I admit it, I had read the excerpts and some short review about Atul’s writings.  Today, I was sent a link again by a fellow reader.  So, I decided to read his article in New Yorker.  The article ” Annals of Medicine: The cost conundrum” is well written, flows well and has introspection analysis.

I have been saying for a while now about the current proposals for healthcare reform are not going to do much good unless we look into healthcare as a system, and then design a solution.  We proposed policy changes to tart reform, from cure to wellness management, from current insurance coverage to a tiered approach, and from government vs private to a partnership.

We have said there is a need to ethics reform as well as a DNA change in healthcare leadership.

And Atul has lots of same point.  The one that really got my attention was his proposal for infrastructural change.  An idea that Mayo and some others have succeeded with.  Here is what he says:

I talked to Denis Cortese, the C.E.O. of the Mayo Clinic, which is among the highest-quality, lowest-cost health-care systems in the country. A couple of years ago, I spent several days there as a visiting surgeon. Among the things that stand out from that visit was how much time the doctors spent with patients. There was no churn—no shuttling patients in and out of rooms while the doctor bounces from one to the other. I accompanied a colleague while he saw patients. Most of the patients, like those in my clinic, required about twenty minutes. But one patient had colon cancer and a number of other complex issues, including heart disease. The physician spent an hour with her, sorting things out. He phoned a cardiologist with a question.

“I’ll be there,” the cardiologist said.

Fifteen minutes later, he was. They mulled over everything together. The cardiologist adjusted a medication, and said that no further testing was needed. He cleared the patient for surgery, and the operating room gave her a slot the next day.

The whole interaction was astonishing to me. Just having the cardiologist pop down to see the patient with the surgeon would be unimaginable at my hospital. The time required wouldn’t pay. The time required just to organize the system wouldn’t pay.

The core tenet of the Mayo Clinic is “The needs of the patient come first”—not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. I asked Cortese how the Mayo Clinic made this possible.

“It’s not easy,” he said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focussed first on what was best for patients, and then on how to make this financially possible.

No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But, almost by happenstance, the result has been lower costs.

“When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing,” Cortese told me.

Skeptics saw the Mayo model as a local phenomenon that wouldn’t carry beyond the hay fields of northern Minnesota. But in 1986 the Mayo Clinic opened a campus in Florida, one of our most expensive states for health care, and, in 1987, another one in Arizona. It was difficult to recruit staff members who would accept a salary and the Mayo’s collaborative way of practicing. Leaders were working against the dominant medical culture and incentives. The expansion sites took at least a decade to get properly established. But eventually they achieved the same high-quality, low-cost results as Rochester. Indeed, Cortese says that the Florida site has become, in some respects, the most efficient one in the system.

Powerful example.  It proves what we have been proposing will work.  As a reminder what has been our proposal. Continue reading this post…

Agency for Healthcare Research and Quality, AHRQ, has released its ranking of states on various health performance metrics.  The reports provide overall score and also score on several other key parameters such as focus on diabetese, focus on asthma, etc.

The overall performance is on rated on an absolute scale of very week, week, average, strong, and very strong.  In the yer 2008, no state fell into the category of very week or very strong.  We have created further granularity in the report by visually creating 3 subcategories in each of the main one mentioned above.  The three sub categories are represented by using prefixes Low, Medium and High in front of each of the man categories.

The data below shows the states for each of the categories with Wisconsin registering the best performer and AR, GA, LA, MS, NV as the worst performer. Continue reading this post…

Does disease prevention cost more that it saves?  Most if not all of us believe that.   But not according to Carla Johnson of AP.  She writes in an article in Denver Post ” When it comes to healthcare spending, an ounce of prevention is seldom worth a pound of cure”.

The article goes on to explain through a hypothetical example of an obese lady at the risk of diabetese.  The cost of using a life style coach to help lose weight and this prevent diabetese is about $900 per year.  The article claims that for every case like this with success, 6 others get nothing out of such program.  They either do not lose weight, or get diabetese anyway, or would’nt have developed it in the first place.  The yearly cost of prevention program for these 6 people is about $5400 which is far more than the expenses one might incur if they had the diabetese.

However this whole logic is misleading.  The prevention is not only about diabetese. Secondly, I am not sure why would one need a coach to lose weight.  Also, as study points, if these were to be the goal, it is not that difficult to create a group programs to reduce the cost. Continue reading this post…

Few weeks back, my friend gave me a book called “Outliers”.  I used to read alot of novels as a kid but since I got into work life, most of the readings have been around technical, business, and leadership related.

I was hesitant to read this.  Then as I read, I got into it.  There are alot of sociological and anthropological information in the book.  What I want to talk here is about the health conditions of a group researched in the book.

The book talks about a group living in rural Pennsylvania.  It is pretty isolated.   The people of this town are very healthy.  They are not much connected to the outside world and their eating habits are not that great either.  People are very health.  The town is pretty much as relocation of a town in Italy. 

Original thinking was that it must have to do with the genetics as all - every single one of them - came from the same town.  But that did not happen to be the case.  As there were many others immigrated from the same town to other parts of the country with quite worse health performance.

Researchers also looked at the eating habits.  It turned out that this group in Pennsylvania ate pretty greasy food.  It was a bit more fatty and junky than averaeg american diet.  Nothing seems to have mattered when it come to the reason behind their superior health conditions.  So what did matter that gives this town to claim that no one below the age of 65 has heart disease.  And those who do have, the average is far below the national average. 

So what did matter? Continue reading this post…

NOTE:  WE apologise for the formating issue.  If you would like a pdf copy, link for that is available at the end of this white paper.

Many believe that there is a shortage of physicians in the USA, especially in the rural areas.  The Association of American Medical Colleges (AAMC) reports[i] that our nation must begin to increase medical school capacity now to meet the needs of the nation in 2015 and beyond. The AAMC projects that we will need about 125,000 more physicians than today, an increase of about fifteen percent. The projected shortage is likely to be unevenly distributed geographical and by discipline, with the greatest deficiencies in rural areas and in primary care.

Prevalence of the Problem

The problem of physicians loosing license due to disciplinary actions for wrongful acts only adds to this shortage. Wall Street Journal reported[ii] that about 3 out of every 1000 doctors were the target of serious disciplinary actions by state medical boards in the last year (see the table below for the states with the most and fewest disciplinary actions).  The wrongful acts, whether captured and punished or not, are also adding to the financial burdens of patients, providers and insurers.

States with the highest rates, averaged from 2006-2008:

States with the lowest rates:

A complete list for all the states is in the appendix.  There is widespread agreement that the numbers of serious investigations have been declining over the past several years.  There are, however, opposing views about why this is happening.  Some claim that these reductions in investigations are due to improvements in our healthcare system, while others argue that they are due to lack of resources necessary for carrying out the investigations.  Many even blame the government and hospitals who, they believe, are trying to protect the physicians who have committed wrongful acts. An article by Andis Robeznieks, titled “Debate over docs being properly disciplined goes on“[iii] presents viewpoints from both sides.

Regardless of the reasons for declining investigations, the current approach for dealing with wrongful acts is based on faulty thinking.

Faulty Thinking

Most of the proposed strategies for solving the wrongful acts problem recommend spending more money and effort on investigating and punishing the perpetrators.  On the surface, more punishment may appear to be a good idea, but it is a faulty notion since it does not address the root cause of the problem.  That is, punishment does not prevent wrongful acts from being committed in the first place.

Focusing on punishment instead of fixing the root causes creates another sets of problems, including:

• Considerable variability in the rates of serious disciplinary actions taken by state boards,
• Increased spending on investigation and prosecution of wrongful acts
• Worsening physician shortage.

In an article in the Public Citizen,[iv] Sidney M. Wolfe, M.D. and Kate Resnevic in write:  

Absent any evidence that the prevalence of physicians deserving of discipline varies substantially from state to state, this variability must be considered the result of the boards’ practices. Indeed, the ability of certain states to rapidly increase or decrease their rankings (even when these are calculated on the basis of three-year averages) can only be due to changes in practices at the board level; the prevalence of physicians eligible for discipline cannot change so rapidly.

Moreover, there is considerable evidence that most boards are under-disciplining physicians. For example, in a report on doctors disciplined for criminal activity that we published recently, 67 percent of insurance fraud convictions and 36 percent of convictions related to controlled substances were associated with only non-severe discipline by the board.[v]

In this report, we have concentrated on the most serious disciplinary actions…A relatively recent trend has been for state boards to post the particulars of disciplinary actions they have taken on the Internet. In October 2006, Public Citizen’s Health Research Group published a report that ranked the states according to the quality of those postings.[vi] The report showed variability in the quality of those Web sites akin to that reported for disciplinary rates in this report. There was no correlation between state ranking in the Web site report and state ranking in that year’s disciplinary rate report (Spearman’s rho = 0.0855; p=0.55). A good Web site is no substitute for a poor disciplinary rate (or vice versa); states should both appropriately discipline their physicians and convey that information to the public. However, no state ranked in the top 10 in both reports.

This report ranks the performance of medical boards by their disciplinary rates; it does not purport to assess the overall quality of medical care in a state or to assess the function of the boards in other respects. It cannot determine whether a board with, for example, a low disciplinary rate has been starved for resources by the state or whether the board itself has a tendency to mete out lower (or no) forms of discipline. From the patient’s perspective, of course, this distinction is irrelevant. 

Boards are likely to be able to do a better job in disciplining physicians if the following conditions are met:

• Adequate funding (all money from license fees going to fund board activities instead of going into the state treasury for general purposes)
• Adequate staffing
• Proactive investigations rather than only reacting to complaints…
• Independence from other parts of the state government so that the board has the ability to develop its own budgets and regulations
• A reasonable legal standard for disciplining doctors (”preponderance of the evidence” rather than “beyond a reasonable doubt” or “clear and convincing evidence”).

…Most states are not living up to their obligations to protect patients from doctors who are practicing medicine in a substandard manner…Action must then be taken, legislatively and through pressure on the medical boards themselves, to increase the amount of discipline and, thus, the amount of patient protection. Without adequate legislative oversight, many medical boards will continue to perform poorly.

The discussion above reflects the typical approach for dealing with wrongful acts, i.e., by calling for more money to be spent on investigation and punishment, rather than through root cause analysis and implementing strategies to minimize the commission of wrongful acts. Punishment, however, is a double edged sword.

Why Punishment is a Double Edged Sword

In a recent article in The Healthcare Transformation^[vii], Dr. Pandey stated that although criminal activities ought to be punished, canceling physicians’ licenses is not a practical or useful solution for many reasons:

1.      While punishment may avoid future wrongful acts by the perpetrator, the damage has been already done and could have a lifetime impact on the health and wellbeing of the injured patient and his/her family.

2.      The damage done often requires additional medical resources, could be used to help other patients.

3.      The use of personal and public funds to fix the damage strains the patient’s and government’s resources even further. 

4.      The financial impact could devastate a family’s finances and creates another level of burden on taxpayers.

5.      When wrongful acts lead to insurance claims, it can lead to increased malpractice premiums over time and, subsequently, increased cost of care.

6.      In cases where the wrongful act has not been caught, the insurance companies, government, and patients have to pay for subsequent care, thereby raising costs.

7.      For every doctor under serious investigation, common sense dictates that there are many more that “fall through the cracks,” such as those who are under not-so-serious investigation and many more may not meet the threshold of investigation. To understand the seriousness of those falling through the cracks, consider this analogy of comparing wrongful acts to traffic violations.  There are several small automobile run-ins that do not get reported for every traffic accident that is reported. Many more drivers exceed the speed limit or violate traffic lights than those who are caught. And then there are many who speed but they are only a few mph above the speed limit and thus do not register on anyone’s radar. Putting a police officer at every corner of the street is simply impractical. This analogy shows that many wrongful acts probably go unnoticed and pervasive investigation to uncover all incidents is unrealistic. 

8.      Since there is a shortage of physicians, every one removed from practice exacerbates the deficiency, which adversely impacts the quality of care.  In Massachusetts, for example, the Boston Globe[viii] regularly reports that patients are frequently turned away due to its severe physician shortage.

9.      The government spends well over $100,000 of taxpayers’ money on training a physician, and that’s just during residency. This expenditure is wasted whenever a physician is no longer able to practice.

There are, no doubt, other ways a physician with a questionable practice can adversely affect people’s lives and our nation’s economy. What we need is a systematic solution that prevents the need for punishment in the first place.

A Systematic Solution of Prevention

With all the negative impacts of investigations and punishments, might there be alternatives that could protect the patient and reduce, if not eliminate, the possibility of wrongful acts? The answer is YES!  The goal should be to create conditions in which wrongful acts do not occur, thereby preventing the need for punishment in the first place.

Categories of Wrongful Acts and the Common Factors Associated with Them

Wrongful acts can typically be grouped into two categories:

1.     Medical mistakes, which are unknowing mistakes-such as making an incorrect diagnosis, prescribing the wrong medicine, performing a procedure poorly, etc.-due to lack of adequate knowledge, lack of experience, too much distraction, or the like.

2.     Unprofessional behaviors, on the other hand, occur when a clinician knowingly/purposely harms a patient’s body, mind or pocketbook due to greed, emotional problems, addiction, etc.

These two groups of wrongful acts are associated with these four common factors that cause (are reasons for) those improper actions:

1.      Process

2.      People

3.      Technology

4.      System and Structure.

Processes. Wrongful acts may happen because certain processes may be used that are not robust.  A process is considered robust if it is so clear that everyone implements its tasks in a similar way and gets similar outcomes.

  Continue reading this post…