Inkwell: Authors and Artists

    
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!
  

    
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/>
  

    <scribbled by 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?
  

    
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.
  

    
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.
  

    
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.
  

    

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.
  

    

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.
  

    

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?
  

    
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?
  

    
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.
  

    

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?
  

    

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.
  

    

<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.
  

    
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? 
  

    

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?
  

    
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. 
  

    
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.
  

    
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.
  

    
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.
  

    
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!
  

    

<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?
  

    
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
money—and a concept that America may be too politically hypnotized to
ever put into wide practice. “Evidence-based” means it’s about what
really works—“health,” because that’s 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.
  

    
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).
  

    
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.