27 November 2015
Dear Interested Readers,
Inside This Week’s Letter
Sometimes things just fall into place and for that I am thankful. This week’s letter begins with a discussion of what I am thankful for in healthcare. The list of things that I am thankful for seemed like a natural introduction to a discussion of EQ or emotional intelligence, a subject that is very interesting to me because it connects to empathy, to awareness, and to engagement. There was an easy segway from the discussion of emotional intelligence to information from one of the “Interested Readers” of these notes, Dr. Tony DiGioia of UPMC. Dr. DiGioia wrote me to say that he has a journal article coming out about hip and knee replacement. What makes his work interesting is that it demonstrates a union between patient and family centered “shadowing” and finance concepts based on the work of Porter and Kaplan at Harvard Business School. That marriage of a focus on how patients and families experience care with focused business observations created an improvement in quality and cost, as well as improved patient and family satisfaction. The “awareness” that is so key to EQ is fundamental to observing patients and families as they move through an episode of care. The letter concludes with an adventure that underscored for me how grateful I am for life.
If you are curious about MACRA but you are just not making much progress in completely understanding how it evolved from the SGR and how it connects to the future of practice you may want to look at the new posting on strategyhealthcare.com. The SHC website is where the fat has been trimmed from these offerings. It is also where your colleagues can sign up to be weekly readers of this letter. Perhaps someone would be thankful if you were to tell them about it.
There is Much To Be Thankful For In Healthcare
At the top of my list of what I am thankful for in healthcare is that I had the good fortune to attend Dr. Robert Ebert’s medical school at a time when he began to realize that healthcare could only improve with a search for transforming concepts in care delivery and finance. He also realized a need for a change in the way we train medical students and house staff if we wanted to produce socially responsible physicians to led the way to better care for populations. I have frequently said that the best thing that has happened to me in medicine was to be a student when he had these ideas. That good fortune extended to the creation of his “pilot”, the Harvard Community Health Plan, which was lead by Dr. Joseph Dorsey, my mentor and Dr. Ebert’s chief lieutenant. HCHP was up and running just in time to employ me when I was ready to start my practice career.
I have often said that when I look at the work of Don Berwick, I am not surprised to see him as a first generation successor who reflects the concepts of Dr. Ebert.. His exposure to Dr. Ebert was equal to, if not greater, than mine. Near the top of my “ I am thankful for” list is the work of the many dedicated physicians, nurses and medical administrators who have devoted their careers to the improvement of safety and quality in healthcare. It is not a surprise that much of this work was led by Don Berwick at the IHI.
There have been many others whose names I should mention as heroes of this movement for whom I am thankful. The list would certainly include Lucien Leape and Paul Bataldan. They have contributed to the quality and safety work and the rapid evolution of our concepts of good cost effective processes in healthcare. It goes without saying that I am enormously grateful that insightful leaders like John Toussaint, Patty Gabow and Gary Kaplan recognized Lean as an operating system that has the power to mend and transform practice. I am so grateful that based on advice from Dr. Toussaint, Atrius Health turned to the Lean expertise of Simpler and the wonderful sensei and senior leadership of that organization who have taught me so much.
I am thankful that there is a growing awareness of the power of the Triple Aim and the imperative that we understand what patients and families want. Next week, once again, as it has for more than 20 years, the IHI will meet in Orlando and thousands of dedicated healthcare professionals from across this country and around the world will be gathered to exchange ideas about how to deliver care that meets and exceeds the expectations of patients and families and to realize the goals of the Triple Aim.
Despite all of the drama of its ups and downs, I am thankful for the Affordable Care Act. It is the quintessential example of something that has achieved much despite the efforts of so many to derail it. The ACA had a tortured birth as a “1.0” system response to a very complex set of problems. I am thankful for the legislative intelligence that found a way for it to survive even after Scott Brown’s election to Ted Kennedy’s Senate seat took away the supermajority control of the Senate. I am thankful that the ACA has been a success even after the loss of the House majority by the Democrats guaranteed that we would live with ACA 1.0 for several election cycles. I am thankful that a Supreme Court, even with a conservative majority, has twice rejected attempts to have the ACA ruled as unconstitutional. Sure, they did give the states the ability to reject the Medicaid extension and thereby deny millions of Americans the healthcare coverage they needed just when they thought it might happen, but I am still thankful that millions more were lucky enough to live in a state with progressive leadership and they do have care that they did not have in 2009. The residual list of benefits for us all that has been provided by the ACA is still quite long. I am thankful that we still have the opportunity to show that even in its imperfect form we can use the ACA to the benefit of millions who would otherwise be denied care.
I am thankful for pundits both liberal and conservative, like Paul Krugman and David Brooks, who may know very little about the practice of medicine but do understand public policy and have written responsibly about healthcare. This week Krugman showed his understanding of what the ACA is all about with a column entitled “Health Reform Lives!”. I have lifted some of his “thankful” analysis that reflects my own feelings.
To the right’s dismay, scare tactics — remember death panels? — and spurious legal challenges failed to protect the nation from the scourge of guaranteed health coverage. Still, Obamacare’s opponents insisted that it would implode in a “death spiral” of low enrollment and rising costs. But the law’s first two years of full implementation went remarkably well. The number of uninsured Americans dropped sharply, roughly in line with projections, while costs came in well below expectations. Opponents of reform could have reconsidered their position — but that hardly ever happens in modern politics...I mention all of this to give you some perspective on recent developments that mark a break in the string of positive surprises. Yes, Obamacare has hit a few rough patches lately... But... Health reform is still a huge success story.
...Nobody ever expected Obamacare to cover all the uninsured. In fact, Congressional Budget Office projections made in 2013 suggested that about 10 percent of nonelderly U.S. residents would remain uncovered: some because they are undocumented immigrants, some because of the gap created by red-state Medicaid rejection and some because they would fall through the cracks of a complicated system. But the law was nonetheless projected to produce a sharp reduction in the number of Americans without insurance, and it has, especially in states like California that have tried to make it work.
Meanwhile, both insurance premiums and the cost of subsidies designed to make them affordable came in far below expectations in both 2014 and 2015.
He goes on from there to admit that prices will be up next year and those who bought policies with high deductibles have had unpleasant surprises despite access to preventive care without a deductible. He finishes his list of concerns with the recent news that several people have asked me to explain:
Finally, UnitedHealth Group made a splash by announcing that it is losing money on the policies it sells on the Obamacare exchanges, and is considering withdrawing from the market after next year.
But he even gives that news a better spin:
There were some puzzling things about the announcement, leading to speculation about ulterior motives, but the main thing to realize is that UnitedHealth, while a huge provider of employment-based insurance, is actually a fairly small player in this market, and that other players are sounding much more positive….
He finishes with a thankful perspective:
So where does that leave us? Without question, the run of unexpectedly good news for Obamacare has come to an end, as all such runs must. And look, we’re talking about a brand-new system in which everyone is still learning how to function...The reality is that Obamacare is an imperfect system, but it’s workable — and it’s working.
I said it was a “1.0” operating system. It is time for an upgrade. We could use all of the experience that we have gained from what has not worked as well as we hoped the first time around and reengineer 2.0 to be better yet. You might say, “Fat chance of that!” My response is that I am thankful that time and time again our history has gotten us to the right place after a long painful pragmatic process. We have a long way to go in healthcare, as we also do in achieving housing, education and employment for everyone. We are still a society with many oppressed by the fact of their race, gender, sexual orientation, or disabilities; but we have made huge progress in all of these areas.
I am very thankful for our collective ability to make progress with complex problems even as we struggle back and forth against odds that may make it seem that there is no hope for success. We validate daily the observation of Winston Churchill. He gave us a sincere compliment when he famously said, “You can always count on Americans to do the right thing - after they've tried everything else”. We always get to the right place--in time, and I am thankful for that.
A Freebie For Which I am Thankful
My email inbox is reloaded every night with stuff from vendors of healthcare information and items for sale. I also get a lot of junk mail that I am sure is evidence that as I wander around on the Internet cookies stick to my computer or that my name is on lists that get sold and resold to people trying to make a buck from their product or for their political cause or favorite charity. In the past I just deleted them with the same reckless abandon that I once used to whack weeds.
Now in retirement, I give some of these offers a second look which is why I am sure my harvest continues to grow. Recently, I fell for the offer of a webinar on emotional intelligence from Becker’s Hospital Review. To my delight it was terrific even though it was clearly a marketing tool for a company that sells consulting services. There were two physicians who were presenters, Alan H. Rosenstein, an internist and consultant from the San Francisco area and Michael Garren, a Clinical Professor of Surgery from the University of Wisconsin.
You can read a summary of the webinar by clicking here. It was written by Tamara Rosin and was published this week. If you have an hour to spare, there are links at the bottom of her summary to the presentation as well as to the slides that were presented. For those of you who do not have the luxury that I have to invest time in a webinar, here are more than twenty points to note that I lifted for you from Ms. Rosin’s summary:- As the healthcare industry becomes increasingly concerned with patient satisfaction and care coordination, technical medical knowledge alone will not suffice.
- Emotional intelligence — plays a significant role in determining how effectively physicians communicate and establish relationships with patients, as well as with their colleagues.
- Effectively leveraging emotional intelligence requires an understanding of how emotional intelligence manifests itself, as well as tools to help understand an individual's emotional intelligence in a healthcare context.
- Emotional intelligence has four components: self-awareness, social awareness, self-management and relationship management. Per Dr Rosenstein, EQ is the ability to perceive, evaluate, understand, respond to and influence emotions. Core is an awareness of self and how others and how you are perceived by others.
- As healthcare evolves to embrace a patient-centered model, physicians who lack self- or social awareness may have a harder time establishing strong relationships with those for whom they care.
- Empathy is a key aspect of emotional intelligence but emotional intelligence and empathy are not the same thing. One of the presenters illustrated this point when he said,"We can all think of a physician we've met or encountered in our careers or in personal interactions who might be high in social sensitivity, self-esteem and social awareness, but perhaps not in empathy. They might be aware of how they're perceived, they just don't really care that much.” The converse is also true. Many physicians who think they are empathetic are unaware of how they are perceived.
- We expect physicians to go beyond clinical excellence and be leaders, but they are not necessarily prepared to fill those roles, and we do not provide them training.
- Physician performance is the fulcrum of any healthcare initiative. Some of the most pressing initiatives in healthcare today are transitioning from volume- to value-based care, succeeding under value-based purchasing and improving the patient experience.
- Without strong communication skills and coordination within the clinical care team and in physician-patient interactions, efforts to improve the patient experience and thrive in a value-based care model will fail.
- When it becomes apparent that someone is unable to communicate effectively or lacks social or self-awareness, assessing his or her emotional intelligence enables leaders to identify and provide appropriate training to target various communication skills.
- Many physicians do not recognize that patient outcomes can be influenced by the emotional intelligence of physicians.
- Patient perception is key and relating to patients with empathy is critical. Complex patients with complications have better outcomes when they are managed in a sympathetic way.
- Studies show that high emotional intelligence correlates with career success and satisfaction.
- Clinical care teams with strong communication skills have better outcomes and physicians with higher emotional intelligence more effectively manage chronic disease.
- Life experiences, as well as generational, gender and cultural differences, all contribute to an individual's level of emotional intelligence. External factors specific to physicians include the isolating nature of medical training and a stressful work environment.
- Some medical schools are beginning to change their core curriculum to include interpersonal relationship training.
- Physicians are increasingly held accountable for quality performance while burdened by administrative work and complying with ever-changing rules and regulations. As a result, many are becoming less aware of how they are experienced by others as they become frustrated and disengaged .
- Stress and conflict management support services can help remedy some physician frustration, as well as help physicians practice communicating their concerns more effectively.
- The best way to increase physicians' willingness to change their behavior is by assessing their emotional intelligence (awareness) level and then use an evidence-based case for improving.
- Physicians can be taught to engage in self-inquiry, which entails thinking back on interactions and determining effectiveness. Did they communicate clearly? Does he or she believe the patient was able to communicate clearly? How do they perceive the patient left the interaction feeling?
- Since emotional intelligence is an expression of self awareness and not just empathy, the goal of support is to get people who are not self-aware to become self-aware.
- Supporting physicians, empathizing with them and listening to their concerns — as opposed to just telling them what to do — will make them more inclined to improve behavior related to emotional intelligence.
- Once physicians understand the role of emotional intelligence then diversity training, customer service training and continual check-ins can help them refine their communication skills, and allow them to continue to learn how to better perceive emotions and empathize with others.
It all makes sense to me. As I have considered these issues I am reminded of the work on “mindset” by Carol Dweck at Stanford. I am also reminded of the work of Helen Riess from MGH psychiatry on empathy that I reviewed a few weeks ago in the piece about Vermont. I see many similarities to the understanding of Sara Faulkner at Group Health that flowed from her programs to improve physician communications that I featured in a piece last February. What follows from these reflections in the next section of this letter is yet another example of what emotional intelligence and an awareness of how care is perceived by patients and their families can do to improve care.
Things Are Changing and They Can Improve
In the October 16 letter I pointed out a recent NEJM Perspectives article written by Rob Mechanic. Rob is an “interested reader” and I thought this article, like so many of his recent articles, had immediate importance for many hospitals and health systems. The essay was a terrific discussion of the new mandatory Medicare bundles for hip and knee surgery. Quoting from the article:
The program [from CMS] would establish bundled payments for total hip and knee replacements, covering hospitalizations, professional fees, and all clinically related Medicare Part A and Part B services for 90 days after discharge, including skilled nursing facility care, home care, and hospital readmissions. CCJR is similar to another model CMS is testing called Bundled Payments for Care Improvement (BPCI), but whereas BPCI is voluntary, hospitals would be required to participate in CCJR. CMS proposes implementing the 5-year program in 75 metropolitan statistical areas with approximately 750 hospitals beginning January 1, 2016.
Rob Mechanic is an economist and Senior Fellow at the Brandeis Heller School for Social Policy and Management. He has published many articles on the AQC and bundled payments and few writers have his experience evaluating the impact of new payment mechanisms in healthcare. In the article he points out:
CCJR is CMS’s first proposed mandatory bundled-payment program extending across multiple providers and settings. Such a proposal was probably inevitable, given the new goal of shifting 30% of Medicare spending to alternative payment models by the end of 2016.” Bundled payment appeals to policymakers because it can cover a much wider spectrum of providers than models such as the Pioneer ACO, in which organizations need a large base of primary care physicians and strong capital reserves to participate effectively. Moreover, CCJR would require that participants accept a 2% discount on their bundle prices, guaranteeing Medicare savings that would be scorable by the Congressional Budget Office.
The economic reasons behind the decision at CMS are staggering since hip and knee surgery consumes billions in resources:
In 2013, more than 400,000 Medicare beneficiaries received hip or knee replacements at a cost of more than $7 billion for hospital stays alone. The initial hospitalization accounts for only about 55% of total episode costs; Medicare also spends about $6 billion during the 90-day post-acute period. Medicare spends about $26,000, on average, per joint replacement episode, but the wage adjusted average ranges from $16,500 to $33,000 among the 196 metropolitan areas considered for the demonstration. Joint-replacement surgeries are elective, relatively standardized, and subject to relatively low spending variation — factors that make them a good starting point for testing mandatory bundled payment.
After giving you these quotes from the article, I suggested that is was time to apply Lean to these bundles. One Interested Reader, Dr. Tony DiGioia, who is both an orthopedic surgeon and perhaps the nation’s foremost practitioner of Patient and Family Centered Care published an article this week that was pretty remarkable. Early this week he wrote to me:
Hi Gene,
We were recently notified that one of our manuscripts has been accepted for publication on how we applied the TDABC (Time-Driven Activity-Based Costing) cost methodology and value structure (from Kaplan and Porter at HBS) combined with our Shadowing tool to the total joint replacement care experience.
I thought that you would enjoy reading the report since it combines cost, outcomes and process improvement all in one approach.
The article is currently available on line and will be published in hard copy form in early 2016. The Journal of Arthroplasty is the most widely read journal within orthopaedics for surgeons that specialize in joint replacement surgery.
We reported on the four month care experience which included one month b4 surgery (typical for most bundling programs). However, this kind of info is directly applicable to participating (and being successful) in the new CMS Coordinated Care Total Joint program which has a 3 months period from the day of surgery plus 90 days. As you know this new CMS program has been gathering a lot of attention and interest.
We have also been applying this “true cost methodology" to several other clinical conditions including peri-op pain management techniques, routine mammography vs the new tomographic techniques, robotic vs laparoscopic lap hysterectomies, and a recent one - outpatient total hip replacement. Each project has been eye opening for the clinicians as well as hospital administration since this approach directly links clinical and financial performance.
Also, we now have a digital, cloud based solution for our shadowing tool that can capture the in-field time studies and data necessary to apply the true cost methodology and for supporting any process improvement efforts. GoShadow is iOS based so both iPhones and iPads can be used to capture the in-field data and the there is a cloud based platform that automatically generates reports like time studies, process maps, touchpoints and care givers etc. This kind of tool can be used by anyone to complement their own process improvement efforts. Some additional info at GoShadow.org.
I’d be glad to set up a short 30 min on-line demo of the new GoShadow for you down the road if you would be interested.
Thanks again for all of your help and support. Happy Thanksgiving too.
Tony
If you are going to Orlando for the IHI meetings you might want to check out a session on “shadowing” that Dr. DiGioia is giving on Sunday December 6. The IHI has also recently put out a blog post from Dr. DiGioia that gives a more complete description of the work. If you are interested and want to learn more, I am happy to connect you to Dr. Digioia or you could click here to connect to the excellent IHI blog post about the work.
Thankful To Be Alive
Every now and then something happens in the life of an ordinary person to reinforce what a blessing it is to be alive and well. I am writing to you this week from Coconut Grove where it feels like a July day in New England. Yesterday was almost a typical Thanksgiving Day. My son, granddaughter and I watched football. We got in one of our jogging tours through the “Grove”. I used a “cheat day” reprieve from my chronic low glycemic diet as I enjoyed every mouthful of a great dinner while chatting with my granddaughter and catching up on her latest academic and athletic achievements in middle school. What was not typical and what enhanced my sense of thankfulness for life itself was the way Thanksgiving Day started.
I have a lot of Scottish DNA which rhymes with a genetic predilection for being cheap. Some years ago I discovered that traveling on Thanksgiving Day and returning mid week after the holiday saved several hundred dollars even on a more economical airline like Southwest. To be in Miami by noon ready for food and football, we booked a 5:35 AM flight to Baltimore with a connection that got us to Fort Lauderdale at 11:55. It is an hour from our home in New London down to the airport in Manchester. We arose at 2:45 AM and by 3:15 we were speeding down Interstate 89 with my wife driving and me drinking coffee. As we were entering the Interstate just before putting the pedal to the metal my wife said, “This is just when we need to be careful not to hit a moose”. Thirty seconds after her warning two large deer suddenly appeared in front of us running as if they were going down the highway and not across it. She swerved left and they swerved left. She then went right as she tried to stop and they went right. We hit them hard with a jolt that shook me in the passenger seat and left me with a sore neck and lower back and her with a sore shoulder and back.
Then the front end of the car was talking to us. It was clear that parts were dangling and banging against what was left of the right side of the grill and the passenger side fender. As I tried to climb out of the car to survey the damage my door creaked as metal was encountering metal that it was not designed to meet. Miraculously, even though the battery and various other innards were exposed by the loss of some part or another of the front end, the various dangling lights and remnants of the fender could be rearranged to allow us to continue on our way after we called the State Police to report the event. Our momentum had carried us some distance past the deer and in the dark we were not sure whether they were still in the highway. I was relieved when in a moment another car passed us suggesting that the road was clear.
I was planning to end this letter with my usual advice to take advantage of the persistence of warm weather across much of the country and the suggestion to you that you walk off some of those extra calories that you might have consumed yesterday. That is still good advice. If you walk at sunset you may be rewarded with a glorious view of the evening sky like I was earlier this week, as the picture in the header of this letter reveals. Life is good and despite all of the troubles in the world there is always a positive bottom line to all that we do, if we are aware and look for it.
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