In my last post, I told about the Value Code, a book that was published at the worst possible time for its ideas to gain any traction. The majority of the companies the book highlights no longer exist, have been taken over or abandoned the activity for which they were being mentioned.
So much for new ideas.
But on closer reading, the point must be accepted; that value is created as much by the arrangement of resources as anything else. The road to success is a via well though-out plan for execution in the context of a good understanding of the strategic landscape followed by a whole lot of luck…
The trouble with many people’s notions of how to bring business innovation to health care is that they are saddled with assumptions that apply to other aspects of the business world, but do not necessarily apply to health care.
For example, competition in health care frequently leads to increased consumption. Price transparency has the potential to paradoxically lead to rising prices, rather than price competition. (“Have we got a sale on brain surgery this week!”) The fact that a third party pays for the services completely distorts consumer behavior. And yet, health care is an under-estimated contributor to overall economic output.
Before trying to introduce innovation in health care, one must first acknowledge the structural reasons that argue against changing anything. Why adopt EMR? It doesn’t add value to the health of the patient in front of you. Frankly, it only adds work with the hope that someday in the future the collective information derived from such systems may improve something or other.
The real innovations in health care are related to the development of new technologies. Tagamet was a pill that nearly cleared surgical waiting lists (anyone remember how many vagotomies and pyloroplasties filled OR lists in the early 80’s?) Then laparoscopic surgery nearly destroyed the financial viability of half the hospitals in this country by reducing length of stay for surgery that would previously need four or five days in-house. Radiography got killed by CT which is displaced by MRI which will succumb to something else. Chemo has come so far that cancer survival rates have been upticking for the past three or four years. Certainly I have missed an awful lot of revolutionary medical innovations of the past two or three decades, but these are some which come to mind.
EMR will never be on this list.
Shared decision-making is not here.
Evidence-based medicine is of tremendous value but is certainly not a revolution.
Group medical visits for chronic disease will not bring down the walls, nor will disease management, case coordination, Health 2.0, concierge medicine, new insurance paradigms or new models for primary care training.
These items, which have engrossed my attention and dominated my interest for most of my career are not revolutionary technologies that will disrupt everything we now know about health care.
A bitter pill, perhaps, but innovations still make their way into health care delivery… the question is how?
Wednesday, August 20, 2008
Monday, August 11, 2008
The Value Code: Throwing Out The Baby With the Bathwater
I've been reading an old book a friend once recommended while she was employed at the now-bankrupt Arthur Andersen. The book, "Cracking the Value Code" was intended for prospective Andersen clients and probably remained quite useful as the consulting group re-invented themselves under the Accenture name.
It was famously published at the peak of the Internet boom. I'm not kidding, it was published in May 2000, two months after the March 10 intra-day high on the NASDAQ. It is filled with examples of companies that had come to understand how to create value from the arrangement of their intangible and difficult to measure assets.
Most of the companies no longer exist and the ones that survive today have learned how to value their assets in more old-fashioned ways than relying on intangibles. The authors never mustered the credibility to write anything else, except for Barry Libert who runs a blog for Amazon in between other ventures.
Enough time has passed to forget about how Arthur Andersen stretched the truth on their audits under a lame premise of reflecting the true underlying value of all those intangibles. But the temptation is always there to throw the baby out with the bathwater. The authors had a point. The true value of many things is not reflected in their price; the market for products is never efficient the way equity markets are. There is a strange rationality to economic decisions on the micro level but it is not always the correct decision based on an external objective framework.
Spock once challenged his father about marrying his human mother rather than a rational, logical Vulcan woman more like him. "It seemed logical at the time," was Sarek's response. So many things that patients do seem to have been sensible at the time.
A book on value written at the peak of a financial bubble teaches me that things may seem valuable or not based on a sentiment framed by the times. I'm not going to throw the book and its ideas out because of bad timing.
What is particularly relevant is that we are all looking for more value out of health care; patients, doctors, payors... everybody. But what value is that exactly? Value is perspective-dependent and has to be defined. It is hard to believe that an employer with a pension and health care benefit liability and a managed care insurance company define value the same way. Certainly a physician and a patient don't quite see ye to eye, but it's a better bed-mate than a Wall-Street reporting insurance com pany.
I've been looking at what primary care physicians do in terms of risk assumption and asserting that reimbursement is inadequate for the level fo risk. But risk (specifically the risk-management skill of the physician) is insufficient only a part of the determination of value to the patient. A lot of decisions depend on how that value is perceived at the moment. Illness has a strange way of changing the perception of value from a treatment!
More to come...
It was famously published at the peak of the Internet boom. I'm not kidding, it was published in May 2000, two months after the March 10 intra-day high on the NASDAQ. It is filled with examples of companies that had come to understand how to create value from the arrangement of their intangible and difficult to measure assets.
Most of the companies no longer exist and the ones that survive today have learned how to value their assets in more old-fashioned ways than relying on intangibles. The authors never mustered the credibility to write anything else, except for Barry Libert who runs a blog for Amazon in between other ventures.
Enough time has passed to forget about how Arthur Andersen stretched the truth on their audits under a lame premise of reflecting the true underlying value of all those intangibles. But the temptation is always there to throw the baby out with the bathwater. The authors had a point. The true value of many things is not reflected in their price; the market for products is never efficient the way equity markets are. There is a strange rationality to economic decisions on the micro level but it is not always the correct decision based on an external objective framework.
Spock once challenged his father about marrying his human mother rather than a rational, logical Vulcan woman more like him. "It seemed logical at the time," was Sarek's response. So many things that patients do seem to have been sensible at the time.
A book on value written at the peak of a financial bubble teaches me that things may seem valuable or not based on a sentiment framed by the times. I'm not going to throw the book and its ideas out because of bad timing.
What is particularly relevant is that we are all looking for more value out of health care; patients, doctors, payors... everybody. But what value is that exactly? Value is perspective-dependent and has to be defined. It is hard to believe that an employer with a pension and health care benefit liability and a managed care insurance company define value the same way. Certainly a physician and a patient don't quite see ye to eye, but it's a better bed-mate than a Wall-Street reporting insurance com pany.
I've been looking at what primary care physicians do in terms of risk assumption and asserting that reimbursement is inadequate for the level fo risk. But risk (specifically the risk-management skill of the physician) is insufficient only a part of the determination of value to the patient. A lot of decisions depend on how that value is perceived at the moment. Illness has a strange way of changing the perception of value from a treatment!
More to come...
Thursday, August 7, 2008
PSA and Prostate Cancer Screening Doubts
I once asked a urologist what he thought about universal screening for prostate cancer by framing the question in very personal terms. I asked him about letting a doctor's finger to approach him. His answer: "Keep the finger away from me."
This was in 1989. And nothing has changed.
The Post reports on the USPSTF revision to PSA screening recommendation, downgrading prior enthusiasm. Note the recommendation is not to deny screening. It merely states insufficient evidedence at this time to support screening. The major difference from prior recommendations (as far as can tell at this point) is the withdrawal of a half-hearted OK that had been given to people at high risk, like African-Americans, people with a family history and especially, men over 75.
The level of protest is remarkable in its lack of scientific integrity. "Too bad, we're saving lives." Well, that's not what the data shows. Men are living longer since PSA screning has become widespread is the same as the autism argument. Maybe men are living longer because of MMR. Have you ever noticed how males get autism more often?
At the risk of offending my favorite urologist, PSA'a are remarkable at their ability to efficiently generate billable procedures (i.e. trans-rectal ultrasound guided biopsy). Those with the greatest interest in a recommendation for universal PSA screening own surgical facilities or benefit from the procedures generated.
The USPSTF is a government agency and since the government, as the country's largest payor, may be construed as having an interest in decreasing its expenses, this agency is not beyond a natural incentive to skew its conclusions. But if you think it through, it means that the standard of proof is necessarily higher. This kind of bias is one I can buy into as more trustworthy. Personal opinion.
The bottom line is that the more people I do PSA's on, I will probably save a life or two, but at the cost of several people going through unnecessary stress, procedures and complications. The sad part about prostate cancer is that the PSA will also detect a number of cancers for which treatment will fail, or be irrelevant due to intercurrent illnesses. By not doing PSA's, I can keep several people peacefully in the dark, but miss one or two cancers that could be impacted. Those people whose cancers are missed but for whom treatment will have no impact also represent a huge malpractice risk. These people are the ones most likely to sue for missed diagnosis, even though the truth may well suggest a different conclusion.
The USPSTF did the right thing, but it would be interesting to revisit their original endorsement of high-risk screening and what changed in the data to support a change in recommendation.
This was in 1989. And nothing has changed.
The Post reports on the USPSTF revision to PSA screening recommendation, downgrading prior enthusiasm. Note the recommendation is not to deny screening. It merely states insufficient evidedence at this time to support screening. The major difference from prior recommendations (as far as can tell at this point) is the withdrawal of a half-hearted OK that had been given to people at high risk, like African-Americans, people with a family history and especially, men over 75.
The level of protest is remarkable in its lack of scientific integrity. "Too bad, we're saving lives." Well, that's not what the data shows. Men are living longer since PSA screning has become widespread is the same as the autism argument. Maybe men are living longer because of MMR. Have you ever noticed how males get autism more often?
At the risk of offending my favorite urologist, PSA'a are remarkable at their ability to efficiently generate billable procedures (i.e. trans-rectal ultrasound guided biopsy). Those with the greatest interest in a recommendation for universal PSA screening own surgical facilities or benefit from the procedures generated.
The USPSTF is a government agency and since the government, as the country's largest payor, may be construed as having an interest in decreasing its expenses, this agency is not beyond a natural incentive to skew its conclusions. But if you think it through, it means that the standard of proof is necessarily higher. This kind of bias is one I can buy into as more trustworthy. Personal opinion.
The bottom line is that the more people I do PSA's on, I will probably save a life or two, but at the cost of several people going through unnecessary stress, procedures and complications. The sad part about prostate cancer is that the PSA will also detect a number of cancers for which treatment will fail, or be irrelevant due to intercurrent illnesses. By not doing PSA's, I can keep several people peacefully in the dark, but miss one or two cancers that could be impacted. Those people whose cancers are missed but for whom treatment will have no impact also represent a huge malpractice risk. These people are the ones most likely to sue for missed diagnosis, even though the truth may well suggest a different conclusion.
The USPSTF did the right thing, but it would be interesting to revisit their original endorsement of high-risk screening and what changed in the data to support a change in recommendation.
Saturday, August 2, 2008
Is Health Care Supposed to Be Compassionate?
I have always had an interest in the liberal arts and philosophy in particular. I never got the formal training, but as a perennial dilettante, articles such as this (courtesy of aldaily) tend catch my interest.
It is a brief and digestible history of the idea of compassion. It made me consider how the religious right views the morality of health care as a kind of theological experience of salvation through pity. It is truly opposed to (may I say positivist?) humanist notions that arose during the enlightenment. It is interesting to me, although perhaps unsurprising, that the origins of both liberal and conservative American political discourse lie in the Enlightenment. Smith and Rousseau are cut of the same material, albeit opposite surfaces of it.
The idea of health care as a right seems to be based on pure sentiment as a moral center, pushing a political process to assuage the suffering of those people for whom we feel sorry. The natural objection would be "Hey, what about me. I've worked hard. I've made all the right moves. These people are suffering because they screwed up. They have no right to anything I didn't have when I made my choices."
Naturally the truth is likely to fall somewhere in between these two positions. Helping people for whom we feel sorry tends not to help them. Conservative thought reveals that some programs create a tendency to dependency which should offend any liberal. But the doctrine of personal responsibility is a sham because it assumes that every choice is made from the same perspective, with the same natural abilities and skills and assume the same opportunities. Once the playing field is leveled in terms of genetics and the psychological, social and economic background of upbringing and then we can talk about personal repsonsibility as a political ethic.
What else have I learned? I have been using the term "enlightened self-interest" without understanding its pedigree traced back to Rousseau. Montesquieu's adherence to the idea that commerce increases "humanity" is close to my heart and sounds a little like compassionate conservatism without the religious wingnut contribution prevalent in American political thought.
Rousseau's attachment to equality is cloying. Nobody really believe is equality any more, do they? Given equal opportunities, no two people will ever produce the same value or achieve the same success, irrespective of the perspectives by which we judge success. It is often difficult to feel compassion for people whose own worst enemies are themselves. Ask any doctor who has ever seen a dysfunctional human being as a patient.
On the other hand, Rousseau's criticism of amour-propre is, in my eyes, an unerringly accruate criticism of America's vomitous middle class self-adulation: the best reason to deny health care to the poor is that I didn't have that advantage growing up and now I am rich and they are not. It discounts the central role of luck and chance and the Grace of God in determining success.
I do not understand the relationship of "modern moral realism" to the neo-con realpolitik of the 20th century. It is difficult to think of paralels between Rousseau and Donald Rumsfeld in the same chapter of political ethics. Rousseau's addition of sentiment to "enlightened self-interest" diminishes its value while the neoconservative denial of it simply darkens it.
Tocqueville's obesrvations should resonate to those readers that have recognized the degree of alienation and isolation in which we live. To find democracy partly responsible for any part of our modern angst is a mind-bending and sadening thought. But perhaps there is something to the fact that people who are more or less equal have little need for compassion as they go about their business.
Nietzche, like Ayn Rand, I still find sickening in that they both propagate this modern sense that the world is there to be controlled. It is the prime message of the serenity prayer to indicate that control is an illusion, yet the 21st century is filled with the drive to control and the anxiety which follows the failure toi control the uncontrollable. Resources, such as money, friends and power, come naturally to those who are best capable of managing and stewarding resources. That does not mean they come to those most willing to nakedly seek them.
So health care is a resource and an intermediate end to the well-being of others. It is an intermediate end because the final end is well-being itself. One cannot be well if one is not healthy but one can be healthy and decidedly unwell; from a philosophical, social and spiritual perspective. health is not just about CT scans and MRI's. Many have argued that health care is a waste of societal resources given the impact it has on the well-being of populations. I respectfully disagree, in that we still cannot measure neither health nor the contribution of physicians and other health care workers.
At the end of the day compassion as a sentiment will probably fail as a justification for health care and reform. On the other hand, a purely utilitarian approach suffers form the lack of empirical method and data. This article, strange as it seems, serves as a stepping stone in the evolution of my thinking about the purpose of health care and health care systems.
It is a brief and digestible history of the idea of compassion. It made me consider how the religious right views the morality of health care as a kind of theological experience of salvation through pity. It is truly opposed to (may I say positivist?) humanist notions that arose during the enlightenment. It is interesting to me, although perhaps unsurprising, that the origins of both liberal and conservative American political discourse lie in the Enlightenment. Smith and Rousseau are cut of the same material, albeit opposite surfaces of it.
The idea of health care as a right seems to be based on pure sentiment as a moral center, pushing a political process to assuage the suffering of those people for whom we feel sorry. The natural objection would be "Hey, what about me. I've worked hard. I've made all the right moves. These people are suffering because they screwed up. They have no right to anything I didn't have when I made my choices."
Naturally the truth is likely to fall somewhere in between these two positions. Helping people for whom we feel sorry tends not to help them. Conservative thought reveals that some programs create a tendency to dependency which should offend any liberal. But the doctrine of personal responsibility is a sham because it assumes that every choice is made from the same perspective, with the same natural abilities and skills and assume the same opportunities. Once the playing field is leveled in terms of genetics and the psychological, social and economic background of upbringing and then we can talk about personal repsonsibility as a political ethic.
What else have I learned? I have been using the term "enlightened self-interest" without understanding its pedigree traced back to Rousseau. Montesquieu's adherence to the idea that commerce increases "humanity" is close to my heart and sounds a little like compassionate conservatism without the religious wingnut contribution prevalent in American political thought.
Rousseau's attachment to equality is cloying. Nobody really believe is equality any more, do they? Given equal opportunities, no two people will ever produce the same value or achieve the same success, irrespective of the perspectives by which we judge success. It is often difficult to feel compassion for people whose own worst enemies are themselves. Ask any doctor who has ever seen a dysfunctional human being as a patient.
On the other hand, Rousseau's criticism of amour-propre is, in my eyes, an unerringly accruate criticism of America's vomitous middle class self-adulation: the best reason to deny health care to the poor is that I didn't have that advantage growing up and now I am rich and they are not. It discounts the central role of luck and chance and the Grace of God in determining success.
I do not understand the relationship of "modern moral realism" to the neo-con realpolitik of the 20th century. It is difficult to think of paralels between Rousseau and Donald Rumsfeld in the same chapter of political ethics. Rousseau's addition of sentiment to "enlightened self-interest" diminishes its value while the neoconservative denial of it simply darkens it.
Tocqueville's obesrvations should resonate to those readers that have recognized the degree of alienation and isolation in which we live. To find democracy partly responsible for any part of our modern angst is a mind-bending and sadening thought. But perhaps there is something to the fact that people who are more or less equal have little need for compassion as they go about their business.
Nietzche, like Ayn Rand, I still find sickening in that they both propagate this modern sense that the world is there to be controlled. It is the prime message of the serenity prayer to indicate that control is an illusion, yet the 21st century is filled with the drive to control and the anxiety which follows the failure toi control the uncontrollable. Resources, such as money, friends and power, come naturally to those who are best capable of managing and stewarding resources. That does not mean they come to those most willing to nakedly seek them.
So health care is a resource and an intermediate end to the well-being of others. It is an intermediate end because the final end is well-being itself. One cannot be well if one is not healthy but one can be healthy and decidedly unwell; from a philosophical, social and spiritual perspective. health is not just about CT scans and MRI's. Many have argued that health care is a waste of societal resources given the impact it has on the well-being of populations. I respectfully disagree, in that we still cannot measure neither health nor the contribution of physicians and other health care workers.
At the end of the day compassion as a sentiment will probably fail as a justification for health care and reform. On the other hand, a purely utilitarian approach suffers form the lack of empirical method and data. This article, strange as it seems, serves as a stepping stone in the evolution of my thinking about the purpose of health care and health care systems.
Friday, August 1, 2008
When I Was a Young Doctor!
When I was a resident I still believed in the incontrovertibility of medical facts. Now that I am older, I am a little more skeptical. I do not doubt truth so much as my access to it.
The thing that brought this to mind this cool coastal morning (yes, we're traveling) is the Lancet's publication of a study out of Seattle's Group Health Cooperative that challenges the degree of protection from influenza vaccine against pneumonia.
Influenza immunization of the elderly was close to my heart during my training. I often thought our approach was too soft, resulting in a 15% immunization rate at the time. Changing the message to a hard-sell, marketing-driven and (some said) fear-mongering approach improved our center's immunization rate to 50% in one season. However the numbers were small, so I barely achieved statistical significance (after considerable torturing of the numbers, I might add) and the study was presented but not published.
Most of all, the public health folks I worked with were leery of such an aggressive message. I protested that the 30 - 50% reductions in hospitalizations and mortality spoke for themselves. How could anyone exercise a different choice when the rational conclusion was so obvious? I never understood why my approach had been so unpopular.
By the time I moved to the states, I gradually became more aware of a public health approach to health messages that resembled marketing. Most notably, CDC's Julie Gerberding seems to have established an unprecedented emphasis on "communications" within her agency. For a time, I remained convinced of the soundness of this aggressive approach.
But as my career developed I started to perceive the flip-flops in medical recommendations. We thought nopbody should eat eggs due their risk of developing cholesterol problems. Then we thought it was OK to eat eggs and meat, even in a cholesterol-reduced diet. Now we worry only a bit about dietary fat as we start to concentrate much more on carbs. Anyone care to tackle estrogen and the risk of breast of cancer or heart disease?
Of course, this dialectic is part of the scientific process. Only people who know their methods are merely an approximatiopn of the truth are willing to make absolute-sounding statements and remain prepared to revise them on a moment's notice. In fact, scientists are only being absolute about what is known. Based on the best available information, we can say things with certainty that will be revised with new information.
This ain't the Bible folks, and even then... well maybe some other time we can discuss exactly how this library of books was assembled by bishops of the early church.
The new data is that the benefit of influenza vaccine is not as outrageously high as once believed. Perhaps my residency overseers knew something about original estimates. A better method for controlling the severity of illness reduced the magnitude of the apparent effect by simply reducing confounding. We give flu shots to the frailest of the elderly, so we over-estimate the impact on a large population who may not be quite as frail overall. Good job! The vaccine is still protective, and I still think anyone who avoids does not have the right information. But clearly, it's not criminally insane to say "I'd rather not."
Sometimes, skeptics rule!
The thing that brought this to mind this cool coastal morning (yes, we're traveling) is the Lancet's publication of a study out of Seattle's Group Health Cooperative that challenges the degree of protection from influenza vaccine against pneumonia.
Influenza immunization of the elderly was close to my heart during my training. I often thought our approach was too soft, resulting in a 15% immunization rate at the time. Changing the message to a hard-sell, marketing-driven and (some said) fear-mongering approach improved our center's immunization rate to 50% in one season. However the numbers were small, so I barely achieved statistical significance (after considerable torturing of the numbers, I might add) and the study was presented but not published.
Most of all, the public health folks I worked with were leery of such an aggressive message. I protested that the 30 - 50% reductions in hospitalizations and mortality spoke for themselves. How could anyone exercise a different choice when the rational conclusion was so obvious? I never understood why my approach had been so unpopular.
By the time I moved to the states, I gradually became more aware of a public health approach to health messages that resembled marketing. Most notably, CDC's Julie Gerberding seems to have established an unprecedented emphasis on "communications" within her agency. For a time, I remained convinced of the soundness of this aggressive approach.
But as my career developed I started to perceive the flip-flops in medical recommendations. We thought nopbody should eat eggs due their risk of developing cholesterol problems. Then we thought it was OK to eat eggs and meat, even in a cholesterol-reduced diet. Now we worry only a bit about dietary fat as we start to concentrate much more on carbs. Anyone care to tackle estrogen and the risk of breast of cancer or heart disease?
Of course, this dialectic is part of the scientific process. Only people who know their methods are merely an approximatiopn of the truth are willing to make absolute-sounding statements and remain prepared to revise them on a moment's notice. In fact, scientists are only being absolute about what is known. Based on the best available information, we can say things with certainty that will be revised with new information.
This ain't the Bible folks, and even then... well maybe some other time we can discuss exactly how this library of books was assembled by bishops of the early church.
The new data is that the benefit of influenza vaccine is not as outrageously high as once believed. Perhaps my residency overseers knew something about original estimates. A better method for controlling the severity of illness reduced the magnitude of the apparent effect by simply reducing confounding. We give flu shots to the frailest of the elderly, so we over-estimate the impact on a large population who may not be quite as frail overall. Good job! The vaccine is still protective, and I still think anyone who avoids does not have the right information. But clearly, it's not criminally insane to say "I'd rather not."
Sometimes, skeptics rule!
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