The Happy Little Box

When you reach a certain point in life–like the age of 50–the indignities start to pile up in five year intervals. You get an unsolicited membership card from AARP welcoming you to their ranks.  Wait staff at restaurants insist that you take their senior citizens discount for dinner at 3. And, if you have a sadistic primary care physician, you begin to get scheduled for medical procedures you used to be thankful you were too young to have to endure.

After having spent the previous week on an actual beach, my wife and I spent last week back on the metaphoric beach of retirement undergoing the same medical procedure.  We have different primary care physicians but both apparently follow the same guidelines.

The procedure which both of us have experienced several times before requires that you have a companion willing to drive you home and stay with you for a few hours as you recover.  No Uber drivers allowed which is just as well given how their newly issued stock has performed. Thus, we had the procedure on separate days.

You start by fasting the day before.  You can have popsicles of a certain color and various clear liquids.  You need to keep hydrated for the ordeal to shortly follow. After midnight of the day of the procedure, no liquids are allowed with one terrible exception.

In the afternoon of the day before, you take your first step in the preparation.  You drink a vaguely cherry favored concoction which is washed down with 32 ounces of water over the next hour.  This first step will soon result in many other quick steps to the bathroom.

A few hours later after midnight, you repeat the process.  It is like the rinse cycle from hell.  If you are lucky, things settle down before you depart for the procedure.

Once at the location of the procedure, you sign a variety of consent forms notifying you of all the bad things which could happen to you.  You sign on an iPad although the signature looks nothing like what you would write on a piece of paper.  This high-tech approach gives you confidence.  You can have the consent forms printed out to take with you but having endured so much already, only a confirmed masochist would do so.

Soon you are taken  to your room where a sympathetic nurse sticks an IV needle into your arm and explains “conscious sedation” to you.  After what you have been through so far, conscious sedation sounds pretty good.

The actual procedure is a breeze.  You remember nothing and you have nurses fussing over you as you recover.  If you are lucky, you won’t have to have the procedure again for another five years.

If by now you have not guess what the procedure is, then you will have a big surprise waiting for you along with your AARP card when you turn 50 and every five to ten years thereafter. Enjoy life until then.

Recently I have noticed a commercial on cable news shows featuring a happy little box with arms and legs touting an alternative to what I outlined above,  You take the contents of the box with you into the bathroom, do what the instructions tell you to do and mail the result for testing.  Mind you, you are hearing all of this right after you have had your dinner.

The problem with this approach is that while the happy little box gives you a result, positive or negative, unlike the other procedure it does not intervene to remove possible conditions that may be a precursor to cancer which is the point of the whole exercise. The happy little box comes with significant limitations.

So why have I gone into such detail?  Aside from the fact that the procedure can and does save many lives, I find it a perfect example of the ability of our healthcare system to adjust to rapid change.  It is, in fact, one of many such examples of how agile our healthcare system is, especially in comparison to the sclerotic state of many other segments of our economy.

Colonoscopies–there, I finally have said the word–were made possible by technological innovation rapidly adopted.  At first, the procedure was done within the confines of a hospital.  Then, as I recall, a few doctors started outpatient centers which did only colonoscopies.  This prompted hospitals to include the procedure in their new outpatient surgery centers at a greatly reduced cost as compared to doing it in the hospital. You see this process of adjustment and change occurring all the time in healthcare.

The pace of technological change in healthcare is accelerating.  New developments in individually tailored cancer treatments, continued development of robotics in surgery and new imaging techniques will test the agility of our healthcare system.  Don’t bet against our vibrant healthcare system and its component parts.

As for the happy little box, it represents a further technological refinement for people who needlessly fear colonoscopies.  If the happy little box tells you need to see a doctor, then you best do so. Better yet, go all the way with the scope.





Health Plans Are Dumb And Medicare May Be Getting Smarter

Last week I was actually on a beach for the first time since I retired in 2017 and two healthcare developments caught my eye.  I know, I know–I probably should have been thinking of alcoholic concoctions with little umbrellas and sunsets but I don’t drink and if you have seen one sunset you have seen them all.

The first development was a tired old story of stupidity on the part of a health insurance plan.  Once again a health plan had tried to renegotiate a contract with a provider and having failed to achieve its goals of vastly cutting reimbursement, terminated the agreement.  The result, hundreds if not thousands, of people will be forced to try to find new doctors.  This was probably not what their employers had in mind when they signed their contracts with the health plan.

Health plans don’t seem to get it.  As third-party intermediaries, they have become commodities with a limited purpose.  In an era where direct contracting will probably become the norm, the need for health plans as we currently know them is coming to an end. Every time you see a health plan put itself in this position, you are seeing its death throes.  Call it health plan suicide by stupidity.

In the particular case at hand, the health plan sent a letter to all the contracted doctors saying they had to sign an attached agreement if they wanted to continue to see their patients, not realizing the doctors were part of the healthcare system with whom they had just terminated the agreement.  The entry bar to management in health plans is clearly low and getting lower.

This is just one more example of large health plans not really knowing the local markets where they are marketing their product.  The corporate empty suits don’t understand that brute force does not work anymore.  As long as they think they are going to make their bonus numbers, they will make stupid short-term decisions.

People really could care less about the name on their health plan as long as they can access their physician of choice and to a sightly lesser extent their hospital of choice.  That is the reality facing health plans and that is why you are seeing strange mergers like drug store companies (also an endangered specie) and health plans coming together to seek a synergy which does not exist.  Are they drug stores with a plan or health plans on drugs?

More to the point, in an era where waits to see primary care physicians and specialists are  long, a threat to physicians to take away patients is not very viable.  Access to primary care doctors is becoming a real problem.  Health plans, always with one eye on Wall Street, don’t really care about patients who become pawns in their silly game.

Add to this the fact that many hospitals run full most of the time and the threat of health plans to take patients elsewhere becomes even sillier.  Integrated healthcare systems were developed so that care could be coordinated and better outcomes realized.  Health plans often get in the way of better care with their disruptive behavior.

The answer to all this which is slowly but surely evolving is the development of nonprofit health plans which are part, not apart, of integrated healthcare systems. Only then will the twin goals of better quality and better cost control be achieved.  In the meantime, watch the existing health plans cut their own throats.

The other development which caught my eye on the beach was the announcement by Medicare of yet more pilot programs to further their goal of “value-based purchasing”, another way of saying rewarding and punishing providers if they don’t meet certain, ever-changing and poorly defined quality goals. Medicare’s previous pilot programs in this regard have been failures although the pundits try to hide that fact.

Two of the new proposals by Medicare would compensate primary care physicians on a  monthly basis per patient.  The two proposals differ by the degree of risk assumed by the physicians.

At first glance, this sounds like capitation in a fancier dress.  A closer look, though, shows it may be more like a subscription model which is gaining favor in other areas of the digital economy.  Even now, you can “subscribe” to a car or have an Amazon Prime subscription. If this is the case, and Medicare can resist its natural impulse to make something simple more complicated than it needs to be, it may be on to something.

There are lots of details yet to come about Medicare’s proposals but at least they deserve credit for thinking differently as they also try to meet the twin goals of better care and cost containment.  Health plans might think about this as they slowly kill themselves.

Health plans are dumb and Medicare may be getting smarter.


Why Do We Have Hospitals?

Many years ago when I was newly promoted to Chief Operating Officer of a large hospital in Berkeley, I was asked by the Chief Nursing Officer who had been my peer but was now my subordinate this question:

Why do we have hospitals?

I offered several fumbling answers, each of which she told me was wrong.  I was beginning to think she was trying to put newly promoted me in my place when she gave me the correct answer:   Because patients need nursing care.  That’s the reason they are admitted.

She was right then and she would still be right today.  The fundamental reason why patients are in the hospital is because after everyone else has had a go at them, they require the care and attention of a nurse to recover.

While nursing care continues to become more dependent on technology and requires increasingly more education and training, it still is at its core a one-to-one relationship with the patient.

My introduction to the profession of nursing took place as part of my graduate education.  I was in the minority of my graduate program cohort in that I had no clinical background.  That’s how I found myself doing the duties of a nurse’s aide in a Bay Area hospital for four months before my first semester.

I worked alongside nurses and saw them using both high-tech and more importantly high touch in their care of patients.  One situation I will never forget was watching late one night from across the intensive care unit a nurse brushing the hair of a seriously ill teen age girl who was crying, offering her comfort with her words.  I watched that girl get calm and for the first time understood the importance of nursing.

Another time I was working in the emergency service when an elderly woman in cardiac arrest was brought in.  She had been on a passenger train when she fell ill.  My job was to fetch things for the doctors and nurses as they tried to revive her to no avail.  When the patient was declared dead, one of the nurses asked me to remain in the room with her and the patient.  She told me that what we were about to do was as important as all the efforts to save the patient’s life.  Our job was to prepare the patient to be seen by her husband who was waiting elsewhere in the hospital.  She said it was important that he see his wife as he remembered her and not as someone with tubes and other equipment connected to her.  That nurse taught me that caring for the patient sometimes means caring for others as well.

I saw other nursing interventions that continue to move me emotionally even many years later.  Often, it seems that the only person taking the time to truly understand the concerns of patients is the nurse.

I am proud that there are now nurses in my family.  It is a great profession with many avenues of opportunity.  Whenever I can, I encourage young people to explore nursing as a career.

While the nursing profession now has many important roles outside the hospital, I remain partial to hospital nurses because, after all, that’s why we have hospitals.

May 6 is National Nurses Day and that week is National Nurses Week.  If you know a nurse, give her or him a thank-you for what they do.  They deserve the recognition.




Remember The EMR!

I have been railing against the roll-out of the electronic medical record (EMR) since I first started blogging when I was CEO of NorthBay Healthcare.  I have continued whining about EMRs in this space.  I have become a serial whiner.

At times I feel like I am beating a dead horse except this horse is not truly dead.  The EMR horse continues to consume oats and spew out you-know-what at the other end.  It’s a mess.

My latest bout of EMR whining is prompted by an excellent article in the April issue of that well-regarded medical journal–Fortune Magazine.  It relates the EMR follies and how good intentions were subverted by poor planning, political posturing and the law of unintended consequences.  Business as usual in D.C.  It is a must read.

Health policy makers (also know as pundits) and politicians on the hustle are a toxic mixture.  It never ceases to amaze me how ignorant these people are about the actual delivery of healthcare.  Yet it is these people we rely upon for considered reform of health care.

As the Fortune article points out, the push to have national adoption of the EMR was because it was viewed as a shovel-ready endeavor which could help with economic recovery from the recession of 2008.  However, the shovels were not ready, physicians and hospitals were not consulted and the providers of EMRs were selling a product which complicated the delivery of care and in many instances caused injuries.

The EMR vendors saw explosive growth after 2010 when healthcare providers were under the gun to adopt EMRs.  The federal government created financial incentives to adopt the EMR as well potential penalties for not doing so.  The EMR vendors as a group were not ready for prime time but they sure prospered.   Their revenue growth was impressive and matched only by their ability to not deliver on their promises.

As I have related recently, we now have scribes entering medical data so that physicians can be freed from that task and devote more time to attending to their patients.  Costs have not gone down as a result of the EMR; they have increased substanially.   And because of the poor design of the EMRs, the quality of care has often been affected.

Making the EMR work to the benefit of providers and patients is now a rescue effort that is likely to involve significantly more expense.  Even most of the early proponents of the EMR including former President Obama are expressing regret about how a good idea turned into a fiasco.

Has the lesson been learned that a good idea is not necessary amendable to uninformed political intervention?   The answer is a resounding “No!”

“Medicare For All” has again reared its head, promoted by a multi-millionaire socialist (only in America is that possible) senator with the 150 Democratic presidential candidates all supporting it.  The other party meanwhile seems to be pretending there is not a problem in terms of healthcare coverage.  Both sides give new meaning to the term “useful idiots”.  Actually, the term should be “useless idiots”.

We have a problem.  Medicare for all is not the answer.  It is an empty slogan meant to be defined in multiple ways.  There is political safety in vagueness.

Doing nothing is likewise not the answer although that seems to be the default position of the other party.

Adopting a solution for political purposes will repeat the EMR fiasco.  Wiping out the health insurance business which needs to be reformed but not eliminated will have its own unintended consequences.  Doing anything that increases demand for healthcare without providing more trained providers will simply make access even more difficult.

Solving the vexing problemn of universal coverage is going to require much more thought than blindly adopting a nonsensical slogan like “Medicare for All”.  A much better slogan would be:

“Remember the EMR”.

A poor memory will result in yet another fiasco and more importantly no improvement in coverage.


The April 17 Wall Street Journal contains an excellent column written by two academics, one of whom frequently writes healthcare related articles for the Harvard Business Journal. The article critically examines “Medicare for All” and contrasts the failing Canada model with much more successful universal coverage models in Germany and Switzerland, both of which maintain a robust private healthcare sector. The last paragraph nicely summarizes the authors’ point:

 Con­sumers and the pri­vate sec­tor drive the health-care sys­tems in these coun­tries, which ac­com­plish ex­actly what Mr. Sanders and his sup­port­ers say they want—uni­ver­sal cov­er­age, con­trolled costs, high qual­ity and ready ac­cess. In con­trast, Cana­da’s ex­pe­ri­ence shows the dan­gers of the Medicare for All model.

 So once again, Remember the EMR!

The Rule

I really did not want to be negative when I read a number of articles updating Walmart’s and other large employers’ efforts to encourage employees to use physicians consider the “best” in their area of expertise as a way to decrease the cost of health insurance. Then I remembered my rule:

When a company or the government says it is about quality and saving money, it is about saving money.

The lead sentence is a recent Wall Street Journal article inadvertently could not have been any clearer:

“Walmart and other employers want more say over which doctors care for their workers, and they are ramping up efforts to pick and choose physicians in health plans as they seek to reduce health spending.”

Pick and choose physicians? A laudable goal, I guess, but a little frightening when you think about it.  Do you really want your choice of doctors determined by someone whose bonus or stock price is tied to financial performance?

The article relates how Walmart has developed a network of physicians they have deemed the “best” and provides incentives for their workers to travel, if necessary, for consultation and treatment by those doctors. Those incentives are meant to guide the decision making by employees to the financial benefit of the employer and secondarily (maybe, possibly, hopefully) result in better quality care..

The assumption is that the care provided to those workers would be better, not to mention cheaper.  The evidence for the “better” part of that assumption is shaky.

Identifying top performing doctors is still a mix of science leavened with a healthy dose of voodoo.  Measuring physician performance is difficult.  Measuring who is a cheap physician is not.

The idea that the plan of care developed by the chosen doctors is an improvement over what a local doctor may think is equally dubious.  In fact, what Walmart is doing is further fragmenting care.  They are looking at sourcing health care the same way they do for the merchandise they sell.  But as Walmart proudly proclaims, it has saved them money.

Walmart employees who choose the travel option will save money.  They get whatever procedure the “better” doctors perform at a reduced co-pay or deductible amount.  Walmart pays the doctor at a negotiated discount rate.  Everyone is happy.

So what happens with the necessary local follow-up care where the Walmart patient lives?  It is one thing to travel hundreds of miles to have back surgery performed by the annointed surgeon but  the “lower” quality local  doctor or hospital is expected to provide that follow-up care.  Good enough to do the follow-up but not good enough to do the procedure.   What’s with that?

The evidence for the success of such programs is anecdotal.  According to the Wall Street Journal, Walmart, Lowe’s and McKesson Corp (which is a vendor of expensive goods and services to healthcare providers) “saved” $19.4 million for spine surgery provided to their employees under the programs.  Just how they “saved’ and the basis of comparison is  hazy and the total amount is not even a rounding error for these huge companies.

It seems to me that tangled in all this may be an absence of a degree of fiduciary responsibility when your employer selects a doctor and steers you to that doctor.  If you have a financial advisor who is a fiduciary you know that he or she does not financially benefit from whatever specific investment they recommend.  Their only interest is do what is best for their clients.

That is not the case with what Walmart and other large employers are doing.  Their first imperative is to save money.

An interesting question:  Suppose under this scheme,  quality improves but costs increase? Would these companies be as interested?  I think I know the answer.

While high quality is not always more expensive, there are many instances where high quality does mean higher expense.  It depends on the definition of quality being used.  As in most of life, you get what you pay for.

There is another time proven way to make sure that a medical course of action is the best–get a second opinion independent of your employer or health plan..  At NorthBay Healthcare, we became part of the Mayo Clinic Care Network and that allowed our doctors and patients to seek a second opinion from the preeminent medical group in the world.  There is no cost to the patient for these second opinions.  That is a better option, free of self-serving conflicts.

Over the years I have grown leery of grand schemes to save money developed under the guise of quality.  I know that is not politically correct.  It is absolutely backward thinking, sufficient to get me booted out of the council of wise people in healthcare. That’s fine with me since I am on the beach and now know that the wise people in healthcare are not as wise as they think they are.

Call me a cynic but I still believe in The Rule:

When a company or the government says it is about quality and saving money, it is about saving money.

Always keep The Rule in mind when organizations with built-in conflicts of interest want to make healthcare decisions for you.







This week marks the second anniversary of my retirement from NorthBay Healthcare where I was CEO for over thirty-five years.  It is an important milestone for me but not for most people taking the time to read this entry.

I had  a total of forty-five years as a senior manager under my belt when you include my time at Herrick Hospital in Berkeley.  I enjoyed having the privilege of trying to make a difference in the providing of healthcare.  I worried whether I could step away from the day-to-day challenges with which I dealt.

Would I be bored?  As my successor recently jocularly texted me, “If you are bored and want some fun in your life, there is always budgets and managed care to entice you off the beach.”  I think he is envious.

To my surprise I am not bored.  I have traveled, spent more time with my seven grandchildren and explored personal interests for which I never had enough time to do when I was actively engaged in healthcare.  My old movie poster collection now numbers over thirteen hundred which inexplicably gives me great pleasure.

I am a retirement cliché and not bothered at all about that fact.

I do miss seeing on a regular basis the people who make NorthBay great.  Some have retired.  Some have moved on.  Sadly, some have passed away.  Still, those who remain continue to live the organization’s mission of compassionate care, advanced medicine, close to home.

I have gained, though, a perspective on healthcare which was not possible when I was in the middle of it.  I have learned not to react to every harebrained idea about healthcare which comes from a politician or second rate actor.

I have come to understand that there is much more right about our healthcare system than there is bad. The ignorant pundits need to get a life.

Most importantly, I now understand that healthcare is important but not as important as those of us immersed in it think it is.

It is part of an array of issues with which we cope.  That perspective–putting healthcare in its proper place–came to me only after I hit the beach.  Unless we fall ill or have chronic health issues, healthcare is not in the forefront of our daily activities.

With the 2020 election campaign now beginning in earnest, healthcare is once again becoming an issue for politicians of all stripes to exploit.  It has been that way since 1969 when Richard Nixon declared a healthcare crisis.  Fifty years later, we are still talking about that crisis.

“Health Affairs” in a September 18, 2018 blog article asked this  question.–how long can a crisis last? It is a great read and adds perspective.

“Health Affairs” in that article points out that most of the problems noted fifty years ago remain.   It also points out, though, that the percentage of healthcare costs covered by insurance for most people far exceeds what was the situation in the 1970s.  That is just one indication that the use of the word “crisis” is overblown. Again, it”s a matter of the proper perspective.

After two years on the beach, I do indeed see things differently.  I am not worrying about budgets or managed care.  And while things could be better in healthcare, they are not as bad as politicians and “experts” would lead you to believe.

I will be thinking about these things later this month when, for the first time since I metaphorically hit the beach, I will actually be on a beach in Maui.  I will be the guy in the Tommy Bahama T-shirt and shorts (required attire for Jimmy Buffett wannabees) reading “Modern Healthcare”  and “AARP Magazine” for pleasure. And I will maintain the proper perspective about healthcare.


If Tesla Ran Healthcare

Would things be different if Tesla ran healthcare?   For one thing, there would be more charges.

OK, bad joke.

Nevertheless, everyone it seems is looking for the killer (kind of a bad term) app in healthcare or the big technology disruptor as Tesla has done with automobiles.   So far, it has not been found.

Sure there are things like urgent care centers with iPads for registration and emergency services which advertise their current waiting times on freeway signs.  Not to be forgotten in this list of non-disruptors are the boo-boo clinics in drug stores.

There are the call centers maintain by health plans where you can call with your health concerns.  Their main goal seems to be to prevent you from going to where you really want to go–your doctor or local hospital emergency service.

Don’t forget the Silicon Valley heroes who are looking to cause disruption in healthcare.  Who can forget Theranos, the brainchild of a 19-year-old Stanford drop-out?  If you have forgotten that sad story of non-disruption disruption, you should watch the excellent documentary currently showing on HBO about this fraud.

Where is Bones from Star Trek with his Tri-Corder?  That handy handheld gadget could diagnosis anything!  Captain Kirk often found himself on the receiving end of the Tri-Corder.  That was real disruption.

Maybe instead of looking at disruption we should lower our sights and simply look at improving service to patients.   That’s where two recent experiences with Tesla come to mind.  Tesla is about much more that technology.

Last week I got two flat tires over the span of four days on my Tesla Model S.  That’s a problem since Teslas don’t have spare tires and towing them is tricky and requires a special technique for reasons I don’t comprehend.

My flat tires were on separate wheels and both were on busy I-80 in the Bay Area.  I called Tesla’s roadside assistance number and they quickly sent out a truck emblazoned with the Tesla logo. My flat tires became a status symbol as cars flashed by.


In the truck was a supply of new loaner tires which would be put on my car if the tire could not be repaired on the spot. The first flat tire was repaired and in 30 minutes I was on my way.  The second flat tire later in the week was removed and a loaner tire put on.  The service was superb in both instances.

That got me to thinking about healthcare and its service component.  Like Tesla, we provide a high cost product or service.  Unlike Tesla, we seem to have a difficult time meeting expectations in terms of how we provide our service.  Long waits and poor communication are more the norm in healthcare.  Why is it despite our best efforts that level of non-service continues?

As I was writing this entry, an example of non-service in healthcare came to my attention.  A friend called who was concerned about his very elderly mother.  She was not eating, getting weaker by the day and beginning to have problems with activities of daily living.  She recently had a stroke. Was she suffering a physical problem or depressed?

She was resolutely refusing to go see her doctor who practiced in a very well-known integrated healthcare system here in California.  Her son found her primary care physician uninterested in trying to arrange a home evaluation.  He tried several ways to enlist aid from the healthcare system to no avail.  It finally took an outside physician friend who wrote a  letter he could send under his signature to gain the healthcare system’s attention.  The letter contained enough trigger words so it was no longer possible for the healthcare system not to do the right thing.  A home telemedicine consultation was arranged.

I think even more highly of Tesla after my two experiences last week. Contrast Tesla’s approach with my friend’s experience with a healthcare system which never misses an opportunity to publicly pat itself on the back. If Tesla ran healthcare,  things would be done differently.

When was the last time you felt there was a true service commitment from your healthcare provider?

I find myself beginning to believe that true disruption in healthcare does not require cutting edge technology, a fancy app or even a Tri-Corder.  The way to true disruption is a lot simpler.  Take care of patients in a way that meets their needs rather than  those of the provider or health plan.  In the long run that pays off.