Trefoils and Lemon Cookies

When I accepted an offer way back in the dim recesses of history to become the CEO of the hundred and ten bed primary care hospital which would become NorthBay Healthcare, the Board Chair told me that his colleagues really wanted me to find a house in the service area. It was important, he said, that my family and I be looked at as part of the community the hospital served. At the time, I was commuting thirty miles from the eastern fringe of what would become Silicon Valley to Berkeley so I said I would do my best to comply. Not having a commute seemed attractive.

1981 was a grim year for buying a new home. Mortgage rates were at 16% and new housing starts were at an all time low. After several months of futility, I told the Board Chair that I had finally found a suitable home but it was in another county and would require a commute. He looked me in the eye and said “Try harder”. I got the message and eventually found a house which was our home for thirty years. I never liked that house but my family truly became part of the community.

I thought of this history because of several things which happened to me recently. Last week I was minding my business in the waiting area of a car wash when a woman in nursing scrubs came in. She paused and looked at me and asked “Are you Gary Passama?” That question always causes my heart to skip a beat. Why, I wonder, was she asking?

As I suspected, she was a NorthBay nurse and had just completed one of her regular 12 hour shifts. She said we had met at her new employee orientation six years ago and liked what I had said about NorthBay’s culture. She then pointed to her name badge and I congratulated her on her degree. No, she said, that was not what she wanted me to see. I took a closer look and then I saw what she was so proud of. She had a daisy symbol on her badge which meant she had been recognized as an extraordinary nurse as part of a program from the Daisy Foundation. She deserved great praise for this achievement and I thanked her for the great patient care it represented. She turned red in the face and started fanning herself. It was wonderful to be able to recognize her personally even though I am almost three years on the beach.

The next day I was with one of my daughters-in-law in a local supermarket. My job during these forays is to keep my twin two year old grandsons distracted in their stroller while their mom races up and down aisles food shopping. We got to the checkstand and there was a NorthBay nurse whom I have known for at least twenty-five years. We hugged (I know, I probably violated at least five laws but they do not apply when you are on the beach). She saw my grandsons and told me that she had just become a grandma for the first time. We talked about the joys of being a grandparent.

Later that week I was standing in line at a Panera Bread store. My mission was to buy two chocolate chip cookies. I was ashamed of myself as I watched other customers order kale salads and other such curiosities. As I looked around I spied another NorthBay person. She is NorthBay’s face to businesses as well as resource for the public’s questions about health plans and Medicare. I violated the law again as we hugged. She is a bubbly person with a great personality and an iron will. We talked about healthcare in general and our families.

I bring up these instances because I fear that as healthcare has become more corporate in nature we are losing a connection to the community, something that board chair felt was very important. When you live in the community served by your organization, you cannot avoid praise as well as criticism. I think that makes you a better manager and your organization more responsive.

NorthBay’s main competitors are Sutter and Kaiser. They have many other geographic areas that also require management attention. Their local top managers cycle through every few years but never become a part of the community. That weakness is a competitive advantage for a local healthcare system or small business competing against a big guy. A NorthBay senior manager living in the community has no place to hide.

One more story to tell—this week as my wife and I were leaving a pizza joint (no kale salad was on the menu, thank goodness) we heard “Mr. Passama, Mrs. Passama!” We turned to our right and there in front of the next door store was a small table staffed by very young Girl Scouts selling Girl Scout cookies. Behind them were two women who were the moms of the girls, both of whom were NorthBay staff members and former middle school students of my retired Science teacher wife. They were the ones calling our names.

I am a sucker for Girl Scout cookies. My favorite are the Trefoils, a shortbread cookie. While my wife talked to her former students, I listened to the sales pitch from the girls. They were well trained. When they learned I liked Trefoils they made sure I got a box. They then began extolling the virtues of a new cookie available for the first time this year–lemon cookies. I took two boxes. That made a total of $15.00. I gave them a twenty and told them to consider the $5.00 change as a donation. That sparked a brief argument among the girls as the donation apparently could be applied to two different possibilities. I suggested they take a vote but the oldest girl said she had already marked the donation in a specific column on the order sheet and that was that. That girl will someday be running Sutter or Kaiser or even better, NorthBay.

I am glad I tried harder and became part of the community that our relatively small but mighty healthcare system served. What I missed out on the national stage was more than made up by feeling like I had made a positive impact locally.

I also liked the lemon cookies. Try them the next time you see a Girl Scout in your community selling them.

Cylinders of Death

One of the great advantages of being figuratively on the beach is that you have more time to occasionally really be on the beach. Put another way, I just got back from spending eight days on a beach on the island of Kauai. If you bear with me I will by the end of this brief piece find a way to tie my Kauai beach experience with a few healthcare comments.

We have been to Kauai several times and compared to the rest of the islands in Hawaii it is by far the most laid back island. Life is slow and languid. The island is very rural. Even the one city of any size is not particularly large. Nothing much happens on Kauai. That’s the whole point of Kauai.

There are the chickens thoughout Kauai. They are everywhere. It seems that Hurricane Iniki which devastated Kauai in 1992 destroyed every chicken coop on the island. The birds took flight to the extent chickens can fly and left the roost. Kauai, being a verdant place, made it possible for the chickens to flourish. The roosters and hens did what roosters and hens do and they quickly multiplied.

Today chickens are everywhere in Kauai. I encountered them on my daily morning beach walks.

We found chickens running around thousands of feet above sea level at the top of Waimea Canyon. Then there were the chickens running around the many open air restaurants hoping for a crumb or two despite the signs (ignored by tourists) not to feed the chickens.

I became convinced that the Kentucky Fried Chicken stores on the island simply opened their doors early every morning after sprinkling bread crumbs and in walked their daily supply of nuggets. Kauai chickens are most definitely free range birds.

When not counting the chickens and avoiding the occasional aggressive rooster, I indulged my love of hot dogs. Kauai is the home of Puka Dog, a hot dog stand made famous by the late gourmand Anthony Bourdain. Most of the time this place has so much business that the line is organized like the lines at Disneyland. You wait your turn while confined by cordons of rope and silver posts.

The Puka Dog Menu

We avoided the lines by eating lunch there twice at 10 a.m. It gave the bored employees something to do while they awaited the hordes. You choose your dog (besides a real hot dog you can opt for a polish dog or if you are from California a vegan dog), the relish you would like (choosing from such exotics as mango, banana and other ridiculous relishes) and whether you would like their special mustard and/or plain ketchup.

The hot dog is long and plump and is dropped into a bun which looks like a small loaf of bread with a long deep hole that traverses its length. The condiments are dropped down the same hole. It’s a big meal. The Puka Dog staff seemed insulted when I asked for just ketchup on my dog. One person I know refers to the Puka Dog as the “Cylinder of Death”. I rounded out my meal with a lemonade and a bag of Maui Chips. Why they don’t serve Kauai chips remains a mystery.

I did have time on Kauai to think about healthcare, especially after I consumed my second cylinder of death. I like to visit urgent care centers when I travel to get a feel for them. As I have indicated previously, I have reservations about their utility. I did scope one out twice during my Kauai stay. It was located in a small but upscale shopping center. Upscale shopping centers in the Hawaiian islands are defined as having a Tommy Bahama store.

The Kauai urgent care center seemed devoid of patients both times I took a look. There was not even a chicken in the waiting room. Perhaps they get busy later in the day after tourists have had their Puka Dog.

I did try to keep up to date on healthcare matters on the mainland by reading several recent issues of Modern Healthcare I took with me. I noted with interest that CommonSpirit Health would be having only one CEO with the retirement of one of its Co-CEOs after just one year of this dual arrangement. I had predicted this outcome in an entry on this site. These arrangements come about because the boards of merged organizations don’t like to make hard decisions.

I also noted that Modern Healthcare said that CommonSpirit Health had a $227 million operating loss in its first year. Outside financial analysts are beginning to get concerned. As I have also noted previously, big is not always better. In fact, it often makes performance improvements of all kinds more difficult. There is no virtue in being ponderous.

A final comment—-another recent issue of Modern Healthcare I read on the chicken island had this headline: “As competition heats up, hospital outpatient visits see first dip in 35 years”. The headline was a little misleading as the “dip” was in emergency visits. Otherwise, hospitals saw an increase in outpatient net revenue of 4.5% which was more than twice the 2.1% increase in inpatient net revenue. The hospital haters don’t get it——hospitals are more than holding their own against so called disrupters in healthcare.

It is nice to be back on the mainland where chickens know their place.


Unholy Alliance Part 2

If there has been one thing I have been consistent about both during the thirty-five years I was a healthcare system CEO and continuing on to my tenure now on the beach, it has been my view that the information collected during the patient care process belongs to the patient and no one else. As a provider of care we maintain custody of that information but it is not ours to give away or sell.

That was the focus of a blog I published in November (Unholy Alliance) which discussed the arrangement which Ascension Health had with Google to share patient data (“Project Nightingale”). The Wall Street Journal ran an article exposing this arrangement and raised questions about it appropriateness, particularly since it was a secret endeavor done without patients’ knowledge.

The Wall Street Journal in a more recent article again explored this subject. WSJ related how some prominent healthcare organizations like Intermountain Health and the Mayo Clinic were considering or have struck deals to provide patient data, some of which might with a little effort allow individual patients to be identify. Kaiser apparently also did some consideration of a similar data sharing arrangement.

It is not just healthcare providers who see patient data as a desirable asset. Health plans think such information belongs to them to use as they see fit. There are no uniform safeguards to protect patient confidentiality.

Its gets more dismaying. Cerner, a major provider of electronic medical records to providers, seems to think that the information which flows through its servers is its data to use or exploit as it deems appropriate. Apparently they had second and third thoughts about such data monetization and decided–for now–not to allow access to their data trove to outside organizations. Cerner would better serve its clients by providing a more efficient and less expensive suite of software. That would be a major achievement to crow about.

Google and Amazon seem to be the most active in attempting to entice healthcare providers to allow them to aggregate such data and in the process provide addtional revenue to the providers. The sale of this patient data is always couched in language which suggest that the common good will be enhanced. Disease processes will be better defined and the efficacy of treatment modalities better understood. I have no doubt that is true but do not believe Google, Amazon or any of the nerd herd are trustworthy recipients of this data. Nothing in their past history is a confidence builder in this regard.

Google, whose self proclaimed mission is “to organize the world’s information and make it universally accessible and useful”, has a dismaying tendency to take action and then beg for forgiveness later. I get the impression sometimes that they would like to be the “University of Google” with the prestige that would give them. If so, hopefully they will have a football team which will be smart enough to keep their helmets on at all times.

All of this is beside the point if you accept the thesis that your personal health record belongs to you and no one else. It is not for sale to others. We in healthcare forfeit our patients’ trust if we enter into such arrangements with the likes of Google or Amazon or Apple or Microsoft—make your own list. Healthcare organizations need to be more forthright about this matter and assure those it serves that their data will not be sold to others.

This is an area which continues to attract the attention of politicians which can be a mixed blessing. Bottom line though is that my healthcare record is my business and it is not for sale without my permission. Take my information off the market.

Dinosaurs Can Evolve

Amazon, the slayer of dinosaurs like WalMart and Target, is suddenly finding that the dinosaurs are biting back and it hurts. That was the subject of several articles in the business press at the end of 2019. I believe this revival of the erstwhile retail dinosaurs has some parallels to healthcare.

Until recently, Amazon has been a devastating competitor in the retail space. Online ordering and the absence of costly stores has allowed Amazon to grow very quickly. Free or low cost delivery made purchasing from Amazon even more attractive. WalMart and Target with their many stores found competing against Amazon difficult. A new paradigm was rising.

That is until WalMart and Target took a look at their business and how Amazon was leveraging online ordering to their disadvantage. Amazon, they realized, did its order fulfilment from massive warehouses located around the country. Could that seemingly insurmountable strength be a weakness?

WalMart in particular and Target to a lesser extent began online order fulfilment using the inventory in their thousands of stores. If necessary, orders could be shipped from the store or, even better from a cost viewpoint, customers could pick up their online purchases at local stores. This past holiday season, both WalMart and Target made it very easy to do such pickups. These dinosaurs had in effect mini-warehouses much closer to the customer than did Amazon. The dinosaurs suddenly became more formidable.

Amazon is now beginning to open stores to assert its presence. I frequently visit a bookstore they have in Walnut Creek, CA. I also visit another Amazon store in Berkeley which only stocks the best selling items in a number of categories. Amazon also owns Whole Earth Food stores (better know as “Whole Paycheck” due to their high prices and air of genteel nonsense— they make you feel good as they shamelessly pick your pocket). Amazon is looking more and more like the dinosaurs it thought it had replaced.

So what is the parallel with healthcare? For years the mantra has been that hospitals are dying. The first book on that subject that I can recall dates to the early 1980s. The author of that book is now a senior citizen pundit who no longer necessarily believes in the death of hospitals. The thesis underlying the hospital death notices was that technology would reduce the need for hospitals and services would be provided in less costly outpatient locations. Outpatient locations with their lower cost were to be the Amazons of that healthcare era.

Except, all the hospital doomsayers were wrong. First of all, technological advances also led to increased use of hospitals for some diseases. More to the point, like Walmart and Target, hospitals did not roll over and bow to the pundits’ outpatient gods. Hospitals big and small morphed into healthcare systems. In many locations, hospitals are the central focus of a campus and are surrounded on their sites or nearby by various outpatient centers they own.

Hospitals are like WalMart Super Centers. Easy to find with all that a customer (or patient) may need. That convenience plays a huge role in allowing hospitals to adapt to changing circumstances. Hospitals did not die. They evolved and in the process made care more accessible.

This reality is hard for many to accept. There are entrepreneurs still trying to form urgent care companies and imaging center companies. The economics work fine as long as they can find venture capital companies dumb enough to fund them. The dumb guys do exist. The fact is, though, that none of these companies have amounted to much or moved the needle in terms of healthcare cost.

Hospitals in their new form, like WalMart and Target in retail, have become effective competitors with self-proclaimed disrupters. The lesson here is to never underestimate the ability of dinosaurs to evolve.

The Price is Right, Right?

Come on down! Guess the price of a MRI procedure and it will be yours to have. Who wouldn’t want to spend twenty minutes in a tube surrounded by a magnetic field?

And behind one of the three doors is a CAT scan worth–well, the price depends on where you get it.

Price transparency for healthcare services has reared its head again on both sides of the aisle in Washington. King Trump, strike that, I meant President Trump, has proclaimed that contracts negotiated between health plans and healthcare providers should be made public so that all can see what prices are contained therein. That proclamation is already being litigated so don’t hold your breath about seeing contract details anytime soon.

Meanwhile, the Impeachment Queen, strike that, I meant Speaker of the House Pelosi, along with many other members of both parties think that the posting of prices by healthcare providers is a dandy idea which will lead to decreased healthcare costs. Their woked enablers in the healthcare parasite community, strike that, I meant healthcare punditry community, are nodding their heads as if they know what they are talking about.

I will leave the sanctity of contracts issue to the lawyers who also have to make a living. The other proposal, though, that the posting of prices by healthcare providers will make a significant difference in where patients choose to obtain services reveals an abysmal ignorance. The medical term is “hogwash”. It is very contagious.

In an emergency or urgent situation, no one stops to check a price for a service. You need the problem taken care of immediately. Most hospital admissions nowadays come through the emergency service or from a doctor seeing a patient in the office and determining that hospital care is urgently necessary.

Outpatient services are a different matter. Most can be scheduled and therefore there is time to shop for the best price if a patient is so inclined. Despite that, most patients do not shop. They rely on their provider to make the necessary referral to an outpatient site. Imagine, they trust their doctor!

It has been possible for many years in California to shop outpatient services provided by hospitals by going to a state-run website where hospitals are required to post all of their prices. You are talking about thousands of prices as hospitals must have prices for everything in order to meet federal mandates. There is little evidence that many patients access the price website and even less evidence that the website influences where the patient obtains a ordered procedure.

When your doctor suggests a test needs to be done, he or she usually has a place in mind that experience has shown will produce an accurate and timely result. For instance, the ordering of a MRI by a provider at a specific location may reflect confidence that the equipment used is up-to-date and the specialist interpreting the test has a good record of accuracy.

Another example would be a surgeon who recommends a procedure which can be done at an ambulatory surgery center where he has privileges and where he trusts that the nursing staff will be competent. Do the politicians and pundits really think a patient is going to shop that service? Maybe the patient can find a cheaper place for the surgery but he will also have to find another surgeon.

Shopping for healthcare services is not the same as shopping for a TV. If Costco has the same TV at a cheaper price than Best Buy, there is no reason not to buy it at Costco. Plus, you can get a hot dog and soda for $1.50 plus tax at Costco which would seal the deal for me.

I have no problem with the posting of prices, mandated or voluntary, by healthcare providers. I have a huge problem with the self proclaimed “experts” who think that will reduce the cost of healthcare. The interplay of third party insurance, government regulations, technological advances and patient preference plus many other factors drives healthcare costs. The posting of prices will not affect these drivers of cost.

Whenever the issue of prices and costs came up before I hit the beach, I would look at this framed quotation from the 19th century English writer John Ruskin which hung in my office:

“There is hardly anything in the world that some man cannot make a little worse and sell a little cheaper, and the people who consider price only are this man’s lawful prey.”

So King Trump and Queen Pelosi and your various enablers and court supplicants, come on down. The price is not always right.

I Got Hugged

Recently as I was leaving NorthBay Healthcare’s fitness center where I regularly work out, I was stopped by an oncology nurse who works in the cancer center located in the same building. She told me that it was her last day before retiring and was it ok for her to hug me?

That request gave me pause. Would it be appropriate for me to let her hug me? I knew the nurse slightly as I did many employees before I hit the beach. I had run into her occasionally as I meandered around NorthBay’s various service sites. I knew her to be a very dedicated nurse. Why would she want to hug me?

I got real and put away my fears of being accused of acting inappropriately. I no longer was in a position of authority and if she wanted to hug me, why not? So I opened my arms and accepted her hug.

She thanked me for having supported the cancer center from its inception and through its growing pains. I thanked her for her long term tenure and her commitment to giving patients the very best in care. I wished her well as she joined me on the beach.

I spent several days mulling over the hug. The whole incident left me a little puzzled. I eventually realized that she was recognizing me for having done something that in her mind merited a hug. She made me feel good.

I always felt that recognizing the people who served our patients, no matter their job description, was the right thing to do. As do most organizations of any size, we had a formal recognition program which included an annual employee recognition program. I suspect, though, that such programs alone are insufficient to convey to staff that their efforts are appreciated and that they are not faceless inputs into the patient care process.

I don’t have answers to what more we can or should do to better recognize the contributions of staff to an organization’s mission. I think more ideas are probably needed. We need more metaphoric hugs to recognize staff.

As we approach the holiday season, things tend to get hectic and we forget to recognize people and their efforts. It is natural but wrong.

All I know is that I got hugged and it felt very good. I hope everyone gets a “hug” in the workplace when they have earned it.

Unholy Alliance

The Wall Street Journal and other news sources reported last week that Google and Ascension Health, a Catholic organization which is one of the nation’s largest non-profit health systems, had entered into an alliance which would provide Google with access to patient data. The project is known internally within Google as “Project Nightingale”. It was more or less a secret endeavor.

The usual gobbledygook ( not a disease although it sounds like it should be) spewed forth from both Google and Ascension like the poor possessed girl in “The Exorcist”. People paranoid like me of Google were concerned. Not to worry says Google. Trust us.

Ascension, having also kept this matter more or less a secret from its patients, resorted to a convoluted explanation similar to what a small child would say when he was caught with hands in the cookie jar. Trust us too!

Politiicans weighed in with their own concerns. Increasingly, the motives of these large Silicon Valley companies are being questioned. Critics are raising issues of privacy and intrusiveness. Information is power and the Googles of the world seem to relish using that power. So do politicians and they don’t like to share power.

Stripped to its basics, it seems this unholy alliance between Google and Ascension had the noble goal of using Google’s strengths in aggregating data and applying artificial intelligence to gain new insights into disease and the care thereof.

I understand Ascension’s motives in working with Google. It seems consistent with their mission of providing health care in the most effective and efficient manner. Purity of motive does not, however, justify betrayal of trust of those you serve.

I, like our elected officials, am very suspicious of Google’s motives. Clearly, Google sees a way to monetize access to patient data. Who benefits the most from this access–the patient or Google? Easy question to answer.

Why is it that when I go to the doctor or use a health system’s services, my health data, even if provided in a manner where my identity is disguised, becomes a product for others to use for profit? It’s my information and my privacy which is being violated.

Yes, there are apparently in the Google/Ascension alliance all kinds of safeguards built into the information aggregation process. The information is safe until it is not safe. Hackers are probably already at work trying to crack this treasure trove of data.

The most basic question, though, is why is my personal data for sale?No matter how pure the motives are on the part of Ascension or how much profit Google foresees access to that data will provide, patients gave neither of these organizations the right to open up their private life for a greater cause.

If this unholy alliance is going to continue, it is time for them to seek permission from patients for access to personal health data even if the information is “deidentified” and since such data has apparently some value, perhaps even pay for the privilege of using it.