Last week I contended that the increasing utilization of hospital emergency services is a good thing.   Before anyone else could do it, I then excommunicated myself from the punditry religion which as a matter of dogma feels otherwise.

This week I will expose myself to possible capital punishment by committing a felonious act against the common view held by a motley crew of policy makers, “leaders” of large healthcare delivery organizations and consultants always on the lookout for a new opportunity to offer their services. Where is Joan of Arc when you need her?

So what heinous act am I committing?  It has to do with the Affordable Care Act (aka “ACA” or “Obamacare”). The ACA was not just a vehicle for mandating insurance coverage.  There were other goodies in its 2000 plus pages including the hospital “Value Based Purchasing Program” or VBP which would be applied to the Medicare program.

VBP also sometimes goes by the more accurate name of “Pay For Performance”.  You don’t see that term used as often as it seems crass to policymakers and politicians, neither of whom wants the public to know what they really are up to.

Under VBP, the Medicare people issued an ever-changing set of goals which if hospitals met them, they would receive a bonus in Medicare reimbursement.  Not meeting the goals would result in a decrease in reimbursement.  The goals would change from process oriented (i.e., did you do the right thing for the patient) to outcome oriented (i.e., how did the patient do) and back again.  With the constant changes in goals and the bureaucracy necessary to oversee VBP, things got complicated.

The VBP was embraced by leaders of large healthcare delivery organizations who always are seeking virtue and a possible cover story about their virtuous selves in “Modern Healthcare” magazine. Here is a way to improve quality, they croaked

Insurance companies also eyed pay for performance as perhaps being adaptable for their  contracts with hospitals.  The insurance companies were not interested in virtue or quality; they were interested in a better bottom line.  VBP gave them good cover.

Your eyes will quickly get crossed if I go into too much more detail.  We are now eight years into VBP and the results are at best mixed.  Studies disagree as to whether VBP has resulted in an improvement in patient care however it is defined.  VBP or pay for performance so far is a disappointment to policymakers but a continued boon to Medicare bureaucrats.

It also is a bit of paradox.  VBP awards more money to hospitals for doing what they are supposed to do, at least according to the goals issued by Medicare.  You get less money if you don’t meet the mark.

Why should you get more money than standard Medicare reimbursement for simply meeting, not exceeding, a standard of care?

There can be very good reasons, particularly for outcome related goals, that a hospital misses a goal.  It may not have enough patients in a given year subject to the goal to adequately measure performance.  It may serve a demographic segment which is less compliant.  A strong case can be made that these hospitals should receive MORE not less reimbursement in light of their circumstances.

At its core,  VBP or pay for performance is not about quality.  It is yet another cost control mechanism.  That is a hard truth that the virtue seekers heading large healthcare systems refuse to acknowledge.

Modern Healthcare recently had this quote in an article about alternatives to VBP that might be more effective:

“We pay more for our healthcare in the U.S. because we pay our providers more,” said Christopher Koller, president of the Milbank Memorial Fund and a former Rhode Island health insurance commissioner. “We have to put the whole system on a diet and let them figure out how to live with it.”

Aside from being Captain Obvious, this guy deserves credit for being honest about the actual intent of the VBP. He has no future in politics.

There you have it.  It’s about money and the solution is to reduce reimbursement. Medicare already pays what it wants for care.  Just ratchet it down further.  End the pretense about it being about quality.  Watch more hospitals, particularly in rural areas, go out of business.

I cannot wait to see how this works under M4A (Medicare For All).

Excuse me as I have a date with the firing squad.

Last week the Public Policy Institute of California (PPIC) released an interesting report on “Emergency Department Use in California–Demographics, Trends, and the Impact of the ACA”.  As the report’s title suggests, a primary focus was whether the Affordable Care Act (aka “Obamacare”) increased utilization of hospital emergency services.  

PPIC’s study found that while what they called “ED outpatient visits” did significantly increase it was not due to the implementation of the ACA.  “ED outpatient visits” was defined as patients “being treated and released the same day”.  Sort of like catch and release when fishing. PPIC expressed concern about the cost of such care and whether alternative ways of dealing with patient needs should be developed.

There is nothing new about the kinds of concerns the PPIC study noted.  Emergency services seem to meet a need but that is vexing to policymakers.  Everyone knows increased emergency service use  is not a good thing, right?

I will now commit heresy.  What’s wrong with something that meets a need, a need which keeps growing?  If I was a member of the pundit religion, I would be excommunicated for that statement.   There is nothing wrong though in questioning orthodoxy.

Emergency services clearly fill a need beyond the traditional idea of saving a life. Mothers with a baby with a high temperature want the reassurance of a physician doing an assessment–even if it is midnight on a Saturday.  An older man with a bad cold and a memory of once having pneumonia wants someone to reassure him that all he needs is some chicken soup and time and he will be better–even if the cost is a hospital bill and several hours time. It goes on and on.

Consider members of the millennial generation who appear not to be particularly enamored with an on-going relationship with a primary care physician. They are young and not creaky. They have a smart phone and if a health app does not cure what ails them there is always the corner urgent care center, assuming it is open after a hard night of playing Fortnite.

Most urgent care clinics are not open late at night and have limited capabilities when they are open.  Some restrict what insurances they will accept.  Don’t believe me? Look at their websites.  The same goes for the clinics in stores.  They are at best partial solutions to a bigger need.

Then there is the difficulty in accessing your primary care physician if you are lucky enough to have one.  Most offices are overwhelmed with patients, some of whom have waited a long time just to get a physical.  When the need is urgent in your mind, you want more rapid accessibility. and the ability to just drop in.

Emergency services have everything a patient may need all in one convenient place, 7 days a week, 24 hours a day.  Yes, they are more expensive than an urgent care center.  The analogy I have used in the past is that a loaf of bread in a 7-11 convenience store is more expensive that the same loaf at a supermarket but try finding that loaf in the early hours of the morning.  Accessibility and comprehensiveness comes with a cost.

In any other field, a service which finds itself in great demand would be considered something worthwhile and worth expanding.   Instead of  devoting more resources to making the patient flow process better in emergency services, we look to alternatives which the market place is not interested in buying.

I don’t believe we should be fighting what the market wants.  Providers and pundits are wrong to do that.  Instead, let’s find a way to make emergency services more efficient and able to take care of the growing demand.  Give emergency services more room to live in and continue to increase the use of nurse practitioners and physician assistant working together with physicians specializing in emergency medicine.

At my core, I am a hospital guy.  Despite the learned but ignorant claims of academics and pundits, hospitals are not dead.  They live and if you doubt it, just go to your local emergency service. People are voting with their feet.

I know all of this is a minority opinion and counter to the punditry religion.  Consider me excommunicated.

I usually like to be a little light hearted when making observations about the state of healthcare. That separates me from the serious pundits, most of whom have never run a Boy Scout first aid clinic, much less a complicated healthcare delivery organization. I hope I am not being unfair to the Scouts. This time I am going to be serious.

In the past week two significant developments occurred which demonstrate that being a relatively small healthcare organization is not the same thing as being a chump.

The first development involved NorthBay Healthcare, the organization where I had been CEO. A few months before I retired (hit the beach as I like to refer to it)  as NorthBay Healthcare’s CEO in 2017, two large health plans cancelled their contracts and began paying NorthBay whatever they deemed appropriate for emergency care and any resultant inpatient care.

Imagine that you go into a supermarket and decide you have the ability to determine the price you will pay for an item without regard to the cost of the item.  Imagine the reaction of the supermarket. That was what those two health plans were doing while NorthBay was providing a very valuable, often life saving, service to their plan members.

One plan was Blue Shield of California and the other was Kaiser Foundation Health Plan. Neither plan to the best of my knowledge allows its customers to decide what premiums they will pay for health insurance.

This practice resulted in a significant revenue shortfall for NorthBay.  Meanwhile both plans were highly profitable and building their reserves to an amount which exceeded regulatory requirements.  It became clear that the only recourse for NorthBay was to the courts.  Both health plans were sued by NorthBay.

The Blue Shield case was decided in a San Francisco Federal Court last week. The jury decided after a very short period of deliberation in NorthBay’s favor. Blue Shield now will be required to pay NorthBay for lost revenue.

Blue Shield, in an absurd, hilarious and fanny covering press release, tried to spin the verdict as if it was the victor.  No one was buying what they were selling.  That jury’s decision should help other healthcare providers faced with similar situations.

Make no mistake, if you are a health plan and end a contract, you do not have the right to unilaterally decided what you will pay for the care provided to your beneficiaries.

Next up is the Kaiser case which involves even more revenue.  NorthBay’s main hospital is the most comprehensive medical center in Solano County and Kaiser members and the health plan have greatly benefited from its emergency services.

At another time I will explain my belief that health plans, except those owned by provider organizations, are part of the problem with the structure of health care today.

In another telling development, Oroville Hospital in Northern California successfully sold $200 million in bonds for a new wing.  Like NorthBay in 2016, Oroville found that they could have sold even more than $200 million given the demand in the marketplace.

NorthBay and Oroville are among a group of stellar independent health care organizations who jointly own a risk retention company which provides high quality risk management services.  There are ways of getting the benefits of “bigness” without sacrificing your local community to control by corporate giants and the risk retention company is just one example. You don’t need to be a mega-monster healthcare system to deliver cost-effective, high quality care.

The marketplace is belatedly recognizing that the huge organizations which are trying to dominate healthcare, whether they are health plans or corporate providers of patient care, come with excessive costs, lack of focus, ego-driven management and poor results.  And that is just for starters!

Meantime, if  you are looking for chumps, you best look at the big guys.  They are hard to miss.

Sometimes when you are on the beach you find yourself doing things you don’t particularly like because others who are important to you love doing those things. That is the reason I found myself at Disneyland last week with my older son and his family.

I am baffled by why so many people love the Magic Kingdom.  It was crowded even during a week in February when all those kids should be in school spreading their germs rather than doing it in Anaheim.

What puzzles me the most is how the presence of Disney employees  dressed in character costumes make grown people lose their sense of dignity.  Kids going bonkers over a facsimile of Mickey Mouse or Goofy I can understand. However, what is up with the adults?  I saw grown women elbowing away little kids so that they could do selfies with Chip and Dale and Pluto.  I’m a Minnie Mouse type myself.

Even more baffling is the riot that ensues every “Magic Morning”.  That is the early entry every morning for a select few a hour before the usual opening time.  The select few number well into the thousands.  You gain entry to the park after undergoing a security check and then are corralled at the end of Main Street awaiting a signal to start your strollers.  When it comes, bedlam erupts as thousands of Moms pushing strollers rush pell mell up Main Street to gain early entry to rides.  In our case, we veered to the right heading to Fantasyland to get to the Peter Pan ride.  By the time we parked our twin grandsons’ stroller in the designated parking space (yes, Disney has parking spaces for strollers), the Peter Pan line was 30 minutes long.

I have come to the conclusion that I belong to a minority born without the Disney gene.  It can be a lonely existence as you wait two hours in line to take a five-minute ride.  For those with the gene, the time flies!

Even not possessing the gene, however, I have come to appreciate the way Disney delivers a consistently great experience.  They are in many ways a model worthy of emulation.

Some years ago I heard the late Fred Lee, author of “If Disney Ran Your Hospital: 9 1/2 Things You Would Do Differently”, give a presentation.  I was so impressed that I ordered a copy of his book for every one of my organization’s managers.  Eventually I arranged for him to give a series of seminars to the managers.  I think it made a big difference in how we approached patient care and particularly patient satisfaction.

I see interesting contrasts. Both Disney and healthcare organizations charge what is considered premium prices for what they provide.  Premium is a nicer way of saying high prices.  

Disney customers don’t complain about the prices; they keep coming back.  Disney has perfected no hands pick pocketing. No dollar bill goes unspent and no credit card goes unswiped when visiting Disney’s parks. This makes people happy. Disney is awesome!

Patients do complain about prices, even when the care is excellent.  A life can be saved and three weeks later you get a complaint about the bill. There is a disconnect in health care from the value proposition.  Patients don’t seem to think their experience was worth the cost.

Then there is the crowd factor. As I indicated previously, Disney fans don’t seem to be bothered by long lines and crowds. That is not the case in health care where long waits are deemed unacceptable.

A final contrast is the focus on making the experience better.  I was getting emails from Disney throughout my stay asking about my family’s experience about various aspects of our visit.  They knew which restaurants we ate at and what rides we took and they wanted to know that day how it had gone.

Healthcare organizations are also concerned about the experience of those we serve. We just don’t do a very good job in monitoring on a contemporaneous  basis that experience so that we can make adjustments as needed.

I understand that running theme parks is a different business than providing health care.  There is though much we can continue to learn from organizations like Disney which meet a different set of needs than we do in health care.

There is yet another gene which Disney has and many other organizations in health care and in other fields appear either to lack or have not activated. That gene has nothing to do with tolerance for large crowds or adults acting like kids. That second Disney gene is about a consistent commitment to doing things better.

I know we all try to do things better but our patients often don’t agree with the results. Time for some genetic engineering.

“Medicare for All” has materialized again from the mists as Democrats begin maneuvering  to become the party’s 2020 presidential candidate.  It is easy to find out who is a Democrat–they are the motley crew running to become President.  If they are a motley crew running from the President , they are Republicans. Generally, motley crews are politicians running to or from something.

When I first made some observations about Medicare for All a few months ago, I actually took the proponents at face value.  I wrote how expensive Medicare actually is with its various premiums, the payment of which is necessary if you want reasonably full coverage.

One respected observer took me to task by replying that the slogan was really aimed at a comprehensive approach for coverage for all.  He was, it turns out, right in one sense and wrong in another.

It is now clear, based upon all the Democrats who plan on being elected President, that Medicare for All means a single payor system for healthcare, i.e., the Feds.  These would be the same folks who have made a mess out of both Medicare and Medicaid.

Several polls indicate that there is support for Medicare for All but the supporters do not want to pay for it.  They want something for nothing.  So do I but that is a path to economic ruin.  Support evaporates if taxes have to be increased.

Support further decreases if people are told that they can no longer have private insurance in a single payor system.  Medicare beneficiaries worry that their coverage, for which they spent their working life being taxed, will be adversely affected.

Most people have health insurance.  It comes from their employer, from Obamacare state exchanges for working individuals not covered by their employer, Medicare and Medicaid (MediCal to Californians).  Obamacare has problems and the price is yet to be fully paid for it but one very positive thing it did accomplish was to encourage the growth of Medicaid.  Medicaid expansion accounts for most of the newly insured folks.

According to the Kaiser Family Foundation, about 27 million people had no health insurance in 2017, the latest year where there is available data.  The nation’s population in 2017 was 326 million.  Is it really necessary to upend the current system in order to deal with the less than 10% who have no coverage?

For politicians of all stripes. the easiest thing to do is to propose solutions before adequately defining the problem to be addressed.  That gets headlines.

It would be far better to spend more time defining the problem and then look for solutions which are not rooted in ideology but offer a practical approach to solving a problem.  Right now, everyone is backed up, if I may so, to a wall and not interested in solving a solvable health care problem.

As long as the motley crews feel health care coverage is worth more as a campaign issue, the 27 million will go wanting.

Because I no longer have an official relationship with NorthBay Healthcare, I try to limit my comments about that organization in this space.  Rather than looking back, I prefer to look ahead.  I’m the Healthcare Outsider now.

Nevertheless, I had a reason to go to NorthBay’s website recently to do some personal health related business.  The NorthBay site (www.northbay.org) has been redesigned.  I find the new look very attractive.

I also discovered that a selection of some of the blog articles I wrote when I was CEO (aka the “Healthcare Insider”) are still available on the site. That’s a mixed blessing as I always worry that I might contradict myself from one blog to another.  My past could come back to haunt me.

One of my more or less persistent themes in those blog articles had to do with the inconsistency of various systems used to rate hospitals, particularly those ratings involving patient care.  Almost all these rating systems rely on a data base developed by the agency overseeing the Medicare program.

As I pointed out in several blog entries, it was very possible to be highly rated by one entity for a given condition and lower rated for the same condition by another entity.  It all depended on how the data was sliced and diced, when it was manipulated and sometime what I believed to be inherent bias of some rating organizations.

Most distressing I am sure to some of the rating organizations was the fact that there was little evidence that anyone used the results to make decisions about where to go for treatment.  Given the inconsistencies, the public was showing good sense.

Now it is emerging that one of the seminal rating systems focusing on quality measures is finally being confronted about its methodology.  That would be the so-called Yale New Haven Study which examined among other things readmission rates.  I am not a clinician or an academic but I did write several times in my old blog  about common sense concerns I had about some of the conclusions reached about readmission rates in that study.

Those conclusions were important because hospitals were judged by them and Medicare reimbursement could be affected.  This was the start of the so-called “value-based purchasing program” which Medicare was trying to roll out in an attempt to improve patient care and save money, mostly the latter.

Could it be possible that value-based purchasing (i.e., what Medicare will pay for care) is based on incorrect conclusions. Yes, indeed!

There is also now emerging concerns about whom the Feds are giving grants for further research into measuring quality care and the criteria being used for selection. Some observers say the same folks who did the initial research for Medicare are getting most of the funding and that poses a potential conflict of interest.

So far my past musings on this issue are not haunting me and for that I am glad,  I am concerned, though, that so many important decisions may have been made on a study which was not further substantiated.

The jury is still out about this type of research but if other more neutral researchers continue to find flaws with the conclusions of the Yale study, value-based purchasing maybe should be called “value-less based purchasing”.

This past weekend I attended a memorial service for Art DeNio, NorthBay Healthcare’s Chief Financial Officer, who passed away unexpectedly last month.  Art had been NorthBay’s Chief Financial Officer since 2001.  His financial prowess made possible great progress as NorthBay brought advanced medicine to its service area.  He was the best chief financial officer that I worked with during my career.

As a mark of the respect which Art had earned from the financial world, his memorial service was well attended by representatives of investment banking firms and institutional financial consultants.

Before and after the service I had an opportunity to speak to some of those representatives and what they had to say about what they were seeing in health care was interesting.

In the last few years there was a boom in financing hospital and outpatient construction projects. This was a result of delayed projects stemming from the 2008 financial crisis and extraordinarily low-interest rates which increased the ability of health care organizations to finance needed replacement and expansion projects.

This was particularly true in the non-profit segment of health care.  NorthBay Healthcare was able to issue $200 million in bonds in 2016 to finance a new patient care wing at NorthBay Medical Center which will open later this year.

Now, I was told, financing that kind of construction was at a low ebb since so many projects had been financed prior to 2018.  Instead what was happening according to one of the financial experts I spoke to was financing “activities for the sake of activities”.

That was another way of saying financing mergers and consolidations in the non-profit sector.  These kinds of organizational marriages may require a restructuring of existing debt and that is where investment bankers and others are currently making their money.

Implicit in “activities for the sake of activities” is that there is no positive net effect on the organizations involved.  To use a well-worn cliché, the deck chairs are simply being rearranged.  One expert was particularly adamant about that.

Which gets back to what I wrote about last week in “It’s The Money”.  Bigness takes on a life of its own without regard to whether anything positive is being achieved.  It almost seems like an ego driven activity.  Look Ma!  I’m merging.

To repeat myself from last week, what’s the point of this activity if patient care is not enhanced and costs reduced?   Despite all the merger and consolidation activity among hospitals and health systems, no one is writing in the New York Times or the Wall Street Journal about improved patient outcomes and less expensive care.  Lots of people are still making a living criticizing the performance of health care organizations on both metrics.

When you see this kind of aimless merger and consolidation activity I believe you are seeing an abject failure of effective governance.  When you look at the boards of a locally controlled health care organizations, you are more likely to see the regional manager of a company or a physician who practices in the community.  These are people who are closer to the marketplace and who see the consequences of their decisions.  They actually care.

When you look at the merging monsters, you are likely to see a highly placed senior manager of a national corporation or a physician who has not practiced clinical medicine for many years.  They are at a far distance from the marketplace.  That brings a different perspective, one which I contend leads to decision-making detrimental to health care delivery.  These board members who live in a rarefied world do not have to live with the consequences of their decisions.  It is just another gig.

If I am wrong, show me where patient care and outcomes have been positively affected by the constant churning of merger activity in health care.   And as for cost effectiveness being a by-product of mergers and consolidations, show me the money.

I’m waiting.

This time of the year is when various health care publications get around to looking at the past year’s events as well as making predictions for the new year.  They tap into pundits who usually have an agenda for many of their predictions, thus providing a  satisfyingly closed echo chamber.

So sitting on the beach I will weigh in with a comment or two about several developments of note for the new year.  I am fully aware that observing from the beach is easy which makes me an amateur pundit of sorts which does not please me.

Of special interest to me in the past year has been the progress of the merger of Dignity Health and Catholic Health Initiatives (CHI) to form a mega-monster health system consisting of 140 hospitals and assorted other endeavors.  The new entity will be called CommonSpirit Health which sounds like the expensive result of working with a branding consultant.  I don’t recall a St. CommonSpirit from my Catholic background so my guess is this is a further attempt to distance the new organization from its Catholic roots as has been the case with Dignity Health in recent years.

It is always difficult to merge two organizations, especially when neither one has been especially stellar financially.  CHI, in particular, has been hemorrhaging red ink for several years, no doubt the result of having achieved operating efficiencies from previous mergers of smaller Catholic health systems.  The expectation is that  by merging with Dignity Health, these financial problems will disappear.  Bigness overcomes such problems according to the financial analysts. How could they be wrong?

CommonSpirit Health, showing great courage and decision-making boldness, will be managed by co-CEOs, i.e., the former CEOs Of CHI and Dignity.  That is a surefire formula for success–for about two months.

My prediction–experience shows that even  with the good intentions of the co-CEOs, there will be within a year just one CEO tasked with managing and making sense of an ungainly and financially challenged organization.

The other big merger of note which will begin operating in earnest in 2019 involves CVS Health and Aetna.  This seems to be an unnatural combination, akin to breeding a goat with a skunk.

CVS Health is, of course, best known for its ubiquitous drug stores on every corner where there used to be a gas station.  They are very easy to find.  All you need to do is look for a Walgreen’s and sure enough there will be a CVS across the street.

CVS’ other business is acting as a pharmacy benefit manager which is where, I suppose, the synergies will come with the merger with Aetna whose health plans have been also-rans in most markets.  Still,, this combination really seems a reach and like a good way to lose a great deal of money.

There is no shortage of other health care related endeavors thrashing around in this new year.  It is telling that no one mentions a goal of improving patient care in any of these machinations.

Bottom line though is the bottom line.  All this activity is less about health care than it is about the money. What a waste.

My 97-year-old father passed away last week after a four-day hospital stay  That is a  matter of private sorrow.  However, that experience renewed feelings I have about a particular aspect of modern health care and they are feelings of anger.

I want to make clear upfront that there were no medical errors involved with the care my father  received.  In fact, the care and attention provided by his physicians, nurses and others was exemplary to my critical but knowledgable eyes.  That included an environmental services aide who while cleaning my father’s room noted how sick he had become and took it upon himself to lobby successfully for a private room for my father.

His caregivers, though, were needlessly handicapped by lack of access to important information which might have changed their treatment plan.

My father was still living independently when he died.  He was hospitalized because some lab values alarmed his new cardiologist.  As I was to discover a day later, those values were normal for him and his recently retired primary care doctor had been monitoring them for years.  I discovered that fact by going to the patient portal used by the health care system to which his primary care physician belonged.

The cause of death was something that could have easily occurred at home, something we had become concerned enough about that we had scheduled a meeting of his children prior to the hospitalization to discuss living arrangement options for him.

The hospital was unique in that it had as attending medical staff its  own medical group as well as  medical groups affiliated with two other large health care systems.  The other health care systems did not have their own hospitals nearby and used the local hospital to care for their patients.

The problem was the electronic medical record (EMR) used by my father’s medical group was not accessible to the hospital’s staff.  At least two of the medical groups used the same vendor for their EMR but even then there was no sharing of information.  This lack of what the IT types call “interoperability” continues to be a flaw in the roll-out of EMRs.  It is dangerous and inexcusable.

An example:  early in my father’s hospitalization, a hospital pharmacist came to the room and asked what meds my father used at home.  I had access to his electronic medical record and showed her the list. Why could she not access that list?  The answer has to do with the siloing of medical records to the benefit of everyone but the patient.

Another example:  as I indicate above, I was able to determine by accessing my father’s medical record that his “normal” lab values were abnormal for most people.  The admitting doctor at the hospital had no way to see that valuable piece of information and the result was more testing.

When I was still a health care system CEO I used to go every other year to the headquarters of the EMR vendor we used.  On each visit I raised hell about this issue of information silos.  The last visit I made before I retired I raised enough of a ruckus that the President of the company joined us at lunch to discuss what his company was doing to make the information more easily accessible.  His promises sounded good but to my knowledge nothing has changed.

My father did not die because of this problem but I believe many people have.  There are task forces looking at the issue but they seem to move at a glacier pace.  There is plenty of resistance below the surface to the idea of interoperability.  The information collected from EMRs has value and it seems to me everyone is benefiting except the patient who is the rightful owner of the information.

Access to a patient’s medical information is crucial when that patient shows up at a hospital emergency service needing life-saving care.  Which medical group he uses and which EMR they use should not be a factor in allowing access to information which could be valuable in treatment.

It is not the EMR vendors’ information. It is not the insurance companies’ information.  It is not even the medical group’s or hospital’s information. It belongs to the patient and it is time it has been freed.  When does this revolution begin?

Free the EMR!

A recent article in the San Francisco Chronicle by John Gerzema, co-CEO of the Harris Poll, caught my eye.  In it he refers to research that seems to indicate that larger organizations are less trusted and esteemed by the people they serve.  He put it this way:

“To sum up, the bigger you are, the less trusted you are, and companies that have the best reputations are small, or they have found a way to connect more personally—or  ‘act small.'”

He was referring to private enterprises and not health care organizations per se. Nevertheless, I believe his observation has applicability to the health care scene.

There has been a great emphasis in health care in getting bigger.  All the pundits say it is a great idea and we know the pundits are never wrong.  Misinformed sometimes but never wrong as they are consultants and wise people.

Actually I think they are both misinformed and wrong.

Here in California, we have mega-monster health care systems like Kaiser, Sutter and Dignity.  In bowing to the god (or goddess–take your pick) of bigness, they homogenize and centralize and in the process lose differentiation.  They become big blobs.

I became familiar during my years at NorthBay Healthcare with many locally based health care systems.  They fly under the pundits’ radar but they have much more local presence than the mega-monsters. They have to do well locally if they are going to do good at all.

They sponsor Little League and Bobby Sox teams.  They participate in “Fun Runs” and local fund rasing events.  They sponsor public schools serving children of less economically advantaged parents.  Their employees proudly wear their logos and colors. They do all of this without having to check in with Oakland or Sacramento or San Francisco or whereever the lords of the mega-monsters live.

They don’t have pension funding problems.  Unlike the mega-monsters which sometime seem to be wildly merging two financially challenged health care systems in the hope that magically the deficits will disappear, the small guys are financially stable and much quicker to react when financial problems do occur.

Perhaps even more importantly, the smaller guys tailor their services for the needs of their local community rather than the needs of a spoke and hub health care system.  The spread of technology is making providing locally based advanced services easier.  All those specialists being trained by the academic medical centers do need some place to land.

When you are rooted in a community, you make different decisions in a different way.  You have no place to hide and no one in a far away place to blame if things go awry.

The mega-monster health care systems have a lot to learn from the small guys. Small is the new big—-and trusted.