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Illusions on Duxbury Beach
Remember the old science fiction movies, where they took a 2-inch lizard or tarantula and superimposed it into the scene of frightened people and cities being crushed? You just knew that Godzilla really was forty feet tall!
Check out this tree-like structure from today's walk on Duxbury Beach, south of Boston. In another setting, you might be persuaded that the photo above is of a large tree knocked over by a storm. But, no, it is just an interestingly shaped sponge, and, as you see here, merely a few inches tall.
Meanwhile, watch the video below. It is a little unclear, but if you watch closely, you will see a flock of birds just to the right of the SUV, turning and swooping as a group. As they do so, they show us bottom, side, and top views; and they go from nearly invisible to dark to shimmering white. (Stick with me here. You may have to watch it 2 or 3 times to see the birds.)
If you cannot see the video, click here.
Before the Earthquake
With all the coverage of recent relief in Haiti, we sometimes forget that US caregivers often went before the earthquake and gave their time, energy and money for medical services for children there. Ruth Adomunes and Marianne Mcauliffe are exceptional PACU nurses here at BIDMC. This is a YouTube video with moving images of the work they have done through the Haitian Health Foundation.
The Year of the Tiger
The BIDMC Employee Involvement Committee decided that we should have a Lunar New Year celebration in honor of the Year of the Tiger. Our staff came together for a great event, featuring Lion Dances and Ethereal Dancers from the Massachusetts Vietnamese Scouts Association, and Chinese dulcimer players and dancers from Boston's Kwong Kow Chinese School. You've seen and heard the older dulcimer players before, but here is a video of some younger ones and the other performers.
If you cannot see the video, click here.
Here’s what’s happening in the Bay State
As the federal government and the various states consider what to do about health care costs, Massachusetts is proceeding along its own path. I thought my readers would be interested in a summary of those events.
Following the creation of the Massachusetts universal health care legislation in 2006, the state expanded its focus from providing access to the issues of quality and cost. The Legislature passed Chapter 305 of the Acts of 2008 in August of that year. A provision of that law requires the Division of Health Care Finance & Policy, in collaboration with the Attorney General’s Office, to hold annual public hearings concerning health care provider and insurer costs trends.
In preparation for those hearings, the Division prepared three preliminary reports, found here, on health insurance trends and the structure of the industry. Also, the Attorney General issued her own report on related topics.
In its letter of invitation to the hearing, the Division has set forth its agenda:
"The Division seeks to understand to what extent - if any - your organization’s experience varies from the agency’s findings, to solicit additional information that explains the premium and cost increases, to gather your perspective on the dynamics driving the trends observed, and to obtain your recommendations for short and long term solutions to such dynamics."
"With your assistance and active participation, the Division seeks to develop tangible policy recommendations to mitigate health care cost growth and to develop an integrated health care delivery system in a final report to the Legislature. "
I thought you would find it interesting to read some of the questions that hospitals have been asked to answer in advance of the hearing.
After reviewing the preliminary reports located at www.mass.gov/dhcfp/costtrends please provide commentary on any data, or finding that differs from your organization’s experience and the potential reasons therefore.
Do you see trends in your revenues, from 2006 to 2008 or more recently, that differ materially from these aggregate trends with respect to:
--The rate of change in outpatient facility prices and faster revenue growth compared with inpatient revenues;
--The growth of revenues for outpatient imaging services;
--Price changes versus other sources of growth in revenues, for inpatient and outpatient services.
What are the one or two most important underlying causes of your experience, as described above? Provide any information you have that will support your assertions.
What accounts for the growth in inpatient facility prices? What accounts for the growth of hospital outpatient facility price per service?
What accounts for the growth in utilization of outpatient hospital facility services? Do you foresee the same factors continuing to drive the growth in total facility revenues in future years?
How does your relative market position or market share affect your cost or revenue trends?
The concentration of teaching hospitals in Boston means that tertiary hospitals effectively serve as the “community hospital” for many patients. If your hospital is located in Boston, what reasonable solutions could your organization develop to provide routine care in less expensive – but appropriate - settings? If your hospital competes for patients with a teaching hospital outpatient facility, how has this impacted your revenues, costs and service mix?
Overall, we found an increase in the proportion of services being provided in more expensive settings. Is this trend occurring in your market area? What is driving this trend and what solutions would moderate this trend without impacting quality?
From 2006-2008, what was your average annual increase in labor costs compared with your average annual increase in patient revenue? What are the major factors driving change in labor costs? What are the major factors driving change in patient revenues?
Are the costs of acquiring medical equipment and technologies increasing, decreasing, or staying the same? Why and how do you think this is the case? What contribution is this having on your overall costs?
The following questions relate specifically to your experience in service prices and mix of services provided:
What factors do you consider when negotiating payment rates for inpatient care and outpatient services?
Do you generally negotiate contracts with carriers as part of a larger system or as an individual facility? Is there a material difference in how you approach contracts when you are contracting as part of a system vs. as an individual facility?
If applicable, do the services provided in your outpatient facilities in suburban areas differ from those in Boston? If so, how? For those services offered in both locations, do you charge the same or similar rates for all locations? If not, how do the rates – or price paid per person - differ and based on what factors? Are these facilities competing with community physicians or hospitals, or both for the same patients?
How has the expansion of outpatient facilities impacted the composition of surgical and medical admissions to your institution? How has the expansion of outpatient facilities impacted the price or cost paid per person of your institution?
How does the variation in prices among different providers in your peer group (e.g., teaching/community hospitals, providers in your geographic area, your key competitors) affect the payment rate increase you seek in negotiations with health plans? Please provide an explanation of how you define your “peer group”.
What specific actions has your organization taken already to address these trends in the short term or long term? What current factors limit the ability of your organization to execute these strategies effectively?
What types of systemic changes would be most helpful in reducing cost trends without sacrificing quality and consumer access? What other systemic or policy changes do you think would encourage or help health care providers to operate more efficiently? What changes would you suggest to encourage treatment of routine care at less expensive, but appropriate settings?
Could enhanced competition or government intervention or a combination of both mitigate the cost trends found in the Division's report? Please describe the nature of the changes you would recommend.
What would be the impact on your organization of making data public regarding quality and the reimbursement rates paid by each carrier to each hospital or system in a manner that identifies all relevant organizations? What is the advantage or disadvantage to your organization of the current confidential system?
Please identify any additional cost drivers that you believe should be examined in subsequent years and explain your reasoning.
Please provide any additional comments or observations you believe will help to inform our hearing and our final recommendations.
As Brent James has taught us . . .
Several months ago, the New York Times Magazine featured an article about Brent James, from Intermountain Health. I have written about him here, too, as one of the experts in improving quality and safety and other processes in hospitals.
Today, one of our doctors was giving a report about the activities of one of our clinical care committees. I perked up when he started a sentence with, "As Brent James has taught us . . ." The rest of the sentence had to do with the idea of not responding to a single clinical event, but rather focusing on a pattern of such events to find underlying systemic issues worthy of investigation and improvement.
I think Brent would be happy to know that his lessons have taken root at this Harvard teaching hospital. I, too, am pleased that we have provided opportunities for our staff to learn from people like him. Academic medical centers have done fine studying disease, diagnoses, and cures, but they lag in understanding the science of process improvement. We aim to change that here.
Bayh-Bayh
Dan Balz writes this column in today's Washington Post about whether Evan Bayh was overstating the degree of partisanship in Congress and whether, notwithstanding that, he should have stuck around to deal with the problem.
I don't think any of us have been alive long enough to know whether the first is true. Politics always seems at its worst when you are in the middle of it. It may be, though, that the existence of social media has made it more combative, for the old-style behind-the-scenes sausage making is no longer possible. Also, clever users of these media can create a "movement" in just a few hours, pushing positions to the extreme. Though politicians have become experts in using social media to run election campaigns, they have not yet figured out how to use these tools to help build bipartisan coalitions to govern.
And, on the second, we have no right to judge this gentleman on his personal decision. If he no longer wants to try to stay in Washington to work on the problem, there will be plenty of other candidates. No one is indispensable.
But I was struck by this quote, ""If I could create one job in the private sector by helping to grow a business, that would be one more than Congress has created in the last six months." Senator Bayh's statement is emblematic of an underlying philosophy of government that might be at the heart of the current partisanship. In this country, many people feel that it is really not the job of the government to be the job creator.
I think lots of people intuitively understand the Keynesian imperative to use federal fiscal policy during a recession in a counter-cyclical manner to boot-strap the economy. But there comes a point where the cost of doing so, and the burden it puts on future generations of taxpayers, becomes a political argument against further expansion along those lines. In my view, that is the tectonic fault line currently in Congress.
I don't dispute that nasty tactics are in use, by both parties. But I am suggesting that there is a legitimate public policy debate behind the discord.
Thus far, President Obama has not figured out how to bridge this gap. Bill Clinton did, after he lost the Congress to the Republicans. He moved their way politically and was able to build a bipartisan coalition on several issues. The first George Bush did likewise with the Democrats.
Obama does not model the behavior he asks Congress to employ. He calls for civility, but then he demonizes or rails against industries and people (banks, bankers, insurance companies, even Cambridge police officers.) Parts of his speeches are brilliant; but parts make him sound like a partisan legislator. He has never really run anything, and he is still getting his leadership legs. He has not figured out how to make his voice count for something in the Senate. There is thus no role model to provide coverage for moderate people in both parties who might be able to build the winning coalition.
A basic rule of negotiation is to give the other side something they can take home to their constituency. That is also an inherent characteristic of the republican form of government that comprises our Congress. Someone has to model that behavior. In these times, it has to be the President.
Wellpoint and Their “39%” Rate Increase
Wellpoint is getting killed in the press over a “39%” rate increase for their individual health insurance block in California.HHS Secretary Sebelius has pointed to the Wellpoint individual rate increases demanding an explanation. The President even brought it up in his interview on Sunday. At a time Democrats are fond of calling insurance executives “villains” this story just adds more fuel to
The Health Care Summit—Who’s Gonna Win the Photo-Op?
Getting Democrats and Republicans to constructively engage on health care is the best way to make progress.To date, the Democrats have blown health care reform once again by being too arrogant in thinking they could just ram their version through.The Republicans have no health care proposal. Their “black book” list of ideas they handed the President in Baltimore is a collection of second and