Doctors are Not Terrorists, But…….

Changing behavior is very complex.  Many management books, philosophical tomes, and academic psychology articles have been written on this subject, so I’m going to simply and quickly get to the connections among doctors, terrorists, and health reform.

1. Changing people’s behavior requires appealing to basic motivating factors. Different individuals have different motivators, but everyone has them.

2. Physicians are a key part of the healthcare system.  Improving quality and controlling healthcare spending will require physicians to do some things differently – particularly how they work with other clinicians (i.e., in teams), prescribe treatments, order tests, make referrals, and interact with patients and their families.  (Physicians receive about 20 cents of every healthcare dollar, but control about 80 cents. And an old axiom is that the most expensive piece of medical equipment is a pen in a physician’s hand – although soon it may be their hands on a keyboard.)

3. Money is a key motivator for many people…. But it’s not the only one. For many clinical thought-leaders and decision-makers, money may be of secondary concern.

Physicians, and Terrorists, and Everyone are Motivated By Specific Factors
I’ve long believed that aligning non-financial motivators is crucial for successful health reform because success will require changing individual attitudes and actions. But I didn’t realize how broadly powerful non-financial influencing factors could be until I read “Counterstrike,” the recent book by Pulitzer Prize winning journalist Eric Schmitt and his co-author Thom Shanker. This book describes how, in the mid-2000s, US anti-terrorism organizations saw markedly greater success by shifting their strategy from prioritizing “find-capture-kill” operations to taking actions that pivot potential terrorists’ motivational forces – in part by similarly pivoting the support potential terrorists receive from their families, communities, and religious leaders.  Some of these non-financial factors are:

  • Personal reputation
  • Personal glory
  • Network cohesion and dependability
  • Well-being of their family

As can be seen from this list, some of the factors that influence terrorists are similar to what could also motivate physicians, i.e. professional recognition, influence within their organizations, community status, etc.

Desired Outcomes
The face of successful health reform will be physicians enthusiastically doing things differently because they recognize that their actions are making their patients and communities healthier, making their own lives better, and also easing the “economic dragooning” that the healthcare system was imposing on society.

Successful Health Reform = Changing Physician Behaviors
Achieving these outcomes will depend upon changing physician behaviors, as described in #2 above. And while financial incentives* supporting those behavior changes are being incorporated into new delivery models – such as Medical Homes and Accountable Care Organizations – the organizations that successfully build these new models will utilize other motivating factors in their quest for higher quality, lower costs, and better care experiences for both physicians and patients.  As I noted in the opening paragraph, many pages have been written on changing behaviors, but the fundamental elements were described in general terms by Everett Rogers in his book, “Adoption of Innovation”:

  1. Relative Advantage
  2. Compatibility (with existing or connected practices and actions)
  3. Simplicity
  4. Observability
  5. Trialability

These principles are important because changing behaviors is synonymous with adopting innovations, e.g., using an ATM rather than a bank teller, writing on a computer rather than a typewriter, inhaling insulin** rather than injecting it. And thus, achieving successful behavior changes and producing our desired three aims will require change leaders to incorporate these elements – and both financial and non-financial factors – into their strategies for motivating physicians, patients, and all groups who make up the healthcare system.


*These incentives are generally described as rewarding value and quality rather than volume of services, and include pay-for-performance, shared savings/risk, bundled payments, and capitation.

** Not all innovations are successful – at least in their first iteration.

Congressional Accomplishments for 2009

Why the Democrats are increasingly becoming politically vulnerable is a topic that pundits are dissecting in great detail.  A general consensus is that the root cause of the public’s growing discontent is a lack of progress on the economy and jobs.

While the economy and the job market have stabilized somewhat – even if they haven’t rapidly rebounded – the President and Congress haven’t gotten much credit for not letting the ship sink.  In addition, most of the President’s and Congress’ major accomplishments occurred in the first part of 2009, while towards the end of the year the focus shifted to the very slow moving health care bill – which also included many real and concocted controversies.

Even the most recent Saturday Night Live’s Weekend Update took a shot at the lack of accomplishments by quickly scrolling past these three items:

  • Cash for Clunkers
  • Defunding the F-22
  • Credit Card Accountability Act

However, National Journal’s January 16th issue had a side-bar with a much more extensive list of 2009 accomplishments:

  1. Protections against wage discrimination (President signed on January 29)
  2. Expansion of the State Children’s Health Insurance Program (signed on February 4)
  3. The economic stimulus package (signed on February 17)
  4. A fiscal 2009 omnibus appropriations bill covering unfinished work from the previous Congress (signed March 11)
  5. A public lands package designating more than 2 million acres as protected wilderness (signed March 30)
  6. Expansion of national service programs (signed April 21)
  7. A fiscal 2010 budget resolution (Congress approved on April 29; President does not sign)
  8. Home mortgage reforms and foreclosure assistance measures (signed on May 20)
  9. Curbs on abusive credit card practices (signed on May 22)
  10. Pentagon acquisition reforms (signed on May 22)
  11. Sweeping tobacco regulations (signed on June 22)
  12. A fiscal 2009 supplemental appropriations bill to fund the Iraq and Afghanistan wars, flu-prevention efforts, and the “cash for clunkers” auto-rebate program (signed on June 24)
  13. Confirmation of Sonia Sotomayor to the Supreme Court (sworn in on August 8 )
  14. The fiscal 2010 Defense authorization bill, including an expansion of hate crime laws to cover offenses based on a victim’s sexual orientation, gender identity, or disability (signed on October 28)
  15. Extensions of unemployment benefits and the homebuyer tax credit (signed on November 6)
  16. The fiscal 2010 appropriations bills (signed on various dates in October and December)

So while the SNL skit was good comedy, it only picked up 3 pieces of 16 substantive Congressional actions – which were not just political talking points that could be written on the palm of a hand.

Palin Hand’s Crib Notes - Tea Party Convention February 2010

The bottom line seems to be that the President and the 111th Congress got handed a bucket of turds at the starting line, (e.g. crashing economy, dramatically deepening Federal deficit, and two wars),  and they’ve been aggressively trying to keep things from stinking too much while making as much fertilizer as possible.

But no matter how much sugar and sweet smelling spices anyone could toss over the bucket, it still has a bunch of turds.  Despite the progress made and the sweeteners tossed about to help people and companies maintain themselves through the economic crisis, the public still perceives that something is rotten and smelly with the government, (as well as financial institutions and some other large companies and organizations), and their response is to want to throw out anyone they can connect to the ongoing stink.










Historical Perspectives on Health Policy: Part 3

I just found my copy of the book “Improving Health Policy and Management” edited by Stephen Shortell and Uwe Reinhardt.  The book’s eleven chapters address many of the hot-button issues in today’s health reform debate:

  1. Creating and Executing Health Policy
  2. Minimum Health Insurance Benefits
  3. Caring for the Disabled Elderly
  4. An Overview of Rural Health Care
  5. Effectiveness Research and the Impact of Financial Incentives and Outcomes
  6. Changing Provider Behavior: Applying Research on Outcomes and Effectiveness in Health Care
  7. Health Care Cost Containment
  8. Redesign of Delivery Systems to Enhance Productivity
  9. Medical Malpractice
  10. Prolongation of Life: The Issues and the Questions
  11. Challenges for Health Services Research

The observant ready will notice one critical issue from today’s debate missing from this list… Information technology.  That is because this book was published in 1992… and actually the titles of the first and last chapters also included “in the 1990s.”

What this points out is that the fundamental issues of controlling costs, defining benefits, and improving efficiency in care delivery and through financial incentives are not new to the health care debate.  Reinforcing this historical reality, I recently ran into Professor Stuart Altman from Brandeis – who is one of the most insightful and clear thinking non-ideological health policy expert I’ve ever had the pleasure of talking to and hearing testify before Congress. And he told me on a rainy NYC sidewalk that he has been talking to people across the country about how the current debate is both similar to and different than the early 1990s, the 1980s, the 1970s….. and back to even the 1930s…and despite the ongoing delays he is hopeful that legislation will be enacted this time.

So while the issues haven’t changed, and likely won’t change no matter what legislation is enacted in the coming months, (and years), the hope is that this time around progress will be made so that health care becomes less of a national obsession, (and drag on the economy), and people and politicians can focus on life, liberty, and the pursuit of happiness, rather than illness, accessing needed treatments, and financial uncertainty.

Thanksgiving Conversations About Health – Engage With Grace Blog Rally

For many years I’ve used the Thanksgiving dinner table conversation as a model for discussions about healthcare – but usually I’ve put it in the context of people who work for healthcare companies, (e.g. pharmaceutical or managed care), trying to address, rebuff and rebut the criticisms they might get from family members, (e.g. Aunt Lilly), about the problems with the US healthcare system and the actions or positions of various companies or industries.  However, last year – and again this year – several bloggers have been cooperating to promote Thanksgiving weekend discussions about end of life care issues.  This effort has been called the Engage with Grace, and last year it was a great success, with over 100 bloggers participating.

The original mission of this “blog rally” was to get more and more people talking about their end of life wishes. But because this year has had quite intensive public debate about health reform, the decision was made for this year to do something a bit different and add a bit of levity to the efforts to promote discussions.

At the heart of Engage With Grace are five questions designed to get the conversation started, but to put a slightly lighter spin on these questions, the first set below has a less serious tone – the “real” Engage With Grace questions are at the end of this post – and I’ve interjected five other humorous ones in between. They’re not easy questions, but they are important – and the goal of both the serious and lighter questions are to get people talking, since if you can’t talk about the funny questions, then how can families and friends expect to seriously talk about the difficult and important ones?

Engage With Grace Questions - Set 1

  1. Which one of your family members would you trade for a celebrity or professional athlete, and who would you trade them for?
  2. After you made that trade, would you want the celebrity or professional athlete to cook or do the dishes at your holiday meal?
  3. Would you want that celebrity or professional athlete to be on your post holiday meal team for Charades or Monopoly?
  4. Would you want that celebrity or professional athlete to be named on your advanced directive or living will so they could make decisions about your healthcare needs and choices if you were unable to do so?
  5. Would you want that celebrity or professional athlete to represent you in the US Congress to make decisions about Medicare and health reform?

Engage With Grace Questions - Set 2

Have a good holiday season – and go with grace.

Making Health Reform Work

With momentum for health reform continuing to build, events have overtaken the scope of the book I’ve been writing – which has had the working title “Fixing the US Healthcare System.”  Therefore, I’m reconstituting the draft text and outline to increase the focus on how to effectively implement changes in the healthcare system – while still discussing the substance of reform.  To highlight the need and importance of effective implementation, the new working title is “Making Health Reform Work.” (A one page summary of the book can be found here.)

“Making Health Reform Work” will be different from other health reform books by going beyond just describing the health system’s problems and recommending solutions, to also exploring processes for effectively implementing positive changes and reforms.

I’d be happy to hear any comments or suggestions about the concepts and ideas presented in the summary.

Humana on Health Reform

Humana has added another “educational” to its YouTube series – this one is about “why do we need health reform.”

It’s a good question, and since I’ve been somewhat critical of other Human videos, I feel obligated to say that this one is OK – mostly because it doesn’t contain too much substance, i.e. it’s a mile wide and an inch deep.  And I do want to give the writers credit because the video starts by answering the question about what is health reform and why do we need it by stating, “The simple answer is…. Well there is no simple answer.”

But beyond that insight, they gloss over many of the important facets of the problems and possible solutions.  For example, in talking about the uninsured, they state that those without insurance have two options:  Pay cash or go without care.  That is the simple answer, but the reality is that there are many sources of free care (including free medicines) for low income people without insurance.  And many of the people without insurance are eligible for free or low cost insurance that they may not be aware of.  So in reality, the choices for the uninsured go beyond Humana’s perspective of pay cash or go without care.

US Life Expectancy and Spending
Second, the video notes that the US spends more per person that other countries, but don’t live longer – and they illustrate that point with a figure of a man using a walker.  While life expectancy at birth makes the US look much worse than other countries, the data for life expectancy at age 65 is very different. (See chart from Commonwealth Fund below.)

Life Expectancy at Age 65 - US v. other countries

This difference is because, in part, the US has much higher mortality at younger ages due to accidents and violence – including suicides.  Also, as the Humana video does depict, our diet and other lifestyle factors lead to poorer health. So it might be that while we are living as long as other countries, we use more intensive healthcare services to treat/manage  our greater burden of chronic illnesses brought about by obesity and lack of exercise, etc.

One reform option that Humana mentions is ensuring that people with pre-existing conditions can get insurance coverage.  The insurance industry has rallied around that change – as long as it is coupled with changes that ensure everyone has insurance so that people don’t wait until they get sick before buying insurance.  This makes sense both for the insurance industry and the country as a whole.

What Insurance Does
The Humana video also presents the concept that insurance is a mechanism for spreading out the costs from a few ill people over a much larger healthy population.  This “social insurance” model is what Medicare is based upon and is really the model for most insurance.  Another theory of insurance – and one that some insurance products follow – is that insurance is a way to prepay for expected future costs.  Some consumer directed health plans with health savings accounts combine these two theories of insurance into one type of policy, i.e. the high deductible insurance policy spreads high costs across a larger group, while the savings accounts enable individuals to put money away for expected future needs.

Competition with a Public Plan
The Humana video glosses over perhaps the biggest reform issue in today’s debate:  Creating a public plan to compete with private insurance.  The video describes the public plan as “like the one government employees have today.” While the Federal Employees Health Benefit Plan is cited as some as a “government plan,” it is really a lot more like an employer plan, since it provides Federal employees with multiple private insurance plan options.  I don’t think this is what most people consider to be a government plan.  Rather they are thinking more of something like Medicare or Medicaid, where the government sets the coverage and reimbursement rules and contracts with private organizations to pay physicians, hospitals, etc. for actual healthcare services.  And of course the VA is another model for a government health plan, where the government actually owns and runs the hospitals, and the clinicians and staff are government employees, etc.  While exactly what the political and policy leaders in Washington are thinking about for a public plan option remains to be seen – there are certainly many options for what this label could become.

Cutting Costs
The Humana video’s final section is about how to reduce costs.  Here they present several current hot-topic options like technology and electronic medical records, giving people more information to compare prices and performance “like they do for everything from new cars to groceries so they might use their money more efficiently,” paying physicians for performance rather than volume, and helping people eat right, exercise more and take better care of themselves.  All these are reasonable ideas, but will require considerable investments up from to achieve costs savings in later years.

The Humana video on health reform presents a number of superficial observations about the problems in the US healthcare system and some of the global options for change, but doesn’t delve into how to actually make any changes, and more importantly, the trade-offs that many of these changes would require.  So while it might make some people feel they understand the issues better, it really won’t move the debate forward to improve the US healthcare system.

The video also notes that no clear consensus has emerged about what options to pursue, and it suggests that “if you have an idea, call your Member of Congress.”  My experience having worked for a Member of Congress makes me wonder if that will really help move the debate forward.  It also reminded me of the idea submitted to a newspaper by a reader to answer the question, “How Would You Fix the Economy?”

Patriotic Retirement
Pay the 40 million people over 50 in the work force $1 million each in severance with three stipulations:

  1. They leave their jobs.  Forty million job openings – Unemployment fixed.
  2. They buy NEW American cars.  Forty million cars ordered – Auto Industry fixed.
  3. They either buy a house or pay off their mortgage – Housing Crisis fixed.

All National financial problems fixed!!!

Sounds good, except it would cost $40 Trillion, the Federal budget is about $3 Trillion, and the US GDP is a bit more than $14 Trillion.  So I’m not sure the numbers for this “idea” really add up. But it sounds good as long as you don’t care about the facts – which is probably why the newspaper printed it.

Communicating Health Quality Measures

Educating patients, (a.k.a. “consumers”), to make the “best” health care choices has been a fundamental principle in some health reforms schools, including those advocating for more high-deductible health plans.  While this concept makes sense in economic theories, it also requires belief that patients can and will make good use of the information available to them – particularly when they are ill.

Another fundamental necessity for making such consumer-directed healthcare work to improve quality and lower costs is that the information provided to people is meaningful and accurate.  A study published in the November/December 2008 issue of Health Affairs illustrates the complexity of providing accurate information.

This study was based upon the very simple question, “How easy would it be for a patient in the Boston area to find the “best” hospital by using different quality rating services?”  And the results were pretty fascinating: 5 different ratings systems designed to provide the public with quality information about individual hospitals didn’t agree on which were the best hospitals overall or even for specific conditions – even when the measure was death from a specific condition.  For example, the article notes, “Neither the observed mortality rates nor the observed/predicted rates were consistent across [rating systems for Acute Myocardial Infarction].  The hospital ranked first by HealthGrades had the second highest observed mortality; it ranked seventh according to Mass QC [a state government run information system].  Conversely, Health Grades’ seventh-ranked hospital (the only hospital ranked statistically worse than average) was ranked first by Mass QC.  This same hospital was ranked fifth in the nation by U.S. News and World Report for cardiology.”

Similarly the rating systems didn’t agree on the quality of care for heart bypass surgery:

Comparing Quality of Hospitals

The study’s authors don’t just throw their hands up and profess rating systems to be complete failures.  Rather they note that transparent quality information reporting can stimulate quality improvement activities within individual institutions, and they also make three recommendations:

  1. Hospitals should embrace quality reporting and make sure that the data collected and the design of the analyses truly reflect the quality of care
  2. Patient experiences must be a meaningful part of quality of care assessments
  3. Quality rating systems must improve how they account for differences in the severity of illness of patients, (i.e. risk adjustment of the data), and for random variations

They conclude that more standardization of data collection methods, analysis and reporting may help improve the value of quality information and comparisons.  These would be positive steps towards providing individual patients with better information they could use to compare their local hospitals rather than just to rate individual hospitals against national or regional averages.

Darwinian Politics of Health Reform in the U.S.

Tomorrow is Charles Darwin’s 200th birthday, and the Economist had a very interesting article about how his original theories have evolved over the past 200 years – and how a greater understanding of human evolution have revealed insights into human society and economics.

One of the most interesting observations in the Economist article is the differing levels of belief in evolution among countries.  The article explains these differences as possibly arising from the country’s safety nets for vulnerable people, i.e., individuals who have less concern about being able to obtain food or housing may be less likely to believe in God and be more likely to believe in evolution.  Essentially the linkage is this:

Better Social Safety Net -> Less Concern About Getting Food, Housing, and Healthcare -> Less Belief in God As Provider of Necessities -> Less Belief in Evolution

This theory is reflected in the Economist article’s chart (see below) which may indicate that Western countries with more organized, socialized and stronger safety nets are more likely to believe in evolution.

Economist - Darwin - Belief in Evolution by Country

Darwinian Politics and Religion
As can be seen from this chart, the people in the United States are almost exactly evenly divided, with about 40% believing in evolution, 40% not believing, and 20% unsure.  This split is essentially the same at voters, with the 20% unsure being the undecided voters in closely contested elections.

Implications for Health Reform
What this information may mean for health reform is that the disorganization of the U.S. health system may itself be producing fundamental resistance in the U.S. population to making changes which would strengthen the system and make it more organized.  That is, placing a greater emphasis on God as a predetermining force for fate and less belief in evolution as a force for changing species and societies, may make people less willing to trust the government or national organizations as sources for addressing their personal needs or concerns.

This may mean that successful health reform in the U.S. will need to gather more support from religious leaders and groups.  Campaign professionals have long realized that this can be key to winning elections, and some public health experts have recognized it as important for success in some public health initiatives.  It remains to be seen how important the support of religious groups will be for the success of health reform at the national level in the United States.  And if it turns out to be an important factor, if religious leaders  line up to support health reform in the U.S. – whatever shape that reform takes.

Napping to Increase Productivity

The New York Times had a great short report about a scientific study comparing a short nap to caffeine for improving a person’s memory.  The study found what many people have suspected for years – a nap is better than caffeine.

The benefits of napping are something that proponents of “power napping” have known for years. (Disclaimer: I’ve used the 20 minute power nap for years to re-energize and turn an afternoon impaired by a severe case of “the weakies” into several very productive hours.)

The study specifically found that naps were better for improving recall of a word list after both 20 minutes and 7 hours.  Naps were also better than caffeine for improving performance on a finger tapping task.  (This tested the ability to recall physically learned memories rather than the word list’s verbally related memories.)

The study also found that the caffeine group performed worse on the finger tapping test than the placebo group, and both napping and caffeine were better than placebo on a perceptual memory task of discriminating textures.

Questions Raised & Possibilities for More Research
Why caffeine is better than placebo for the perceptual task is an interesting finding?  Perhaps caffeine has some performance improving effect in peripheral nerves or nerve receptors.  This possibility could be examined by studying how caffeine effects other perceptual senses such as vibration and proprioception.

The statement from the study author in the New York Times that, “People think they’re smarter on caffeine,” points to the possibility that caffeine’s central neurological effects create false impressions of performance.  This might be another interesting avenue for research.  Particularly what does this increase in believed performance ability have on errors rates in important tasks such as flying an airplane or performing medical procedures?

Postscript: Reading this study also reminded me of a discussion I had many years ago with a corporate HR person about napping.  She had distributed information about identifying employees who had substance abuse or health problems that included “sleeping at work” as one of the warning signs.  The next day, the newspaper had an article about power-napping for productivity – which I sent to her, and she later confirmed that this was not what was meant by “sleeping at work.”

Humana Does Drugs

Humana has put another couple of videos on YouTube in their ongoing series to explain – from their perspective – how the healthcare system works.

The first new video is “Insurance Companies and Prescription Drugs.” Like their other videos, this one paints the insurance industry’s as rosy and altruistic, while stating that “Prescription drug manufacturers are allowed to set their own prices, and they often build large profit margins into name brand drugs to recoup the costs of researching, marketing and advertising.”

This statement strikes me as very curious.  First, how do companies “build large profit margins into name brand drugs?”  Maybe Humana means that pharma companies are making sure that their medicines provide patients with significant clinical benefits? Or more likely, what I think they meant, was that prices are set to include large profits.  However, the problem with that implication is that prices for pharmaceuticals – both brand name and generic – are really set at whatever the market will bear to fulfill the simplest of economic theories, i.e. to maximize profits.

Recouping research and manufacturing costs really comes into play for company’s research and development decisions and priorities.  These decisions are important for keeping innovative pharmaceutical companies in business because analyses show that only about 3 of every 10 new medicines ever recoup their to development costs.  And from what I leaned by talking with people in other industries, this is a lot higher than the ratio for book publishing or movies – which are in the 1/10 to 1/20 range.

Later in the video is another curious statement about how mail order delivery means that the patient gets a monthly supply of their medicine every 90 days. [Go to time stamp 1:30 in the video.]  Wouldn’t that leave patients without medicines for 2 months?  This doesn’t seem like a good way to encourage disease management through pharmaceutical compliance.

And lastly, the other Humana video is about the difference between PPO and HMO health insurance plans.  This video is titled “What is a PPO?” While simple like the other videos, it doesn’t seem as skewed.