Wednesday, May 26, 2010

Hard to be a physician... slightly harder in Massachusetts

From the Massachusetts Health Council:

Doctors say practicing in Massachusetts, where elected officials often tout gains under the 2006 universal health care access law, has become a tougher challenge. According to a Massachusetts Medical Society analysis released Tuesday, physicians face a growing burden from liability insurance rates, increasing use of emergency departments by patients, an aging physician workforce, and increasing costs associated with maintaining their practices. The society's latest Physician Practice Environment Index declined slightly, “representing a continued deterioration of the practice environment for physicians in Massachusetts.” The society identified liability insurance reform as the best step to take to improve the practicing environment, noting “defensive medicine” efforts aimed at preventing lawsuits come with a cost of $1.4 billion per year. Society officials say the index results conflicted with national surveys showing an improved climate for physicians. The report also concluded visits to the emergency department were up 3.5 percent in 2009 and that Massachusetts residents are using emergency departments at a rate 40 percent greater than in the nation. “A strong practice environment is essential to maintain a strong physician workforce, and both together mean better care for our patients,” society president Alice Coombs said in a statement. This becomes even more critical with universal coverage, given the added pressures that it puts on physicians, especially those in primary care specialties. The continued viability of physician practices should be a cause for concern about our state’s health care delivery.” The index has declined in 16 of the 18 years that it has been assembled.
There's nothing particularly new in this report (though the mention that Massachusetts residents are 40 percent more likely to use an emergency room than in other parts of the nation is alarming... and curious) which states that it's getting harder to practice medicine in Massachusetts.  We've been hearing that for a long time given the complexities and burdens of expanding payer requirements, much publicized malpractice woes, shortages of key staff, declining incomes, etc.  It is interesting to note that leading indicators for the U.S. and for Massachusetts seem to be moving in opposite directions.  Across the country, doctors are a bit happier.  In Massachusetts, a bit less so.

This coming decade will be marked by new advances in "physician extender" strategies.  Advance practice nurses will be given greater responsibility (for example, being able to order ancillary services, including home health care), primary care will continue to shift toward nurse practitioners and physician assistants, highly skilled technicians will assume tasks formerly completed by physicians, and the general public will become more accustomed to seeing physicians later on in the care process.  The debate will shift from whether this is a good or bad thing to how best to implement the changes.

Organizations such as the Massachusetts Medical Society will increasingly need to determine whether to support and lead this movement... or whether to buck it and defend the historical role medicine has played.

Monday, May 24, 2010

The Pendulum Giveth, the Pendulum Taketh...

I was an HMO executive at the time and remember well sitting in that darkened movie theater.  The Helen Hunt character said, clear-as-day, "______ HMO, ______ pieces of ____!  Think of the spiciest, nastiest words you can and insert them into that sentence and you'll understand how tobacco company executives feel.  The movie, "As Good As It Gets", contained a single mom's struggle to obtain adequate health care services for her ill son.  The pretext was a vehicle only as it helped spark the relationship between Hunt's character and the one played by Jack Nicholson.  The underlying merits of the health care coverage/access issue at stake was preposterous, but that didn't matter to the movie audience who erupted into wild applause at Hunt's three-bad-words-in-one-sentence commentary.  You know a backlash is in full swing when an audience vigorously claps in the middle of a mainstream movie at an insult lobbied by one of the characters.

The heart of the matter is that, back then, the health maintenance organization movement was continuing along its predestined path to control health care costs by selectively restricting access to providers and services.  As a general rule, in order to cut waste you need to direct care to the most efficient providers and you must eliminate duplicative and unnecessary services.  Some view that as rationing.  Helen Hunt's character clearly did.

So the HMO industry responded.  Networks were opened up, benefits were expanded, and the industry witnessed the return of fee-for-service medicine.  Pay-for-performance and bonus structures based on quality outcomes were introduced as a mechanism for inducing responsible behavior among providers.  Sticks gave way to carrots.

But the pendulum is clearly coming back the other way now.

Last week, the Massachusetts legislature advanced a bill requiring small group insurers to offer restricted networks to spur premium savings.  Yes, requiring smaller provider networks.  That means limiting choice.  What would Helen Hunt say?

And today, The Boston Globe reports that insurers, emboldened by the public scrutiny of the Partners system, reports from the Attorney General's office about payment discrepancies that are not tied to performance and quality, and a more activist legislature when it comes to health care costs, are reaching out to providers seeking payment cuts.  We have already seen benefits packages being stripped and the reimbursement cutting will not only narrow choices, but prompt closed network models of care delivery.

It will be interesting watching this unfold.  Interesting until the next backlash...

Wednesday, May 19, 2010

Are all home care agencies the same - part 3?

It's a great challenge that many of us face: keeping straight all of our prescription medications.  For the home bound, who are often frail and elderly, this challenge is even greater... and more important as mistakes can have troubling consequences.  Home health clinicians actively assist and teach their patients how to manage this vital task.  As a result, all Medicare certified agencies track the measurable progress their patients make in this regard.  The above graph shows how the Visiting Nurse Association of Boston (dark blue line) fares compared to Massachusetts (green line) and U.S. (red line) averages.  As indicated, and dramatically so, our patients improve at a substantially higher rate than do patients of other agencies.  Again, this is compelling evidence that not all home health agencies are the same!

Tuesday, May 18, 2010

They're watching....

I have one of these in my wallet.  Often, I'm glad I do because I can buy one package of Thomas' English Muffins and get a second package free.  Or the four for a dollar cans of Polar Seltzer becomes five for a dollar with the simple swipe of the card across an infrared beam reader.  It's quite nice of Stop & Shop to do this for me.

But alas, I clearly understand that the company is watching my every move and that niceness has nothing to do with it.  They are analyzing my buying patterns not only for valuable market research purposes, but also so that they know precisely how to target me.  It's no accident that when my receipt is spit out of the automated register, it's accompanied by coupons for english muffins and seltzer water.

There's nothing new here.  Marketers have been assessing our shopping habbits and buying patterns for decades, but newer technologies have brought the practice to even higher levels of sophistication.  Google's entire business model is predicated on intricate and automated means of understanding what we do when we're on-line, what we search for and what we type when we're in places like their gmail program.  I once typed to a friend in a gmail message that I had passed through a town named Spoon River and the very next day I received an "exclusive" email offer on a new set of silverware.  Coincidence?  Maybe.

Over the weekend, The Wall Street Journal addressed the reach of similar technologies into the delivery of health care.  Selected excerpts from the article, by Anne Kadet:
Whether a patient comes in for a gall-bladder operation or to have a baby, the routine remains the same for staff at Sharp HealthCare hospitals in San Diego. The front desk checks insurance records to make sure the bills get paid on time. Nurses take vitals and tag their charges with a bar-coded wristband. And behind the scenes, fund-raisers scan the assets of each patient -- to find out whether they're "megarich," "wealthy" or merely "comfortable."
While the folks checking in don't know it, the nonprofit hospital chain is hunting for prospective donors. Armed with powerful data-mining software, staffers screen admissions records to find wealthy patients who've shown prior interest in the hospital. Those who make the cut may enjoy a bedside visit from a "patient-relations director" who offers perks like free parking passes for visitors.

Medical institutions have been particularly aggressive about prospect research. Some use software to screen admissions lists; some even train doctors to identify new prospects. Once a patient is scouted as a VIP, the perks roll in. At the Hospital of the University of Pennsylvania, some 1,200 donors and volunteers can get priority for appointments with specialists. At San Diego's Sharp HealthCare, major donors receive a card with staffers' pager numbers.
Some people question whether these practices should be overlapping with medical care. Arthur Caplan, a bioethicist at the University of Pennsylvania School of Medicine, says it's hard to justify "golden runways" that whisk donors past waiting lists. During treatment and recovery, he adds, patients may feel too vulnerable to refuse a solicitation.

Hospitals say grateful patients are their only natural donor constituency. Paul Mischler, the Pennsylvania hospital's senior executive director of development, says the donor relationship "can be a natural, rewarding part of the healing process."
The key question pertains to the ethics of not-for-profit health care organizations utilizing sophisticated technologies and techniquess to "hunt for prospective donors" and "screen admissions lists".  What about providing perks (e.g., faster appointment times) for patients with means?  And training physicians to screen patients for donor prospecting purposes?

It strikes me that the mere deployment of sophisticated tools to facilitate more effective fundraising performance for often cash-strapped, mission oriented health care organizations is not a bad thing.  It can drive efficiencies and aid in supporitng needed programs and services.

But the latter scenarios, such as offering differential care for those who are better prospects but who do not pay for the higher end services and asking clinical staff to do prospecting, crosses over the line.

“One person’s waste is another person’s income....’’

Great piece in today's Boston Globe by columnist, Joanna Weiss.  Harkens back to a few themes from my own post here, particularly her comments regarding the impact of the profit motive on driving health care costs upward.

The full article:

By Joanna Weiss

Globe Columnist / May 18, 2010

Another axiom: Eventually, something will happen to your family.

Take, for example, my own elderly relative, who recently spent time in the hospital. Everyone wanted him to recover at home, but we knew that would require nursing care. And his care coordinator in the hospital had strange, bad news: If he went to a residential nursing home, Medicare would foot the bill. But if he wanted an at-home nurse, at substantially less cost, Medicare would only cover a few hours of care, a few days a week.

To anyone with a smidge of common sense, that sounds absurd. But when I relayed the story to Dr. Brent James, he wasn’t surprised. As chief quality officer at Intermountain Healthcare, a network of hospitals and providers in Utah, he’s an expert in Medicare’s one-size-fits-all solutions and perverse incentives. More than a decade ago, his hospitals put a reform in place, involving the timing of antibiotics, that helped patients recover more quickly and completely. But the hospitals were losing millions of dollars, and the billing records solved the mystery. If a patient got pneumonia and went on a ventilator, the reimbursement from Medicare was $800 more than the treatment itself. If that same patient didn’t get pneumonia, the billing codes changed, and the payment for his briefer, simpler hospital stay was $800 less than the cost.

As Congress turns to the must-do task of cutting Medicare costs — and considers Cambridge-based health care innovator Donald Berwick to lead the effort — it’s worth reminding ourselves what Berwick surely knows. It’s not just that many of Medicare’s problems are well-known. So are many of the solutions.

James has already implemented many of them at Intermountain, which is known as a national model for sensible management. Among them are “global payments,’’ which opponents have managed to demonize as rationing of care. As James explained it to me, it’s a far-less-nefarious way to create the the right incentives in a system that now often has the wrong ones.

In the case of my elderly relative, Medicare would give his hospital a set amount of money to coordinate and spend. Any money left over would be profit. If the payment fell short of the cost of his care, the hospital would eat the loss.

In theory, that could give doctors and nurses a reason to provide him with less care. Careful monitoring of quality would have to go hand in hand with global payments. But this change could also encourage steps known to reduce the length and cost of illnesses. Washing hands more often to reduce the spread of infection. Coordinating better among hospital divisions. Offering better access to the home-based nursing care that would cost a lot less.

“Over 50 percent of expenditures on a patient on health care are technically waste,’’ James told me. But “one person’s waste is another person’s income is a major political contribution.’’

In other words, he says, the probable downside isn’t so much that patients would get less care, but that some providers would get less autonomy, and oftentimes, less money. That’s the heart of the resistance to some other reforms, such as competitive pricing for Medicare, which would provide payments based on bids instead of uniform rates. Insurers would bid for Medicare business by promising to hold care costs within limits.

According to some health care and economics experts — including Roger Feldman and Bryan Dowd at the University of Minnesota and Bob Coulam at Simmons College, who wrote a recent paper on the subject — competitive pricing would shave 8 percent off the annual Medicare budget. That amounts to $50 billion to $60 billion every year. And yet, every time that reform has been proposed, providers have revolted, and Congress has blocked it in a very bipartisan way.

Now we have a looming crisis, a foreseeable future when the Medicare Part A trust fund will go bankrupt, or when Medicare costs will start to overwhelm the federal budget. There will come a point when ignoring the problem won’t be feasible anymore. Maybe it will happen too late to help some of my own relatives. But when it does happen, there’s some small comfort in knowing that solutions are out there — just waiting for action, a little bit of courage, and a will to change.
Joanna Weiss can be reached at

Monday, May 17, 2010


Are all home care agencies the same - part 2?

Homebound patients often have a difficult time moving around, walking, getting in and out of bed.  Organizations such as the Visiting Nurse Association of Boston strive, through skilled nursing and physical therapy services, to improve the ambulation of patients.  As the above graph indicates, such organizations have improved in this regard over the past few years.  As also indicated, the VNA of Boston performs at a level steadily above National and Massachusetts averages.

Thursday, May 13, 2010

What is iPad?

Here is the marketing propaganda.  My own real world experience propaganda is forthcoming.

Are all home care agencies the same?

Recently, I wrote a post suggesting that not all home care agencies are created alike.  That post (included here) pertained to the fact that some companies accept a limited and very choice (from a payment perspective) slice of the population while others, such as the VNA of Boston, serve all.

Well, not all home care agencies are created alike for other reasons too and those reasons relate to quality and outcomes.  This post is the first in a series designed to point out these differences across a variety of important and widely measured dimensions.  The graph above shows the improvement in pain for the patients we serve versus Massachusetts and US averages.  The red line shows the National figures while the pink one is for the state.  The top line (dark blue) shows that VNA of Boston patients fare significantly better overall than others when it comes to pain management for home bound patients.

What a great tribute to the skilled clinicians and supporting staff and managers here at the VNA of Boston.

I'll show results for several other measures in the coming days.  Here's a quick preview: they all show the same difference... VNA of Boston patients just simply do better!

Dennis blips too!

(Photo by Dennis Cunningham)

Dennis, a clinician at the VNA of Boston for over twenty years (not an uncommon feat here), shares a common interest with this blogger.  He is an avid photographer and he blips about it.  I wrote, some time ago, about blipping (the act of photographing and posting, in the same day, one photograph) -- see post here.  The sad truth is that when the VNA of Boston went to the Blackberry platform (a good thing) and I had to forego my beloved iPhone, I couldn't keep up with the daily task.  But seeing Dennis' work (featured here) inspires me to try again.  His compositions are varied and interesting.  I hope you'll agree.

A Legend

You don't often have an opportunity to work with someone considered to be a legend.  I've been fortunate enough to say that I have.

From an email to all staff today:

After nearly 18 years of steering the VNA of Boston through many a financial storm, Ken McNulty is announcing his retirement from the VNA and his position as our Senior Vice President for Finance. Ken will be trading in his spreadsheets and picking up a tennis racquet at the end of November.

Although I have had only six months to get to know and work with Ken, it is evident to me why he is the first person people inquire about as I travel to national conferences. Ken is quite literally a legend in home health care. He has helped shape our reimbursement systems through active involvement and advocacy on both the Federal and State levels and has positively influenced legislation and regulation in our industry at crucial times in our history. It was Ken’s leadership that made the VNA of Boston one of the test agencies for the Prospective Payment system and it has been largely Ken’s efforts that keep us the only agency in the state to be reimbursed by Medicaid on a episodic basis.

Ken has actively taught and consulted across the country and his impact has been felt at home care agencies near and far. Ken has also always placed patient care and quality first and has worked hard to ensure that our clinicians and other staff have had the tools and resources needed to help VNA of Boston maintain its status as an innovative and influential leader in home care. Of particular note, last year Ken was awarded the first Founders Award by our local association, the Massachusetts Home Health Alliance, in recognition of his considerable contributions.

On a personal level, Ken has helped me to transition into this organization, always eager to add context, explain the historical significance and implications of various actions and decisions, and to provide valuable insight on a variety of topics. It has been a pleasure getting to know him and I will miss his presence within our organization.

The VNAB will begin a transition process during the next month. As part of this process, Judy Toy, Controller, will be attending many meetings with Ken and will work closely with him to help assure a smooth transition.

We will begin a search process this summer and hope to have the position filled before Ken’s retirement at the end of the year.

Please join me in congratulating Ken on a long and impactful career both here at VNAB and in the years preceding, when he served in many senior positions in both non-profit and for profit companies, as well as the U.S. Army.

Tuesday, May 11, 2010

Monday, May 10, 2010

Valuing a Life and Remembering Who We Are

A 14 year old boy at the basketball court. The honor roll student who woke up on Saturday morning not knowing it would be his last.

My Saturday morning included a breakfast in honor of VNA Week for our weekend staff followed by a presentation on safety by Boston Police Officer, Claire, our resident expert on such matters. The breakfast was light and enjoyable. The talk after was eye-opening and sobering.

According to Claire:

Much of the violence in Boston is gang related. Gangs form on the basis of territory, race and culture and target ever younger ages. The pressure for these children to belong and conform can be intense and unbearable.

Gang members are increasingly brash and defiant, not fearing police involvement. They will follow officers to their homes and boldly take photos of them for posting on the web.

The operative goal is "crime displacement", not "crime prevention". Law enforcement initiatives most often seek to frustrate would be offenders so that they will move their ambitions elsewhere. Someone intent on committing a crime "will do so... eventually, they will do so."

Spikes in violence and murders follow an increase in tension in the school system, which is often underreported by school officials. The violence that takes place at night and on weekends often springs from arguments that originate in classrooms.

Claire, with chilling effect, said that the fundamental challenge is that so many do not value life... their own or others.

Jaewon Martin was on a basketball court in Boston Saturday afternoon. He and his family lost the potential of a life to be lived, lost at the hand of one or more who were settling a classroom dispute or completing an initiation or maybe mistaking the young Jaewon for someone else... We do not know.

Violence is an epidemic. Increasingly, the disaffected, disillusioned, hopeless, fearless, heartless among us resort to violence. Laws, enforcement, order and humanity falter when at the most fundamental level a higher and higher percentage of us, when our children, disregard the value, the sanctity of a human life.

American novelist Mary McCarthy said: "In violence, we forget who we are."

I hope we remember who we are. And soon.

- Posted using BlogPress from my iPad

Saturday, May 8, 2010

The Swagger Wagon? The minivan as fly...

Here's your marketing challenge.  Take the chronically uncool minivan and poke fun at its uncoolness, thus making it cool.  How'd they do?

Oh, one more question.  Did they take stereotypes a bit too far?

Friday, May 7, 2010

Taking on maternal depression... one home at a time...

Sunday is Mother’s Day, when many will celebrate their mothers and the joys of being a parent. But mothering isn’t always sunshine and rainbows. In fact, research shows 10 to 20 percent of women with young children suffer from depression. For low-income women, those numbers more than double. So there’s a new effort in Boston to help depressed moms — and ultimately their children.

BOSTON (Sacha Pfeiffer/WBUR) — Laura Starr rolls a small suitcase along a sidewalk in Brighton. She’s a social worker who makes house calls, and this luggage is her office. On this day, she’s visiting a depressed mother.

Fabiola, 31, moved here from Guatemala seven years ago and has clinical depression. She used to do home renovation work, but now she stays home with her two-year-old daughter, who’s going off to spend the day with relatives.

After Fabiola kisses her daughter goodbye, the two women sit down to talk. Laura asks her how many days in the past week she’s felt depressed. “Three or four,” Fabiola replies. When Laura asks Fabiola how much she enjoys life, she answers quietly with just two words: “Un poco.”

“This tells me that your depression is a little bit worse this past week,” says Laura, who works for the Visiting Nurse Association of Boston.

Fabiola is part of a new program that sends social workers to the homes of low-income mothers. Fabiola says she really needs Laura’s help.

Some studies show depression rates among low-income mothers range as high as 60 percent.

She says she wishes her mother or sister lived nearby to help her with child care. Sometimes her daughter wants to do puzzles with her or have tea parties, but Fabiola says she feels so depressed she’d rather do nothing at all.

After her visit with Fabiola, Laura remarks how unsurprising it is that some mothers get depressed; she’s a young mom herself, so she understands.

“After having my own daughter, I realized, ‘Wow, this is really not a Betty Crocker commercial,’” Laura says. “This is really hard.”

It’s even harder for the women Laura visits because many of them are poor and struggle with English. That means they’re less likely to get treatment for their depression because they can’t afford it or they don’t have transportation or they’re afraid to leave the house. Others think they’ll be stigmatized if they admit they want help.

Some studies show depression rates among low-income mothers range as high as 60 percent.

“Depression is something that really has a pervasive effect on somebody’s life,” Laura adds. “It affects how they view themselves, it affects how they view the world. There’s really nowhere that depression doesn’t touch — and ultimately on the children.”

That impact on children is what this program ultimately wants to reverse, because maternal depression doesn’t just take a toll on the mom.

“When that mother isn’t responding to the cries, isn’t responding to the vocalizations and the cooing and the babbling and all those wonderful things that babies do, it’s amazing the impact it has on the actual development of the brain,” says Laurel Deacon, of the United Way of Massachusetts Bay and Merrimack Valley, which funds the program.

“Even neuroscientists would now say that the single most important factor in the development of the child’s brain is the relationship with the primary caregiver,” says Dr. Bill Beardslee, a child psychiatry professor at Harvard Medical School who has studied maternal depression for 30 years.

Dr. Beardlese says depression in mothers can lead to emotional and behavioral problems in their children, among other issues.

“These kids, when they’re older, have higher rates of depression, they have higher rates of school difficulties when they’re very young, they have more medical problems,” he adds.

But depression is also highly treatable. Since the program started in March, it’s identified 15 low-income women in Allston and Brighton as being depressed. Nine of them have signed up for treatment.

The appointments at their homes cost them nothing. But Fabiola says what she gets from Laura’s visits is invaluable.

“I feel better when I talk about my feelings and my depression” Fabiola says.

She says she doesn’t trust just anyone to talk about her feelings, but she does trust Laura to help her work through her depression — because not only will Fabiola benefit, but so will her daughter.

Tuesday, May 4, 2010

Monday, May 3, 2010

The Fickle Fan

Last March, I wrote a post entitled "Why I'm done with the NHL", which was prompted by Penguins Matt Cooke's ridiculous cheap shot hit to Bruins best player, Marc Savard.  When the NHL front office failed to properly respond, I hung up my skates.  Not really, but you know what I mean.

All seemed lost.  The Bruins were afloat without an anchor and their spirit seemed more than questionable.  And now, just a few months later, the Bruins are making a run for The Cup, Savard has returned, and the Bruins are now up in their best-of-seven series against the Flyers.  In fact, in true storybook fashion, Savard scored the overtime goal to win the first game.

I was at tonight's game and the electricity was back in the Garden.  Back as we've not experienced in thirty plus years.  The Bruins are back.

And so am I.

Sunday, May 2, 2010

First Impressions

Is it really "magical and revolutionary" as Apple's marketing machine would like you to believe? After two days of playing around with the 3G version of the iPad, I would have to say categorically and unequivocally, I think it might actually be.

Some observations:

The set-up is pure Apple. Simple and fast. You won't need to read through an instruction manual. There's not one in the box if you decided that you wanted to. The actions required to get you hooked up to a computer so you can register and start downloading numerous apps (including the many useful free ones, e.g., Evernote) are painless. The process to sign up for 3G service, piece 'o cake, the interface, nothing to it.

The form factor is liberating. I told a friend on Friday that the size and feel is unique and that once you use it, it's hard to go backwards. Imagine that for centuries we all became accustomed to reading books that were attached to the wall. We were used to it and we didn't know any better. Then one day, someone introduces you to a book you can hold in your hands. The book you can bring wherever you go. The book you lift and raise and manipulate to fit your position and mood. You would never go back to a wall mounted book ever again. Similarly, the iPad makes it difficult to return to a desktop (and yes even notebook) computer again.

Keyboards? Years ago, Apple introduced the iMac computer sans floppy drive. At that time, floppies were the de facto means of transporting data. Not so said the company from Cupertino. That's what the Internet and new devices such as USB thumb drives were for. Apple was right and floppies were dead. I've been using the onscreen keyboard for two days now and find it simple and accurate. I'm typing this post on it now and find the error rate and speed to be quite close to the real deal. I would not invest in a physical keyboard company any time soon.

Many iPad apps are not bigger versions of iPhone/iPod Touch apps. Evernote, Things, Ewallet and others have added some amazing improvements capitalizing on the bigger screen and faster processors. To those who said this is just a big iPod, I would say: not so.

The battery life is amazing. I've been on this device quite a bit all weekend and still show 54% battery life left. Again, liberating.

In closing, the first impression is very good. Tomorrow, I begin to put this through the paces as a full-on commuter replacement in the office. More updates to follow.

- Posted using BlogPress from my iPad