The Meatball Sandwich Syndrome

It started with a take-out meatball sandwich for dinner. It continued several hours later with a trip to the emergency service with what I was certain was a bad case of heartburn but the pressure on my chest raised concern about a possible serious cardiac problem.

Before I hit the beach, I had heard many cautionary stories from physicians and nurses about not taking any chances when you have chest discomfort. I summoned my inner wuss and asked my wife to drive me to the hospital.

I have been through this clinical protocol before so I knew I would be in the emergency service for at least six hours as various tests were done and repeated. When the final tests were completed, I was told that my results were “perfect”. I asked my wife whether she heard what the doctor had said—I was perfect! Knowing better, she just rolled her eyes. Some support system she is!

This was the first emergency service visit for me since I hit the beach. I have recently accompanied other family members on emergency visits at three other hospitals. There are common threads to all the visits. The staff–doctors, nurses, aides and others–work often under stressful conditions yet in all cases made the patient feel like he or she was the most important person present. These front line staff can make or break a patient’s experience.

Another common thread which I had more time to observe on my visit was the incredible additional demands which are put on emergency service staff. I noticed on my visit that there were several people sleeping on beds in an alcove. They were homeless people who knew that if they presented themselves at a hospital they would have to be evaluated and monitored. That’s the California way. The next morning if they had not left, they were entitled to a social worker visit. Most left.

Hospital emergency services have become the refuge of last resort for the homeless due to feckless politicians requiring hospitals to become a provider of social services as well as medical services. This is yet another unfunded mandate foisted on hospitals.

Homeless people need help, to the extent they desire such assistance, but a busy hospital emergency service is not the place to provide it. It is, though, a place where elected leaders can dump their responsibility for a more comprehensive solution. They are good at that.

Elected leaders would not think of having cots set up at a local fire station or, even better, at the state capitol building. Too messy and far too visible. Better to dump the homeless elsewhere where they are out of sight and out of mind. That way the politicians can work on restoring power to the state.

Hospitals and other healthcare providers are the victims of mission creep mandated by irresponsible elected leaders. Mission creep without conscious purpose can be deadly to any organization. This mandated mission creep comes with a cost that other patients and their health plans have to cover. This cost adds to the total cost of health care in a significant way. It is a different kind of “perfect”–a perfect example of how difficult it will be to reduce the growth rate of health care costs.

Perhaps my meatball sandwich made me too dyspeptic about things. As I write this though, we are once again under the threat of losing power. It is enough to make me want to make another trip to the emergency service to, like the homeless, seek respite. Call it the meatball sandwich syndrome.

Good Thing Hospitals Are Not Power Companies

The great power shutoff here in Northern California is over—for now. PG&E recently instituted a series of rolling power shutoffs, some lasting for days. There were stories of people who live pay check to pay check having their week’s groceries spoiled and people dependent on power to maintain their health suffering.

The announced reason was to prevent the kind of catastrophic wild fires which destroyed or greatly damaged several cities last year. The root cause of those fires was incompetent, shortsighted top management and governance with a dose of political interference thrown in. Unfortunately, PG&E’s front line employees bore the brunt of the public’s outrage as they went about checking power lines and other equipment. They were a convenient target for the sins of management.

When power was finally restored to everyone and the smoke had cleared (pun not intended), PG&E top management began a public relations campaign to explain their incompetence. Full page newspaper ads ran for days and they continue to do so as I write this entry.

One ad proudly proclaimed “When faced with dangerous weather, WE CHOOSE SAFETY”. It explained why it was necessary to inspect power lines in times of threatening weather. It expressed its gratitude to its customers and field crews “who showed great resilience in a difficult time.” As if they had a choice. Nowhere was an acknowledgement of management culpability from years of deferred maintenance and the expenditure of funds on other endeavors that should have been spent on the power lines.

The most recent ad addressed “TO OUR VALUED PG&E CUSTOMERS: The Recent Public Safety Power Shutoff by the Numbers.” We were supposed to be impressed by the fact that the company was doing what it should always be doing–providing power in a safe manner. Except it was providing no power in a safe way. That sounds like it should be the company’s new mission statement— we exist to provide no power in a safe way.

Now, PG&E’s new CEO (poor guy must have really needed the job) is insisting that we can expect periodic power shutoffs for the next ten years. What other company can say it will provide poor service for a prolonged period of time to its valued customers? I would prefer having electricity and not being valued at all.

As all this was occurring, I was thinking about healthcare care providers and specifically hospitals where errors are an issue and safety an overriding concern. Hospitals cannot just shut down for a prolong period of time and ignore the needs of the patients they serve. When a problem of patient care or safety occurs, the root cause needs to be rapidly determined and a solution devised and implemented immediately. You cannot wait ten years.

If a hospital told the public that it would intermittently be closing for safety reasons, it would be reasonable to ask why that facility in its current form is allowed to continue to operate at all. Safety is an expectation in healthcare, not a voluntary condition which only matters after great damage has occurred. Good management and effective governance in hospitals should never allow conditions to deteriorate to such an extent that continued operation means someone will be hurt.

One of the strengths of healthcare and again especially hospitals is that we have professionals (physicians, nurses, therapists and others) who think first of patient needs and who do not hesitate to voice their concerns. They may not always be right but their voices are heard and in effective organizations their concerns seriously considered.

We acknowledge errors and safety concerns in healthcare. We have a long way to go to achieve zero errors but at least we don’t have to run newspaper ads gratuitously patting ourselves on the back for not causing damage by not providing services.

PG&E and similarly situated power companies could learn a great deal about management, governance and accountability by looking at healthcare.

We Don’t Trust Doctors…..Enough

One thing I have noticed since I have been on the beach is that we don’t trust doctors. I reluctantly have come to that conclusion based upon the experiences I have in helping family members as well as myself navigate our healthcare system.

You would think I would have realized that fact a long time ago but things look differently when you are caught up in the day-to-day work of healthcare. You sometimes see the needs of everyone but the patient.

We (whoever “we” is) have constructed an obstacle course which doctors must traverse in order that their professional opinion meets their patients’ needs. Patients must wait for prior authorizations to be granted by health plans and other entities before a doctor’s advice can be followed. There is a whole bureaucracy both within and without the organization devoted to second guessing the patient’s doctor.

My experience is that most requests for prior authorization are granted and those that are not are usually approved after further consideration. What a waste of time and money.

The justification for this process of second guessing has both clinical and financial components. There is concern that needless tests or procedures may lead to clinically dubious results. Too many false positives lead to potentially harmful interventions.

While I recognize the clinical argument for oversight of doctors’ decisions, the cynic in me thinks the bigger motivation for not trusting doctors is the financial component. A test not done is a test not billed. Think of the money saved if each doctor has one MRI order a month denied. Anyone who thinks the clinical argument is the real reason for second guessing physicians’ decisions is displaying a naivety that needs a review in itself.

The problem with this lack of trust in decision making by doctors is that it carries its own risk of leading to poor clinical results and also creates an expensive structure devoted to second guessing. Back when I was in the office and not on the beach, I watched in dismay as we built a staff to manage the interface between doctors, patients and health plans. This expense became significant.

I used to joke that it might make more sense just to take the risk that one or two doctors might order tests excessively in order to avoid the expense of overseeing the decisions of all the rest of our medical group. Now I am not so sure that is a joke.

It may be time for us to begin trusting our doctors again. If there are outlier doctors in terms of inappropriate use of resources, it would be better to deal with them after the fact. It might mean those doctors and their decisions would be subject for a period of time to oversight while the remaining medical group members would be able to use their professional judgment without second guessing. Why punish all doctors and their patients for the sins of a relatively few?

We have the means now through the electronic medical record to gather relevant data and look for the outliers. The money saved could be substantial if we once again began trusting our doctors enough and reducing the nanny bureaucracy. Patient and physician satisfaction would certainly increase and one needless layer of cost would be gone.

Open Season

Where I live you can hear gun fire in the far distance hills at this time of the year. The first time I heard it was years ago when we first moved in. I was told it was open season.

Open what I asked? Open season was again the reply. Hunters were after quail and this was the time of the year when it was permissible. Elsewhere, deer and boars are the targets.

I came to conflate open season with open enrollment for health plans. When you think about it, hunters looking for quail are not a whole lot different than health plans looking for customers. There is only one time of the year when they are easily bagged.

For me, this is the time of the year when I get mail from Medicare Advantage plans seeking to lure me from traditional Medicare Part A and B. They make promises about extra goodies and lower premiums. I prefer to have more control over my healthcare including having a voice in whom my doctor is and what hospital I can utilize. Still, every year it seems the Medicare Advantage health plan hunters bag more prey. Seniors living on a fixed income have to make economic decisions.

For many employees of private enterprises this time of the year also provides an opportunity to make changes in health plans. That decision is often based at least in part by how much will be taken out of the person’s paycheck as a partial contribution to the premium paid by the employer.

A similar dynamic occurs for public employees who often have more health plans to choose from than is typically the case for private sector employees. The public employer will pay only a certain amount for health plan coverage. If a health plan’s premium is greater than that amount, the public employee pays the difference.

In a rational world where employees have an incentive to make decisions based upon economics, this annual dance of health plans should lead to those plans having lower premiums gaining more customers. That is what is happening with Medicare Advantage plans with their lower premiums and extra goodies.

It is not happening, though, for many private employers and most public employers. The reason is that employers don’t like confronting their employees with this kind of economic decision. Often, a floor for what the employer will pay is established based upon union agreements and/or political pressure. I saw this dynamic when I sat on a nonprofit provider owned health plan board which often had the lowest premiums but could not gain as many new members as it should have.

In California, Kaiser has a large marketshare. The inertial you must overcome for an employee to switch his health plan away from Kaiser is immense. I used to joke that Kaiser was like a cult and once an employee was captured that was it. In all fairness, a part of that “stickiness” was due to Kaiser effectively meeting its members’ needs, albeit at a higher premium than other plans.

It helps Kaiser,though, when an employer, particularly public employers, establish the Kaiser premium as what it will pay. Health plans which offer equivalent coverage for a lesser premium don’t gain new members in that scenario. Employees have no financial incentive to change their health plan. And so it goes and has for years in California.

I was recently asked in response to another blog entry what I would do to make health care more affordable. The first thing I would do is to make sure employees have real financial incentives when making health plan choices during open enrollment. I believe you would see health plans begin competing more robustly for members if they felt that lowering premiums would bring in more business. That does not happen now and until it does it will be open season for ever rising premiums.

The Right Answer

A few years before I hit the beach, my wife and I made our first trip to Great Britain. When we were in London and unsure of how to navigate the many historic sites, we did what many tourists did—we took the hop on, hop off bus to get to places. While that was not the most efficient way to get to a given site, we knew sooner or later the bus would reach our desired destination. Sometimes that meant a ninety minute ride to get to a place which was only five miles or so from our hotel.

By our third day, we were getting brave so we decided to try one of the famous black cabs of London. They were expensive as compared to a one day hop on, hop off pass but time is money too. We hailed a cab and with a $8o fare we arrived thirty minutes later at the Tower of London which was actually a combined fortress, royal palace and prison. Centuries ago unfortunates received a haircut of a non-financial sort there. Just a little off the top. Permanently.

That steep $80 dollar cab fare was, though, instructive in another way. The cab driver seemed very sad and I asked him if he was OK. He said that he would not normally be driving that day but his adult daughter had just died from breast cancer and he needed to raise money for her funeral. I felt awful for him.

The cabbie said that at least the family did not have to worry about her medical bills since she had been a patient of the national health service. I asked him how he viewed that health care provider for most citizens and he said it was satisfactory. Most people knew it was not “posh” as he put it, but what it had in long wait times and lack of amenties was more than made up by removing financial worries when one got sick. Still, he recognized that more citizens with means were availing themselves of a private healthcare system which has developed in order to avoid the inconveniences of the public service.

Later on that vacation, we found ourselves on a walking tour of the sites of Glasgow in Scotland. We came upon a particularly large, old and ugly building which our guide said was the Glasgow Royal Infirmary where Dr. Joseph Lister first promoted the idea of techniques to insure sterile surgery. It was located uncomfortably within easy walking distance of the famous Glasgow Necropolis, final resting place of posh Scottish Victorians who may not have had the advantages of sterile surgery.

Glasgow Royal Infirmary

I asked our Scottish guide what he thought about the public National Health Service. Being Scottish and therefore obstinate, he quickly pointed out that the public Scottish Health Service was somewhat different and definitely better than the English version. He too acknowledged that there were deficiencies in the public service but that was more than made up by not having to worry about the financial aspects of being ill. He also liked haggis, a Scottish dish primarily made of lamb entrails, so his judgement may need to be discounted.

I thought about the cabbie and the haggis loving guide as the Democratic candidates for President have been discussing their various health care schemes. In Great Britain, polls both formal and in my case very informal indicate that the public likes the National Health Service, warts and all. So at most, politicians nibble around the edges. No one wants to disrupt that service.

Here in the the United States polls consistently show that while citizens would like to see health care be more affordable, they do not want to lose their private health plans. Yet many of the Democratic candidates seemed to want to replace the private plans with a public scheme, contrary to voters’ desires.

How do you make health care more affordable without replacing existing private health plans? That is a question someone needs to ask. The right answer might make someone President.

A Toast To The Unsung

Last week marked an end and a beginning for me. That sounds more dramatic, perhaps, than the occasion merits but sometimes you have to let your inner drama king out to breathe.

NorthBay Healthcare hosted a special night for supporters to have a preview showing of its new $200 million wing at NorthBay Medical Center which will open for patients next month. This was the last project for which I can claim some responsibility as we began planning it in 2014 and when I retired in 2017 the financing had been secured and the steel was going up.

It’s a beautiful high tech facility full of the latest technological innovations. When we were designing it, we did not want to make compromises which might affect the care we would be delivering. Mission accomplished.

I was recognized at the beginning of the event by my successor who had to ride herd over much of the construction process and now will have to integrate it into the ongoing expenses of the organization. He is more than up to that task.

I felt both sad and also strangely liberated as I contemplated the building. Going forward, whatever happens at NorthBay will not bear any traces of me. Ego aside, a connection is being broken. Time for me to move on.

A special recognition and the focus of the evening was a bequest made to the building by a couple who have long supported NorthBay and other community endeavors. They are unassuming and do not seek recognition for their efforts. Nevertheless, their bequest of $5 million was the largest single gift the organization has ever received and recognition needed to be given.

As the ceremony finished and people began to take tours of the building, it occurred to me that others had an important role in making that building happen. Two NorthBay boards had to give approval for the financing and construction. Their trust in and support of management was not acknowledged. I did so later that evening in notes I wrote to each of them. Board members seldom get recognition for the tremendous burdens they carry.

There were three people who were instrumental to the project but were also not recognized that evening. NorthBay’s CFO who passed away unexpectedly last December built relations over a long period of time with financing entities. Their trust in him led to more buyers for NorthBay’s bonds than we had to sell. Thank you, Art.

Similarly, the Vice President and Assistant Vice President responsible for facility development brought the project in on time and under budget. They had to deal with the rest of us, our ideas, complaints and often uninformed opinions. They deserved recognition of the highest sort. I wrote them notes as well.

Which brings me to the real point of this entry. Positive recognition is so important to the people who make up an organization. It seldom is provided in sufficient quanity and yet it is always welcomed by its recipients.

We had at NorthBay an annual employee recognition dinner for employees who attain certain levels of tenure. We would have slide shows about each of them for dinner attendees to see. Then the employee would be asked to come to the front of the room to receive their award from me and have a photo taken with the board chair. Their families would be present to watch.

I often would get hugged by the recognized employee, no doubt breaking several federal and state employment laws in the process. I would always whisper to every award winner my personal appreciation for their dedication. Those moments were special, an opportunity for me to give a toast to the unsung. For that moment, they were the most important person in the room and their families could see that.

To my mind, you can never give enough recognition to the people who make an organization successful. That’s particularly true in healthcare where teamwork is necessary. Perceptive physicians and nurses know that their efforts would be for nought without the many other staff members toiling in the background.

So to me, that new wing at NorthBay Medical Center merits a toast to the unsung thousands of staff members who made it possible. Here’s to all of you!

Being Beloved

According to the story in Modern Healthcare, Blue Shield of California has formed a new company called “Altais”, the spelling of which my spellcheck keeps trying to change. Perhaps that is because it sounds like a terrible disease, as in “I have a bad case of Altais.”

Or maybe Blue Shield sees treating bad breath as a natural extension of being a health plan and Altais will be competing against Altoids. I know dealing with Blue Shield always left a bad taste in my mouth. Anything is possible when your spellcheck runs amuck.

In fact, Altais is Blue Shield’s latest attempt to stay relevant in a changing healthcare environment. Altais will offer management services to the ever decreasing number of physicians in California who have not joined with hospitals to form clinically and economically integrated healthcare delivery systems. The fox is trying to get into the hen house by pretending to be a good guy. Not going to work. The chickens have been to medical school and they are too smart to fall for that ploy.

Blue Shield of California is not the only health plan trying to escape being a commodity. United Healthcare is among the health plans now actually trying to acquire physician practices in a forlorn attempt to avoid not being relevant. That will be an expensive mistake when they learn that physician practices don’t behave the same way a spreadsheet full of actuarial statistics does. It’s the hubris of the ignorant.

It is not fun being in a boring business and that is what the health plan business is. Stand alone health plans (as opposed to hospital and physician owned health plans) really cannot be easily distinguished from one another. The role of any kind of insurance is to manage and hedge risk. Risk management is not the same thing as delivering a service or product. You don’t see auto insurance companies building cars.

Real people—not the “lives” as health plans refer to their members—do not particularly care what health plan they have as long as they have access to their preferred physicians and hospitals. After all, no one goes to Blue Shield’s or United Healthcare’s headquarters with an illness on a Sunday night. Or for that matter, try calling their customer service department for a phone consult.

It is not just health plans who envy the central role of physicians and hospitals in healthcare. The same week the Modern Healthcare article appeared, the New York Times published an op-ed by one of its former writers who bemoaned the fact that hospitals are “beloved”. Being “beloved” is apparently a bad thing in some quarters.

From her point of view, hospitals should be lumped with health plans and pharmaceutical companies as villains. Pundits love finding villains. It’s a living. This was also one of the points of a book she wrote a few years ago which after a brief period of hype disappeared from view. Her present frustration no doubt stems from that experience and perhaps from not being beloved.

Those darn hospitals and doctors really get in the way of the schemers who know better. The public just does not know how bad they are. Here is a message to the schemers of all types: the public does know who, when they have a healthcare need, they can rely upon.

Health plans are trying to weasel their way into physician practices in order to escape being a commodity. Pundits like the one who wrote the op-ed also know the sting of not being relevant. The fact that hospitals and physicians are the target of such actors is a compliment to how relevant healthcare providers are to the public.

Not being relevant is no fun. Being beloved is nice, though, and it is earned as a result of meeting real needs of real people.