Archive for January, 2013
Congratulations to Jane Brock and CFMC
Today in JAMA is an article about transitions of care, and reducing readmissions. Dr. jane Brock and others demonstrated that with the mobilization of community resources, readmissions decline twice as fast as the background rate: http://jama.jamanetwork.com/article.aspx?articleid=1558278#qundefined
Jane and I met during this trial, and have been friends ever since. I chaired the steering committee for Northwest Denver, one of the 14 communities Jane studied. The stories were remarkable. Hospitals that are ostensible competitors came together with lots of community agencies to design uniform protocols and tools to make transitions of care more effective, efficient, and safe. Jane tells stories about another part of Denver that was the alpha test site. The hospital and nursing home staffs in that project had never met each other prior, even though they had shared hundreds of patients. When they realized how poor and dangerous their communication had been, people teared up, and apologized to one another. “I had no idea what I was doing to you. I am so sorry.”
There is much road to travel before we have safe, reliable, and effective transitions for everyone moving from one site of care to another. But Jane’s effort began and continues the right way. It recognized that the experience of care should be continuous, not segmented; that people visit caregivers, but they live in communities; and that few things are as powerful as knowing the people you work with in the common service of your neighbors. My deepest appreciation goes out to Jane and her team for their vision and hard work to tell the rest of us how much better care can be.
Individual effort, underlying infrastructure, and producing better health
I just retweeted a David Brooks article from a friend that explored a more nuanced view of one of the political axes along which we are arrayed in this country: the role of government and community vs. the role of individual effort and drive in American success: http://www.nytimes.com/2012/08/31/opinion/party-of-strivers.html?smid=tw-share&_r=0 At the one extreme are those who believe that there are no individual successes, that we are so intertwined in this complex era that bootstrapping is an artifact of the nineteenth century. What matters now is, well, luck, being in the right place at the right time to take advantage of an opportunity amidst the chaos. It is therefore government’s responsibility to make sure that those opportunities are justly distributed, and that their polar opposites, random catastrophes, are not disproportionately visited on those disadvantaged by birth and circumstance.
At the other extreme are those who believe that America’s success is the amalgamation of only individual successes, and that pretty much any aggregation of power is an attempt by those with lesser talents to overwhelm those with greater talents, and in fact appropriate the fruits of those greater talents. Luck exists, but is largely irrelevant for the talented because they can overcome any obstacle. They make their own luck. Random catastrophe is simply the outward manifestation of an individual’s inability to cope successfully, and not the responsibility of your neighbor. You may hope for your neighbor’s charity, but you may not feel entitled to it.
Who is right?
I am always suspicious of these kinds of black and white arguments, because I view them as a desire for simple theories to explain a complex world. It is understandable that we seek those in the age of information overload. Somebody somewhere has probably studied this, but my guess is that we are exposed to a couple of orders of magnitude more information daily than people a hundred years ago. Whether we want to or not, because we process emotionally, we have a feeling about everything that crosses our field of view. So the search for easy ways to categorize those things as friend or foe quickly gives rise to snap judgment, emotional processing on the fly, and gets codified as prejudgment. Why? Because when you are flooded with information, it’s all you have time for. Prejudging saves time. You are obligated by survival instinct to evaluate events and information to make sure they don’t cause your demise, and that’s done in areas of the brain completely below the level of rational thought. Ironically, I am afraid abundant information has made us less rational on average, not more.
Instead Brooks’ article lays out a more nuanced view of productive American society, one where infrastructure and community enable individual success. Both the infrastructure, which includes government and community resources, and the individual’s talent, effort, and perseverance are necessary but not sufficient. Infrastructure cannot compensate for lack of talent and effort, and we should not attempt that substitution. Talent and effort cannot replace adequate infrastructure, and neither should we rely on those things as the sole driving force for a healthy society. Without convenient prejudgment, every success is the product of the synergy between the two.
I agree with David Brooks. I would imagine his article in August 2012 was decried by lots of people. Some I’m sure dissented because it did not celebrate the individual as the only true American hero. Others dissented because it did not give communities enough credit, or responsibility. I choose to believe with David Brooks that the truth isn’t simple, and that in matters as important as our public life, we should spend some time and thought to find the answers that are harder to explain in thirty seconds.
By now I hope it is obvious why this is appearing in a health care blog. Random catastrophes are legion in health care, but so are the successes related to individual effort and perseverance. Good health is the product of many factors, some related to our efforts and some related to our circumstances. Marc Lalonde, a Canadian Minister of Health in the 1970s had a lot to say about that. He estimated that about 40% of health outcomes are related to behaviors, about half related to genes and environment, and only about 10% of health outcomes related to our attempts to fix the effects of the other factors on our bodies and minds (this last factor is of course health care, and we spend $2.7 trillion annually on it). The policies we adopt as a nation and in our communities can be ineffective if we fail to recognize the portions of our health that are related to individual responsibility, as well as those related to our underlying circumstances, in more or less equal proportion.
Watching Culture Change
I do a fair amount of work in payment and delivery system reform, in various communities around the country. I have been speaking to physicians about change coming for over a decade. If you have done any of this work, you may have had this common experience: that change is hard, and people have to have a really good reason to change the status quo. I admit it sometimes seemed to me that change would never come.
But lately I have noticed some of the conversations are different. I have been in a couple of meetings recently where audience physicians were answering the doubts and objections of other audience physicians.
“Aren’t all these quality measures arbitrary, and unhelpful in real patient care?” one might pose.
“No, in my organization, knowing our real performance has helped us improve things for patients. We’re thankful for this information, and we’re proud of doing better,” another would answer.
“Isn’t this just a race to the lowest price? Isn’t this just a way to penalize me for investing more in the care I give?”
“No, in fact quality and value rankings have helped weed out the bad performers in my procedure. The guys looking to make a quick buck are gone, and should be gone. And, my designation as a center of excellence has brought me new business.”
Say what? Where did this second group of docs come from?
I’m not sure of the answer, but here are some guesses:
- From integrated delivery systems. Many of the docs in this new category come from places that have been able to generate their own internal quality and value reports. Because these systems often have advanced IT shops and analytics, they are able to generate useful information based on both financial and clinical data. This definitely is an advantage in the era of Big Data, and is one reason why we have seen and will see more provider consolidation.
- From specialties that are competing for business nationally. If your particular niche is a rare and expensive one, you’ve already experienced something many of your peers have not—buyers shopping actively and aggressively for value, holding up your services to the light. They don’t come to you because you’re down the street, or even in the same state. They come to you because you are able to offer something predictable, affordable, and professionally excellent. And what buyers are shopping for is expanding. They are looking at more services and conditions every day, and shopping for them regionally and nationally.
- From those who have grieved the loss of unaccountability, and moved on. If no one can measure whether you’re doing a better or worse job than the next person, it’s hard to penalize anyone for bad performance. (It’s also hard to reward anyone for good performance.) This is a real loss for us docs, as we took the lack of shopping by buyers as a tacit endorsement of our judgment and competence. But truthfully, it probably represented as much an inability to judge quality by any meaningful criteria. That’s hard to swallow, but those who are succeeding in quality-driven markets have gotten over that loss.
This second group of docs is by no means a majority. But a decade ago, they were almost nonexistent. I think we are following the typical innovation diffusion curve: experimenters, followed by early majority, followed by late majority. I think what I have been seeing recently is the move from experimenters to early majority. And that, as those familiar with that S-shaped curve know, is the steepest part of the curve. Here’s hoping.
Disaster and disease vs. social cohesion
What do death rates during a summer heat wave in Chicago have to do with health care reform?
In the January 7 issue of the New Yorker, Eric Klinenberg has a fascinating article about the resilience of communities to disaster. This was especially timely in the wake of Hurricane Sandy, and in fact part of his article visits people trying to recover from its damage on Long Island. Dr. Klinenberg has been studying community responses to disaster for a couple of decades, most notably the heat wave during the summer of 1995 in Chicago. During that disaster, 739 people died. Analysis of the patterns by neighborhood found things you might expect. The poor died disproportionately to the better off. But there were some poor neighborhoods that had death rates that were lower than in the more affluent neighborhoods on Chicago’s North Side. Two neighborhoods on the poor and predominantly African-American South Side had mortality rates an order of magnitude different from each other. What does he make of this latter finding?
In response to disaster, communities have at least two categories of response: physical infrastructure and social infrastructure, he explains. Many communities around the world have gotten good at dealing with the kind of flooding we saw from storm surge during Sandy. They have installed dikes and seawalls, waterproofed utility lines, etc. A mass effort to install air conditioning in every apartment in Chicago would have been such a response. (Having air conditioning apparently reduced one’s odds of dying by 80%.)
Instead because Chicago now knows about neighborhood specific mortalities under these conditions, in hot periods they escalate welfare checks to the people they know are vulnerable there. Klinenberg thinks these high mortality rates are reflective of low social cohesion, and that the low mortality neighborhoods (the ones that don’t differ much in geography, income, or race from the higher mortality ones) have high social cohesion. There, people know who their vulnerable neighbors are on their block, and in their apartment building. They know this because they have lived there for years, and know when their neighbors usually shop for groceries, or visit the hair salon. The differences are not related to physical infrastructure; they are related to social infrastructure.
Put simply, lack of social cohesion kills.
So what if disaster response (or lack thereof) isn’t the only way poor social cohesion kills? What if the same factors also predict medical mortality? Re-admission rates to the hospital? Medication adherence?
What if building more hospitals, ambulances, and emergency rooms amounts to a physical infrastructure response to problems that are much more amenable to social infrastructure improvement? As hospital beds continue to proliferate while demand is falling, are we just building more seawalls behind seawalls because we only know how to finance building seawalls, and have no clue how to finance building sustainable neighborhood associations?
These questions I believe will become more and more prominent in our dialogue on progressing our American system for health optimization. The health care delivery system seems to be mostly a physical infrastructure solution, and an unsustainably expensive one. Developing a health optimization system seems to me to lead inevitably to a social infrastructure development system. No matter how good they are, it seems unlikely that professional repairmen will ever substitute for a neighbor knowing the signs you’re not well, and being willing to do something about it.
New Year’s Resolutions
Usually I begin the year with a resolution about weight loss, exercise, meditation, or some other health habit: you know, the usual kind. I will probably make some of these resolutions again this year, as in years past. But this year, I’m also resolving to blog once a week. I think I set up this blog about a year ago, and have been much less than diligent since about writing in it.
Part of this lack of blogging is related to the fact that I don’t entirely get its use and benefits, at least not yet. Fortunately, I have experience with not getting it, and persevering despite that. When I headed a company, I did networking the conventional way, meeting people in person, going to lunch, etc., for a full three years before I understood why. So I have some faith that some time down the line, this will get clearer for me.
Right now, here’s why I think we do this, in person or on the Internet. I don’t think one blogs purely to supply others with information. Most of what I could tell anyone about anything they care about has already been posted by Reuters or CNN an hour before I found out about it. We live in the information age, and about the last thing anyone needs is more information. People take long vacations on desert islands to escape that sort of thing.
Instead, if we are lucky, blogging give others insight into the way we think, and how that might be helpful in their own situation. I think I have shied away from posting partly because it seems odd to assume that the random firings of my neurons might be interesting/entertaining/thought-provoking for others. And, in the vast majority of cases, I think that will be right; people will read and think, “Not helpful”. But the beauty of the blogosphere is that those people can move on to someone else’s blog that they do find helpful. To all that remain, welcome. Both of you.
We live in an extraordinary time in so many ways, but germane to this blog, we live in the age of American health care reform. Some of you may have heard me speak about this, but there are a few core reasons why this is:
- We as a nation are out of money.
- We as private enterprises are out of money.
- We as individuals and families are out of money.
- I have slides to prove all of the above are related to the cost of health care.
- Other than that, it’s going very well.
Okay, there are other things at play here, which we will go into over time, but suffice it to say for now, being out of money has an amazing clarifying effect on one’s thinking. All the other things we will talk about here have been true for many years, even decades. But the one thing that compels us to have this conversation now, this topic that ranks just below having root canal for most of us, is that we are out of money to buy off the pain of real reform. I don’t know if anyone’s noticed, but the debate over entitlement reform is largely about one really big entitlement, the one we call Medicare. Yes, there is Social Security, but simply by changing the cost of living adjustment and raising the eligibility age some, we can take care of most of that problem.
But Medicare, there’s a problem that goes beyond actuarial analysis of the stability of an insurance pool. While it is technically an insurance program, it is so much more to so many people. In the simplest terms, it is hope. It is an amorphous institution in most of our minds, that attempts to buy miracles with pooled resources created by a collective agreement to pay into the pot, without know which miracles we will need for ourselves, of even if we will need them at all. Unfortunately, the price of this hope is going up at roughly two to three times the rate of general inflation, and it is crowding out other things that also create hope. But these latter things are for those closer to the beginning of their lives rather than those closer to the end. These are things like bridges, roads, schools, and other things that create future prosperity, for individuals and the American community as a whole. There is a commercial on TV right now that decries the tyranny of the “or”, the necessity of choice. Why can’t we have it all, it asks while the spokesperson does a funny dance?
We can’t have it all, because we never could, and we are having trouble believing that our perception of limitless resources was an illusion. We make popular movies in which against impossible odds, the hero/heroine saves the day, no matter what any stinking authority figure tells them. In the movies, the one in a million shot always comes through.
In a way that makes me a little sad, we are having to give up the illusions of childhood, and become adults. We are being asked by our posterity to recognize limits, that we will not be forever young, that we must choose the nuanced discussion over the sound bite, choose the understanding of others as being as complex as we feel ourselves to be, and just as sympathetically flawed. We have met the authority figures, and indeed they are us, only with wrinkles and lines that we do not recognize as our own in the mirror. These things all fall to us: the necessity for mercy, for difficult choices, and for prayers for wisdom in an imperfect world. None of these can be delegated or outsourced anymore.
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