- Recommit to improvement science
- Embrace transparency
- Protect civility
- Listen, really listen
- Reject greed
He rightly tells us that a focus on finance and incentives coupled with complex measurement systems will not produce better care. We have tried that for a long time and have little to show for it. He also knows that doctors and institutions seeking their individual will and not searching first for the collective improvement of the patient and the community will lead to ultimate failure.
Don’s “do’s” are designed to regenerate empathy. He would create an open environment where transparency and civility encourage progress and innovation. He reminds us that the concerns of the patient dictate not only the management of an individual case but the direction of a profession and industry. He emphasizes that no one practitioner and no single institution can provide the services and coverage required in our complex world. We are all connected for a purpose. We must move forward together.
Two things stand out for me on the list of “do’s” that are most enabling and will be the hardest to follow. First is the recommitment to improvement science. For me that means redoubling efforts to help individuals and institutions make Lean or some form of continuous improvement the core of their culture and their operating system. Leadership, insight, will and a realization that improvement and innovation are easy to say and hard to do are all necessary for Lean or if you prefer, improvement science, to have a chance to help us. I have grave concerns about the lack of will for individual and institutional transformation necessary to have effective improvement science, whether you call it Lean or whatever your preference. Era 3 ready leadership is in short supply. It is ironic that improvement with waste reduction and increased efficiency is the most certain path to the preservation of individual self interest and self interest is the biggest barrier to transformation.
The second issue is a real lack of willingness to meaningfully engage in the effort to lower the cost of care. There are some very emotionally charged nouns in our language. The use of words like “evil” or “sin” to call out a problem almost always evokes strong responses. We manage profanity and pornography with less emotion. The word “greed” triggers the same response as sin and evil in most of us, since we consider greed and its vector, money, to be high on the list of things that are evil and sinful. There are also some strong verbs that we do not like to use. What if Don had said “accommodate greed” or “study greed” or “work around greed”? He might have even said “ignore greed”, “negotiate greed” or “legislate the control of greed”. If he had chosen any or all of those verbs he would have been accurately describing what we are doing. What we are doing is not making much of a dent in greed. He gave us no room when he said “reject greed”. I could feel the room squirm when he said “reject greed”.
Rejecting greed in favor of a better way is not a new concept for Don. In 2010 when Don was the new “recess appointed” administrator of CMS, I made an ill advised trip to Washington to see him with the motivation that he might think favorably about Harvard Vanguard and Atrius Health while he and Rick Gilfillan were in the early stages of mapping out the work of CMMI. His quick response was to tell me that we had all the money we needed and the time had come to consider doing more with less. He walked me down the hall to meet Dr.Gilfillan and it was the beginning of our journey to become a Pioneer ACO. We became a Pioneer ACO, not as a way of collecting more revenue, but as a way of delivery more value. Back then the language was softer. I heard, “You probably have enough. Be a better steward and don’t ask for more”. Now what I hear is more direct, “You must reject greed because your greed is hurting your community and is an excessive burden to your patients.”
It is amazing to me how we can easily pass on the responsibility to lower the cost care. Perhaps most readers of Monday’s Boston Globe were focused on the disaster of the Patriots in Miami and missed the headlines,
Health expenses surging in state. I was truly surprised to find the most empathetic and insightful statement in the article came from the spokesman of the right leaning Pioneer Institute.
“People cannot sustain the amount of money they’re paying for health care, ” said Joshua Archambault, senior fellow at the Pioneer Institute, a right-leaning Boston think tank. “At some point, people really can’t afford it.”
The article was the typical scatter gun approach to analysis. It threw up the usual suspects as explanations for our failures. The villains mentioned were the vagaries of the ACA, the greed of big pharma, and the expense of new and effective meds and medical devices that are being used more and more. Nowhere in the article was there a discussion of waste, pricing structure for medical services, or any of the issues that physicians and institutions control by continuing to practice in the modes that Don called Era 1 and Era 2.
The first realistic question to ask when trying to solve any complex problem is, “What part of the problem am I/ are we?”. Don seems to have answered that and jumped to solution when he says with deep feeling, “Reject greed”. We can not say that we respect patients or that we are empathetic to their plight if we continue to passively accept the rising cost of care and do not hold ourselves accountable for much of the pain that it inflicts on those who are the most vulnerable members of our community. But wait, is it just the poor and disadvantaged that are having real problems with the cost of their care?
In Massachusetts there has been a pretty clear conversation going on for the last decade among members of the community who think that the cost of care creates harm to patients, businesses and to the community. We have had an off and on again conversation between this group of concerned citizen and the legislature. Chapter 224, passed in 2012, was a gentle solution that gave the healthcare industry the chance to show that it got the message and would begin to curb the rise in expense to a number not to exceed the state GDP. This year’s cost increases look to be about twice the GDP on average and much more for many segments of the market. Those hurt worse are those who are on Medicaid, Medicare and in products with high deductibles and co-pays. I wonder what the next recommendation of a right leaning think tank will be? My guess is that it will be to repeal something that is not working.
I am a regular reader of the articles that Drew Altman writes in the
Wall Street Journal. Altman is a physician and the CEO of the Kaiser Family Foundation. This week he addressed the issue of the current cost of care. The
WSJ article is hard to access if you are not a subscriber but you can read the whole column through the Kaiser Family Foundation. Just click on
Kaiser Family Foundation and then on the January 5th blog posting and then on the link at the “Read Post” which will bring you to
How Health-Care Bills Hinder Millions of Americans. You are almost there! Now click on the third word in the text which is “column” and you are there! It is a multi step process but worth the effort.
If you want to follow the thread, Altman’s column is a real resource that will link you to many recent publications from the Kaiser Family Foundation, working with the New York Times, to examine the burden of cost on patients and families. There is a terrific graphic in his piece from that work that shows the specific populations that are reporting difficulty paying for their care. Altman calls it “under-insurance”. I think under insurance has many causes but all of them would be ameliorated by the reduction of waste which is why “improvement science”[Lean, etc.] is so important in Don’s new Era 3. To quote Altman:
... the number of Americans who have problems paying their medical bills in a given year runs into the tens of millions, a survey conducted by the Kaiser Family Foundation and the New York Times found. These are not only people who are uninsured, have low incomes, or are very sick. For many, their uncovered medical expenses affect their ability to meet other basic needs–such as paying for housing, food, or heat–or make it tough for them to pay other bills.
Later in the article he makes a statement that should motivate us all.
The impact of medical bills can be felt across family budgets. Three in 10 people (35%) said they could not pay for other basic needs such as housing, food, or heat because of their medical bills. Sixty-one percent said the expenses made it harder to pay their other bills. People with medical debt also put off health care for fear of running up more bills. For example, 43% say they did not fill a prescription in the last 12 months because of the cost, about three times the share (14%) of those who did not fill a prescription but did not have bill problems. Slightly less than half of people with problems paying medical bills (47%) also have trouble paying other bills, but some have no problems besides their medical bills (31%) or have had other bill problems only because they needed to pay their medical bills (19%).
These issues can come close to home. I have several family members whose experience fits these statistics. Some have care through the Medicaid extension, some are on Medicare and some have insurance from their employers. All of them are left with huge out of pocket expenses that they can ill afford to meet. For some, I have done what Don did for his friend and looked at their bills. What Don saw, I see. I see bills that represent unnecessary care. I see prices that are inflated by facility fees or just high because the institution can get away with it because they have “clout” in their market. I see evidence of office visits that were required for script refills for stable hypertension that is well controlled. I presume the visit was required so that a visit fee could be charged since there was no medical indication.
One of my son’s and his wife are employed in the Santa Cruz area. They have good care but it is expensive, as is everything. The out of pocket cost of care is just part of an extremely high cost of living in their area. My daughter in law pointed out an article to me this week that I somehow missed in the New York Times that came out in mid December. The article has the intriguing title “The Experts Were Wrong About the Best Places for Better and Cheaper Health Care.”
The article is essentially a reworking of some of the studies, like the Dartmouth Atlas, that showed where the cost of care for Medicare patients was low and demonstrated a wide variation in resource utilization and expense. Now we discover that commercial insurance costs are quite high in many of those places where Medicare expense was low. For example, the famously low cost of publicly funded care in Grand Junction, Colorado (third lowest cost in the country) does not look so good when you see that Grand Junction ranks number 42 in the country for commercial expense out of about 300 geographical areas. In my neighborhood the cost of Medicare is pretty good in Lebanon, NH. Think Dartmouth. [The college is in Hanover but the Medical Center is in neighboring Lebanon.] Lebanon is 76th in Medicare which barely gets it into the lowest quartile but Lebanon is right in the middle in commercial insurance costs at 162. These statistics suggest “cost shifting” to me, or if not cost shifting, a greed that allows institutions to get all the money they can from wherever they can. The authors go on to say something that we have known for a long time, but that the public is slow to realize. The variation is not only market to market, but within markets.
The wide ranges of price occurs not just in different places, but often within the same community. The researchers examined prices at 7 hospitals in the Boston area and found the surgery [knee replacement] can cost insurance companies as little as about $14,800 or as much as about $35,900, depending on the hospital a patient chooses.
Perhaps to your surprise, the cost variation for knee replacement is even wider across the country.
The least costly price in the study for the simplest type of knee replacement was only about $3,400. The most expensive one was about $55,800.
At this point in the cost conversation people begin to advance explanations that justify the findings. I am sorry but I must stand with Don and say that old fashioned “greed” must be a significant part of the explanation. In 2011 I served on a commission appointed by Governor Patrick to examine the variation in price for similar services across hospitals in Massachusetts. The findings had some impact on Chapter 224, the bill passed in 2102 that launched the Health Policy Commission. “Politics” prevented a more direct approach to fixing the substantive findings of the price commission. The commission found, and we had known for sometime, that variation was huge, even between hospitals affiliated with the same medical school and located in the same neighborhood! Even before the commission’s work was done Atrius used this fact to shift thousand of admissions to the lower cost institution, that had equal if not better quality and safety, as a major part of our response to the realization that we needed to lower the cost of care.
My tirade is over. Attention to cost must be the focus for 2016. Overcharging patients and putting them in financial jeopardy or forcing them to chose between care and other necessities of life is wrong. The ACA can work but there is work that we can do that will hasten the day when it works without creating new cost problems. A first step that an individual physician or other clinician might take is to examine the charges that are generated after the visit and then ask a simple question: Was that a good value for my patient?
If you are thinking about joining the movement to Era 3, you might be interested in the survey recently published by Medical Economics. They canvassed physicians to discover the ten biggest challenges of 2016. Challenge number 1 was “getting paid what you deserve”. Here is the whole list. - Getting paid what you deserve
- The ACA
- Chronic care’s uncertain purpose
- Payer merger mania
- Independence v. Employment
- Maintenance of Certification battle rages on
- The end of Meaningful Use?
- The remote medicine disruption
- Risks and rewards of team care
- Data Vulnerability
There is a disconnect here with only remote crossover between Don’s list of nine concerns for Era 3 and what doctors from around the country seem to be concerned about. Don’s speech gave us an invitation to join a movement based on a vision of the future. Medical Economics is holding up a mirror to show us what many physicians are concerned about now. Don’s speech was about focusing on the patient and the patient seems not to be a top concern for many doctors in 2016. I molded Don’s concerns and speech to fit my concern about costs, specifically how the costs are a barrier to care today and a threat to access in the future. Those concerns do not make the Medical Economics list because they are not the current concern of most physicians who demonstrate by their concept of the “challenges” for 2016 that they are still unaware of the reality that putting the best interest of your patient first is the best way to serve your own best interests. There is a lot of work to do in 2016.
