Posts | Heartland Health Research Institute

Wisdom We Can All Live By – From Dr. Martin Luther King Jr.

Posted on: 01.21.19 By: David P. Lind

Every now and then, I will stumble across a poignant quote with sage advice that cuts deeply to my inner being. A powerful quote can become so clear, as if it was only directed to me. Truth be known, the following timeless gem should resonate with each of us, as it provides the essence of why we exist.

You may be 38 years old, as I happen to be. And one day, some great opportunity stands before you and calls you to stand up for some great principle, some great issue, some great cause. And you refuse to do it because you are afraid… You refuse to do it because you want to live longer… You’re afraid that you will lose your job, or you are afraid that you will be criticized or that you will lose your popularity, or you’re afraid that somebody will stab you, or shoot at you or bomb your house; so you refuse to take the stand…Well, you may go on and live until you are 90, but you’re just as dead at 38 as you would be at 90. And the cessation of breathing in your life is but the belated announcement of an earlier death of the spirit.

– Martin Luther King Jr. (From a November 5, 1967 sermon)

Are Generic Drugs ‘Reasonably’ Priced? Perhaps Not

Posted on: 12.12.18 By: David P. Lind

This coming January, I will have spent 35 years in the insurance and healthcare arena. During this tour of duty, I have learned that nothing surprises me anymore, especially as it relates to the trust we blindly give to those who appear to act in the ‘best interest’ of the patient and general public.

Here is yet another example – generic drugs and how they are priced.

Generic medications have proven to effectively keep our drug costs low after patent protection expires. As proof, 90 percent of all prescriptions written in the U.S. are for generic drugs, yet generics comprise only 23 percent of total Rx costs (Source: Association for Accessible Medicines). Yet, new breaking developments suggest that, for at least 300 generic drugs, we are unsuspecting prisoners of a generic drug “cartel” that keeps generic drug costs higher than necessary – thanks largely to a friendly game of price fixing. The adage, “You scratch my back and I’ll scratch yours,” seems to apply quite well in this situation.

A December 10 article in Vox by Dylan Scott, “A groundbreaking antitrust lawsuit is ensnaring the generic drug industry,” explains how at least 16 generic drug companies allegedly rigged the market and fixed prices for roughly 300 generic medications. This article references a recent Washington Post piece that reveals most every state attorney general has now joined in a lawsuit on this ‘itchy’ topic. Have generic manufacturers become the new ‘Pinocchio’ with regulators and the general public?

When our non-healthcare markets are healthy and working appropriately, we can all benefit by paying lower prices for a higher-quality product (or service). However, in healthcare, when left unchecked, simple greed erodes the trust we have placed in a system we believed would ‘fix’ our cost conundrum. With this type of market behavior, American economic theory about consumer choice and market-based pricing mechanisms will find tough sledding in any market, especially with healthcare.

We can do better.

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Hospital Patient Safety Culture Does Matter

Posted on: 11.20.18 By: David P. Lind

A few years back, I walked into an Iowa healthcare executive’s office to discuss an idea that I thought carried a great deal of merit regarding patient safety. The executive politely listened to me. The idea was both simple and very intuitive. Because the mission of this particular healthcare organization is to promote quality and safe care, I was assuming it would be open to potentially embracing this approach in Iowa.

This idea was generated from the Hospital Survey on Patient Safety Culture, which is a staff survey designed by the Agency for Healthcare Research and Quality (AHRQ) to help hospitals assess safety culture within their own walls. When you think about it, who better to ask about quality of service within a hospital than the frontline workers themselves – staff, nurses, technicians, etc.? In fact, a 2017 report in BMC Health Services reported that hospitals with “higher staff perceptions of safety culture were associated with better overall safety, as measured by a composite of reported harms and patient satisfaction.” Additionally, when noted physician, Marty Makary and his staff performed a joint study with risk management firm, Pascal Metrics, they found “hospitals that scored well on the staff survey had lower rates of surgical complications and other important patient outcomes.”

The simple idea? Have ALL Iowa hospitals undertake this survey every other year with the results becoming public. After all, this approach would tie nicely with the mission of the organization I visited that day. Including outpatient surgery centers would be ideal.

The response I received from the medical executive was not what I had expected. To paraphrase his feedback: “These surveys usually occur in larger eastern (U.S.) hospitals, but not in small rural hospitals, like Iowa. The data findings from Iowa hospitals would not be statistically relevant…” I was absolutely floored when I heard this half-baked argument. What this executive failed to understand – or more likely, refused to understand – was that such surveys can be used within hospitals REGARDLESS of employee size. To be effective, the two critical cautions for this survey are:

Mandatory participation of all staff within each department
Assure staff that honest responses are extremely important and any retributions for this honesty will not be tolerated.

Frankly, if a hospital is large enough to care for patients, then it should be large enough to be surveyed on how it reports its organization’s patient safety culture. Clearly, the executive did not want this to become public knowledge, as the results could undermine the trust the public places within each of the state’s 118 community facilities. For those hospitals that do utilize the culture of safety survey, their identity is hidden from the general public. In fact, AHRQ shared with me that “Hospital-identifiable data from the Hospital Survey on Patient Safety Culture Comparative Database are not available for public reporting purposes per the data use agreement AHRQ has with each hospital that voluntarily submits data to the database…reporting at state level can also put hospital confidentiality at risk especially in smaller states.” This means that we don’t even know how many hospitals participate in any given state. How’s that for transparency?

Safety of care, I have learned, can be more about the optics (carefully spoon-fed to the public) than actual substance. For example, developing safety awards for hospitals who report few errors can dangerously promote behaviors to withhold adverse event reporting, a solemn fact that I have learned from trusted, first-hand sources (in Iowa). Although well-intentioned, poorly-constructed safety awards can manipulate the system for a desired outcome – giving the public a false sense of security on receiving safe care. Manipulating sacred patient trust is a gross violation of professional ethical codes.

The November issue of Health Affairs dedicated the entire publication to the latest findings on patient safety-related matter. One article by Aiken, Et al., “Nurses’ And Patients’ Appraisals Show Patient Safety In Hospitals Remains A Concern,” summarizes the process of surveying hospital nurses from 535 hospitals in four states (California, Florida, New Jersey and Pennsylvania). The survey took place in 2005 and then again in 2016. In addition, patients from those hospitals were surveyed during that same time period. The bottom line is this: “Clinical work environments in most hospitals did not improve between 2005 and 2016.” The concluding summary of this article was to the point: “Our findings confirm that patient safety remains a serious concern. Failure to substantially improve clinical work environments in most hospitals, as recommended by the Institute of Medicine, may be hampering progress toward improving patient safety.”

As stated in our ‘Silently Harmed’ white papers, preventable harm in healthcare is a public health crisis, and much of this problem stems from organizational systems tolerating (or hiding) poor safety cultures. I received a very descriptive comment from Donna Helen Crisp, who spent eight years writing a book about what happens in hospitals when things go wrong. In North Carolina, Ms. Crisp served as a nurse, nursing professor medical ethicist, dying patient, and author (Anatomy of Medical Errors: the Patient in Room 2). As an advocate, Crisp helps raise awareness about preventable medical errors and adverse events so that they can be eliminated – or at least mitigated.

Her extensive background provides a wealth of perspective that lends great credence to this topic. As she indicated, “All the time and energy spent arguing about how many medical errors occur, or how patients abuse the legal system to make money, or why doctors and surgeons deny and delay the truth, or how dying patients should not be counted in medical error statistics – all this time and energy would be better spent by pursuing the following:”

Changing the medical paradigm by putting patients and families first.
Learning to see and accept the problems inherent in hospital care.
Developing core values to address and decrease medical errors.
Improving patient safety through transparent care.
Supporting clinicians who want to be truthful but fear retribution.
Training clinicians how to ethically support patients.
Training clinicians how to identify and ameliorate suffering.
Making safe care a higher priority than training doctors or corporate profit.

Because most medical errors go unreported, it is necessary to establish baselines, however they are determined, to track future progress on eliminating these errors. But we can learn a great deal by heeding Ms. Crisp’s words.

I only hope this same courage allows others who serve in crucial roles throughout our healthcare delivery system (including those we elect) to proactively do the right thing and provide the transparency in care that we so desperately need.

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Secret Contracts Between Insurers and Providers – Who Benefits?

Posted on: 11.13.18 By: David P. Lind

Most of us have insurance coverage – whether it be through an employer, purchased individually, or accessed through Medicaid or Medicare. This coverage is commonly administered by a third-party organization, such as an insurance company, or a private administrator contracted by Medicaid and Medicare.

Insurers serve as a proxy for their policyholders by being given cryptic authority to act on their behalf in the purchase of healthcare. As the surrogate for those who pay insurance premiums, insurers negotiate the prices and terms of access with doctors and hospitals who then provide healthcare services to their insureds.

Do policyholders know the specific terms that insurers negotiate on their behalf? Most often, they do not.

Opaque Contract Terms

Agreements between insurers and their contracted in-network providers are kept under lock and key, leaving out those that actually foot the bill – the REAL payers. Similar to most other industries, healthcare is a profit-driven sector. The terms of provider agreements become THE economic advantage that insurers and their contracted providers have within the local marketplace they operate. Opaqueness of these terms cement any competitive advantage for their own interests.

A fundamental question to ask: Should the REAL payers of healthcare, e.g. the policyholders, have access to the specific terms of these agreements? This is a valid question, especially given the latest Federal Trade Commission investigation of hospital contracts.

By far, the U.S. spends more per capita on healthcare – almost 20 percent of its gross domestic product – compared to other developed countries in the world. This mammoth spending is not because Americans consume more healthcare per capita than their foreign counterparts, but rather, the prices Americans pay are often grossly higher than elsewhere. Part of this has to do with opaque prices and terms REAL payers must accept through their hired surrogates, the insurers.

Market Power vs. Patient’s Best Interest

Through a ‘keyhole,’ a September article in the Wall Street Journal (WSJ) attempted to peek inside the terms some insurers have with their contracted healthcare providers. What they found was actually not too surprising. Hospital systems attempt to exercise their market power with insurance companies by demanding contract agreements that prevent having competitively-priced networks within the insurance marketplace. Depending on how limited a network of providers will be, the cost savings can range from three to ten percent – possibly more.

Largely known as anti-steering clauses, these restrictive hospital-insurer agreements secretly limit insurers from steering their policyholders to other providers that improve the quality of care and keep costs lower. Even large purchasers that should have market clout, such as Walmart Inc. and Home Depot Inc., are kept in the dark from such agreements when trying to incentivize their employees to use high-quality/low-cost providers.

Other provider contracts may be constructed to not allow insurers to lower copayments to incentivize patients to use less-expensive or higher-quality providers. Additionally, hospital contracts might stipulate that the insurer will always keep that hospital system within the preferred network – even though their prices may be considerably higher than other competing hospital systems. Do we have such contracts in Iowa? Hard to know.

For their part, insurers will concede to these demands because they desire to attract more policyholders to enroll in their health plans. Having more policyholders can provide added leverage for insurers to negotiate more favorable contracts in the future, while hospital systems continue to grow by purchasing other types of providers. A recent Journal of Health Economics study found that the price of physician services increase an average of 14.1 percent after being purchased by hospital systems. The ‘dueling leverage’ escalation seldom benefit the REAL payers, who will eventually pay the inflated cost through higher premiums. This perverse incentive happens without the REAL payers having this knowledge.

To justify this behavior, hospitals say patients should be able to choose their healthcare provider without having financial pressure from their insurers or employers.

Secret Agreements Now Challenged

Lawsuits are occurring around the country regarding these restrictive contracts. The Justice Department is suing a large North Carolina hospital network, Atrium Health, because it “uses its market power to impede insurers from negotiating lower prices with its competitors…”. Sutter Health, a large hospital system in northern California is being sued by the California attorney general for anticompetitive practices.

On October 10, Iowa Senator Charles Grassley, Senate Judiciary Committee Chairman, sent a letter to the Federal Trade Commission to investigate whether contracts between insurers and hospital systems are limiting competition and pushing up healthcare costs. This letter was prompted by the WSJ article mentioned earlier.

Pending review by the FTC and the various lawsuit outcomes, what recourse do the REAL payers of healthcare around the country have to keep costs more affordable?

Solutions?

According to a November 4 WSJ article, watching the state of North Carolina might be a good start. North Carolina’s employee health plan covers about 727,000 people, which includes teachers, university workers and state police. North Carolina’s state treasurer announced in October that it wants to pay hospitals’ and doctors’ rates that are pegged to Medicare’s reimbursement schedule. The state treasurer said the new rates – beginning in 2020 – would average around 177 percent of Medicare’s fees, which is lower than the current reimbursement average of 213 percent – projecting an annual savings of $300 million. The N.C. hospital community is predictably pushing back to keep this from happening.

According to an article in ProPublica, the state of Montana pursued a similar approach a few years ago, and has found the program is now saving healthcare costs for its employees (and taxpayers).

Employees and their employers must be resolute and insist that all insurance contracts are in the best interest of those who are the REAL payers of healthcare. As suggested in a recent Harvard Business Review article, employers may consider banding together to establish purchasing alliances. This is not a new concept, but the above circumstances may warrant a rebirth of this approach.

REAL payers do have legitimate leverage in the healthcare marketplace – they just need to act. Otherwise, we can only speculate what is hidden behind the keyhole.

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Are Hospitals Adequately Accredited to Allow for Safe, Effective Care?

Posted on: 11.06.18 By: David P. Lind

When it comes to hospital oversight, we assume the care we receive will be safe, effective and appropriate. But is this assumption fact or fiction?

Most of us like to be assured that when purchasing a product or service, we will receive the best value possible for the money we spend. To do so, we typically perform background “research” on the desired product(s) to help us become more comfortable before spending our hard-earned money. From this, we hope the purchase will at least meet our desired expectations.

To save us time, or at least help augment our individual sleuthing methods, we often rely on employing outside research organizations that have extensively researched thousands of products on our behalf. Consumer Reports is one excellent example. Another is the Good Housekeeping Seal of Approval.

Good Housekeeping Seal of Approval

The Good Housekeeping “stamp of approval” assures the general public that, once approved, a product will meet consumer expectations, as intended. In fact, the Seal includes a limited two-year warranty to financially protect the consumer should the product be “defective.” To earn the seal of approval, organizations must request a review of their product(s) from the Good Housekeeping Institute, which will then have their own scientists and engineers rigorously evaluate the product in their labs. If approved, a product is allowed to advertise the coveted seal on its package. Good Housekeeping serves as an independent, third-party that protects the public from inferior products, promoting a marketplace place built on trust.

Comparing Hospitals

How do you know a particular hospital delivers appropriate quality care that is safe when you or a loved one need it? Hospitals, through various national organizations and publications, are ranked annually to assist patients and their doctors to make informed decisions on where to seek the most appropriate care. For the period 2018-19, U.S. News & World Report performed their 29^th annual Best Hospitals rankings. The rankings are made for 16 different specialties. Three other prominent hospital rankings are:

It is important to note that each ranking applies different methodologies when comparing hospitals. Because of this, a hospital may perform well in one ranking, but look considerably less favorably in another ranking – during that same year. Consequently, such disparate results can be very confusing (and frustrating), both for the general public and for hospitals. Additionally, some ratings organizations won’t disclose their methodology on the grounds that it is proprietary. If the methodology isn’t completely transparent, then one should be skeptical of its rankings.

Hospital Accreditation

The public generally assumes that, beyond rankings, the quality and safety of each hospital is appropriately inspected, monitored and highly regulated by a government agency and/or independent organization that is sanctioned by the government to perform this oversight. For the most part, this is true. The Centers of Medicare and Medicaid Services (CMS) grant accreditation authority to CMS-approved accrediting organizations to identify deficiencies in healthcare delivery and help providers correct those deficiencies. For each hospital, accreditation serves as a fundamental process to assure a high baseline level of healthcare quality is provided to patients. For hospitals that serve Medicare patients and are eligible to receive Medicare payments, each hospital must take a great deal of preparation time (and pay accrediting organizations) to obtain this accreditation every three years (or pass state inspections).

On the surface, this all sounds reassuring to the public. However, it appears, thanks largely to a 2017 Wall Street Journal (WSJ) article, in addition to a recent study by Lam, Figueroa, et al., in BMJ, that accreditation may not be as rigid and transparent as we would assume (or hope). Like the Good Housekeeping Seal of Approval, accreditation should signify a stamp of approval that a hospital provides safe, effective care. Recent evidence suggests that accreditation is not accomplishing that goal.

The Joint Commission

The Joint Commission, a nonprofit organization that provides hospital accreditation, is responsible for about 88 percent of U.S. hospitals becoming accredited. Many Iowa hospitals and providers utilize the services of The Joint Commission. The other 12 percent of hospitals obtain accreditation by other CMS-approved accrediting organizations or are state reviewed only (with no independent accreditation). The Gold Seal is awarded by The Joint Commission to hospitals that receive accreditation.

The 2017 WSJ article found, through analysis of hundreds of inspection reports from 2014 through 2016, that The Joint Commission “typically takes no action to revoke or modify accreditation when state inspectors find serious safety violations.” In fact, in 2014, “not only did 350 hospitals have accreditation while in violation of Medicare safety requirements, but 60 percent of them also had such violations in the preceding three years.” Hospitals are allowed to keep their full accreditation despite being ousted from the Medicaid program for safety violations.

Pay-to-Play?

In addition to indirect costs of time spent preparing for the accreditation process, hospitals pay the Joint Commission an annual fee (based on hospital size) from $1,500 to $37,000. Additionally, hospitals must pay The Joint Commission to inspect them (every three years) for an average fee of $18,000. Finally, Joint Commission Resources, a subsidiary, can be hired by hospitals to help them attain and keep the accreditation. This relationship between hospitals and The Joint Commission provides the appearance of a ‘pay-to-play’ arrangement – a game that is not in the best interest of patients. The WSJ article quotes a former hospital-accreditation director at The Joint Commission citing this payment process as a “conflict of interest.” The evidence has become so compelling that last month the Trump Administration has announced increased oversight of the accreditation process.

Until recently, there has been little research that investigates whether accreditation affects patient outcomes. Much of the research performed reveals that accreditors focus largely on structural factors and processes, rather than achieving good patient outcomes. The recent study by Lam, Figueroa, et al. revealed that “…we did not find an association between accreditation status and patient outcomes…the data did not consistently support our hypothesis that hospitals accredited by The Joint Commission would have better outcomes.” Through many findings, this study concludes that “we found that hospitals accredited by private organizations did not have better patient outcomes than hospitals reviewed by a state survey agency…The Joint Commission, which is the most common form of hospital accreditation, was not associated with better patient outcomes than the other lesser known, independent accrediting agencies.”

Why Should This Matter?

The Iowa Patient Safety Study^© reveals that one-in-five patients in Iowa experienced a medical error within the past five years – with about 60 percent occurring in Iowa hospitals.

Every patient wants to know if a particular hospital is safe, effective and appropriate before receiving care. This also applies to clinics and other venues of care. After all, this is part of the transparency movement that calls for patients to become more informed while being an active participant in the care process. To do so, the healthcare system must provide credible (and honest) outcomes documentation that will instill confidence and trust. Unfortunately, there are large variations in complications and mortality rates across hospitals – putting the patient at great risk.

Let’s focus on what is most important, such as patient outcomes, and come clean with how this accreditation process is determined and ultimately revealed to the general public. Only then will we have the Good Housekeeping Seal of Approval on the most important ‘product’ we purchase.

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Atul Gawande – A Healthcare ‘Insider’ with ‘Outsider’ Views

Posted on: 06.26.18 By: David P. Lind

And now, the highly-anticipated healthcare ‘initiative’ begins. This will be important because it may eventually impact all of us. But I’m getting ahead of myself…

This past Wednesday, after great fanfare and anticipation, the joint venture of Amazon, Berkshire Hathaway and JP Morgan anointed Dr. Atul Gawande as the inaugural CEO of the yet-to-be-named company that was announced in February. Although we don’t yet know the precise nature of this healthcare venture, as it is still shrouded in great speculation and mystery, we do know it will be based in Boston and become an “independent entity that is free from profit-making incentives and constraints.” The three organizations have stated they would initially focus on technology that would provide their employees and their families “Simplified, high-quality and transparent healthcare at a reasonable cost.” Gawande will begin his work on July 9.

The media is abuzz about the potential impact this new organization will have on a bloated and inefficient industry that comprises the size of Germany’s economy (GDP of $3.5 trillion in 2016 – the fourth largest nominal GDP in the world). Healthcare in the U.S., commonly acknowledged by those who are openly honest to admit this, has become a revenue-motivated business that creates an enormous jobs program, both of which make it difficult to politically challenge and reform. This powerful industry continues to prosper and wield its tight influence through lobbying and political pressure to those individuals we elect.

Here come three highly-regarded titans within their respective industries – CEOs Jeff Bezos (Amazon), Warren Buffett (Berkshire Hathaway), Jamie Dimon (JP Morgan) – and now another highly-respected healthcare ‘insider’ – Atul Gawande. Bezos, Buffett and Dimon are each fascinating in their own right, but Gawande is the wildcard that piques my attention. Here’s why…

Dr. Gawande’s accomplishments are both vast and deep. He is well known as a surgeon – he practices general and endocrine surgery at Boston-based Brigham and Women’s Hospital. He is also a professor at Harvard Medical School and Harvard T.H. Chan School of Public Health. Since 1998, he has been a highly popular staff writer at The New Yorker magazine. He has written critically-acclaimed books about healthcare, describing its’ problems and offering sensible solutions. Dr. Gawande is also the founder and executive director of Ariadne Labs, a research center looking for scalable health solutions to improve childbirth, surgery and other care.

What fascinates me the most about Gawande – primarily because of his professional medical background – is that he abhors inefficiencies and wasteful systems, both of which prevent our healthcare system from achieving much better medical outcomes and high-value care. The three sources of waste Gawande would like to eliminate are: 1) the layer of costs added by middlemen, 2) inflated pricing, and 3) misallocated care. While speaking in Aspen, CO, this past Saturday, Gawande mentioned this work will be a “tall fricken order.” He personifies the antithesis of a riddle that continues to dog the current approaches being used to ‘fix’ healthcare:

Question: “What do you get when you put more people into an already high-cost, low-performing and inefficient system?”
Answer: “A grossly higher-cost inefficient system that becomes even more untenable.”

We MUST find new approaches in healthcare that offer the right type of incentives (and disincentives) to re-direct the behaviors of the key healthcare players. Based on what he has written in the past, Gawande is unafraid of honest evaluations about an industry he has participated for decades.

Detractors of Gawande are somewhat skeptical for the following reasons:

Too Complex to Fix – Even an accomplished healthcare expert (like Gawande) can only do so much within a dysfunctional mammoth industry that is unwilling to change – especially if revenue is threatened. The medical establishment may voluntarily publicly acknowledge that real change is needed to ‘fix’ healthcare, but behind closed doors, the devil will be in the ‘details.’ In healthcare, that devil usually centers around revenue – lost revenue.
Lack of CEO Experience – Another perceived drawback for Gawande is his lack of CEO experience for a large, successful organization. How important this is, I’m not sure. Without knowing the specifics of the leadership hierachy and responsibilities in this new, unconventional role, Gawande will have three iconic business gurus solidly behind him to provide the necessary support, credibility and vision. Rest assured, this will not be a typical Ma and Pa startup.
Must be Focused – Gawande apparently appears to be keeping his other commitments in play while assuming this new CEO role – physician, instructor and writer. Whether this will be humanly sustainable, only time will tell. I assume that Gawande will surround himself with talented and experienced lieutenants to provide the support system needed for this venture to be successful.

This new venture is entering a high-stakes poker game that requires a wildcard or two. When the smoke settles, we should hopefully have a better understanding on just how well the cards have been played.

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“Alexa, diagnose my cough.”

Posted on: 04.17.18 By: David P. Lind

Imagine having a common but persistent medical symptom that you’re unsure how to treat. It’s quite easy, right? What if you were able to have a brief ‘conversation’ with a simple device located inside your home that would enable you to determine the best course of treatment – or at least provide you with a higher-level of confidence that seeking a medical provider is most advisable.

I recently acquired an Amazon Echo as a birthday gift and found it simple to use. Echo is a brand of smart speakers developed by Amazon that connects to the voice-controlled intelligent personal assistant service which responds to the name “Alexa.” A few other popular competing brands include the Apple HomePod (“Siri”) and Google Home. Alexa, we found, provides a form of entertainment for the user. Simply mention “Alexa” first, then issue your question or command.

Team games can be played with Alexa, including: Bingo, Tic-Tac-Toe, Song Quiz, True or False, Jeopardy, and many, many more. It is also enjoyable to invite Alexa to provide comical responses to simple questions, such as:

“Alexa, tell me a baseball joke.”
“…why is water wet?”
“…give me a tongue twister.”
“…give me a fortune.”

Of course, Alexa can also provide time-sensitive information beyond the aforementioned nonsensical dialogue, including:

“Alexa, provide me with current news.
“…what is today’s weather forecast?”
“…what’s the score of (my favorite sports team)?”
“…call (my favorite pizza delivery place).”

Impending Healthcare Disruption?

About two months ago, we learned that three major titans within their respective industries – Amazon, Berkshire Hathaway and JPMorgan Chase – are planning to develop a bold and independent healthcare consortium for their U.S.-based employees. The details have yet to be fleshed out, but for three innovative and iconic ‘disruptors’ to take aim at the largest U.S. industry – that is ripe for disruption – there is great interest to learn more specifics about this ‘new’ approach.

Organic disruption of the medical industry will most likely result from avant-garde’ individuals and organizations who infiltrate niches to solve the ‘needs’ that patients have – making healthcare more affordable, possibly understandable, and just as importantly, more efficient. These smaller players will make inroads with the lower-hanging fruit not considered as profitable to the ‘legacy’ groups who currently fill that role today. Over time, unable to affordably compete, legacy groups will retract from their entrenched roles and become more motivated to fight new battles in progressively profitable niches. This view is held by Clayton M. Christensen, a leading expert on disrupting markets that are ripe for new innovations that will transform expensive, complex and sophisticated solutions into solutions that are simpler, more convenient and affordable. The push for value-based payments, medical science advancements, enhanced data analytics and consumer demand for value and convenience are driving the necessary changes.

Voice-Activated Artificial Intelligence

Along with its’ competitors, Amazon’s involvement around the voice-activated artificial intelligence (AI) is quite intriguing, especially as it may relate to healthcare. In a recent NY Times article, ’Dr. Eric Topal, physician-scientist, and noted author, was quoted as saying, “…They (Amazon) could start to use voice platforms, like Alexa, to help discuss symptoms and get feedback, to coordinate hospital post-op care through voice-activated A.I., to do these and other rote things.”

Asking AI to assist with mainstream medical problems (e.g. colds, flu, skin rash) will most assuredly be problematic – beginning with legal liability hurdles. Another major barrier would be for AI to apply the best and latest medical research to those who choose to interact with AI for medical care steerage. By having this vital ‘medical assistant’ available at all hours of the day and night, one may not need to make a doctor’s office visit, which is both time-consuming and expensive (e.g. average U.S. office visit is $115).

A major challenge for modern medicine is to take the latest peer-reviewed medical literature and use it to benefit the medical delivery system. According to research from the University of Ottawa, there were about 50 million science papers published from 1665 to 2009, but during the past decade, approximately 2.5 million new scientific papers are published EACH YEAR. Due to this exponential growth of knowledge, the medical world is drinking large volumes of medical research information from a fire hose, making it difficult for medical providers to discern which findings are most beneficial to their patients. That is where AI may eventually benefit providers and patients – but it will take both time and money to do so.

A current game available through Alexa, ‘Akinator,’ includes a deductive binary search process that asks up to 20 questions of the player allowing Alexa to guess a prominent person, celebrity or fictional character the player has in mind. Alexa, using AI capabilities stored in the database, can determine the most appropriate questions to ask that will allow Alexa to choose correctly.

Using a similar approach, Amazon could potentially ‘harvest’ peer-reviewed medical literature (sanctioned by the appropriate authorities in various medical communities) and ask their subscribers a bank of questions about their medical symptoms and conditions to assess the best practice of treatment for that patient and whether care should be sought in-person from a medical provider determined through this discovery process.

Although not a substitute for seeing a physician, this service could help people decide how urgent their concerns are, and whether they should visit a doctor immediately or wait a few days before seeking care. This could help reduce overtreatment and act as a first-line triage system to winnow out those who don’t need immediate treatment from people who should seek immediate care. This would be somewhat similar to the symptom checker at familydoctor.org that can help people decide how urgent their needs are.

This service may not sound very realistic today, but neither did having ‘Alexa’ or ‘Siri’ serving as our personal assistants just a few short years ago. We can never underestimate the growing boundaries of technology, especially if it will help overcome human limitations often made in our daily lives – such as delivering the right kind of convenient medical care.

The monetization of providing this service will be fascinating to observe in the years to come. Perhaps a monthly subscription would be paid to access a yet-to-be-invented ‘Amazon Medical’ app (similar to gaining access to Amazon Music). It just takes creativity and imagination – both of which would assuredly be welcomed in this particular industry.

Now that we have this problem and solution mapped out, “Alexa, fix my leaking toilet!”

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Hospital Patient Safety Culture Does Matter

Posted on: 04.05.18 By: David P. Lind

A few years back, I walked into an Iowa healthcare executive’s office to discuss an idea that I thought carried a great deal of merit regarding patient safety. The executive, also a medical physician, politely listened to me. The idea was both simple and very intuitive. Since the mission of this particular healthcare organization is to “facilitate exceptional healthcare quality and safety for Iowans,” I had hoped it would be open to potentially embracing this approach in Iowa.

My idea was generated from the Hospital Survey on Patient Safety Culture, which is a hospital-staff survey designed by the Agency for Healthcare Research and Quality (AHRQ) to help hospitals assess the culture of safety within their own walls. When you think about it, who better to ask about quality of service within a hospital than the frontline workers themselves – staff, nurses, technicians, etc.? In fact, a report in BMC Health Services found that hospitals with “higher staff perceptions of safety culture were associated with better overall safety, as measured by a composite of reported harms and patient satisfaction.” Additionally, when noted physician, Marty Makary and his staff performed a joint study with risk management firm, Pascal Metrics, they concluded “hospitals that scored well on the staff survey had lower rates of surgical complications and other important patient outcomes.” AHRQ’s 2018 Patient Safety Culture Survey results are found here.

My idea? Make this carefully-crafted survey tool become mandatory for ALL Iowa hospitals to complete and eventually share with the public. A very small number of hospitals in Iowa do perform this survey, but unfortunately, the results are not meant for public disclosure.

The response I received from the medical executive was not what I had expected. To paraphrase his feedback: “These surveys usually occur in larger eastern (U.S.) hospitals, but not in small rural hospitals, like Iowa. The data findings from Iowa hospitals would not be statistically relevant…” I was absolutely floored when I heard this half-baked argument. What this executive failed to understand – or more likely, refused to understand – was that such surveys can be used within hospitals REGARDLESS of employee size. For this survey to be effective, there are two critical precautions that must be taken to safeguard unintended consequences:

Mandatory participation of all staff within each department.
Assure staff that honest responses are extremely important and any retributions for this honesty will not be tolerated.

Safety of care, I have learned, can be more about the optics (carefully spoon-fed to the public) than actual substance. For example, developing safety awards for hospitals who report few errors can dangerously promote behaviors to withhold adverse event reporting, a solemn fact that I have learned from a trusted, first-hand source in the hospital community. Although promoting safety awards may have good intentions, poorly-constructed programs can exploit an already dysfunctional healthcare system for a desired outcome – giving the public a false sense of security in which to rely on receiving safe care. Manipulating sacred patient trust is a gross violation of professional ethical codes.

As stated in our ‘Silently Harmed’ white papers, preventable harm in healthcare is a public health crisis, and much of this problem stems from organizational systems tolerating (or hiding) poor safety cultures. In a prior HHRI blog, “Another Estimation on Hospital-Related Deaths Due to Medical Errors,” I received a very descriptive comment from Donna Helen Crisp, who spent eight years writing a book about what happens in hospitals when things go wrong. In North Carolina, Ms. Crisp served as a nurse, nursing professor medical ethicist, dying patient, and author (Anatomy of Medical Errors: the Patient in Room 2). As an advocate, Crisp helps raise awareness about preventable medical errors and adverse events so that they can be eliminated – or at least mitigated.

Changing the medical paradigm by putting patients and families first.
Learning to see and accept the problems inherent in hospital care.
Developing core values to address and decrease medical errors.
Improving patient safety through transparent care.
Supporting clinicians who want to be truthful but fear retribution.
Training clinicians how to ethically support patients.
Training clinicians how to identify and ameliorate suffering.
Making safe care a higher priority than training doctors or corporate profit.

Because most medical errors go unreported, it is necessary to establish baselines – however they are determined – to track future progress on eliminating these errors. But we can learn a great deal by heeding Ms. Crisp’s words who courageously educates us about this public health crisis.

I only hope this same courage allows others who serve in crucial roles throughout our healthcare delivery system to proactively do the right thing and provide the transparency in care that we so desperately need.

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Patient Safety Awareness Week – Embracing the Right ‘Culture of Safety’

Posted on: 03.13.18 By: David P. Lind

Patient Safety Awareness Week began on Sunday. Therefore, it is only appropriate to commemorate this week (and all following weeks) with awareness about safe patient care among healthcare professionals and the public.

Much too often, patient safety is overshadowed by other healthcare-related issues (and agendas), such as expanding insurance coverage in state and local markets, medical and insurance mergers and acquisitions, and the opioid crisis – to name just a few. Some issues can’t be appropriately addressed soon enough (e.g. opioid epidemic), while other agendas are more about obtaining growth through acquisitions, often in the guise that more ‘value’ will be created to benefit the patient and the public. In healthcare, it appears optics is an extremely important and powerful tool.

So why is it so hard to make healthcare safer? There are many reasons, but four primary culprits stand out above all others:

Complexity of healthcare delivery system
Flawed systems are not designed to optimize patient safety
Ineffective communication contributes to patient harm
Weak incentives to push improvement processes

We all know that healthcare is complex. Much of it is due to flawed systems that are laden with unclear and distorted regulations often resulting in unintentional consequences which adversely impact patient care. Additionally, poor organizational safety cultures and communication practices compound the previous two reasons for unsafe care.

Much of the patient safety problem stems from not having a ‘business case’ to do the right thing at the right time. Business models are dependent on incentives – strong incentives – that will steer behaviors to the desired goal(s). When it gets down to it, inadequate financial incentives stunt the necessary initiatives required to spark safer patient care. Come to think of it, this is also part of human nature.

Unfortunately, in healthcare, it appears to be less about ‘doing the right thing’ and more about having appropriate incentives that will create the ‘business case’ of providing safe care to patients. This mentality must change.

After publishing ‘Iowans’ Views on Medical Errors,’ I created a number of Fact Sheets that address some takeaway thoughts for patients, employers and healthcare providers. These printable documents are found in the right sidebar on this HHRI webpage. Given the importance of this week, I would like to briefly address one particular Fact Sheet, ‘8 Strategies for Hospitals and Clinics to Prevent Medical Errors.’

I clearly realize that healthcare administrators will likely scoff at my ‘attempt’ to help them reform themselves, after all, they have been doing this reformation work for years, if not decades. But it seems to me – and many national medical experts included – patient safety begins with having a legitimate culture of safety at each medical establishment. And, it begins in the boardroom on down to each department in the organization. From this embedded culture, all other safety strategies can successfully follow.

My strategies, in no particular order – follow ‘culture of safety:’

Embrace a culture of safety
Treat staff burnout as an organizational priority
Adopt a structure to improve patient handoffs
Develop and nurture a patient and family-led advisory council
Be vigilant about reducing infections
Work to avoid diagnostic errors
To avoid medication errors, find opportunities to include pharmacists
Electronic health records systems must be interoperable

In 2017, the American College of Healthcare Executives and the Institute for Healthcare Improvement/National Patient Safety Foundation published an excellent resource to address this critical strategy for delivering safe care: “Leading a Culture of Safety: A Blueprint for Success.”

Patients experience medical errors not because doctors and hospitals wish to do them harm. Rather, unsafe care occurs because the systems and cultures of medicine influence medical providers to make decisions that don’t produce the best clinical results. It’s really quite simple. What patients want and need – coordinated and compassionate care that is affordable and safe – must align with the ‘business case’ of those who are paid to deliver it.

A ‘culture of safety’ should not just be a slogan in advertisements, but rather, THE reason healthcare organizations exist.

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Posted on: 01.17.18 By: David P. Lind

Confronting problems we have in healthcare today and fulfilling our vision for the future begins with having the courage and willingness to do the ‘right thing.’ Too often, however, doing the ‘right thing’ runs contrary to how we are incentivized to perform. As we know, incentives drive behaviors – both good and bad.

In his book, “Mistreated: Why We Think We’re Getting Good Healthcare and Why We’re Usually Wrong,” Dr. Robert Pearl appropriately wrote: “The design of our healthcare system – how it’s structured, reimbursed, technologically supported, and led – determines how the people in it will behave.” This sentence clearly articulates the inherent problems found in a haphazardly-designed system that now comprises almost one-fifth of the U.S. economy.

I have learned a great deal from our recent “Iowans’ Views on Medical Errors – Iowa Patient Safety Study^©.” Five large takeaways from this study include:

Nearly one-in-five Iowa adult patients experienced medical errors in the past five years, either for themselves or for someone close to them.
When a medical error occurs, six-in-10 Iowa patients are not notified of the error by the responsible healthcare provider.
Most Iowans who experienced medical errors desire to report the error because they want to prevent the same error from happening to someone else. This runs contrary to conventional belief that patients desire to report medical errors primarily to receive compensation for the harm they received.
Iowans strongly feel that medical errors must not be hidden from the public and should be reported, both to the patient and to an appropriate regulatory agency.
Iowans believe medical errors are mostly caused by overworked staff, lack-of-care coordination and poor communication.

Reading between the lines on many of the survey findings, here are some of my general thoughts on what we can learn from this report:

Medical errors are a national public health crisis, and Iowa is certainly not immune from this persistent epidemic.
Making healthcare safer is difficult largely because healthcare organizations operate in a very complex healthcare system. They use a myriad of inoperable electronic health-record systems that are not fundamentally equipped to allow for effective communication between providers. Most importantly, strong incentives to push appropriate patient care in the right direction is sorely lacking. Because of this, delivering efficient and safe healthcare appears to be more problematic than putting a man or woman on the moon.
Surveyed Iowans are not necessarily blaming individual workers who devote their worklife to the medical profession, but rather, they tend to believe that well-meaning medical professionals are trapped in a subpar delivery system.
The patient ‘perspective’ must be actively pursued to measure the outcomes of the care they receive, and this experience can help reveal the prevalence of medical errors. The future of healthcare will be determined as much or more by patients as by physicians.
Zero-tolerance of preventable medical errors should be the norm, rather than exception – Most everyone knows that this problem is happening, but little has been done to determine the extent of this problem and how to make it unacceptable in the future. When errors occur, provider care systems are largely silent on this topic, often failing to share prompt, open disclosure and a full apology to harmed patients. This primarily happens because providers wish to avoid the possibility of malpractice lawsuits and maintain a pristine public reputation. Patients, on the other hand, have reasonable expectations that are woefully unmet after an error occurs. They likely feel thrust into a confrontational situation while still being in a fragile state of health. In short, if we don’t demand safe care, they don’t supply it. In 2017, commercial passenger airlines had zero deaths due to accidents…because that industry has a zero-tolerance approach to preventable errors. The medical industry can learn greatly from other industries.
Organizational culture is critical to the success of delivering safe care. The environment in which medical staff work – such as hospitals and clinics – can provide the necessary organizational culture to ensure the healthcare delivered is as error-free as humanly possible. Medical staff should not be afraid to report medical errors when they do occur. Safety improvement initiatives will only succeed when leadership, safety culture programs, fundamental communication practices, commitment to transparency and patient engagement are fully-aligned with the objective of greater patient safety.

Thought leader and author Frank Sonnenberg describes trust quite succinctly, “Trust is like blood pressure. It’s silent, vital to good health, and if abused it can be deadly.” To have an efficient and effective healthcare delivery system, trust will be required at all levels and by all participants. This means that, at their most vulnerable time, patients should not be taken advantage of by those who are given this trust – especially when medical errors occur.

If we can put a man on the moon in 1969 using technology dated 50 years ago, why can’t preventable medical errors be tracked and mostly eliminated today? We must first have the moral will to succeed, and then design and install correct incentives to ensure the desired behaviors and outcomes.

The re-design of our healthcare system requires the grit we used when launching a rocket to the moon. In healthcare, however, its more about human (and organizational) behavior than rocket science.

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