Inkwell: Authors and Artists
Julie Sherman (julieswn) Wed 20 Jun 12 09:29
This week we welcome Joe Flower aka <bbear> to Inkwell to discuss his new book :Healthcare Beyond Reform: Doing it Right at Half the Cost." Joe Flower has been an active member of the Well for over two decades, and writing about healthcare for more than three. He is well-known within the healthcare industry as a speaker and commentator, is on the speaking faculty of the American Hospital Association and the board of the Center for Health Design. His new book, "Healthcare Beyond Reform: Doing It Right For Half The Cost," is written from his intimate insider's understanding of the industry, and makes the audacious claim that we could provide healthcare to everyone in America for vastly less than we are paying now but only by doing it much better. The cost savings have nothing to do with rationing or cutbacks, and actually little to do with the current debate over healthcare reform legislation. They arise, rather, out of changes already happening across the industry that keep people healthier for far less. Interviewing Joe will be our own <debunix>: Debunix is a pediatric specialist in Southern California, who works at a major children's hospital. Being a physician and sometimes also being a patient, she sees the inefficiencies of the current medical system from both sides. She has plenty of reminders to encourage her patients and their families to support health care reform, because it's not fixed enough yet when crazy things keep happening, coming between patients and families and the care they need. She gets rented out to various satellite offices in addition to her primary hospital because that's the only way for the practice keep in the black. Welcome Joe and Debunix!
Joe Flower (bbear) Wed 20 Jun 12 13:58
Hello, everyone! And thanks for having this. Let me just plop this in here as a bit of a starter: We put out a press release today saying that the Supreme Court can't stop real healthcare reform. The shifts in the underlying economics of healthcare have gone too far. There is no going back. Take a look and see what you think: <http://www.imaginewhatif.com/healthcare-futurist-supreme-court-cant-stop-healt hcare-reform/>
Diane Brown (debunix) Wed 20 Jun 12 23:49
<scribbled by debunix Thu 21 Jun 12 00:21>
paralyzed by a question like that (debunix) Thu 21 Jun 12 00:21
Hi Joe! As a practicing health presentist, I love the vision of the future I see in your book--more and better primary care to avoid the need for expensive treatments after conditions are established or dangerous; data mining available to the practitioner and patient right there in the clinic to help them decide the best treatment for that patient; less of the obstacles that so often seem to consist of very nice and smart people doing their best to keep me from helping my patients; and more rational, reasonably priced medical records systems that can all talk to each other to make care more transparent. But I find it very very hard to see how to get from here to there. Here: today, I spent some time with an electronic medical record specialist who in 20 minutes cut through months of intermittent support phone calls and e-mails back and forth to show me a feature of the medical record system that was better than what she was going to demo for me, a customized report that didn't appear to work half as well as what she showed me did, a feature built into the system but unknown to the local and EMR company tech support I'd previously been working with. Six months to build something not as good as what was already there, because one person took a few minutes to actually sit beside me and SEE what I was trying to do. I sat on my local institutional review board meeting, where the complexity of the work that goes into each and every sentence in a medical textbook is brought to life, as we see how hard it is to do meaningful research--complying with regulatory and ethical and legal requirements is so expensive that hardly anyone except the pharmaceutical industry can afford to sponsor it. And I spent a good portion of my evening when I'd have preferred to be finishing your book duplicating work, dictating a patient note that was already handwritten, but needed to be redone in more detail to justify to her insurance the new treatment I wanted to try for her--a treatment approved for the same condition in adults, but not for the childhood version (and never mind that as a post-pubertal teen, she's biologically pretty much adult anyway). I then searched online for case reports and of the use of this drug in children, all because this particular drug is quite expensive, and the staff of her insurance is answerable to their shareholders (ok, in this instance of someone on public insurance, to the taxpayers). It's not because the drug is particularly dangerous--I can prescribe far riskier drugs with a lot less fuss if they're cheap--or because the drug has been little used in children--it's been used in thousands. It's because the drug is expensive, and that clinical experience from all those patients is scattered across thousands of different insurance entities, because the condition is rare enough that it's hard for anyone to collect enough patients to publish a meaningful paper. I would so rather have spent my day with more patients, and less paperwork. But that last example brings up my first question: I work a lot with some phenomenally expensive drugs--'biologics'--that also happen to be phenomenally effective. They're so effective that the structure of our clinics has changed, and we no longer need the full-time attendance of the paraprofessionals who helped to manage the long-term disabilities of the diseases. They're not just marginal improvements on what went before--they're orders of magnitude better. And being based on antibodies--taking advantage of millenia of evolutionary adaptations--they're exquisitely precise and often have shockingly few side effects for such powerful drugs. Because they have to be produced in tissue culture, which itself is very costly no matter how you do it, I can't see them ever becoming cheap, even if they do go generic. Are we going to save enough by shunning the on-patent 'me-too' drugs to be able to afford the inherently expensive drugs that DO work?
Joe Flower (bbear) Thu 21 Jun 12 10:20
Welcome, Dr. Brown! I am glad you consented to join me in this discussion. Your post actually raises a number of questions. Let me use them to introduce the primary theme of the book: People do what you pay them to do. So whenever you see something that is not working, you have to ask what, exactly, the various actors are getting paid to do. So, in your example of the maddening complexities and opacities of a clinical information system, the financial incentives of the company that installed the system and the executives who oversaw the implementation were tied to getting the job done, selling the system and getting it up and running. No one in charge in any way had their success or compensation or personal interests tied to making the system really work at the clinical level. There _are_ IT systems that, as far as I can tell from talking to clinicians who use them, really do work for the clinicians. Every one that I have seen that does work deeply involved clinicians in the project. I believe that if we shift the incentives of healthcare providers, payers, and suppliers, from the C-suite to the operational level, from fee-for-service to some kind and degree of being tied to outcomes everything over time will shift. Suddenly clinical efficiency, including the efficiency of IT, of clinical coordination, all that, will become of central importance to the people in charge. And there are lots of ways we can make this shift.
Joe Flower (bbear) Thu 21 Jun 12 10:29
The question about expensive biologic drugs actually has a similar answer. The first thing to note is that Sun Pharmaceuticals in India, in collaboration with some Chinese companies, has declared a path toward making generic biologics and bringing the price down greatly. More importantly, though, we have a situation common throughout healthcare: Use item X (technique, device, drug, treatment modality) that is more expensive to avoid outcome Y, which would be much more expensive except that this is a fee-for-service system in which the provider could get reimbursed for each piece of the regrettable outcome Y (hospitalization, long-term care, surgery, whatever). And every "cost-control" measure is focused on item cost, not system cost. So you can't get the expensive item that would lower the system cost of the bad outcome. If we had a system that intelligently balanced the overall cost to the system of using various modalities against their probable outcomes, we would in many cases use the more expensive modality up front, in many other cases use the far less expensive one, but we would end up with both better outcomes and lower cost. And we get there by routing around the dominant commodified, insurance-supported, fee-for-service system.
paralyzed by a question like that (debunix) Thu 21 Jun 12 12:55
I need to look into Sun Pharmaceuticals and what they're doing, in my abundant free time! But that's good to know that some progress is being made, because I love what those drugs can do for my patients.
. (wickett) Thu 21 Jun 12 17:22
I, enthusiastic about the ideas in your book, discussed it with my neurologist a few days ago, Joe. How would comparative effectiveness research work for the sickest of the sick, such as lupus patients on chemotherapy? Having work intensively with each of her patients, the neurologist knows what works *best* for each individual. They are not remotely the same. Yet, even with documented benefit, she has to spend her time fighting hard with insurers for the drugs that she has determined are most efficacious for each patient. Do you propose to use comparative effectiveness data with the sickest of the sick, their often highly individual and idiocyncratic pharmaceutical needs, and provide them with the care they need for a reasonable quality of life? Or, is it too expensive with too little benefit to do the research? If so, then how is a physician to be compensated for the time spent determining to specific pharmaceuticals and treatment? Such patients are unlikely to be cured, so outcomes tend to be towards maintenance and not needing even more expensive treatments. How is that assessed and the physician rewarded? Many of us have been/will be very ill, but still able to live well with relatively costly treatments. But not all such treatments involve cures, substantial improvement, or even quantifiable improvement. Some is simply preventing worsening symptoms or the avoidance of new symptoms.
descend into a fractal hell of meta-truthiness (jmcarlin) Thu 21 Jun 12 17:50
I have a few questions that I'll pose one at a time. But first, I'd like to put an Amazon review into the record here. Executive summary: buy the book! Joe has written a book on healthcare for everyone. First, it's very readable. Rather than a lot of complex jargon, he lays out the situation in plain English. Almost everyone grumbles about the American health care system and gigantic political fights are underway about it. But just about everyone does not realize exactly how and why the system is broken, why costs are so high and results are so bad. For example, CAT scans in the US typically cost $1000 to $1500. But in Japan they only cost about $150. That's a ten times difference for something that is a standard test. Besides charges that are all over the map, he also writes about how the best hopsitals in the US have vastly different prices for the same services. This is not comparing good and bad hospitals, but comparing top quality hospitals. He then explains one serious problem - that the market does not operate. When you buy something, say a car, there are lots of competitors and buyers. You know what the sellers are charging and can go from one to the other to get a good price. With health care, the buyer and the seller are messy because you have the patient, the doctor, the insurance company and often a hospital with no reasonable competition. Another part of the problem is that medical billing systems are not clearly set up to tell hospitals what is really costs to deliver a specific service. That number is hidden and obscured by their real accounting systems. When it comes to solutions, he's very down to earth and sensible. He does not see what Republicans and Democrats fight over as being a key to the solution. Rather he discusses structural reforms. Sensibly, he does not advocate one size fits all solutions, but rather lays out reasonable principles that would seriously control costs. One obvious solution is to help those with chronic illnesses avoid costly hospitalizations. If a diabetic can avoid an amputation, for example, it saves everyone money. Whether you accept his thesis that we can cut the cost of health care in the US by 50% or believe the number is not quite as good, I'm convinced that if we adopted his ideas patients would get better served, doctors and nurses would be happier and we'd save a lot of money. I therefore highly recommend this book to everyone who cares about health care whether it be delivering better care or saving money.
descend into a fractal hell of meta-truthiness (jmcarlin) Thu 21 Jun 12 17:51
My first question: Change is always opposed by what I might call evolutionary inertia. I understand your thesis is that the pain is so great that change is happening. But there are also forces who would rather see everything fall apart rather than change. So I'm interested in you saying more about how the forces opposing change are fighting back. I'm specifically thinking about the CFO you mentioned on page 145 who was against improvement because it apparently cost the hospital money. Then you mentioned the anti-transparency provider on page 153. Outside of putting such people up against the wall, what can we as both health care professionals and consumers of health care do to promote positive change?
Joe Flower (bbear) Thu 21 Jun 12 18:02
Thanks for asking, Elizabeth. This is perhaps a good example of why the book is peppered with phrases like "for most," and "in many cases." The really big expenses in healthcare are not in the rare case that need really expensive treatment. They are in the far more common cases that we treat poorly, or over-treat. For the same reason, it is those expenses that are good targets for comparative effectiveness research, such as, what is really the best path toward preventing second heart attacks? The more unusual, highly variable cases for which there is no known, clear path to stabilization and cure are not good candidates for CER, and indeed probably always need to be treated as fee-for-service, unless they are under the broad umbrella of an organization like Kaiser. As in any policy discussion, the outliers do not make for good general policy. Unfortunately, in healthcare policy and payment systems, we are perpetually advocating the one perfect policy for every situation. Which is ludicrous. Can you imagine an argument about what is the perfect motor vehicle for everyone, and the perfect way to buy it? I am imagining a future of healthcare that is far more highly varied in its providers, and its payment systems. There is no one right way, and why do we need to imagine that there is?
Joe Flower (bbear) Thu 21 Jun 12 18:10
Thanks for the kind review, Jerry. As for your question: Great question! > Outside of putting such people up against the wall, what can we as both health care professionals and consumers of health care do to promote positive change? I would say: Don't focus on changing their minds. Their opinions don't matter. What matters? Economics. Ask yourself what can be done at whatever level you are at (healthcare professional, citizen, employer or influence on employer, opinion-maker in the blogosphere or media world) to change the rules? The CFO on page 149, complaining that better primary care would deprive his Emergency Department of cases that could be reimbursed at the much-higher ED rate, was absolutely correct as long as his ED was working fee-for-service. The instant he is at risk for the health of a population, his opinion will disappear. Or, as in the Blue Cross Blue Shield of Massachusetts "Alternative Quality Contracts," when someone else gets strong incentives to treat those patients so well, early, often, and conveniently that they are unlikely to show up in the Emergency Department, his opinions don't matter. Don't fight bone-headed opinions. Make them irrelevant.
paralyzed by a question like that (debunix) Thu 21 Jun 12 19:29
No matter how we spin it, many of the redundant dollars in health care are keeping some people in work. In the leaner system you propose, some of those people will be absorbed providing more intensive support services to the people who now are using the most health care dollars due to uncontrolled chronic conditions, but not all of them. How fast do you see us moving towards that better, cheaper, faster system--and with or without major economic dislocation?
. (wickett) Thu 21 Jun 12 19:39
Makes sense not to invoke CER for complex, chronic illnesses. But fee-for- service? That won't work either. I'll never forget my first visit to my neurologist. I was wheelchair-bound at that time...and she spent five hours with me! That is how she operates with *every single patient.* I understand that making critical, dramatic, systemic changes are important to grab people's attention and sustain a powerful new direction. An oceanliner cannot be turned from its course by any number of canoes. And, yes, no one solution fits all problems. But, it is important to include proposals for how adequately to compensate physicians who treat the complicated chronically ill, so that those patients, too, do not become more incapacitated due to inadequate treatment. The disabled have borne much of the political and social blame for breaking the bank and being undeserving for untold decades already. That is one population that is recurringly excoriated for requiring too many resources and, then, denied adeqiate medical care to keep them functional, or even alive. As you point out, spending for durable medical equipment is shamefully low in the US.
Paulina Borsook (loris) Thu 21 Jun 12 22:03
<bbear>, i have loved your what i have known about your larger project and your new book for as long as i have known about either. but a couple of questiions somewhat echoing the concerns of the good <wickett>: - as you know, i have become come more engaged with the life of my nephew, ex covidien medical director, no-longer-practicing surgeon. he has his snailmail forwarded to me and so -i- read the to-me fascinating surgical trade press and promotions for conference. related to outcomes-and-evidence- based medicine, it's obvious from what i have read is that surgeons who arent just in the field for the bucks for good reason dont like the idea of a hospitalist working with software punchng in whatever (limited) set of data s/he is presented and then dictating to the surgeon what and how to perform. idea here is again that patients dont necessarily fit templates; clinical intuition and experience isn't factored in to the Software Way of Knowlege; and the same drivers that currently drive practitioners and patients mad in the fighting with what insurance companies will or wont approve would also be present with evidence-based medicine/epistemology. - in a more general sense, i have gotten from reading the junk sent to surgeon mailing lists and hearing the complaints of all the former doctors in my family (i used to joke that being a doctor was a disease that ran in both sides of my family; now the disease is being an ex doctor) they want to practice medicine the right way and they can no longer do it. and they arent convinced that technocratic optimization is going to create medicine that's about care and doing right by the patient. the fact that there are now entire conferences devoted to 'what to do after you dont want to be a doctor any more' which is even being pitched to people who have just finished their residencies, that says something.
Jane Hirshfield (jh) Thu 21 Jun 12 22:18
Congratulations on the book, Joe, and huge gratitude for all your work in getting us out of the current absolute quagmire... for your clarity, practicality, and wisdom. I have a question also somewhat related to Elisabeth's--if payment is tied to outcomes, how does that apply in the (absolutely the opposite of rare) case of... death? We all will die. Issues of over-treatment and under-treatment both apply here. Doctors may not prescribe enough pain relief because it looks bad in their state-kept records if they're "too free" with the opiates. Patients might demand continued treatment when that no longer makes medical sense--and everyone makes money if it's given, and no one does if it stops. Other patients might be virtually forced to continue treatment they wouldn't want if they could have chosen. And still others (you can tell that I think from the patient's point of view) might be excluded from treatments they might otherwse get because of some decision being made they aren't even aware of. ("Not a good candidate for transplant, won't take the follow up meds reliably enough.") Plus death is such a hot issue that people start talking about "death panels" and then suddenly no one can talk about it at all--or at least not be paid for the time it takes to have that much needed conversation. Is the "outcome" of a good death part of this conversation, or does it just muddy the waters to try to address it?
descend into a fractal hell of meta-truthiness (jmcarlin) Thu 21 Jun 12 23:01
Next question: On page 106, in a discussion of evidence-based health, you make a pessimistic statement that political polarization is hindering and even stopping this good sounding idea from being adopted. Given your other statements about change happening in spite of politics, why is this area so different? And is there any way we can apply even a little pressure in upping the odds of it being adopted?
Joe Flower (bbear) Fri 22 Jun 12 07:53
Gadzooks! What a raft of great questions! Let me see if I have any answers. Dr. Brown asks: > How fast do you see us moving towards that better, cheaper, faster system--and with or without major economic dislocation? If I waved my wand and the system re-created itself into the way I am imagining instantly, it would create a major depression in the U.S., and consequently across the world. But I have no such wand, and the change in the most optimistic scenario will not be quick, but stretched out over the rest of this decade. The industry will shrink some in absolute size, with parts dying off and others becoming more leas (and some sectors growing) as the economy as a whole grows, until the percentage of GDP consumed by healthcare falls to half of today's. Within the industry, the changes will be quite wrenching for some parts. In fact, this is already happening and it will be more wrenching, not less, if the Supreme Court tosses the whole healthcare reform bill.
Joe Flower (bbear) Fri 22 Jun 12 08:10
Elizabeth asks about: >how adequately to compensate physicians who treat the complicated chronically ill...fee-for-service? That won't work either. ... The disabled have borne much of the political and social blame for breaking the bank and being undeserving for untold decades already. You do point out a serious problem. Maybe "fee-for-service" doesn't capture what I meant. If you contemplate something like replacing a knee or a hip, it is possible to bundle everything together and put a price on the whole package. Common chronic diseases like diabetes have common pathways for management, they can be managed well by generalists (mostly) and even assistants, and are good candidates for a package prescription which encourages the provider to treat them early and well, so that they don't progress. On the other hand, highly variable, debilitating diseases like MS require a lot of trial and error. There is little in the way of a clear, common pathway. They require, as you said, a lot of attention from an expensive specialist. They are an example of why health risk needs to be spread broadly across the population, whether through single payer or through community ratings and striking down medical underwriting. Private insurers always want to dump people with difficult, complex problems off onto the government. But as long as the payment schemes for them are separated out into separate programs, they will be given short shrift. They need to be recognized as part of the whole range of health risk.
Joe Flower (bbear) Fri 22 Jun 12 08:27
Paulina, thank you for your comments. They inspired three thoughts: 1) A recurrent theme of the book is: "No idea works well is it is done stupidly." There are legitimate complaints about disease management programs, hospitalists, medical software, surgical management algorithims, all kinds of things. And when you look at the details, almost always the thing being complained of was implemented stupidly, or the tool used badly. If someone set up the rules so that hospitalists truly are dictating to surgeons what must be done in ways that the surgeons are bound to once they get in there, that is obviously stupid. But I wonder how real or how common that is, and how much it is that the surgeons just don't want any interference or consultation at all. 2) Surgeons tend to be the more extreme example of the need for doctors to be part of a team, and the resistance to that very real need. Surgery is an extreme mental and physical skill, doctors tend to feel that they are really good at it, they know what they are doing, and we should all just leave them alone and let them do it. The reality is that most of them are, but some are not, as your nephew has complained bitterly to me. There is a great need to bring all of medicine into a much more collaborative, collegial model. And yes, software has a big part to play in that, both because the information universe in which doctors work is highly complex, and because their choices can be far more idiosyncratic than the medical science would support. 3) There are many reasons besides interference and bad software that are creating ex-doctors at this point. It's tough to be a doctor. All of these solutions must make it easier, not harder, not only to do medicine but to make a decent living at it.
Joe Flower (bbear) Fri 22 Jun 12 09:13
Jane brings her usual articulateness to bear on the subject of death. It is a tough subject and yes, it very much has to be addressed. From the point of view of cost, we spend vast sums every year on clearly futile "heroic" medical procedures on people who really should be in hospice on palliative care. None of these decisions are ever easy, but they would be enormously helped if we could just change the conversation, make it a cultural norm that we all, patients and clinicians alike, talk about the fact of death and its approach, what our wishes are, how to implement them. It is a prime example of ways in which lessening the suffering also saves money.
Paulina Borsook (loris) Fri 22 Jun 12 09:28
the pessimist in me wonders - will the needed change iin conversation around death only happen when boomers, having seen what their frail elders endured as they failed, decided 'no way no how'. sort of like the decline of homophobia seems to be very generational - the software is -always- SUPPOSED to do good things, but so often it does not (i wrote gave a talk, later published as an essay, about this more than a decade ago. i dont see that the problem has gotten better) but onward with your great project!
descend into a fractal hell of meta-truthiness (jmcarlin) Fri 22 Jun 12 09:54
<bbear>, while I wait for an answer to my second question, I'm going to pose a third since I'll be running around today partially dealing with a friend who's just moved into assisted living. And that raises a third question: There are more and more people who are not quite able to take care of themselves and who thus need assisted living, home health aides and other such services. I don't remember you addressing these kinds of situations in your book so I'm wondering if you have any thoughts about this area?
Joe Flower (bbear) Fri 22 Jun 12 09:59
Here's the paragraph that Jerry is referring to on page 106: 'Evidence-based health is a backbone-brilliant concept that actually produces better healthcare, and better health, for significantly less moneyand a concept that America may be too politically hypnotized to ever put into wide practice. Evidence-based means its about what really workshealth, because thats the goal.' Jerry asks: >Given your other statements about change happening in spite of politics, why is this area so different? And is there any way we can apply even a little pressure in upping the odds of it being adopted? What makes it different is that many of the things that make for better health go beyond healthcare they are social, cultural, educational. Things like really good, widely-available childcare; strong local banks; small business credit; good housing available at all price points, and so on. A big piece of our political culture now flat-out believes that _anything_ that is good for the society as a whole is a "socialist dictatorship" and "catering to the deadbeats." This largely means that we must find ways of accomplishing these things, if possible, in ways that don't put them to a vote, especially not the kind of legislative vote that a minority can block. In short, what we must do is build healthy communities. I expand on this notion in Chapter 11: Beyond Healthcare.
Joe Flower (bbear) Fri 22 Jun 12 10:01
Paulina wonders it the response to death is generational. I think you're right. And I think that's why we are really beginning to see a shift now, because we in the Boomer generation are going through the failing years and deaths of our parents' generation, and experiencing how brutal and dehumanizing that is (not to mention how draining of resources).
Joe Flower (bbear) Fri 22 Jun 12 10:07
Paulina says: > the software is -always- SUPPOSED to do good things, but so often it does not Yes, most early versions and many present versions failed miserably at the clinical level. The whole Appendix A in the book ("Stupid Computer Tricks: How Not To Digitize Healthcare") details those failures. It consists almost entirely of notes contributed by a doctor who chose not to be identified in the book. That said, what keeps me from being a complete pessimist about software in medicine is that I have seen a number of instances in which it really seems to work; and because I am involved with the Health 2.0 movement (keynoting their conference this fall), where I see so much stuff that seems really smart on the clinical level.
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