for small business. What the polls don't always measure is that the tax credits would not be sufficient to pay for the insurance; getting a tiny wee tax credit toward a very big expensive health insurance bill doesn't sound so good.
Create "affordable insurance policies" that don't cover anything. We know how to make health insurance premiums cheaper. It's simple: Limit what's covered and raise the cost-sharing. But wait, isn't that what everyone's mad about?
Encourage consumers to buy "affordable insurance" from an insurance company in another state that has no consumer protection and no contractual relationship with local doctors and hospitals. Practically, insurance executives tell me, there really are no states with significantly cheaper policies that could be sold in other states, unless of course they are trying to eliminate consumer protection. Or maybe it's because of the bargaining clout that an insurer in Alabama has over my doctor in Palo Alto, Calif.
Reform malpractice caps to reduce defensive medicine and let doctors focus on offensive medicine. Policy wonks dismiss malpractice as a driver of health care costs, but it is a big issue to doctors and to Republicans. (Personally, I believe the Obama administration missed a huge opportunity from the beginning by not embracing comprehensive medical malpractice coupled to patient safety reform.)
Increase personal responsibility. Successful surgeon senators advocate for "skin in the game"; community organizer presidents empathize more with $40,000-a-year families who can't pay for food or gas, let alone health insurance. These families have more than enough "skin in the game."
Borrow more money from the Chinese so we can cut taxes. Deficits would remain large and growing even if all these "sensible, step by step" plans were pursued. Therefore any tax cuts would have to be financed by borrowing from the Chinese, just as we have over the last decade.
The Democratic Plan
In the interest of being fair and balanced, we need to scrutinize the health reform legislation that just passed in Congress with the same degree of "vitriolic sardonicism" as Monty Python called it. Democrats will cover 30-plus million of the uninsured (10 times the Republican number) and they achieve this as follows:
Expand Medicaid by 16 million because it is such a swell program. The bill expands Medicaid by 16 million enrollees. When did Medicaid become such a great program? Did I miss a class? I thought it was horribly inefficient from an enrollment point of view and provided such pathetic levels of reimbursement that most mainstream providers won't accept Medicaid patients. Yet it has become the vehicle for half of the newly covered. Maybe that is why so many moderates liked the Wyden-Bennet proposal where people get a voucher. And there's your answer to why the Wyden-Bennet plan had no traction: It's pretty easy to stop printing little vouchers under a change in administration; it's a little more difficult to dismantle an entitlement program for 60 million people.
Have taxpayers in the states with generous Medicaid programs subsidize the Medicaid expansion in the states with less generous Medicaid. I spent the week of the Kabuki Summit, not in Washington, New York or California, but in Oklahoma and South Dakota. And I heard about, and experienced directly, entire local state legislatures and majorities of individuals in the community committed to sending back Obamacare money to Washington if it passed, refusing to accept the rule of the federal government if reform passed, and pleas of "Liberty or death."
Whoa! The delicious irony is that the greatest potential beneficiaries of Obamacare are the very states with the most tight-fisted Medicaid programs. Liberal California software executives and closet lefty Goldman Sachs partners would be paying increased federal taxes to support the Medicaid programs for the less than munificent taxpayers of Texas and Alabama. The Massachusetts voters figured this out in their vote for Scott Brown; they already had Obamacare and like it, so why did they need to pay twice?
Mandate that most other uninsured Americans buy health insurance that they can't really afford. Under Obamacare you must have health insurance, unless you really can't afford it, or you work for a very small business (where most of the uninsured are) or you are a Christian Scientist, or you take a free ride because you can do first-grade arithmetic and figure out that paying the fine is way cheaper than buying insurance. Apart from those limited exceptions, you must have insurance.
And then subsidize them so they can. Did we tell you that we are subsidizing you to buy unaffordable insurance? (Ben Stein, the noted economist, columnist and media celebrity, said on CNN after the summit that we should just give poor people the money to buy health insurance in the private market.) Here's the conversation you would have with a typical uninsured family with two kids, making $40,000 a year:
"Hey folks. I am from the government. Here's $12,000, but we would like you to buy health insurance with it."
"This is Candid Camera, right?"
Regulate insurance companies to take all comers even though all comers are not going to come. There is this pesky little problem with private health insurance markets. Insurers want to make sure that the people who sign up are not just sick people. And if they sign up only sick people, they want to be able to charge what it costs to treat those sick people, plus a fee for administration. Come on now. Be reasonable.
Raise fees and taxes on stakeholders who will pass it on in higher costs to the end consumer. Tax drug companies, medical device manufacturers, insurers and providers. These taxes will be passed on immediately to the end user in higher prices.
Start the taxes now; add the coverage later so in the next 10 years it actually reduces the deficit. Gather in all the taxes, now, so you can pay for expanded coverage later. If you have new revenues for a few years before the costs start, it makes it easier to make it budget neutral and in fact actually reduce the deficit. But…
In the long run, hold your breath and be prepared to borrow even more money from the Chinese. Once we get to a true run rate of the costs of reform, it may be difficult to say we are reducing the deficit because of reform.
We now know who really won the Kabuki Summit. Rahm Emanuel and the Democratic leaders in Congress have "persuaded" enough blue dog Democrats to vote for the good of the party for health reform with this parting comment:
"We know you are going to lose your seat over this, but you have to vote for this; otherwise we won't have health reform for another decade, and then it's too late. We're sorry it didn't work out for you here. But we have some parting gifts for you. Thanks for playing."
This is historic, important and directionally correct legislation that will change health care dramatically when it is fully implemented in 2014. But even in the interim, we will have Government Run Health Care no matter what. We just have to learn how to make it all work better.
Ian Morrison is an author, consultant and futurist based in Menlo Park, Calif. He is also a regular contributor to H&HN Weekly and a member of Health Forum's Forum Faculty Speaker Service.
This article 1st appeared on May 3, 2010 in HHN Magazine online site.
Government Run Health Care
By Ian Morrison
Powerful forces will expand public funding of health care no matter what.
About the time you read this column we will have Government Run Health Care. No, it's not what you think. While Obamacare has just passed in Congress, the full effect of the legislation will not be felt until 2014 and beyond. No, what I mean is that even if health care reform is repealed, or blocked in implementation, the public sector share of health spending will exceed 50 percent in 2010 for the first time.
Wait, you wonks say, the recent official CMS projections say that doesn't happen until 2012. (See "Health Spending Projections Through 2019: The Recession's Impact Continues," by Christopher J. Truffer, Sean Keehan, Sheila Smith, Jonathan Cylus, Andrea Sisko, John A. Poisal, Joseph Lizonitz and M. Kent Clemens, in Health Affairs, vol. 29, no. 3 [March/April 2010], http://content.healthaffairs.org/cgi/reprint/29/3/522.pdf.) True, but read the fine print. That forecast assumes that Medicare follows current law and cuts Medicare physicians' fees by 20 percent in March because of the sustainable growth rate (SGR) provisions. Since SGR is set to get its annual stay of execution extended for another year, if you follow the authors' own math, then sometime in mid-2010 public payment will exceed private payment in American health care for the first time.
Demography and Recession
As the CMS projections show, this is a result of relentless demographic change, coupled to the lingering effects of the massive economic downturn, which raised Medicaid burdens by a record annual increase of 3.3 million eligibles (to a total of 46.3 million), swollen the ranks of the COBRA-subsidized, and reduced the total number of privately insured by 1.2 percent. But, this is no short-term phenomenon. CMS' current law projection has the public sector growing more than the private sector as far as its eye can see (which is up until 2019). Beyond that, you don't need to be an actuary or futurist to realize that the private sector is unlikely to make a late-breaking comeback in the fourth quarter because of the aging of the baby boom. (By the way, one of my working definitions of a futurist is an actuary who doesn't like numbers.)
Remember, the baby boomers have just started to become Medicare eligible. We are on our way! We boomers can't wait to convert from the uncertainty and capriciousness of private-sector health insurance coverage—especially those of us buying individual coverage from Anthem in California (as my family does)—and get our hands on one of those Magic Kingdom cards that is Medicare, which guarantee we can see pretty much any doctor and that Medicare will at least pay them something. Sounds pretty good to me, even though the benefit consultants and financial planners tell us we also will each need to save $500,000 for our lifetime out-of-pocket medical costs not covered by Medicare. That still may be a better deal than a lifelong relationship with Anthem, trust me.
Higher Taxes Are Inevitable
Republicans are not the mean-spirited rubes that so many sneering progressive intellectuals make them out to be. They understand this math perfectly, and they do not want any part of the massive tax increases that this inexorable, demographically induced march implies.
Republicans were therefore not exactly big fans of the Obama administration wanting to expand coverage to the poor and middle class through government subsidies (albeit that the administration plans are in part financed by provider rate cuts in Medicare). Plus, all of the Democratic legislation expands Medicaid by 16 million enrollees. Medicaid is another publicly financed program, not particularly near and dear to the core Republican voter (or, as the polls show, it is not particularly popular with Independents).
The Republican Plan
So the demographic inevitability of higher taxes for health care motivates Republicans to fight any health care coverage expansion that is funded through public financing.
This partly explains what happened at the exquisite Kabuki Theater of the Health Care Summit at Blair House. The Republicans' goal was to stop this rollercoaster; better yet, reverse it. Step 1 was to stop Obamacare. The Republicans had exactly the same cue cards—some Republican leaders read them better than others—but they all said, "Start over, clean sheet of paper, step by step." It could be a top-40 electro-pop lyric that would make the Black-Eyed Peas proud.
Step 2 is to propose sensible, reasonable, American alternatives. (By the way, clue me in here, who gets to decide what are sensible, reasonable, American alternatives?)
The Republican plan was estimated to reduce the uninsured by 3 million and this was achieved, as follows:
Say "free market" a lot. Government health care is bad, free market health care is good. (I graduated from Edinburgh University 200 years to the day after Adam Smith went there to write The Wealth of Nations, and we still see each other at alumni meetings. He would be appalled that the term free market was applied to anything in American health care. Even private-sector health care bears little resemblance to a free market.)
Create high-risk pools at the state level so you can turbo-charge the death spiral in the insurance market. A high-risk pool makes health insurance cheaper for healthy people and more expensive for sick people. Whenever high-risk pools have been established at the state level, they rapidly death-spiral out of control.
Provide tiny wee tax credits for "affordable insurance." The polls show Americans like tax credits, particularly for small business. What the polls don't always measure is that the tax credits would not be sufficient to pay for the insurance; getting a tiny wee tax credit toward a very big expensive health insurance bill doesn't sound so good.
Create "affordable insurance policies" that don't cover anything. We know how to make health insurance premiums cheaper. It's simple: Limit what's covered and raise the cost-sharing. But wait, isn't that what everyone's mad about?
Encourage consumers to buy "affordable insurance" from an insurance company in another state that has no consumer protection and no contractual relationship with local doctors and hospitals. Practically, insurance executives tell me, there really are no states with significantly cheaper policies that could be sold in other states, unless of course they are trying to eliminate consumer protection. Or maybe it's because of the bargaining clout that an insurer in Alabama has over my doctor in Palo Alto, Calif.
Reform malpractice caps to reduce defensive medicine and let doctors focus on offensive medicine. Policy wonks dismiss malpractice as a driver of health care costs, but it is a big issue to doctors and to Republicans. (Personally, I believe the Obama administration missed a huge opportunity from the beginning by not embracing comprehensive medical malpractice coupled to patient safety reform.)
Increase personal responsibility. Successful surgeon senators advocate for "skin in the game"; community organizer presidents empathize more with $40,000-a-year families who can't pay for food or gas, let alone health insurance. These families have more than enough "skin in the game."
Borrow more money from the Chinese so we can cut taxes. Deficits would remain large and growing even if all these "sensible, step by step" plans were pursued. Therefore any tax cuts would have to be financed by borrowing from the Chinese, just as we have over the last decade.
The Democratic Plan
In the interest of being fair and balanced, we need to scrutinize the health reform legislation that just passed in Congress with the same degree of "vitriolic sardonicism" as Monty Python called it. Democrats will cover 30-plus million of the uninsured (10 times the Republican number) and they achieve this as follows:
Expand Medicaid by 16 million because it is such a swell program. The bill expands Medicaid by 16 million enrollees. When did Medicaid become such a great program? Did I miss a class? I thought it was horribly inefficient from an enrollment point of view and provided such pathetic levels of reimbursement that most mainstream providers won't accept Medicaid patients. Yet it has become the vehicle for half of the newly covered. Maybe that is why so many moderates liked the Wyden-Bennet proposal where people get a voucher. And there's your answer to why the Wyden-Bennet plan had no traction: It's pretty easy to stop printing little vouchers under a change in administration; it's a little more difficult to dismantle an entitlement program for 60 million people.
Have taxpayers in the states with generous Medicaid programs subsidize the Medicaid expansion in the states with less generous Medicaid. I spent the week of the Kabuki Summit, not in Washington, New York or California, but in Oklahoma and South Dakota. And I heard about, and experienced directly, entire local state legislatures and majorities of individuals in the community committed to sending back Obamacare money to Washington if it passed, refusing to accept the rule of the federal government if reform passed, and pleas of "Liberty or death."
Whoa! The delicious irony is that the greatest potential beneficiaries of Obamacare are the very states with the most tight-fisted Medicaid programs. Liberal California software executives and closet lefty Goldman Sachs partners would be paying increased federal taxes to support the Medicaid programs for the less than munificent taxpayers of Texas and Alabama. The Massachusetts voters figured this out in their vote for Scott Brown; they already had Obamacare and like it, so why did they need to pay twice?
Mandate that most other uninsured Americans buy health insurance that they can't really afford. Under Obamacare you must have health insurance, unless you really can't afford it, or you work for a very small business (where most of the uninsured are) or you are a Christian Scientist, or you take a free ride because you can do first-grade arithmetic and figure out that paying the fine is way cheaper than buying insurance. Apart from those limited exceptions, you must have insurance.
And then subsidize them so they can. Did we tell you that we are subsidizing you to buy unaffordable insurance? (Ben Stein, the noted economist, columnist and media celebrity, said on CNN after the summit that we should just give poor people the money to buy health insurance in the private market.) Here's the conversation you would have with a typical uninsured family with two kids, making $40,000 a year:
"Hey folks. I am from the government. Here's $12,000, but we would like you to buy health insurance with it."
"This is Candid Camera, right?"
Regulate insurance companies to take all comers even though all comers are not going to come. There is this pesky little problem with private health insurance markets. Insurers want to make sure that the people who sign up are not just sick people. And if they sign up only sick people, they want to be able to charge what it costs to treat those sick people, plus a fee for administration. Come on now. Be reasonable.
Raise fees and taxes on stakeholders who will pass it on in higher costs to the end consumer. Tax drug companies, medical device manufacturers, insurers and providers. These taxes will be passed on immediately to the end user in higher prices.
Start the taxes now; add the coverage later so in the next 10 years it actually reduces the deficit. Gather in all the taxes, now, so you can pay for expanded coverage later. If you have new revenues for a few years before the costs start, it makes it easier to make it budget neutral and in fact actually reduce the deficit. But…
In the long run, hold your breath and be prepared to borrow even more money from the Chinese. Once we get to a true run rate of the costs of reform, it may be difficult to say we are reducing the deficit because of reform.
We now know who really won the Kabuki Summit. Rahm Emanuel and the Democratic leaders in Congress have "persuaded" enough blue dog Democrats to vote for the good of the party for health reform with this parting comment:
"We know you are going to lose your seat over this, but you have to vote for this; otherwise we won't have health reform for another decade, and then it's too late. We're sorry it didn't work out for you here. But we have some parting gifts for you. Thanks for playing."
This is historic, important and directionally correct legislation that will change health care dramatically when it is fully implemented in 2014. But even in the interim, we will have Government Run Health Care no matter what. We just have to learn how to make it all work better.
Ian Morrison is an author, consultant and futurist based in Menlo Park, Calif. He is also a regular contributor to H&HN Weekly and a member of Health Forum's Forum Faculty Speaker Service.
This article 1st appeared on May 3, 2010 in HHN Magazine online site.
Wednesday, March 31, 2010
Keys to leadership success in getting people to act their way to a new way of thinking
April 1,2010
With the passage of new national laws pertaining to health care, and the ever changing pressures within the existing health care environment, there appears to be the need for another look at the role of leadership. With total credit to the author, John Kenagy, M.D., I want to share with my current and past students, his refreshing and successful approach to health care leadership.
Acting Your Way to a New Way of Thinking
By John Kenagy, M.D.
Understanding human behavior opens new doors for health care management.
Scientific discoveries and new technologies promise much improved patient care. But delivering on that promise means that people must think and act differently. The history of innovation shows that it is a lot harder than most people realize.
It's just like the adage "A tiger doesn't change its stripes." Throughout my career as a physician, health care executive, academic scholar, advisor, author and patient, I have seen how changing behavior can be very difficult.
For 30 years, the basic behavior change tools in health care management have been gathering data and aligning incentives. One of the constant refrains of the current health care reform effort is "We must realign incentives."
Are data and aligned incentives the key to delivering on the promise? Let's examine the evidence.
Leading Companies Often Fail to Innovate
The health system I helped manage in the mid-1990s was an industry leader in the managed care revolution. We had integrated physicians with aligned incentives, our own health plan, an electronic medical record system, lots of data and a multitude of quality improvement initiatives. But the managed care revolution failed and eventually petered out.
Puzzled by why lots of data and aligned incentives failed, I became a visiting scholar at Harvard Business School studying industry transformation. There I discovered the topsy-turvy world of disruptive innovation.
Disruptive innovation teaches us that when the world changes, many leading companies fail to innovate. Lotus could not compete with Microsoft, General Motors could not compete with Toyota and now Toyota is challenged. American and United Airlines cannot compete with Southwest, and now Microsoft can't compete with Google. Why? Changing behaviors is a lot harder than most realize, even if it means lost business, bankruptcy or the demise of a company.
That's a depressing discovery, but fortunately there is a solution. My research at Harvard focused on the few companies that were able to adapt and change when others failed—companies like Intel and Southwest Airlines. I found these adaptive companies shared a common characteristic: an organizational DNA that was "designed to adapt."
Thinking Is Part of the Problem
For the last 12 years of working with many people around the country, I have tested, validated and improved these characteristics in the complex, dynamic, unpredictable world of health care. One discovery was that data and aligned incentives are helpful but not sufficient to deliver on their promise because it is very difficult to get people to think their way into a new way of acting. Instead, people must act their way into a new way of thinking. It's action innovation, not thinking innovation, that makes the difference.
I believe most of us understand the difference. Recent research on the neurobiology of human decision-making offers the scientific explanation. The surprising first discovery is that humans are often not rational.
We do not analyze all options when we decide to do something. Instead our past experiences create predetermined pathways for behavior that we repeat, even when those actions may not be in our best interests.We have all seen it—very intelligent people making the wrong choice over and over again.
For example, in doing consulting work with Microsoft, I spoke with many brilliant people who had worked in failed IT companies before coming to Microsoft. I remember an executive explaining how it felt to be a senior manager at Digital Equipment, one of the world's greatest technology companies until it crashed and burned in the mid-1980s.
He said, "We would sit around the management team table, analyze all the data and come to a decision, but all of us had, in the back of our minds, the thought, 'Here we go again, this isn't going to work either.'"
The Science Behind the Experience
If you want to change behavior, you need more than data and aligned incentives. Behaviors are driven by beliefs. To change behavior, you must first change beliefs. This is where the neurophysiology of decision-making comes into play.
Our beliefs do not reside in some anatomic filing cabinet in our brains. Rather, f-MRI studies show beliefs are generated by complex recurrent firing of patterns of neurons accompanied by subtle but very specific changes in hormones and neurotransmitters. This brain activity is developed by experience and linked to the feelings that experience engenders.
In other words, we are not rational but we are sentient. Our brains are hardwired by experience and feelings. The stronger the positive feeling and the more frequent the experience, the more we become hardwired to respond in the same way.
To change behavior you must first use experience to change beliefs; you have to act, not think. Experience generates feelings that inform future experiences. The more positive the feelings and the more direct the link to experience, the more likely beliefs are to change. When beliefs change, behavior changes.
So, you can't think your way into a new way of acting; you have to act your way into a new way of thinking.
We have all experienced this phenomenon. I saw it in action when I worked in a Harvard Business School research project to better understand the Toyota Production System. The "thinking" approach says we will change peoples' behaviors by implementing "lean" process improvement tools. I worked with Toyota experts for two years, but I was never taught a lean process tool.
Instead, I was constantly told to go the workplace, understand the work through observation, then engage in small experiments to change the work in concert with front-line staff. This experience, experience, experience close to the work—not thinking, thinking, thinking in meetings—made the difference at Toyota. I wonder now if thinking about how to become the world's largest automaker has become part of Toyota's current problems.
Prove That Action Works by Acting
I have rigorously tested experiential change management in health care for the last 12 years in many different environments. It works. Here are the keys to leadership success in getting people to act their way to a new way of thinking:
1. Set a clear, simple and meaningful direction.
2. Develop and empower people; it's people, not technology, that make the difference.
3. Build trust and optimism through positive results in problem solving the needs of patients.
4. Solve those problems as real-time experience, close to the work, not in meetings.
5. Grow by repeating your success and relentlessly challenging the status quo.
The results are always positive. For example, in one year, staff on a Midwestern hospital medical-surgical nursing unit changed their behavior to generate the greatest increase in patient satisfaction in a 17-hospital system, while simultaneously increasing productivity 14 percent, decreasing length of stay 8 percent, and generating $1.7 million in new revenue and savings.
Action Innovation Opens New Doors for Leadership
New technologies offer the promise of wonderful improvement in patient care. But we will never achieve that promise without changing people's behavior. That means more than gathering data and aligning incentives.
Fujio Cho, Toyota's chairman, said it well: "No mere process can turn a poor performer into a star. Rather you have to address employees' fundamental way of thinking." The recent evidence that Toyota management ignored brake problems in a "culture of secrecy" for years suggests that they forgot that this lesson also applies to leadership.
Behaviors are driven by beliefs. Beliefs are formed by experience and feelings. Instead of thinking your way into a new way of acting, you act your way to a new way of thinking.
Our brains say it's so. Leading people to act their way into a new way of thinking opens new doors for health care management.
John Kenagy, M.D., is a physician, patient, former visiting scholar at Harvard Business School and author of Designed to Adapt: Leading Healthcare in Challenging Times (Second River Healthcare Press, 2009).
This article 1st appeared on March 22, 2010 in HHN Magazine online site.
With the passage of new national laws pertaining to health care, and the ever changing pressures within the existing health care environment, there appears to be the need for another look at the role of leadership. With total credit to the author, John Kenagy, M.D., I want to share with my current and past students, his refreshing and successful approach to health care leadership.
Acting Your Way to a New Way of Thinking
By John Kenagy, M.D.
Understanding human behavior opens new doors for health care management.
Scientific discoveries and new technologies promise much improved patient care. But delivering on that promise means that people must think and act differently. The history of innovation shows that it is a lot harder than most people realize.
It's just like the adage "A tiger doesn't change its stripes." Throughout my career as a physician, health care executive, academic scholar, advisor, author and patient, I have seen how changing behavior can be very difficult.
For 30 years, the basic behavior change tools in health care management have been gathering data and aligning incentives. One of the constant refrains of the current health care reform effort is "We must realign incentives."
Are data and aligned incentives the key to delivering on the promise? Let's examine the evidence.
Leading Companies Often Fail to Innovate
The health system I helped manage in the mid-1990s was an industry leader in the managed care revolution. We had integrated physicians with aligned incentives, our own health plan, an electronic medical record system, lots of data and a multitude of quality improvement initiatives. But the managed care revolution failed and eventually petered out.
Puzzled by why lots of data and aligned incentives failed, I became a visiting scholar at Harvard Business School studying industry transformation. There I discovered the topsy-turvy world of disruptive innovation.
Disruptive innovation teaches us that when the world changes, many leading companies fail to innovate. Lotus could not compete with Microsoft, General Motors could not compete with Toyota and now Toyota is challenged. American and United Airlines cannot compete with Southwest, and now Microsoft can't compete with Google. Why? Changing behaviors is a lot harder than most realize, even if it means lost business, bankruptcy or the demise of a company.
That's a depressing discovery, but fortunately there is a solution. My research at Harvard focused on the few companies that were able to adapt and change when others failed—companies like Intel and Southwest Airlines. I found these adaptive companies shared a common characteristic: an organizational DNA that was "designed to adapt."
Thinking Is Part of the Problem
For the last 12 years of working with many people around the country, I have tested, validated and improved these characteristics in the complex, dynamic, unpredictable world of health care. One discovery was that data and aligned incentives are helpful but not sufficient to deliver on their promise because it is very difficult to get people to think their way into a new way of acting. Instead, people must act their way into a new way of thinking. It's action innovation, not thinking innovation, that makes the difference.
I believe most of us understand the difference. Recent research on the neurobiology of human decision-making offers the scientific explanation. The surprising first discovery is that humans are often not rational.
We do not analyze all options when we decide to do something. Instead our past experiences create predetermined pathways for behavior that we repeat, even when those actions may not be in our best interests.We have all seen it—very intelligent people making the wrong choice over and over again.
For example, in doing consulting work with Microsoft, I spoke with many brilliant people who had worked in failed IT companies before coming to Microsoft. I remember an executive explaining how it felt to be a senior manager at Digital Equipment, one of the world's greatest technology companies until it crashed and burned in the mid-1980s.
He said, "We would sit around the management team table, analyze all the data and come to a decision, but all of us had, in the back of our minds, the thought, 'Here we go again, this isn't going to work either.'"
The Science Behind the Experience
If you want to change behavior, you need more than data and aligned incentives. Behaviors are driven by beliefs. To change behavior, you must first change beliefs. This is where the neurophysiology of decision-making comes into play.
Our beliefs do not reside in some anatomic filing cabinet in our brains. Rather, f-MRI studies show beliefs are generated by complex recurrent firing of patterns of neurons accompanied by subtle but very specific changes in hormones and neurotransmitters. This brain activity is developed by experience and linked to the feelings that experience engenders.
In other words, we are not rational but we are sentient. Our brains are hardwired by experience and feelings. The stronger the positive feeling and the more frequent the experience, the more we become hardwired to respond in the same way.
To change behavior you must first use experience to change beliefs; you have to act, not think. Experience generates feelings that inform future experiences. The more positive the feelings and the more direct the link to experience, the more likely beliefs are to change. When beliefs change, behavior changes.
So, you can't think your way into a new way of acting; you have to act your way into a new way of thinking.
We have all experienced this phenomenon. I saw it in action when I worked in a Harvard Business School research project to better understand the Toyota Production System. The "thinking" approach says we will change peoples' behaviors by implementing "lean" process improvement tools. I worked with Toyota experts for two years, but I was never taught a lean process tool.
Instead, I was constantly told to go the workplace, understand the work through observation, then engage in small experiments to change the work in concert with front-line staff. This experience, experience, experience close to the work—not thinking, thinking, thinking in meetings—made the difference at Toyota. I wonder now if thinking about how to become the world's largest automaker has become part of Toyota's current problems.
Prove That Action Works by Acting
I have rigorously tested experiential change management in health care for the last 12 years in many different environments. It works. Here are the keys to leadership success in getting people to act their way to a new way of thinking:
1. Set a clear, simple and meaningful direction.
2. Develop and empower people; it's people, not technology, that make the difference.
3. Build trust and optimism through positive results in problem solving the needs of patients.
4. Solve those problems as real-time experience, close to the work, not in meetings.
5. Grow by repeating your success and relentlessly challenging the status quo.
The results are always positive. For example, in one year, staff on a Midwestern hospital medical-surgical nursing unit changed their behavior to generate the greatest increase in patient satisfaction in a 17-hospital system, while simultaneously increasing productivity 14 percent, decreasing length of stay 8 percent, and generating $1.7 million in new revenue and savings.
Action Innovation Opens New Doors for Leadership
New technologies offer the promise of wonderful improvement in patient care. But we will never achieve that promise without changing people's behavior. That means more than gathering data and aligning incentives.
Fujio Cho, Toyota's chairman, said it well: "No mere process can turn a poor performer into a star. Rather you have to address employees' fundamental way of thinking." The recent evidence that Toyota management ignored brake problems in a "culture of secrecy" for years suggests that they forgot that this lesson also applies to leadership.
Behaviors are driven by beliefs. Beliefs are formed by experience and feelings. Instead of thinking your way into a new way of acting, you act your way to a new way of thinking.
Our brains say it's so. Leading people to act their way into a new way of thinking opens new doors for health care management.
John Kenagy, M.D., is a physician, patient, former visiting scholar at Harvard Business School and author of Designed to Adapt: Leading Healthcare in Challenging Times (Second River Healthcare Press, 2009).
This article 1st appeared on March 22, 2010 in HHN Magazine online site.
Thursday, March 18, 2010
Evolving Senior Care
I would like to share this interesting article entitled "Evolving Senior Care" with credit to the author ... Molly Forrest. Senior care is a high priority issue in the USA and it is refreshing to see these signs of professional leadership in the field.
Robert E. Hoye, Ph.D.
Faculty Mentor
Health Services
Walden University
Evolving Senior Care
By Molly Forrest
The Los Angeles Jewish Home is designing innovative programs to meet the needs of seniors of all stripes.
Molly Forrest
What will senior care and housing look like in the 21st century?
For starters, we know that baby boomers are living longer and better (even with chronic medical conditions) than any generation in history. We also know that, as they have done their whole lives, they will question outdated approaches and expect a new era of awareness and action. These two factors create a new world of opportunities for hospitals and other health care providers that want to be part of the solution.
But today's economic climate is causing health care organizations of all stripes to hesitate before expanding services or branching off into uncharted waters. Yet that's exactly what must be done if we want to influence how senior care and senior living will evolve. At the Los Angeles Jewish Home, one of the foremost multilevel senior living communities in the United States, we realized that standing still was not a viable option and, as a result, we are now recognizing the benefits of creative planning and proactive program development.
New Undertakings
It's one thing to be open to new ideas; it's another to execute them and be willing to commit the resources—time, money and energy—to see them through. Even though we are a nearly century-old institution blessed with many emulated business practices and successful programs, we needed to look anew to serve a growing need in a changing world.
Despite the difficult economy that we're all feeling, the Jewish Home has recently launched new large-scale programs in hospice, psychiatric care and nursing education that we believe are central to the ongoing health and well-being of our organization. We've also taken a fresh look at how health care can and should be delivered to aging boomers. We believe that any new model must begin with the understanding that there will be a growing need for highly intensive medical, rehabilitative and health care services as society ages.
All of our recent development directly addresses clear community voids that we believe our organization is best positioned to fill in unique and innovative ways. Our Skirball Hospice program, for example, expands the Jewish Home's services beyond our two campuses by taking the compassion and dignity found in hospice care directly into a person's home, providing for the physical, psychological and spiritual needs of both patient and family during the end of life.
Our new Auerbach Geriatric Psychiatry Unit addresses the special needs of seniors in a setting that makes them feel comfortable, welcome and understood, with special emphasis paid to depression and other issues that often affect this population. Our Annenberg School of Nursing—highly unusual in an organization like ours—is helping train tomorrow's health care professionals as we do our part to address the nation's severe nursing shortage.
We've also launched the Brandman Centers for Senior Care, the name for our PACE development. PACE (the federal and state Program of All-inclusive Care for the Elderly) aims to ensure that vulnerable seniors who choose to live at home can do so safely and securely while receiving coordinated and well-managed medical care, home assistance, personal needs care, meals and transportation services. With this development we believe that we have taken great strides toward providing exactly what the marketplace is telling us is needed. And, by doing so, we retain and strengthen our position as the regional leader in senior care and housing.
Lessons Learned
Our venture into new areas was driven by our organization's long-standing commitment to develop programs and services that balance the physical, medical and social well-being of those we touch. The insights we've gained from this experience are not unique to us or confined to senior care. Here are six lessons that might be helpful to other health care organizations:
Whatever you do and whatever innovations you develop, always remain true to your brand. Remember that your brand is your promise to your customers. It is what helps define your organization's unique characteristics. Never forget who you are. Never compromise your values, mission and heritage.
Look for partners who share your passion and commitment. We found other nonprofit organizations who believe as we do in the importance of treating all with the dignity and respect they've earned. What's more, they share our 21st-century vision of extending to the community the caring hands and compassionate hearts we have historically offered to our residents.
Where senior health is concerned, throw away any old notion that one size fits all. It doesn't. Often we simply bundle all older adults together into a category generically marked "senior" and expect everyone's needs will be met. Just as hospitals have become increasingly savvy in recent years in segmenting their consumer market, "seniors" and their needs must be segmented into multiple submarkets and programs planned accordingly.
This economic downturn is an opportunity to try new things and take intelligent risks. Nobody knows for sure what tomorrow's health care landscape will look like, but we do know that it will be different in the way costs are paid and services provided. That means that hospitals need to be open to change. The successful hospitals will be those that lead the change and don't just wait to be swept up in the current. In our case, we realized that by making the Jewish Home's medical specialties, geriatric services and wellness programs available to more of the community and not just the residents within our walls, we could have a positive impact in changing how elder care is accessed and specialized services are delivered.
Make sure that everyone is on the bus and make a compelling case for them to be there. That means working with a committed board, seeking and respecting the input of your community, involving your employees and helping everyone understand that new challenges mean exciting opportunities.
Finally, and most importantly, hospital CEOs and other health care leaders must recognize that the issues we collectively face are societal and that we are all in this together, along with the communities we serve. While these are momentous times, they also provide us with remarkable opportunities to enhance the life and wellness of those who often rely on us during their most vulnerable days of life.
We must seize these opportunities. There is no better time to begin than today.
Molly Forrest is a 35-year veteran of senior housing and health care and the chief executive officer and president of the Los Angeles Jewish Home.
This article 1st appeared on March 16, 2010 in HHN Magazine online site.
Robert E. Hoye, Ph.D.
Faculty Mentor
Health Services
Walden University
Evolving Senior Care
By Molly Forrest
The Los Angeles Jewish Home is designing innovative programs to meet the needs of seniors of all stripes.
Molly Forrest
What will senior care and housing look like in the 21st century?
For starters, we know that baby boomers are living longer and better (even with chronic medical conditions) than any generation in history. We also know that, as they have done their whole lives, they will question outdated approaches and expect a new era of awareness and action. These two factors create a new world of opportunities for hospitals and other health care providers that want to be part of the solution.
But today's economic climate is causing health care organizations of all stripes to hesitate before expanding services or branching off into uncharted waters. Yet that's exactly what must be done if we want to influence how senior care and senior living will evolve. At the Los Angeles Jewish Home, one of the foremost multilevel senior living communities in the United States, we realized that standing still was not a viable option and, as a result, we are now recognizing the benefits of creative planning and proactive program development.
New Undertakings
It's one thing to be open to new ideas; it's another to execute them and be willing to commit the resources—time, money and energy—to see them through. Even though we are a nearly century-old institution blessed with many emulated business practices and successful programs, we needed to look anew to serve a growing need in a changing world.
Despite the difficult economy that we're all feeling, the Jewish Home has recently launched new large-scale programs in hospice, psychiatric care and nursing education that we believe are central to the ongoing health and well-being of our organization. We've also taken a fresh look at how health care can and should be delivered to aging boomers. We believe that any new model must begin with the understanding that there will be a growing need for highly intensive medical, rehabilitative and health care services as society ages.
All of our recent development directly addresses clear community voids that we believe our organization is best positioned to fill in unique and innovative ways. Our Skirball Hospice program, for example, expands the Jewish Home's services beyond our two campuses by taking the compassion and dignity found in hospice care directly into a person's home, providing for the physical, psychological and spiritual needs of both patient and family during the end of life.
Our new Auerbach Geriatric Psychiatry Unit addresses the special needs of seniors in a setting that makes them feel comfortable, welcome and understood, with special emphasis paid to depression and other issues that often affect this population. Our Annenberg School of Nursing—highly unusual in an organization like ours—is helping train tomorrow's health care professionals as we do our part to address the nation's severe nursing shortage.
We've also launched the Brandman Centers for Senior Care, the name for our PACE development. PACE (the federal and state Program of All-inclusive Care for the Elderly) aims to ensure that vulnerable seniors who choose to live at home can do so safely and securely while receiving coordinated and well-managed medical care, home assistance, personal needs care, meals and transportation services. With this development we believe that we have taken great strides toward providing exactly what the marketplace is telling us is needed. And, by doing so, we retain and strengthen our position as the regional leader in senior care and housing.
Lessons Learned
Our venture into new areas was driven by our organization's long-standing commitment to develop programs and services that balance the physical, medical and social well-being of those we touch. The insights we've gained from this experience are not unique to us or confined to senior care. Here are six lessons that might be helpful to other health care organizations:
Whatever you do and whatever innovations you develop, always remain true to your brand. Remember that your brand is your promise to your customers. It is what helps define your organization's unique characteristics. Never forget who you are. Never compromise your values, mission and heritage.
Look for partners who share your passion and commitment. We found other nonprofit organizations who believe as we do in the importance of treating all with the dignity and respect they've earned. What's more, they share our 21st-century vision of extending to the community the caring hands and compassionate hearts we have historically offered to our residents.
Where senior health is concerned, throw away any old notion that one size fits all. It doesn't. Often we simply bundle all older adults together into a category generically marked "senior" and expect everyone's needs will be met. Just as hospitals have become increasingly savvy in recent years in segmenting their consumer market, "seniors" and their needs must be segmented into multiple submarkets and programs planned accordingly.
This economic downturn is an opportunity to try new things and take intelligent risks. Nobody knows for sure what tomorrow's health care landscape will look like, but we do know that it will be different in the way costs are paid and services provided. That means that hospitals need to be open to change. The successful hospitals will be those that lead the change and don't just wait to be swept up in the current. In our case, we realized that by making the Jewish Home's medical specialties, geriatric services and wellness programs available to more of the community and not just the residents within our walls, we could have a positive impact in changing how elder care is accessed and specialized services are delivered.
Make sure that everyone is on the bus and make a compelling case for them to be there. That means working with a committed board, seeking and respecting the input of your community, involving your employees and helping everyone understand that new challenges mean exciting opportunities.
Finally, and most importantly, hospital CEOs and other health care leaders must recognize that the issues we collectively face are societal and that we are all in this together, along with the communities we serve. While these are momentous times, they also provide us with remarkable opportunities to enhance the life and wellness of those who often rely on us during their most vulnerable days of life.
We must seize these opportunities. There is no better time to begin than today.
Molly Forrest is a 35-year veteran of senior housing and health care and the chief executive officer and president of the Los Angeles Jewish Home.
This article 1st appeared on March 16, 2010 in HHN Magazine online site.
Monday, March 1, 2010
Collecting Demographic Data
Having worked with hundreds of graduate students in the collecting of data and information to support research projects, I was impressed with the article: "UNDERSTANDING PATIENT DEMOGRAPHICS" by Adaeze Akamigbo. She is a Senior Researcher at the Health Research & Educational Trust. This article 1st appeared on February 16, 2010 in HHN Magazine online site.
Before collecting data, I am an advocate of conducting an "environmental scan". Taking time to identify and examine the total environment in which the research is to take place. Many times, important entities are not identified, and tend to "fall through the cracks" and thus, the final results of the research might be seriously lacking in validity. The author's focus on "real data" is worth considering when constructing the research plan.
Understanding Patient Demographics
By Adaeze Akamigbo
REAL data can be an effective tool for improving delivery of care.
Adaeze Akamigbo
Many hospitals do not systematically collect REAL (race, ethnicity and language) data. Understanding this aspect of patient demographics can be extremely helpful in improving delivery of care. It can also help hospitals raise patient satisfaction levels and capture a larger market share.
REAL data can demonstrate that differences exist in the quality of care among different racial or ethnic groups. It is helpful for leaders to be mindful of these disparities, which are present throughout health care and can be found in almost every setting. Because the hospital is often the point of entry for many people into the health care system, gaps in hospital care and in the community can be identified and addressed by this data.
Hospital executives can play a key role in acquiring demographic data, recognizing the gaps in care, then putting the data to good use. By doing so, care in hospitals and entire communities can be more effective and safe for all patients. Mindfulness of this issue can also position a hospital as a center of quality.
Acquiring the Data
For REAL data to become useful, it must first be collected in a standardized format. The hospital executive can make an impact on quality by insisting on high-quality demographic data. High-quality data is critical to making the business case for improvement, effectively targeting needed resources and creating a plan to address the local health care community.
Appropriate data collection and analysis can help hospitals track population trends and forecast emerging changes. One example is an increase in the Spanish-speaking population. It would, of course, be helpful to offer hospital materials in Spanish and to provide translators or bilingual providers who could enhance the patient experience during a hospital stay.
Improving quality depends on accurate demographic data to help target the necessary interventions. In order to start making the business case for collecting REAL data, there are three key questions executives can ask:
Do we have data to verify that we are delivering safe and high-quality care to members of all racial and ethnic groups who come to this hospital?
If we do not have the data, how can we efficiently work with our existing infrastructure to collect standardized demographic data?
What are the key questions we want to address in collecting accurate demographic data on our patients? (For example: Do we have any evidence that our patient satisfaction scores regarding communication are impacted by our staff's language proficiency?)
Executives will find that these questions are often not easy to answer. The best intentions may give way to the limitations of current IT systems or staff members' hesitation to ask pointed questions of patients. However, there are multiple resources to train and educate staff on collecting demographic data for quality improvement. There are also cost-effective ways to collect this standardized REAL data while complying with privacy regulations.
The Institute of Medicine recently recommended the Health Research & Educational Trust Disparities Toolkit as a key resource in starting hospitals on standardizing their data collection and on using the data to make improvements. The toolkit provides ongoing training, teaching front-line staff how to interact with patients on this issue and how to meaningfully implement the toolkit. Hospital executives are invited to be full partners in this process.
Translating Data into Action
Once executives make the commitment to collect demographic data, there are many uses for the information. Much depends on the interpretation of the data. For every situation of perceived differences in quality, a solution will present itself differently.
For example, a hospital might determine that among their acute myocardial infarction patients, 30-day readmissions are higher for one ethnic group than for another group after accounting for all other personal characteristics. The hospital might then further determine that these patients do not have good access to primary care services outside the hospital. The hospital may also find that these patients typically rate their satisfaction lower than that of other patients. This may suggest that there are aspects of the hospital encounter that disproportionately affects those patients.
These are important findings for the hospital. They give executives actionable items to address. They can remove barriers within the hospital to create a more patient-centered experience for these individuals. This might include patient education sessions before discharge. It might also include a training program to help employees learn how to be more culturally sensitive to the needs of a given population. This may improve patient satisfaction scores. The hospital may also determine that it needs to engage the broader health care community to identify appropriate sites of primary care to improve continuity of care for this population.
Moving Forward with Demographic Data
Organizations such as HRET are a resource for hospitals ready to make a genuine effort to collect data and measure organizationwide outcomes. Measuring demographics—REAL data in particular—is yet another tool in an arsenal to combat factors that may adversely impact the bottom line and, more importantly, impede the delivery of high-quality health care services.
Adaeze Akamigbo, Ph.D., M.P.P., is a senior researcher at the Health Research & Educational Trust.
This article 1st appeared on February 16, 2010 in HHN Magazine online site.
Before collecting data, I am an advocate of conducting an "environmental scan". Taking time to identify and examine the total environment in which the research is to take place. Many times, important entities are not identified, and tend to "fall through the cracks" and thus, the final results of the research might be seriously lacking in validity. The author's focus on "real data" is worth considering when constructing the research plan.
Understanding Patient Demographics
By Adaeze Akamigbo
REAL data can be an effective tool for improving delivery of care.
Adaeze Akamigbo
Many hospitals do not systematically collect REAL (race, ethnicity and language) data. Understanding this aspect of patient demographics can be extremely helpful in improving delivery of care. It can also help hospitals raise patient satisfaction levels and capture a larger market share.
REAL data can demonstrate that differences exist in the quality of care among different racial or ethnic groups. It is helpful for leaders to be mindful of these disparities, which are present throughout health care and can be found in almost every setting. Because the hospital is often the point of entry for many people into the health care system, gaps in hospital care and in the community can be identified and addressed by this data.
Hospital executives can play a key role in acquiring demographic data, recognizing the gaps in care, then putting the data to good use. By doing so, care in hospitals and entire communities can be more effective and safe for all patients. Mindfulness of this issue can also position a hospital as a center of quality.
Acquiring the Data
For REAL data to become useful, it must first be collected in a standardized format. The hospital executive can make an impact on quality by insisting on high-quality demographic data. High-quality data is critical to making the business case for improvement, effectively targeting needed resources and creating a plan to address the local health care community.
Appropriate data collection and analysis can help hospitals track population trends and forecast emerging changes. One example is an increase in the Spanish-speaking population. It would, of course, be helpful to offer hospital materials in Spanish and to provide translators or bilingual providers who could enhance the patient experience during a hospital stay.
Improving quality depends on accurate demographic data to help target the necessary interventions. In order to start making the business case for collecting REAL data, there are three key questions executives can ask:
Do we have data to verify that we are delivering safe and high-quality care to members of all racial and ethnic groups who come to this hospital?
If we do not have the data, how can we efficiently work with our existing infrastructure to collect standardized demographic data?
What are the key questions we want to address in collecting accurate demographic data on our patients? (For example: Do we have any evidence that our patient satisfaction scores regarding communication are impacted by our staff's language proficiency?)
Executives will find that these questions are often not easy to answer. The best intentions may give way to the limitations of current IT systems or staff members' hesitation to ask pointed questions of patients. However, there are multiple resources to train and educate staff on collecting demographic data for quality improvement. There are also cost-effective ways to collect this standardized REAL data while complying with privacy regulations.
The Institute of Medicine recently recommended the Health Research & Educational Trust Disparities Toolkit as a key resource in starting hospitals on standardizing their data collection and on using the data to make improvements. The toolkit provides ongoing training, teaching front-line staff how to interact with patients on this issue and how to meaningfully implement the toolkit. Hospital executives are invited to be full partners in this process.
Translating Data into Action
Once executives make the commitment to collect demographic data, there are many uses for the information. Much depends on the interpretation of the data. For every situation of perceived differences in quality, a solution will present itself differently.
For example, a hospital might determine that among their acute myocardial infarction patients, 30-day readmissions are higher for one ethnic group than for another group after accounting for all other personal characteristics. The hospital might then further determine that these patients do not have good access to primary care services outside the hospital. The hospital may also find that these patients typically rate their satisfaction lower than that of other patients. This may suggest that there are aspects of the hospital encounter that disproportionately affects those patients.
These are important findings for the hospital. They give executives actionable items to address. They can remove barriers within the hospital to create a more patient-centered experience for these individuals. This might include patient education sessions before discharge. It might also include a training program to help employees learn how to be more culturally sensitive to the needs of a given population. This may improve patient satisfaction scores. The hospital may also determine that it needs to engage the broader health care community to identify appropriate sites of primary care to improve continuity of care for this population.
Moving Forward with Demographic Data
Organizations such as HRET are a resource for hospitals ready to make a genuine effort to collect data and measure organizationwide outcomes. Measuring demographics—REAL data in particular—is yet another tool in an arsenal to combat factors that may adversely impact the bottom line and, more importantly, impede the delivery of high-quality health care services.
Adaeze Akamigbo, Ph.D., M.P.P., is a senior researcher at the Health Research & Educational Trust.
This article 1st appeared on February 16, 2010 in HHN Magazine online site.
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