What evidence?

The recent Health Affairs article proclaims "Some consumers are wary of evidence based healthcare".  And I say to that, "they should be!"  "What a heretic, how backward can you be?" you are asking yourself and me.  My response "Where did they get the evidence?"  When every study to-date except the recent Group Health Cooperative Medical Home study suggests that doctors listen to their patients for 13-30 seconds and that is really generous, before they go off on a diagnostic path of their own evidenced by interupting the patient and ceasing to listen.  Patient, after trusting patient, stops telling their doctors anything, assuming as my father does that someone has read his records before he came in that day, because they seem so on top of it that they don't need to hear from him.  Or the women that trusted their cardiologists as they applied evidence from male only studies for 20 years.

The Medical Home information is about slowing down the most critical process, the office visit from whence all the tests and treatments begin.  The idea is that someone might ask questions beyond the first 30 seconds and might listen to the whole story.  They might hear that it really is indigestion and not heart disease or vice versa.  They might hear the dementia.  They might check a reference book or email a specialists for a second opinion before taking the high risk patient off his coumidin for a minor procedure.

I get the wariness; I get the weariness of many patients who have probably had minor and major procedures that treated one symptom and not the whole problem, leaving that to its more costly course later down the road.  Evidence directed care, yes, but could we begin to use a bit more evidence when heading down these paths.  And maybe clue the patient in to where the path is leading.

"imponderingly complex technical society"

David Brooks of the New York Times wrote an OpEd piece on May 27 http://www.nytimes.com/2010/05/28/opinion/28brooks.html?scp=1&sq=drlling%20for%20certainty&st=Search  about the dangers of managing in our technologically intricate society.  Of course he was referring to the BP "spill".

He looks at a number of points but as he points out so eloquently "This isn't just about oil.  It's a challenge for people living in an imponderably complex technical society".  And that society as we well know includes healthcare.  I think BP could have learned from our experience of the last decade but we too could continue to be reminded of the perils of being "placed in situations too complicated to understand".

So his points are as follows:
1. "(P)eople have trouble imagining how small failings combine to lead to catastrophic disasters".
2. "People have a tendency to get acclimated to risk".
3. "People have a tendency to place elaborate faith in backup systems and safety devices"
4. "People have a tendency to match complicated technical systems with complicated governing structures"
5. "People tend to spread good news and hide bad news".
6. "People in the same field begin to think alike whether they are in oversight roles or not".

This is a great set of reminder to keep in front of management, medical leaders and the board.  Even though we have many great minds outlining the paths to safe and effective care, we are not there yet.  In fact, as the model changes with reform adding more complexity to the system, we would be wise to reflect on these with our Boards.  The authority matrix alluded to in Mr. Brooks fourth point and the Governance responsibility in the last point are well worth considering as we head into the next chapter in health care delivery in a very complex and potentially dangerous system.

Lots to celebrate

I am doing alot of thinking about the good old days....not about healthcare but about my son who just graduated and how old I really must be....my high school graduation was 3...years ago...I couldn't write the last digit..I am in denial.

And when I told his friends they were all like Eddie Haskell and they looked at me like I had lost my mind, I thought, maybe I just never got along with high school boys.

And those kids who won the Stanley cup and were dancing to 2 million fans.  They were born in the late 1980s.  The Blackhawks were guys that had made it....how could they have made it if they were born yesterday.

Okay Prom really did it to me!  I could not believe that a whole generation and a few extra years had passed since my high school prom.  Of course, it didn't matter to me at the time, I didn't even go, but now that my son was going with a beautiful young lady, I could not get over how I was no longer a kid.

I can hear the screams of just grow up...its about time.  Its not as if I haven't had mature and even senior moments in the past; this just cemented it in a way that was way too visceral.

I hate to say that my blog this morning on reform felt similar...I could recall all the major changes in healthcare over the last 30 years starting with the switch from pure fee for service to cost  based budgeting.  Then to revenue caps, then to DRGs, and managed care and IPAs and POSs and then to the IOM study and on and on...  I wonder whether all that history is a good thing.  I think so in many ways because I have lived through accountable care organizations - when I worked for Group Health - and working toward a single payor system in Washington State and Medicaid expansion and the move to ambulatory care and corporate practice of medicine and safety vs. tort reform.

 But somehow I don't feel old.  I feel experienced.  And I feel energized to figure out how to make this work for Americans who don't feel it works now. 

I wonder whether that is the same feeling out there...that what's new is great, that we can't rest on our laurels and ride it out to retirement; that this is the moment for true creativity, and value creation based on real data and real experience.

I took a break....

After all the buzz around health reform, then health insurance reform, then no reform, then yes reform....I like all my colleagues in health management had to take a giant breath and regroup.  No longer were we wondering "if and when" but now it was "oh my", "how and why" or "so what".  I had to come off the policy and political junkie high and continue to think through the reality of expanding care.  I had to think through the reality of expanding the national deficit.  And I had to get my hands around the one true fact - there will not be more money but less for what we currently see as healthcare and there will be more money and power in what we traditionally have undervalued.

So it was interesting to me when 85% of a recent survey of CEOs announced that they had plans in place to deal with reform!  Do you really? That was kind of interesting to me given that the healthcare world that I know grew up with competition, not health planning and with an internal view of healthcare from an institutional perspective not from a consumer or god-forbid a community perspective.  So what is it that health leaders are doing?

It seems that there is understandably a huge focus (read huge potential outlay of capital) on IT and EMR.  This is so understandable and so right for a small percentage of organizations (read major systems).  For small or independent hospitals it seems like the cart before the horse.  Is this record ambulatory or inpatient - is it portable?  What is your size and can you continue to manage risk and inpatient operations for a defined population?  If not, will you be purchasing other hospitals and clinics, or will you be looking to partner to expand your capacity for change?  What system will they have just purchased and do you have the capital to integrate?  What change will the new system drive - that is the key question.

The second area of great strategic effort is on physician relations.  Does that mean opening clinics - how many makes sense - what is the ratio of ambulatory to inpatient beds?  Are you employing subspecialists - based on what?  Medicare cuts or community need?  Where are your primary care physicians going to come from?  Do your bylaws allow midwifes, PAs etc?  Have you bundled payments since your IPA days and how successful was it?  Who took the risk?

Is this a strange new world; that may not be so new but certainly will be strange.  When in 1980, I worked for Group Health Cooperative of Puget Sound, we had 28 clinics and 3 specialty centers (read doctors and procedures) for 3 small hospitals. The hospitals were not where the power was.  Is your ambulatory care at a size and breadth to assure financial sustainability as you move more and more to ambulatory care.  If you add one to two days of care to replace a 4 day readmission do you have a queue in your clinics to fill the capacity?

What is your plan for Medicaid expansion?  Are you in a state where Medicaid is underfunded and the costs of care are not covered?  What about DSH hospitals - what will you do without that added payment?

Can you afford the transition of a revenue generating inpatient facility to a cost center inpatient facility?

This is an exciting time but the fixes are systemic not peripheral.  This is much less about who pays than on who delivers!

I am not sure if this brave new world is as well understood by those responding to the survey.  I think the questions outnumber the answers right now, but the one thing you can count on is that there will be more financial pressure than relief as you go through the change.

And as I say to those I coach, its not only the system that has to change, its you!