The Daily Beat

What you should care about in healthcare today, from the editors of Becker's Hospital Review

Has Patient Satisfaction Gone Too Far? — The Case for Jerks in Healthcare

Among healthcare leaders, there has been a call to arms of sorts, which has swelled over the last five or so years, to rid medicine of, well, jerks.

The more technical term we've been using to describe this phenomenon of clinicians (mostly physicians) who are condescending, argumentative, aggressive and/or refuse to play well with others is "disruptive medicine."

In 2008, The Joint Commission created a new policy classifying disruptive behavior as a sentinel event, urging the organizations it accredits to take a zero-tolerance approach toward such situations.  


According to TJC, disruptive behaviors include "overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities."

Research has shown that both overt and passive behaviors are not rare (98 percent of healthcare workers reported observing such behavior, according to a study by the American College of Physician Executives) and can be detrimental to patient safety.

As a result, healthcare systems across the country have cracked down on disruptive behavior, choosing to cite physicians rather than looking the other way — the typical response by administrators for many years. In extreme cases, hospitals have dropped credentials or fired physicians for disruptive behavior.

At the same time, Medicare and commercial payers have begun to reward clinicians for strong patient satisfaction scores. Physician groups have also begun compensating clinicians based on their scores. In rare cases, clinicians with the lowest scores could be dropped from networks or fired.

Despite trends toward kinder, more empathetic, clinicians, Wen Shen, MD, an endocrine surgeon at the University of California-San Francisco, says the push for "a kinder, gentler surgeon" is misguided.

"My profession is filled with exceptional individuals who do amazing, lifesaving work. Many of us are jerks," Dr. Shen writes in an article for Pacific Standard, a publication put out by the Miller-McCune Center for Research, Media and Public Policy. "This is the trouble with surgeons. We are a sub-tribe of doctors who have long been celebrated for our abilities yet reviled for our personalities."

He continues:

"Within the past two decades, though, the surgical profession has attempted a wholesale revamping of its image and ideals. Compassion, communication, and collaboration are now strongly emphasized during training. It’s been a rapid and turbulent metamorphosis that has undoubtedly led to improvements for patients, hospital co-workers, and even surgeons themselves. Nonetheless, in the process, surgery may have created its own identity crisis. We want to believe we’re better off with nicer surgeons. But what do we lose?"

While Dr. Shen admits many of the effects have been positive  — a 2011 survey that found patients who perceive higher levels of empathy in their surgeon have better outcomes — he worries our industry's push for more likeable surgeons may have unintended consequences.

Has our emphasis on patient satisfaction gone too far?


What the Microsoft Fail Can Teach Healthcare Leaders

Workforce reduction, downsizing, streamlining, or as Microsoft CEO Satya Nadella explained in a now-notorious memo to employees last week "the first step to building the right organization for our ambitions is to realign our workforce," all describe what most Americans would call, simply and accurately, a layoff. Another accurate description: A mass firing.

Over and over again (yes, you, Citigroup, and you, Best Buy), CEOs (and no doubt their HR and communications advisors) find the need to obfuscate what is clear to most workers receiving the email: some of your colleagues, and maybe even you, are going to get fired. They can't bring themselves to be straightforward, and they end up looking foolish in the process.

Most of the Microsoft layoffs will affect legacy Nokia employees, which Microsoft acquired last year. Perhaps Stephen Elop, former CEO of Nokia and now an executive at Microsoft, did better? Try again. Here's how he announced the layoffs to his division:

"It is particularly important to recognize that the role of phones within Microsoft is different than it was within Nokia. Whereas the hardware business of phones within Nokia was an end unto itself, within Microsoft all our devices are intended to embody the finest of Microsoft’s digital work and digital life experiences, while accruing value to Microsoft’s overall strategy. Our device strategy must reflect Microsoft’s strategy and must be accomplished within an appropriate financial envelope. Therefore, we plan to make some changes."  


Microsoft and Nokia have a largely professional workforce, and still that paragraph probably left most of their heads spinning.

How do organizations with a less skilled workforce 'obfuscate' a mass firing?

The good ones don't.

Just say it
People feel better when they have clear, transparent information. Even if it's bad it feels better than uncertainty.


What It’s Like to Use Telemedicine as a Patient

A recent study found the vast majority (82 percent) of young adults age 18 to 34 say having a consultation with their physician on a mobile device would be the best option for them.

On Thursday, I found out I probably agree with most of my peers.

I tested out a mobile app from American Well, a telemedicine company that offers remote physician consults for minor, acute conditions. I wasn’t sick, but the public relations representative from American Well assured me I wouldn’t be disturbing their physicians.

So I downloaded the app to my smartphone, created a passcode and entered my basic personal information and then was taken to a “Choose Your Provider” screen. Available physicians in my state of Illinois, along with their pictures and specialties, were listed. I selected the first on the list, Ingrid Antall, MD. The app prompted me to describe my condition (I confessed to being a journalist), select a pharmacy for prescriptions and enter my credit card information for the $49 charge for the 10-minute consult (I tested the app for free, and users can enter their insurance information if their plans cover the service).

The first attempt to connect me to Dr. Antall failed, though it was more than likely due to my wireless Internet connection. On my second attempt I was connected, and was able to see Dr. Antall at the bottom of a split screen.

We talked for a bit, and she told me what usually happens during these consults. She said the online visits are similar to office visits — she takes the patient’s history and then conducts a physical exam.

Of course, a telemedicine physical exam is slightly different. Dr. Antall said she’ll have sinus infection patients touch their own necks and cheeks and report what they feel, and patients with stomach troubles will examine their own abdomen. “Most people have never really examined themselves like that before,” she said. “It’s fun for them.” She also said a lack of medical supplies where the patients are occasionally necessitates creativity, like having patients use the smartphone light to help Dr. Antall see down their throats.


Nurses vs. EHRs: Why the NNU is Fighting the Wrong Fight

One of National Nurses United's most attention-catching new TV spots, "Nurses vs. Computer Care," portrays a hospital where patient care has been mostly given over to a glitch-ridden computer and hapless IT staffer. When a patient's condition suddenly worsens, the computer malfunctions and is unable to help. A nurse soon steps into the room.

"Don't worry, you're in the care of a registered nurse now," she tells the panicked patient. She then turns to her presumed replacements: "You and your computer are in over your heads. Get a doctor, and get out of my way."

Part of the NNU's "Insist on an RN" campaign that launched in May, the ad is designed to highlight (through acknowledged exaggeration) the union's stance that electronic health records are compromising patient care.

The problem, says NNU Co-President Deborah Burger, RN, is that EHRs are inherently billing and collections tools. "Everything is about capturing the DRG and ICD codes," she says. "They never were honestly intended for improving patient care."

Patient safety concerns emerge, she says, when EHRs' clinical decision support functionality steers clinicians toward standardized, low-cost treatment plans without accounting for a patient's individual situation like nurses have been trained to do. "[Nurses] look at the patient, not just the disease but any comorbidities, their relationship with their families — it all has an effect on treatment, so it has to be taken into account," she says.

Of course, CDS alerts and recommendations can be overridden by clinicians, and frequently are. Despite the option to ignore the computer-generated recommendation, Ms. Burger believes the presence of the CDS can still sway clinical judgment. 


Close Hospitals? Not So Fast.

A blog post I wrote last week raised the question of whether closing hospitals and firing low-performing physicians could help healthcare in the long-run. The story was based on comments from thought leaders, including athenahealth CEO Jonathon Bush, Cleveland Clinic CEO Dr. Toby Cosgrove and Dr. Ezekiel Emanuel, about America having too many hospital beds and the need for some to close and find a presence elsewhere in the healthcare spectrum.

Panel discussions at "idea festivals" can gain momentum and get provocative rather quickly, and I regret if my blog post did the same. I was not suggesting much-needed safety-nets or critical access hospitals in rural communities shutter and abandon their communities. Unfortunately, they are already doing so: 14 rural hospitals shut down across the country last year alone, according to the National Rural Health Association as cited in this Al Jazeera America report.

When 49-bed Vidant Pungo Hospital in Belhaven, N.C., closed July 1, it left the town's 1,500 residents with a 30-minute drive (at least) to the closest emergency room. There is the possibility that the distance may have already contributed to one patient's death, as it took an hour to transport a 48-year-old woman experiencing a heart attack to the next closest hospital via helicopter. The mayor of Belhaven began marching 273 miles to Washington, D.C., this week to draw attention to the closure and break away from his fellow Republicans by supporting Medicaid expansion. If North Carolina had expanded Medicaid, Pungo may be in a different spot.

Rather, the idea of closure or reduction of inpatient services was targeted more toward markets and metro areas saturated with hospitals. As my colleague Lindsey Dunn wrote yesterday, there are 121 metropolitan statistical areas (or markets) with only a 20-50 percent occupancy rate in the U.S., according to data from MedPac.

As care shifts from inpatient to outpatient and hospitals move toward pay-for-performance models — the ultimate goal being to keep people healthy and out of hospitals — the need for some hospitals to close doesn't seem so radical. For instance, Summa Health System in Akron, Ohio, recently closed inpatient services at its Wadsworth-Rittman Hospital after seeing low volumes. Rebranded as a health center, Wadsworth-Rittman will still house a freestanding emergency department and expanded primary care offices. 

Vidant Pungo and Wadsworth-Rittman's situations are different, but same can be said for each and every healthcare market, which is one problem in discussions about "hospital closures" being helpful. Given a community's political circumstances, demographics, and other confounding factors, a hospital closure can mean any one of a hundred different things.

Alan Sager, PhD, a professor with Boston University School of Public Health, called me earlier this week to talk about the inherent problems in viewing hospital closures as a solution to healthcare's cost and quality problems. First and foremost, he says overbedding is not a cause of high cost in U.S. healthcare.


America Loves Getting Bigger, and Therein Lies the Problem for Healthcare

I'm a big fan of Morgan Spurlock. If you don't recognize the name, he's the guy that, back in 2004, ate only McDonalds for 30 days and made a documentary about it. (For the record, he gained nearly 25 lbs in the 30 days).

The problem with McDonald's, Spurlock argues, isn't the food itself. While it wouldn't be considered health food, a regular McDonald's hamburger has just 250 calories and 9 grams of fat. Instead, what makes McDonald's so detrimental to our health is that it encourages us to 'supersize' everything — causing us to eat more than we need, and more than we would have eaten without the 'supersize' prompt.

Why do Americans say yes to supersizing? 

Because in America, bigger is better — or at least, that's been the way of thinking for a long time.

The same accepted wisdom has been alive and well in healthcare for decades. 

"It's America. We don't make ourselves smaller," said Kenneth Kaufman, managing director and chair of healthcare consulting firm KaufmanHall. I spoke with Kaufman a few weeks ago about various trends in healthcare, including consolidation.

"A lot of these organizations would be much more effective in the future if they were smaller. They're too big," he explained.

In 1975 there were more than 7,000 hospitals in the U.S. Today there are 5,700. Despite having fewer hospitals, the occupancy rate has also declined. In 1975, 76 percent of hospital beds were filled. In 2012, the rate was 61 percent. In fact, in the six years from 2006 through 2012, the average Medicare inpatient occupancy for the country declined 13 percent, according to MedPAC. Even more telling, there are 121 metropolitan statistical areas (the technical term for 'market') with only a 20-50 percent occupancy rate in the U.S.

Our country is over-bedded.

We've seen the affects of this by way of hospital closures and significant consolidation — both of which are likely to continue as medical advances and preventive care help keep more patients out of the hospital.

What does this mean for healthcare leaders?

There will be fewer hospitals.


What Wayne Gretzky Can Teach Healthcare About Transitioning to Pay-for-Performance

Hockey great Wayne Gretzky played 20 years in the National Hockey League, earning his place as one of the most talented and celebrated athletes in the sport in the late 1970s through 1990s. I lived just outside St. Louis in 1996, his one and only season with the team. When he was traded from the Kings, the excitement for his arrival was electric.

Wayne Gretzky had incredible physical talent, but like any superstar athlete, what separated him from the rest of the very talented professional athletes he played against was a mental and intellectual edge.

One of his most famous quotes (I remember a high school friend with this exact poster hanging on his wall) is this: "I skate to where the puck is going to be, not where it has been."

The way he played the game wasn't to race over to where he saw the puck, but to anticipate where the puck would be next, and go there. The approach certainly served him well.

Gretzy's quote recently came up in a conversation I had with Kenneth Kaufman, managing director and chair of healthcare consulting firm KaufmanHall. Kaufman mentioned it as we were talking about hospitals' difficulty in transitioning to value-based payment models.

Specifically, we talked about how so many health system executives and boards are looking for guidance in timing the jump from fee-for-service to a new model (an issue that I previously wrote about here). That approach (i.e., 'timing' the transition) misses the point, he said. 

If Wayne Gretzky were a healthcare consultant, he would agree.


Close the Hospital, Fire the Physician: The Case For Harshness in Healthcare

Compassion is upheld as a central virtue in healthcare. But what the $2.8 trillion industry that fatally harms upwards of 440,000 patients per year might need is a good dose of mercilessness — toward itself.

Subpar hospitals will need to close. Bottom-tier physicians (if hospitals even know which ones those are) need to be fired, or their contracts should not be renewed. Patients and their families should stop donating money to hospitals, especially if said money will fund something like an expanded waiting room.  

These were some of the ideas brought up at the Aspen Ideas Festival last week during a panel discussion featuring Toby Cosgrove, MD, CEO of Cleveland Clinic and Jonathan Bush, CEO and co-founder of athenahealth. There is plenty of talk about healthcare becoming more accountable, but Dr. Cosgrove and Mr. Bush explained what that really looks like. (And it has nothing to do with an ACO.)

The first issue? We have too many hospitals. This has been raised by a few different thought leaders (Dr. Zeke Emanuel's take was especially interesting). Our volume-driven system extends beyond tests and procedures ordered. We've come to think that a country with more hospitals is a healthier one, which is faulty logic. Mr. Cosgrove threw out some statistics: The hospital occupancy in the United States right now is 65 percent. There were a million hospital beds 20 years ago. "Now there are 800,000 and we still have too many," he said.

Mr. Bush agreed, saying the weak links in healthcare need to go on and become something else. It's easier said than done, of course. It will hurt, and communities will feel the pangs. It's analogous to America's sensitive problem with end of life care: Are we keeping something or someone surviving rather than thriving? Is it time to let nature run its course?

Mr. Bush said yes, and he brought up another ruthless idea: Patients and families should stop donating money to hospitals. "I don't care if they name a pavilion after you," he said. "You're a murderer if you donate."

It's some provocative language, but I think what he's saying is this: If a hospital can't stay open and offer high-quality care by its own merits — if a patient's donation is somehow involved in the likelihood of such — maybe it deserves to close. Donations may keep subpar, even low-quality hospitals on life support. Patients go to these places for care, but also for medical errors and patient safety issues, which can ultimately kill them. (There's where the murderer accusation comes in.)

Another harsh reality? "When the nuns or the community hospitals come to Washington to ask for a bailout — because they will, because they will close, because they must — do not let your congressman bail them out," said Mr. Bush. "It's going to be very painful for your congressman, because they have tons of jobs and they're not exactly sure where those people in the hairnets and the smocks are going to go next. And they're terrified. But they must go somewhere else, because they are hurting their patients, they are shortening their lives, they are dehumanizing and they are making the product too expensive."


Google, Healthcare and the Problem of Fun

For a company with a mission to "organize the world's information and make it universally accessible and useful," there is one industry in which Google co-founders are less enthusiastic about doing so: healthcare.

This indifference isn't overwhelmingly apparent. The tech giant has made some footprints in health ventures: It made recent headlines for its glucose-reading contact lenses, and its Google Fit platform lets users organize their fitness and health data (steps, sleep, calories, etc.) in one place. Google is a major investor in Calico — a company focused on combating aging and disease — which sparked excitement among biotech pros and geneticists last year, and Google Ventures also backs Flatiron Health, a data analytics platform for oncologists. 

You might think such ventures indicate some long-term interest in health and healthcare, but these may remain isolated projects to the Google co-founders, who are seemingly tepid about the industry. Co-founder Larry Page said investments in health IT startups are "very small by comparison to our core business," and their mobile platform doesn't, and likely won't, have the health ambitions of Apple's HealthKit.

Part of the reason is healthcare's regulatory demands. In a discussion at the annual Khosla Ventures CEO Summit, venture capitalist Vinod Khosla asked Google co-founders Sergey Brin and Mr. Page if they can imagine Google becoming a health company. ("Maybe a larger business than the search business or the media business?") Mr. Brin and Mr. Page showed hesitation at the idea.

"Generally, health is just so heavily regulated. It's just a painful business to be in. It's just not necessarily how I want to spend my time," said Mr. Brin. "Even though we do have some health projects, and we'll be doing that to a certain extent. But I think the regulatory burden in the U.S. is so high that I think it would dissuade a lot of entrepreneurs."

Mr. Page agreed with his co-founder, using an example to illustrate his concern that regulations kill possibilities for innovation in healthcare.

"Imagine you had the ability to search people's medical records in the U.S.," said Mr. Page. "Any medical researcher can do it. Maybe they have the names removed. Maybe when the medical researcher searches your data, you get to see which researcher searched it and why. I imagine that would save 10,000 lives in the first year. Just that. That's almost impossible to do because of HIPAA [sic]. I do worry that we regulate ourselves out of some really great possibilities that are certainly on the data-mining end."

As Forbes contributor David Shaywitz noted, it's interesting to see a company tackle such outlandish projects as driverless cars but get foiled by healthcare. If Google built itself on anticipating the needs not yet articulated by its audience and meeting them with products and services that set new standards, it is astounding to see the company intentionally avoid doing so in healthcare, where hundreds of billions of dollars are wastefully spent.


Disruption Overkill? What Healthcare Can Learn From Blockbuster, Borders


Last week I wrote a blog on preparing for change in healthcare and cited Harvard Professor Clay Christensen's work on disruptive innovation. After I published the piece, Becker's Managing Editor Molly Gamble stopped by my desk to see if I had seen this week's New Yorker.

I hadn't.

In it is an article by staff writer Jill Lepore, who holds a PhD from Yale, that rails against disruptive innovation. While disrputive innovation, as a theory, describes why some legacy companies fail, it doesn't do much of anything to help those same companies not fail, which would seem of the most value, she argues.

According to Lepore:

"Disruptive innovation as a theory of change is meant to serve both as a chronicle of the past (this has happened) and as a model for the future (it will keep happening). The strength of a prediction made from a model depends on the quality of the historical evidence and on the reliability of the methods used to gather and interpret it. Historical analysis proceeds from certain conditions regarding proof. None of these conditions have been met."

Despite a lack of clear evidence supporting the theory, Lepore argues, 'disruptive innovation' has become an ubiquitous part of the American business lexicon, and has led many leaders to adjust their business strategy accordingly. Lepore writes:

"If the company you work for has a chief innovation officer, it's because of the long arm of 'The Innovator's Dilemma.' If your city's public-school district has adopted an Innovation Agenda, which has disrupted the education of every kid in the city, you live in the shadow of 'The Innovator's Dilemma.' If you saw the episode of the HBO sitcom 'Silicon Valley' in which the characters attend a conference called TechCrunch Disrupt 2014 (which is a real thing), and a guy from the stage, a Paul Rudd look-alike, shouts, 'Let me hear it, DISSS-RUPPTTT!,' you have heard the voice of Clay Christensen, echoing across the valley."

Throughout the article, Lepore presents counter arguments against many of the cases used by Christensen and his followers as illustrative of his theory. I won't get into the nitty-gritty of her counterarguments, but I encourage you to check out the article in its entirety if you get the chance. Here, a few of the arguments she makes: