Inkwell: Authors and Artists

    
> home health ... assisted living

Two forces make me hopeful about things like this:

1) Boomers: Historically, when something becomes important to Boomers,
something happens to meet those needs. This is becoming important to
Boomers now because of their parents, and confronting their own aging.
As I have been predicting since I wrote Age Wave with Ken Dychtwald in
1989, by the time I get to be 85, we are doing to have kick-ass
convalescent homes in this country!

2) Efficiency: The right kind of assisted living and home care
actually is much more cost-effective for keeping people healthy. This
means that as more health systems move from a strict fee-for-service
model to an outcomes-based, at-risk model, they will become very
interested in finding ways to support really good assisted living and
home care, whether by taking over parts of the business, or contracting
with those already in it. I think we will see an expansion of,
improvement in, and a lot of new investment in home health and assisted
living.
  

    

Medicare and the private insurers I know about currently refuse to pay for
PT, OT, etc. that merely stabilize the patient and prevent worsening of
symptoms or function. Progress is absoultely required.

This is a recipe for increasing dysfunction or death in those patients 
who do not have a curable problem. Increasing dysfunction will certainly 
increase costs somewhere down the line unless lack of care kills the 
patient first, and death, too, can be hugely expensive, depending on 
duration of the process and interventions.

Really, seriously STUPID.

How would you propose to set up systems, Joe, both for doctors and for 
ancillarly care to maintain maximum pain-free functionality in chronic 
situations?
  

    
yeah that demand for -progress- as opposed to 'help this person stabilize'
is killer.

was also wondering how in your ideal world patient choice would work?
for example i have practitioners all over the greater bay area, folks
i have found who can work best with my particular medical wackitudes.

they arent part of group practices nor of -teams-. and what they do is help
me -manage- chronic fu. and i chose them after lots of interviewing.
  

    
> How would you propose to set up systems, Joe, both for doctors and
for ancillary care to maintain maximum pain-free functionality in
chronic situations?

Again, the situation you describe is an artifact of "cost controls" on
a fee-for-service system: They are "controlling costs" by refusing to
do expensive things — even though in the long run it is costing them
more. As more systems (even under Medicare and Medicaid) take on
risk-bearing contracts, they come to consider the _long-term_ expenses
of this patient, and what help they need that would help keep those
expenses down, rather than just the short-term cost of a particular
item.
  

    
> how in your ideal world would patient choice work?

In my ideal world? Lots of patient choice, but informed by expert
guidance, much like we use financial counselors today, or read reports
on which car might be best for us. Like financial counselors, some of
that advice might be provided by an interested party (like our
insurer), some would be independent.

For example, one option with Blue Cross Blue Shield of Massachusetts
that you can sign up for gives you full choice of any provider that
takes BCBS if you, say, are going to have a baby or get a new knee. But
they give them all quality ratings and cost ratings. Choose the
lowest-cost provider in the highest quality class, and you pay no
copay. Choose the most expensive one, and your copay will be about
equal to the difference in cost.  
  

    
As for teams: I don't believe that we shop for "healthcare." We shop
for solutions to our health problems. We are not really interested in
knowing who is the greatest health system around. Our real question is
who is best at solving my bad back, or my depression, or whatever. 

The most effective care is usually done by highly effective teams.
Most of us don't have a lot of experience with this, because they are
still rare in healthcare — and because the "teamness" of the experience
may or may not be all that visible to the patient. For most of us, at
this point, the experience feels more like yours — we are shopping for
the what seems to us like the most effective individual practitioner.
  

    
#27:  so, so true!

I take care of quite a few patients who cannot maintain their range of
movement without getting outside assistance, and for whom the natural
course is progression to complete dependence.  But they make
improvement so slowly, if at all, that it is very difficult for them to
get the desperately needed therapy services to keep them out of a
wheelchair.  

Absolutely heartbreaking, and even more so because they're just kids.
  

    
Really heartbreaking. I don't know how clinicians like you can do it
every day, <debunix>.
  

    
For every child for whom your heart breaks like that, you have another
whose parent says to you, "thank you for giving me my daughter back"
after treatment has restored the outgoing, bouncy, playful child to
herself.  And if the latter don't at least equal or exceed the former
group, you burn out and find another profession, I think.
  

    

I've personally seen good ideas turn into fads which are badly implemented
and result in the idea being discarded when in fact the implementation
was terrible.  For example, I once worked for a company that promoted
6 sigma management but was absolutely intolerant of any mistakes.

Often this happens after the process starts when the careful early
adopters are replaced by slip-shod and haphazard second or third
waves. Have you seen any evidence of this and/or are you concerned about
it here?
  

    
I am very concerned about it here. In fact, pretty much every process,
suggestion, new way of thinking that I talk about in the book has been
tried and failed somewhere, has detractors, and even learned papers
all about why it's a sucky idea — when very example cited is a poster
child for how _not_ to do it. The whole basis of the book is, hey you
know, there are some people, some organizations, some places, that
actually do this a whole lot better, right here in this system as it
exists today. Wouldn't it be smart to take a look and see what they are
actually doing.

When I encounter learned papers by economists and health care experts
proving that something is a bad idea by using poor examples of it, or
by cherry-picking their statistical armamentarium to prove that black
is white and the sky below us, I have to wonder about their ethical
integrity. 
  

    

Time for a technical question:

You mentioned breaking the health care "Nash equilibrium"
as a driver for what is now starting to happen. Wikipedia
http://en.wikipedia.org/wiki/Nash_equilibrium#Stability discussed more
complex ideas such as "Strong Nash equilibrium has to be Pareto efficient"
and "coalition-proof Nash equilibrium (CPNE)". So are you using "Nash
equilibrium" in the general sense reflecting the current state of the
health care business or in the more formal sense that the Wikipedia
page discussed?
  

    

This is reminding me to tell you how much I loved your clear and concise 
explication of the difference between a linear regression analysis and a 
semi-log regression analysis and why some ***unethical*** economists use 
the later when only the former is appropriate for the analysis of health 
care spending in prosperous countries.

Truly brilliant!
  

    

oops, slipt by jmcarlin.
  

    
Heh, Elizabeth, that is exactly the passage I was thinking of. For
those of you who have not read the book yet, it's a discussion on a
paper by some economists using sophisticated statistical analysis to
prove that the U.S. does _not_ spend more on healthcare than it should
compared to the size of its economy. To show this, they used semi-log
regression analysis, which is used to show relations between two
variables that _do not have_ a linear relationship, like numbers of
lemmings versus generations of lemmings. In other words, to choose that
tool was to assume the conclusion, that the relationship of costs to
size of economy is non-linear, without giving any reason why that might
be so.
  

    
Jerry, I do have to preface this by saying that I do not pretend to be
an expert on game theory, and certainly not a mathematician.

However, within the limits of my understanding, it seems to me that
the traditional state of healthcare was a good example of a
coalition-proof Nash equilibrium on the Pareto frontier. That is, not
only can no actor improve his situation by a unilateral move (a doctor
that spends more time with her patients, or a pharmaceutical company
that lowers prices, is punished for doing so), but no coalition of
players could break free and improve their situation vis-a-vis other
players — and within each group it is largely a zero-sum game: No one
hospital or insurance company can improve their situation except by
damaging others.

We are now in a situation in which this logjam has been broken by the
introduction of new energies, constraints, and players, in the form of
state and federal legislation, new pressure from employers, and new
technologies that allow the management of the system in a much more
complex way than before.

That's why this is such a great moment. Things have come unstuck.
  

    

>  Things have come unstuck.

That leads me to another question:

The book covers the strategy but I've been thinking tactically as well.
Let's say that I'm an HR or health care person in a company. I like your
ideas and wants to sell them to higher management. Putting "swarm the
customer" on a slide won't do it for many reasons. So what I'm looking for
is in effect a presentation that I can modify to convince a CFO/CEO that
we can take a demonstration step to prove the ideas work. This needs to
be couched in terms of saving the company money primarily because that's
what the CFO/CEO is interested in. Are there presentation examples I
can use as the basis of my own slides?
  

    

What I'd love to see is the same health care spending data on a linear 
regression chart and on a semi-log regression chart.
  

    
> What I'd love to see is the same health care spending data on a
linear regression chart and on a semi-log regression chart.

What it looks like, Elizabeth, is a chart with GDP per capita across
the bottom, and health spending per capita up the side, with dots
representing the various countries. As expected, the dots make a pretty
tight bunch not far off a straight line representing the obvious truth
that the wealthier the country, the more they spend per person on
healthcare. But the United States dot is way off the line, with health
spending far above even what its greater wealth would suggest. The
semi-log analysis produces a line that is not too far off of the
straight line, swooping below it in the middle, then swooping way above
it on a long tail at the end to just, lo and behold, touch the U.S.
dot. 

I would have loved to put it in the book just to ridicule it, but it's
copyrighted. But here it is, in a presentation. Go to slide 9:

<http://www.aei.org/files/2006/10/17/20061017_OhsfeldtSchneiderPresentation.pdf
>
  

    
> This needs to be couched in terms of saving the company money
primarily because that's what the CFO/CEO is interested in. Are there
presentation examples I can use as the basis of my own slides?

You know, Jerry, that's a great idea. I use vivid language (like
"swarming the customer" and "exploding the business model") to make
people notice the argument, remember it, and talk about it. But for
someone else to make a presentation about the ideas, they would need
something that looked and sounded more like a boring corporate "just
the facts" PowerPoint. I should make such a presentation and make it
available for free. 

There is a private conference on the Well where we have been
discussing these ideas, and I know you are part of it. We can talk
about the making of such a presentation there. Thanks for the thought!
  

    
I'm further into a close reading of the book itself now, Joe (though
I've known many of the concepts from conversations in the Well and your
excellent website).

One thing I want to say I really appreciate is that I'm getting a
better basic understanding of capitalism, not just health care, from
reading some of your explanations. The analogies are terrifically
comprehensible and useful for someone like me, who simply has not had
much reason to analyze economic systems at this level in my life. But
the bit on the rug purchase in a bazaar vs the Trabant car is just a
brilliant piece of teaching/laying out.

You are doing this all the way through, from what I've read thus far.
Making things comprehensible, sorting them out. It's a bit like the old
Watergate saying: follow the money. Showing without judgment how
things have come to be as they are because of both the incentives of
capitalism (people want to make a living and will find a way to do so)
and the ways that health care is disconnected from capitalism (the user
is not the payer, no one knows what things actually do cost, etc) and,
finally, the ways that healthcare is subject to one of the
shortcomings of capitalism as it is currently practiced (short term
analysis trumps long term analysis).

Also the very basic point that this is closer to how we've made autos
safer (many small changes) than to switching a train from one track to
another by throwing a single lever (that one's my analogy, unless you
use it later on in the book). The point that the current reform act is
a third-drink level issue--eye opening. (Joe made up a superb saying:
"Anyone arguing about whether or not to have a third drink has already
had two."

People want simple solutions. You are pointing out that some things
need multiple solutions. And then simplifying down those multiple
solutions to something we can still hold in our brains without too much
difficulty.

Have I got all that kind of right? I hope so. If I don't, no blame to
the excellent teacher!
  

    
Thank you, Jane. I am glad you are finding it helpful. 

The teaching about basic economics comes from my experience of being
out there in the public sphere, online, giving seminars, doing radio,
writing blogs for year after year, and hearing very intelligent people
pop out with simple solutions and insist on them: Single payer! Free
market! Socialized medicine! And realizing that my response to all of
them is, "It's not that simple." 

One can (and many do) argue from one or another ideological
simplicity, such as "government interference is inherently evil," or
"medicine is no place for profit," for instance, but such simple
prescriptions neither map well onto a very complex reality, nor give a
direction forward that will actually work.

I start from a general idea that we want to build a society that
works, and that includes people not suffering and dying unnecessarily,
people not being bankrupted just because they get sick, and an economy
not burdened by unnecessary costs, and then ask how we get there from
here. To answer that question, we have to "follow the money," we have
to understand how capitalism works, and the specifics of how and why it
has failed to work in healthcare to provide us what we need for the
lowest possible cost.
  

    

The NY Times is singing your song today:

<http://www.nytimes.com/2012/06/23/your-money/health-insurance/navigating-the-l
abyrinth-of-medical-costs-your-money.html?_r=1&hp>
http://tinyurl.com/82rggcd

The end of that article is:

  Then, when the $132,000 hospital bill came, the patient was told he
  owed $9,200 and it had to be paid in 10 days. As it turns out, only
  one of the insurers had paid its share, which was hard to decipher
  from the bill. Ultimately, the patient only owed $164.99. “There
  were three explanation of benefits from Blue Cross Blue Shield, each
  with an different amount due,” she said, ranging from about $164 to
  $81,900. “How’s that for confusion?”

  All told, Ms. Poole spent about 96 hours dissecting each bill, line by
  line, comparing it with the providers’ medical records and keeping track
  of it all in a complex spreadsheet.

  “It’s a broken system,” she said. 

That article links to a blog post "Decoding Your Medical Bill"
http://bucks.blogs.nytimes.com/2012/06/22/decoding-your-medical-bill/
  

    

Another question:

Evidence-based medicine is a great idea. But some people are concerned
that the process would take too long and be error prone. This is beyond
those who have self-serving interests to ignore medical knowledge or are
just recalcitrant. For example, we've recently seen some opening salvos
in this area including the value of the PSA test.

This is my personal biggest area of concern especially on the other
side where insurance companies routinely classify something that is well
proven as experimental.

So how can systems be designed to respond quickly enough to changes in
knowledge or at least in belief when the evidence turns from today's
breakthrough to tomorrow's "oops we were wrong". For example, we thought
that increasing HDL cholesterol was a good idea.  But now there's a
finding that increasing it does not help.  But is the new finding really
solid? 

So how can we keep the system flexible so that the best practices can
be changed quickly when needed?
  

    
Here's a new question for you, Joe. Which may in fact be outside the
mandate for what your book covers (though I'm still in process reading
it), but maybe you'll have an idea.

A woman lives in assisted living, but not a life care community--there
are no health services on site. She wakes up too dizzy to get out of
bed. She phones downstairs, they phone an ambulance, she is taken to
the hospital emergency room, where she's kept until she's a) stabilized
and b) can convince them to let her out without staying overnight--if
she can.

Variation of this has happened multiple times now. No one can pinpoint
what the actual problem is, they just do this and that to this and
that, but no explanation for the intense vertigo and no changed
treatment for her to do after she leaves. Rinse and repeat a half dozen
times.

This is all covered by Medicare and her secondary insurance. There's
no disincentive for this very expensive protocol. There's also no
alternative to it on offer. If the woman tried to get out of bed and
function, she'd be likely to fall. 

In a functional health care system, what would look different, barring
the assisted living place being a life care place with its own skilled
care facility and doctors? And what if the woman were living
independently at home, unable to afford assisted living? Is this a
"swarm the patient" situation, and if so, what would that look like?
The only thing she's been told to do differently is drink more
water--and she has been.