Category Archives: Health policy

A pediatrician gives vaccine advice to presidential candidates

A pediatrician gives vaccine advice to presidential candidates

 | CONDITIONS  

First, I’d like to thank you for taking the time to read this; I know you’re busy fund-raising and campaigning, so I’ll try to keep this brief. It’s recently become quite apparent that several of you have some misconceptions about our immunization program. That’s unfortunate for people who are seeking such a prominent position. I know science can be complicated, but public health is a pretty important topic. (It’s especially disappointing that the physicians among you don’t seem to fully understand this issue, but I suppose immunizations are outside your specific fields.)

Anyway, the following are a few brief facts about vaccines that I hope you will find useful in your next debate.

1. Vaccines do not cause autism. Numerous studies have demonstrated this, and a huge meta-analysis involving over 1.2 million children demonstrated that pretty clearly. Evidence doesn’t get any better than that.

2. The guy that started this whole autism/vaccine thing lost his license because of his fraudulent study, which has since been retracted.

3. “Too many, too soon” is not a thing. Children encounter many viruses and bacteria every day, and their immune systems are not overwhelmed. (And they don’t develop autism.)

4. Although a popular book about alternative vaccine schedules has been quite a hit, the guy that wrote it didn’t bother to prove that his schedule was effective or safer than the schedule developed by the most knowledgeable infectious disease experts in our great nation. He just made it up.

5. Spreading out immunizations has been shown not to reduce the risk of complications from vaccines. All it does is extend the time period during which children are at risk for these infections. And since the most significant risk of immunizations is driving to the office to get them, it creates some indirect risks as well.

6. While we obviously disagree about some of those points, I support your assertion that we shouldn’t bother immunizing against insignificant diseases. So I’ve narrowed the list down to the diseases that cause “death or crippling.” (The links are from the CDC, a government organization made up of people who know more than you do about infectious diseases. You should get to know them; they will work for one of you some day.)

7. Since you’re probably not familiar with the CDC vaccine schedule that you think people should avoid, I just listed every one of the vaccines it recommends. All of those diseases kill people. Fortunately, they don’t kill very many people anymore. (Because of vaccines.)

8. And since I know your world isn’t all about saving lives, vaccines save money, too. That might be a good talking point.

I could go into more details, and I’d be happy to speak to you personally if you’d like to hear more. In fact, there’s a huge network of pediatricians that would be happy to field the vaccine questions while you tend to your more important affairs. (We were actually going to talk to these families anyway, because their children are our patients.) But hopefully, this basic information has been enough to allow you to speak a little more intelligently about the topic–especially since one of you will be running our country.

But in the future, if you’re unsure about similarly complicated topics, please feel free admit your lack of knowledge and defer to the experts. That’s what real leaders do.

Chad Hayes is a pediatrician who blogs at his self-titled site, Chad Hayes, MD.

http://www.kevinmd.com/blog/2015/10/a-pediatrician-gives-vaccine-advice-to-presidential-candidates.html?utm_content=buffere6c81&utm_medium=social&utm_source=facebook.com&utm_campaign=buffer

 

Basta attenzione solo alla struttura, lavoriamo sul cambiamento dei sistemi organizzativi e della cultura

Sir Muir Gray ci ha offerto un (apparentemente) semplice schema di interpretazione dei servizi sanitari: ognuno di essi è caratterizzato da una struttura (istituzionale, giuridica, economica, geografica, fisica), da sistemi organizzativi (idealmente impostati per realizzare le finalità dei servizi sanitari), dalla cultura (generale, professionale, organizzativa).

schermata-2016-09-24-alle-12-01-47

Dobbiamo riconoscere che in Italia, e in tutte le sue Regioni e Province autonome, l’unica modalità per introdurre un cambiamento dei servizi sanitari è quello di pensare a una riforma: cioè a un cambiamento della struttura (istituzionale, giuridica, economica, geografica, fisica). Nessuna attenzione, invece, viene dedicata alla necessità di cambiare i sistemi organizzativi e la cultura sottostante.

Il recente libro di Roberto Perotti (ex Commissario alla spending review) “Status quo” affronta il tema del “perché in Italia è così difficile cambiare le cose (e come cominciare a farlo)”.

Una frase, in particolare, mi ha colpito: “E’ proprio della mentalità giuridica attribuire importanza spropositata all’impianto istituzionale, compiacersi dell’eleganza formale e dell’equilibrismo di un compromesso, e immaginarsi che piccole variazioni a uno statuto possano portare benefici strutturali al paese. Se solo il mondo fosse così semplice…” (pag. 170).

Lavorare sui sistemi organizzativi e sui necessari cambiamenti culturali significherebbe “chinare la testa e lavorare” (R. Perotti, ibidem) sui problemi veri, sulla loro dimensione quantitativa e qualitativa, ipotizzare nuove soluzioni praticabili (socialmente e politicamente) e sostenibili (economicamente, professionalmente e culturalmente).

Certamente è più semplice fare una nuova legge, una nuova deliberazione, un nuovo atto aziendale pensando che un atto legislativo o amministrativo possano di per sé determinare il cambiamento.

Chissà se ce la faremo? Si dovrebbe cominciare smettendo di raccontarci bugie!

 

Può la Serenissima Repubblica di Venezia aiutarci a nominare “politicamente” direttori generali delle aziende sanitarie competenti? @WRicciardi @leadmedit @drsilenzi @redhenry88

Il recente convegno sulla corruzione in sanità ha riportato alla ribalta il problema delle nomine dei direttori generali delle aziende sanitarie, ritenute oggi troppo legate al potere discrezionale delle Regioni che non valuterebbero correttamente requisiti e competenze dei nominati, dando priorità all’affiliazione politica e alla nomina di yes men, semplici esecutori di desiderata politici più o meno leciti.

La lettura del libro di David van Reybrouck “Contro le elezioni: perché votare non è più democratico” mi suggerisce di proporre il metodo usato per una decina di secoli dalla Serenissima Repubblica di Venezia per “eleggere” il Doge. Si trattava di un sistema misto di sorteggio e di elezione, al fine di designare, comunque, una persona competente senza che la nomina fosse oggetto di liti anche cruente tra le famiglie nobili. Tutti i membri del Maggior Consiglio (oltre 500) scrivevano il loro nome e lo riponevano dentro una ballotta di legno (da cui deriva il termine ballottaggio); il più giovane consigliere si recava nella Basilica di San Marco dove chiamava il primo bambino tra gli otto e i dieci anni che incontrava; questo ballottino, innocente, estraeva 30 nomi che venivano ridotti a 9 con una seconda estrazione. I nove estratti, con una procedura di elezione a maggioranza (in realtà una cooptazione) allargavano il collegio elettorale a un totale di 40 persone. I 40 venivano ridotti per sorteggio a 12. Questa procedura di riduzione per sorteggio e d’incremento per elezione/cooptazione veniva ripetuta con lo stesso meccanismo fino al nono e penultimo “turno” dal quale si ottenevano 41 grandi elettori che si riunivano in conclave e eleggevano il Doge. L’intera procedura durava cinque giorni e si articolava in dieci fasi.

Potrebbe questo metodo essere utilmente usato per designare i direttori generali che devono gestire il servizio sanitario nazionale? Non vi è dubbio, a mio avviso, che i direttori generali, che amministrano ingenti risorse pubbliche, debbano essere nominati da chi risponde ai cittadini elettori. Per arrivare a una nomina “politica” che, tuttavia, assicuri la competenza dei nominati e sterilizzi gli effetti ritenuti negativi della attuale discrezionalità, si potrebbe costituire in ogni Regione un “Maggior Consiglio” composto da tutti i consiglieri regionali, da 20 consiglieri comunali estratti a sorte e (opzionale se si vuole coinvolgere il mondo professionale) da 10 rappresentanti delle professioni sanitarie (estratti a sorte dagli albi di ordini e collegi). Per sorteggio questi potrebbero essere ridotti a 31 persone, ulteriormente ridotti a 11 con una seconda estrazione. Questi, con un meccanismo di elezione/cooptazione, potrebbero coinvolgere altre persone fino a un massimo di 25. Proporrei di stabilire 5 turni di sorteggio (per ridurre il numero) e di elezione/cooptazione (per allargare il collegio). Al penultimo turno, si eleggono/cooptano 21 persone che si riuniscono e designano i direttori generali facendo riferimento all’elenco nazionale la cui istituzione è stata recentemente decisa dal Governo.

Naturalmente, l’intera procedura di sorteggio e di elezione/cooptazione dovrebbe essere attentamente supervisionata da un organismo di garanzia super partes: la storia ci insegna che, nel passato, le procedure pubbliche per l’estrazione dei commissari delle commissioni di concorso hanno mostrato poca trasparenza.

L’elenco nazionale dovrebbe, tuttavia, assicurare non solo il possesso di requisiti formali (laurea, anni di lavoro direzionale, ecc.), ma anche di standard di formazione di base, specialistica e continua e di competenze motivazionali, manageriali e di leadership senza le quali le nostre organizzazioni sanitarie non possono prosperare. Ma sul tema dell’elenco nazionale varrà la pena di offrire una riflessione a parte.

La procedura è solo apparentemente farraginosa: tutto si potrebbe risolvere in pochi giorni.

Questa riflessione potrebbe sembrare una provocazione. Se vogliamo lo è, ma in senso positivo: ha l’ambizione di suscitare una discussione che aiuti il sistema sanitario a selezionare i migliori, mantenendo la responsabilità della designazione in capo alla politica.

E’ solo un’idea preliminare che deve essere necessariamente affinata, discussa, criticata, sostituita magari da un’altra più brillante. Non affrontare il tema determina conseguenze negative sulla percezione che la pubblica opinione ha su chi gestisce ingenti risorse economiche e ha grandissime responsabilità nell’erogazione di servizi molto delicati per la vita stessa dei cittadini.

http://www.quotidianosanita.it/lettere-al-direttore/articolo.php?articolo_id=38656

 

BETTER HEALTH CARE AND LOWER COSTS @leadmedit @medici_Manager @pash22 @WRicciardi

REPORT TO THE PRESIDENT BETTER HEALTH CARE AND LOWER COSTS: ACCELERATING IMPROVEMENT THROUGH SYSTEMS ENGINEERING

Executive Summary

In recent years there has been success in expanding access to the health-care system, with millions gaining coverage in the past year due to the Affordable Care Act. With greater access, emphasis now turns to guaranteeing that care is both affordable and high-quality. Rising health-care costs are an important determinant of the Nation’s fiscal future, and they also affect the budgets for States, businesses, and families across the country. Health-care costs now approach a fifth of the economy, and careful reviews suggest that a significant portion of those costs does not lead to better health or better care.

Other industries have used a range of systems-engineering approaches to reduce waste and increase reliability, and health care could benefit from adopting some of these approaches. As in those other industries, systems engineering has often produced dramatically positive results in the small number of health-care organizations that have implemented such concepts. These efforts have transformed health care at a small scale, such as improving the efficiency of a hospital pharmacy, and at much larger scales, such as coordinating operations across an entire hospital system or across a community. Systems tools and methods, moreover, can be used to ensure that care is reliably safe, to eliminate inefficient processes that do not improve care quality or people’s health, and to ensure that health care is centered on patients and their families. Notwithstanding the instances in which these methods and techniques have been applied successfully, they remain underutilized throughout the broader system.

The primary barrier to greater use of systems methods and tools is the predominant fee-for-service payment system, which is a major disincentive to more efficient care. That system rewards procedures, not personalized care. To support needed change, the Nation needs to move more quickly to payment models that pay for value rather than volume. These new payment models depend on metrics to identify high-value care, which means that strong quality measures are needed, especially about health outcomes. With payment incentives aligned and quality information available, health care can take advantage of an array of approaches using systems engineering to redesign processes of care around the patient and bring community resources, as well as medical resources, together in support of that goal.

Additional barriers limit the spread and dissemination of systems methods and tools, such as insufficient data infrastructure and limited technical capabilities. These barriers are especially acute for practices with only one or a few physicians (small practices) or for community-wide efforts. To address these barriers, PCAST proposes the following overarching approaches where the Administration could make a difference:

  1. Accelerate alignment of payment systems with desired outcomes,
  2. Increase access to relevant health data and analytics,
  3. Provide technical assistance in systems-engineering approaches,
  4. Involve communities in improving health-care delivery,
  5. Share lessons learned from successful improvement efforts, and
  6. Train health professionals in new skills and approaches.

Through implementation of these strategies, systems tools and methods can play a major role in improving the value of the health-care system and improving the health of all Americans.

Summary of Recommendations

Recommendation 1: Accelerate the alignment of payment incentives and reported information with better outcomes for individuals and populations.

 

1.1  HealthandHumanServices(HHS)shouldconvenepublicandprivatepayers(includingMedicare,Medicaid, State programs, and commercial insurers) and employers to discuss how to accelerate the transition to outcomes-based payment, promote transparency, and provide tools and supports for practice transformation. This work could build on current alignment and measurement-improvement efforts at the Center for Medicare and Medicaid Services (CMS) and HHS broadly.

1.2  CMS should collaborate with the Agency for Healthcare Research and Quality (AHRQ) to develop the best measures (including outcomes) for patients and populations that can be readily assessed using current and future digital data sources. Such measures would create more meaningful information for providers and patients.

Recommendation 2: Accelerate efforts to develop the Nation’s health-data infrastructure.
2.1 HHS should continue, and accelerate, the creation of a robust health-data infrastructure through widespread adoption of interoperable electronic health records and accessible health information. Specific actions in this vein were proposed in the 2010 PCAST report on health information technology and the related 2014 JASON report to the Office of the National Coordinator for Health Information Technology (ONC).

Recommendation 3: Provide national leadership in systems engineering by increasing the supply of data available to benchmark performance, understand a community’s health, and examine broader regional or national trends.

3.1 HHS should create a senior leadership position, at the Assistant Secretary level, focused on health-care transformation to advance information science and data analytics. The duties for this position should include:

  • Inventory existing data sources, identify opportunities for alignment and integration, and increase awareness of their potential;
  • Expand access to existing data through open data initiatives;
  • Promote collaboration with other Federal partners and private organizations; and
  • Create a more focused and deep data-science capability through advancing data analytics and
  • implementation of systems engineering.

3.2 HHS should work with the private sector to accelerate public- and private-payer release of provider-level data about quality, safety, and cost to increase transparency and enable patients to make more informed decisions.

Recommendation 4: Increase technical assistance (for a defined period—3-5 years) to health-care professionals and communities in applying systems approaches.

4.1 HHS should launch a large-scale initiative to provide hands-on support to small practices to develop the capabilities, skills, and tools to provide better, more coordinated care to their patients. This initiative should build on existing initiatives, such as the ONC Regional Extension Centers and the Department of Commerce’s Manufacturing Extension Partnership.

Recommendation 5: Support efforts to engage communities in systematic health-care improvement.

 

5.1  HHSshouldcontinuetosupportStateandlocaleffortstotransformhealthcaresystemstoprovidebetter

care quality and overall value.

5.2  Future CMS Innovation Center programs should, as appropriate, incorporate systems-engineering

principles at the community level; set, assess, and achieve population-level goals; and encourage grantees

to engage stakeholders outside of the traditional health-care system.

5.3  HHS should leverage existing community needs assessment and planning processes, such as the

community health-needs assessments for non-profit hospitals, Accountable Care Organization (ACO) standards, health-department accreditation, and community health-center needs assessments, to promote systems thinking at the community level.

Recommendation 6: Establish awards, challenges, and prizes to promote the use of systems methods and tools in health care.

6.1 HHS and the Department of Commerce should build on the Baldrige awards to recognize health-care providers successfully applying system engineering approaches.

Recommendation 7: Build competencies and workforce for redesigning health care.

 

7.1  HHS should use a wide range of funding, program, and partnership levers to educate clinicians about

systems-engineering competencies for scalable health-care improvement.

7.2  HHS should collect, inventory, and disseminate best practices in curricular and learning activities, as well as encourage knowledge sharing through regional learning communities. These functions could be accomplished through the new extension-center functions.

7.3  HHS should create grant programs for developing innovative health professional curricula that include systems engineering and implementation science, and HHS should disseminate the grant products broadly.

7.4  HHS should fund systems-engineering centers of excellence to build a robust specialty in Health-

Improvement Science for physicians, nurses, health professionals, and administrators.

Full Report: http://www.whitehouse.gov/sites/default/files/microsites/ostp/PCAST/pcast_systems_engineering_in_healthcare_-_may_2014.pdf

How and why do countries vary so much in their use of health services? @WRicciardi @leadmedit @Medici_Manager @pash22

BY ADAM WAGSTAFF , http://bit.ly/1e48HAI

I’ve been struck recently by how little we (or at least I) seem to know about variations in use of health services across the world, and what drives them. Do people in, say, India or Mali use doctors “a lot” or “a little”. Even harder: do they “overuse” or “underuse” doctors? At least we could say whether doctor utilization rates in these countries are low or high compared to the rate for the developing world as a whole. But typically we don’t actually make such comparisons – we don’t have the numbers at our fingertips. Or at least I don’t.

I’m also struck by how strongly people feel about the factors that shape people’s use of services and what the consequences are. There are some who argue that the health problems in the developing world stem from people not getting care, and that people don’t get care because of shortages of doctors and infrastructure. There are others who argue that doctors are in fact quite plentiful – in principle; the problem is that in practice doctors are often absent from their clinic and people don’t get care at the right moment. There are others who argue that doctors are plentiful even in practice and people do get care; the problem is that the quality of the care is shockingly bad. Who’s right?

WHS to the rescue – again

As in a recent post of mine on Let’s Talk Development, I thought the World Health Survey might shed some light on these issues. The WHS was fielded in the early 2000’s in 70 countries – spanning the World Bank’s lower-, middle- and high-income categories. The WHS enumerators asked a randomly-selected adult in each household about his or her use of inpatient care and outpatient care; in the numbers that follow I’ve focused on use in the last 12 months. As I said in the earlier blog post, the WHS does have some drawbacks: it covers some regions fairly fully, other much less fully; it’s 10 years old; and all we can tell is whether inpatient or outpatient care was received, not the number of contacts. But despite these problems, the WHS gets us quite a long way.

A lot of variation – but not necessarily what you’d expect

The maps below show the inpatient admission and outpatient visit rate – actually the fraction of people who had at least one admission or visit in the last 12 months. Green countries are above the developing-country average; red countries are below it.
For IP admissions, most of the OECD countries are above the developing-country average (6.98%). Brazil, Namibia and the European and central Asian countries are also above it. African and Asian countries are mostly below or close to the developing-country average.

The picture is different for outpatient visits. Several OECD countries are actually below the developing-country average (27.52%). And for the most part, the countries below the developing-country average are in Africa: many are considerably below it (Mali stands out dramatically); only a few are above it (Kenya and Zambia stand out). By contrast, several countries in Asia are above the developing-country average: India and Pakistan are dramatically above it, but China and Vietnam are also above it; a few Asian countries are below it – Laos and Myanmar are considerably below it, Malaysia and the Philippines less so.

Do variations in doctor numbers and infrastructure explain variations in utilization?

The maps below show data on doctors and hospital beds per 1,000 persons. I got the data from the World Development Indicators, and took the country averages for the first half of the 2000s. As before, green countries are above the developing-country average; red countries are below it. The countries above the developing-country averages are mostly those in the OECD and Europe and central Asia, though in the case of doctors per 1,000 some of them are also in Latin America and the Caribbean. Except for China, most of Asian countries fall below the developing country average.

Correlating the WHS utilization data with the WDI doctor and beds data shows that doctors and beds per 1,000 persons are positively associated with outpatient visit and inpatient admission rates. A lack of doctors and beds looks like it could indeed be part of the explanation for low utilization rates, though of course we haven’t established causality.

But a lack of doctors and hospital beds is only part of the story. Together they “explain” only 60% of the cross-country variation in inpatient admission rates, while doctors “explain” an even smaller 20% of the cross-country variation in outpatient visit rates.

Some countries – India and Pakistan are examples – are below the developing-country average on doctors per 1,000 persons, but above the developing-country average on the outpatient visit rate. Doctors and hospitals in these countries treat far more patients than one would expect given the number of doctors and hospital beds in these countries. In these countries, it doesn’t look like accessibility is the pressing issue; as research by my colleague Jishnu Das confirms, at least in India, poor quality is the bigger problem.

By contrast, much – but not all – of Africa is in the opposite camp: these countries have inpatient admission and outpatient visit rates that are below what would be expected on the basis of their doctor and beds per 1,000 figures. So it’s not just that these countries lack doctors and beds; it’s also that people are not getting the level of contacts you’d expect from the existing staff and infrastructure. Here it looks like absenteeism could well be part of the story; recent research from my colleague Markus Goldstein confirms it – pregnant women whose first clinic visit coincided with a nurse’s attendance were found to be 46 percent more likely to deliver their baby in a hospital.

Two take away messages

Message #1 is that countries differ considerably in their utilization rates. Much of Asia visits doctors more regularly than both the developing world and the entire world; India’s consultation rate is a third higher than the global average. Africa stands out as the continent where outpatient visits and inpatient admissions lag behind the rest of the world.

Message #2 is that these variations are partly explained by differences in doctors and hospital beds per capita, but only partly. The problem goes deeper than hiring more doctors and building more hospitals. Africa has lower outpatient visit rates than its doctors per 1,000 figures would suggest, while the opposite is true of India and Pakistan. In Africa, it looks like the binding constraint may well be absenteeism, while in S Asia it looks like the first-order problem is the poor quality of care that’s actually delivered.

2013: The Year In Healthcare Charts @pash22 @Medici_Manager @WRicciardi

By Dan Munro , http://onforb.es/1bU2qCK

This is the 3rd and final installment of my year-end series for 2013.

Part 1: Healthcare’s Story Of The Year For 2013 – Pricing Transparency(here)

Part 2: Top Ten Healthcare Quotes For 2013 (here)

Like the Top Ten Healthcare Quotes, this collection of 15 charts is far from complete or comprehensive, but they are ones I found to be representative of a broader healthcare trend or story. In most cases, the charts are self explanatory, but in others they are simply gateways into larger, more compelling stories.

Given the complexities around data collection and presentation – there is often a lag between the current year and the latest available data from a major/reliable source.

As a part of what I called the “story of the year” (Healthcare Pricing Transparency – here) was this chart from Elizabeth Rosenthal’s multi-part series on “The $2.7 Trillion Medical Bill.”

NYTPriceComp

Source: The $2.7 Trillion Medical Bill by Elizabeth Rosenthal (here)

While it’s too early to call it a trend, this chart for ER visits (1996 – 2010) is notable because 2010 is the first time in 14 years that the consecutive upward trend was broken. The unknown at this stage is why and if it will continue (lots of speculation and debate), but it’s an important barometer for reasons around cost and healthcare more broadly.

ERVisits

Source: CDC / National Center for Healthcare Statistics (PDF here)

The Milliman Medical Index is another broad indicator around annual healthcare costs for a family of 4 with PPO coverage.

Milliman2013

Source: 2013 Milliman Medical Index (PDF here)

For Health Insurance Premiums alone (no accounting for “out-of-pocket” expenses), the Kaiser Family Foundation gave us these two related charts:

Kaiser1

Kaiser2

Source: Kaiser/HRET 2013 Employer Health Benefits Survey 2013 (PDF here)

According to Medscape – Orthopedics edged out Cardiology and Radiology as the specialty with the highest average annual compensation for 2012 (reported in 2013).

Medscape2012

Source: Medscape Physician Compensation Report 2013 – (26 slides here)

Obesity and related illnesses saw coverage from every direction throughout 2013. Once again, the relatively small town of McAllen Texas (population of about 135,000 and profiled by Atul Gawande in The Cost Conundrum – 2009here) was front and center again in a story by The Washington Post that included this provocative chart on the correlation (by U.S. region) of childhood obesity and poverty (as measured by the Federal Poverty Limit):

WaPoObesity

Source: The Washington Post – Too Much of Too Little by Eli Saslow(here)

This next chart has broad healthcare implications and the dubious distinction of making an entirely different list – “The Most Important Charts in the World” (at least according to “Wall Street’s ‘Brightest” Minds).

FoodStamps

Source: Wall Street’s Brightest Minds Reveal The Most Important Charts In The World [Chart #57 – Monthly Food Stamps by Nicholas Colas of the ConvergEx Group – here]

Another contributing factor to several healthcare related illnesses is the global consumption of sugar – and soda in particular. Once again, at least according to Credit Suisse, the U.S. is an outlier relative to all of the other industrialized countries.

CSGlobalSoda

Source: Credit Suisse Research Institute – Sugar: Consumption At A Crossroads (PDF here)

From their Biennial Health Insurance Survey, The Commonwealth Fund delivered this chart as a part of broader analysis that concluded: “In 2012, nearly half (46%) of U.S. adults ages 19 to 64, an estimated 84 million people, did not have insurance for the full year or had coverage that provided inadequate protection from health care costs.”

TCWFund

Source: The Commonwealth Fund Report – Insuring the Future (PDF here)

Reducing the number of uninsured continues to dominate the healthcare headlines more broadly and Sarah Kliff at the Washington Post used this chart to summarize the effect of the ACA on coverage by 2016.

SarahKliffWaPo1

Source: Obamacare Explained In 2 Minutes by Sarah Kliff at The Washington Post (video here)

No less than 3 of healthcare’s larger topics (Big Data, Gamification and Wearable User Interfaces) made it to the top of another chart – Gartner’s Hype Cycle for Emerging Technologies. All 3 appeared at (or near) the “Peak of Inflated Expectations.” Clearly the trend that Gartner was identifying is larger than just healthcare, but healthcare is a part of the broader picture too.

GartnerHC

Source: Gartner Hype Cycle For Emerging Technologies 2013 (here)

Big Pharma continued to make restitution to the Department of Justice for past grievances around overly aggressive marketing of some of their drugs. Just this month, GlaxoSmithKline announced their intent to change some of those practices – which included paying doctors (in a variety of ways) to sell their branded drugs. This chart (created by ProPublica for a larger piece on the flow of dollars from big pharma to providers) doesn’t include the Johnson & Johnson settlement on behalf of their subsidiary Janssen for $2.5 billion which was finalized and announced just last month (here).

PharmaDoJ

Source: Big Pharma’s Big Fines by Lena Groeger for ProPublica (here)

Pricing transparency throughout the year revealed wide variations – some of which was explained by L.E.K. Consulting in their analysis which produced this chart (for a broader discussion on the profit profiles ahead for hospitals under the Affordable Care Act). They make a compelling argument that only one of the 4 different payment types seen by hospitals is profitable and this one category of payment has to offset the negative margin of the other 3.

LEKFigure1

Source: Hospital Economics and Healthcare Reform by Tip Kim and Scott Miller for L.E.K. Consulting (PDF here)

This final chart is one I’ve used extensively in the past, but has now been updated with OECD data for 2011. The older version was using data from 2009. Not much change – but strengthens the argument that we still have a long way to go in our healthcare reformation and transformation.

OECD2011

Source: OECD Health Data 2013 (Access the OECD StatExtracts Databaseonline here)

 

Talking about the Network Era @LeadMedit @Medici_Manager @WRicciardi @muirgray

By Harold Jarchehttp://bit.ly/1krMYIf

Interesting things happen when hyperlinks subvert hierarchy, as the writers of theCluetrain Manifesto said in 1999. Wikileaks, Edward Snowden, Arab Spring, and the Occupy Movement are just a few recent examples. Spying on entire populations is another network era phenomenon. In education, the current subversion is the MOOC, which has already itself been subverted by corporate interests. In the labour movement we are seeing things like alt-labour as well as a growing shareable economy. Networked, distributed businesses, like AirBNB, are disrupting existing models, with the inevitable push-back as they become successful.

Networks will transform education, business, the economy, and society even further. In the network era, the creative economy will gain dominance over the information and industrial economies. Professional knowledge distribution will move away from institutionalized business schools into networked communities of practice.

The key to a flourishing society in the network era will be distributed sense-making. Self-instruction, the basis of personal knowledge management, will be a requirement in a growing number of peer-to-peer networks. Networked learning will give rise to networked decision making. David Ronfeldt articulates this well, with his TIMN [Tribes-Institutions-Markets-Networks] framework. Anyone raised during the past several decades probably understands tribes and institutions and even market forces. This is a triform society(T+I+M). But what happens as we become a quadriform society (T+I+M+N)?

TIMN has long maintained that, beyond today’s common claims that government or market is the solution, we are entering a new era in which it will be said that the network is the solution (e.g., here and here). Aging contentions that turning to “the government” or “the market” is the way to address particular public-policy issues will eventually give way to innovative ideas that “the network” is the optimal solution.

In the network era we have to understand how to become contributing members of networks, for work and for life. This should be a major focus for all professional training and education.

“Reed’s Law” posits that value in networks increases exponentially as interactions move from a broadcasting model that offers “best content” (in which value is described by n, the number of consumers) to a network of peer-to-peer transactions (where the network’s value is based on “most members” and mathematically described by n2).  But by far the most valuable networks are based on those that facilitate group affiliations, Reed concluded. – David Bollier

Without good sense-making skills, the citizenry cannot understand complex issues that affect us all, such as individual privacy versus national security. These issues require networked, human intelligence, not broadcast sound bites, nor ‘learning objects’.

Sensemaking should drive policy. Policy drives decisions. Decisions, of course, need to be informed. If the People don’t know what makes their world go ‘round, the folks on the Hill sure won’t. Globalized governments can’t. – Gunther Sonnenfeld

As David Bollier concludes, “Legitimate authority is ultimately vested in a community’s ongoing, evolving social life, and not in ritualistic forms of citizenship.” Should not education move beyond ritualistic forms of subjects, classes, and certifications and toward ongoing, evolving social learning? How else will we be able to deal with the complexities of this networked, connected sphere that we inhabit?

Jon Husband says that we are all in this together.

The interconnected Information Age is beginning to show us that we’re all linked together – and that the whole system matters.

This principle applies to organizations, to networks of customers, suppliers, employees and communities, to our societies and to the planet.

New language for this principle is popping up everywhere – knowledge networks, intranets, communities of practice, systems thinking, swarming, social software, social networks, tipping points.

Awareness is the key.  Maintain an “open focus”.

Being aware of yourself, others and the effects of your actions and ways of being in relation to others is a fundamental requirement in these conditions.

To thrive in the network era we need to understand networks – social networks, value networks, information networks, etc. Therefore we will need network era fluency.

network era fluency

Network era fluency could be described as individuals and communities understanding and being part of global networks that influence various aspects of our lives. For individuals, the core skill will be critical thinking, or questioning all assumptions, including one’s own. People will learn though their various communities and in doing so, develop social literacy. Information literacy will be developed by connecting to many networks. Diversity of our knowledge networks can foster innovation and improve our collective ability to adapt.

Mass network era fluency will keep our knowledge networks social, diverse, and reflect many communities. This kind of fluency, by the majority of people, will be necessary to deal with the many complex issues facing humanity. We cannot address complex issues and networked forces unless we can knowledgeably discuss them. To understand the network era, we need first to be able to talk about it.

The network era has already changed politics, created new dominant business models, opened up learning, and is now changing how organizations operate – on the inside. Once we are able to talk about networks, we will see that many of our current work practices are rather obsolete. From how we determine the value of work, to how we calculate pay for work; organizations will need to adapt to the network era.

I think business leaders and HR departments do not understand this shift, or the fact that this shift is accelerating, so that in a year or two 75% of peoples’ value will be based on their network performance, their ability to contribute to and accept from others. – Stowe Boyd

 

* Content from jarche.com is protected under a Creative Commons Attribution-NonCommercial Share Alike License

Solving the high rates of hospital readmissions @kevinmd @Medici_manager @pash22

By  , http://bit.ly/1abkQiX

Statistics show that about 1 in 5, or 20 percent of all Medicare patients are readmitted to hospital within 30 days of discharge. That’s a staggering number, not to mention all those patients that are readmitted frequently during the course of a year, but not necessarily within 30 days.

The problem of frequent hospital readmissions is actually one that exists all over the world and not just in the United States. Health care systems everywhere are seeking solutions to keep their patients healthier and away from hospital. Any doctor practicing at the frontlines will be able to tell you what a big issue this is right now. We regularly see the same patients on something of a merry-go-round of frequent hospital admissions, often with the same illness.

Why does this happen? This issue is complex. In my experience as a hospital medicine doctor, there are number of factors in play, falling into different categories according to the type of illness, availability of definitive treatment, and the social circumstances of the patient.

Severity of illness. Certain chronic conditions, such as congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD), when in their advanced stages, are very labile and prone to exacerbations. As much as doctors try to control these with medications, it’s a very difficult task, as it only takes a slight precipitant such as a minor infection or dietary indiscretion to push somebody over the edge. By their very nature chronic diseases tend to get worse over time. And with an aging population, these conditions are increasing in prevalence. Unless we find definitive cures, hospitalizations are always unfortunately a possibility.

Social situation. Patients who have inadequate family support tend to be admitted to hospital more frequently for a couple of reasons. Firstly, their threshold for being able to cope at home with their illness is much lower. Secondly, they will not be able to co-ordinate their regular follow up care so easily. We see the effects of this all the time at the frontlines — two patients with the same level of illness severity; one will be managed at home, the other will require hospital admission for several days.

Lack of follow-up. Many studies have shown that lack of follow-up with a primary care physician in the weeks after discharge can lead to a higher likelihood of re-hospitalization. Seeing a doctor quickly post discharge allows for any potential problems to be “nipped in the bud”. It also allows for care co-ordination and medication reconciliation. Sadly, a large number of patients do not have a regular primary care doctor (mostly for insurance reasons). They therefore tend to use the emergency room as their first point of contact when they feel unwell again.

Suboptimal discharge process. By its’ very nature, the process of discharging a complicated patient from hospital is one that is fraught with possible problems. The discharge process needs to be thorough, seamless and diligent. Areas for improvement in most hospitals include medication reconciliation, clarifying follow-up appointments, follow-up laboratory tests, and making sure that the patient and family is clear about these instructions. Too often, this process is rushed and glossed over. Nothing beats having the doctor sit down with the patient and their family, spending time reviewing all the pertinent information.

Low health literacy. Many patients are not fully educated and informed about the nature of their illness and how best to manage it at home. This can be dealt with by regular reinforcement and utilizing home nursing services to keep on checking in with the patient post-discharge.

Certain very obvious patterns do exist in how patients tend to be readmitted to hospital. Several initiatives are underway across the country to try and improve the situation. Primary care doctors, specialty clinics, home nursing services, and even social workers are all being utilized as part of a team-based approach. The strategies broadly involve:

  • Identifying high-risk patients early
  • Educating the patient and involving family members
  • Having very close follow-up with a collaborative care team

As part of health care reform, hospitals are also facing financial penalties for consistently high readmission rates. But financial penalties alone aren’t the answer, especially for “safety net” hospitals that struggle more with this problem. It’s important to remember that the drive to reduce readmissions is not just about saving the health care system money, but ultimately about keeping our patients healthier and stronger. Whatever can be done to keep them at home enjoying life as much as possible instead of lying in a hospital bed, can only be a good thing.

Suneel Dhand is an internal medicine physician and author of Thomas Jefferson: Lessons from a Secret Buddha and High Percentage Wellness Steps: Natural, Proven, Everyday Steps to Improve Your Health & Well-being.  He blogs at his self-titled site, Suneel Dhand.

A right to a personal health budget @tkelsey1 @Medici_Manager @pash22

Luke O’Shea, NHS England’s Head of Patient Participation, explains why a “quiet ministerial announcement” is so significant.

http://bit.ly/1h4VSr0

Last week in Parliament, ministers quietly made an announcement : From October next year, thousands people in receipt of Continuing Health Care funding will gain a new legal ‘right to have’ a Personal Health Budget.

The announcement went largely unnoticed by the media, patients and professionals.  Usually Personal Health Budget announcements generate Marmite-like reactions – either heralding the end of the NHS as we know it, or being seen a panacea for a person-centred NHS. But last week there was little reaction.

However, this is a significant announcement for a group of people who have less ability than most to determine the path their lives take.  The hope is that Personal Health Budgets will change that. But will they?

It made me reflect on an important experience I had working as a commissioner in the NHS. It was a trip to meet a man about my age receiving Continuing Health Care.  I think about him quite a lot.

He’d been given a diagnosis of ‘treatment-resistant schizophrenia’ and had been moved around the country for over 10 years because of his complex needs.   After a three hour drive, I arrived at the care home where he had lived for the last five years.  We got on well and talked quite a bit.  We sat in the kitchen and I asked him about his hopes for the future.  He wanted a flat of his own.  However, he’d been told for a long time that they were hoping to sort out a flat, with little sign of progress.  He was stuck.

For the NHS, the care home placement was a success.  He was high risk but had had no hospital re-admissions in recent years.  But it did not offer him what he wanted most, to build a normal life.

When the Personal Health Budget announcement was made it occurred to me that his placement budget would have paid for a flat, a full-time support worker and employment support or training, with some left over.  I wondered whether a right to have a Personal Health Budget would have started a different conversation that day I met him.

For me, the announcement on Personal Health Budgets is part of a wider historic movement where people whose lives have been constrained by the state have been offered greater self-determination.

Why would the NHS not want people to actively determine the path of their own lives?  Should people be allowed to choose and buy their own care?

Well, there is a tension.  They might choose services that fit round their lives and not what suits the NHS.  They might decide a job is more important to them than managing the likelihood of hospital re-admissions.  But what does the evidence say?

The University of Kent controlled trial of Personal Health Budgets, involving 2,000 people, showed patients with PHBs out-performing the control group, and even had fewer hospital admissions.  It seems that patients can be experts too.

The Lancaster University Poet Survey also showed significantly improved well-being for most carers, who tend to bear a huge personal responsibility for this group.  It’s rare that we measure the impact of an intervention on families of patients, but here we have.

So we need a bigger debate about Personal Health Budgets and personalisation in the NHS.  The evidence is good, but there are tensions and the implementation challenges are significant.

Personal Health Budgets are not a panacea, but they do start a different kind of conversation.  And they are not going away.  This announcement is part of a wider historic shift towards personalisation and greater self-determination across public services, which once introduced is very hard to go back on.

So let’s hope this announcement is one small step towards a time when everyone, regardless of health need, is given the chance to determine the course of their own lives.


luke-osheaLuke O’Shea is Head of Patient Participation at NHS England.

He has previously worked in national policy and strategy roles at the Department of Health and as a commissioner in a local authority and the NHS.

Prior to that he worked in a range of government departments including leading work on early year services at the Prime Minister’s strategy unit, as a private secretary to a children’s minister and leading cross government working on ageing.

He describes as his proudest achievements his “modest role at the inception of Family Nurse Partnership in the UK and of my work on ageing”.

Value-Based Health Care Is Inevitable and That’s Good @Medici_Manager @pash22 @leadmedit

by Toby Cosgrove  http://bit.ly/17GkMG7

Vaccines. Anesthesia. Penicillin. Bypass surgery. Decoding the human genome. Unquestionably, all are life-saving medical breakthroughs. But one breakthrough that will change the face of medicine is being slowed by criticism, misunderstanding, and a reluctance to do things differently.

That breakthrough is value-based care, the goal of which is to lower health care costs and improve quality and outcomes. It will eventually affect every patient across the United States. Not everyone, however, is onboard yet, because part of the value-based equation is that hospitals will be paid less to deliver better care. That’s quite a challenge, but one that Cleveland Clinic is embracing as an opportunity to do better. Others must, too.

How the Health Care World Will Change

We all know that U.S. health care is too expensive, too inefficient, and the quality is too varied. The goal of value-based care is to fix that.

A major component of the Affordable Care Act is to change the way hospitals are paid, moving away from a reimbursement model that rewards procedures to one that rewards quality and outcomes. No longer will health care be about how many patients you can see, how many tests and procedures you can order, or how much you can charge for these things. Instead, it will be about costs and patient outcomes: quicker recoveries, fewer readmissions, lower infection rates, and fewer medical errors, to name a few. In other words, it will be about value. And that is good.

Whether providers like it or not, health care is evolving from a proficiency-based art to a data-driven science, from freelance physicians to hospital-employed physicians, from one-size-fits-all community hospitals to vast hospital networks organized around centers of excellence. Each step in this process leads to another.

When hospitals employ physicians on an annual salary as we do at Cleveland Clinic, a doctor is paid the same no matter how many patients he sees, how many procedures he performs, or how many tests he orders. One-year contracts hold our doctors accountable, with yearly performance reviews that include each doctor’s quality metrics, clinical outcomes, and research. And having all your doctors on the same team makes it easier to coordinate patient care among different groups of specialists.

As more independent physicians begin to be hired by hospitals, the opportunity for large group practices and hospital consolidation grows. As consolidation expands, data and transparency become increasingly important, as a way to ensure that caregivers across the system are providing comparable care.

All of this, of course, leads back to quality, which requires an effort to achieve standardization, reduce variation, and eliminate unpleasant surprises. It’s analyzing processes, measuring outcomes, and changing practices until you get it right.

To remain viable in today’s rapidly evolving environment, health care systems must reduce costs while continuing to improve quality and outcomes.

The Cleveland Clinic’s Journey

In the October issue of Harvard Business ReviewMichael Porter and Tom Lee cite six components of high-value care-delivery systems: integrated practice units; cost and outcomes measurement; bundled payments; integrated care delivery across facilities; expanded services across geography; and an information technology platform to enable those processes.

As they note, Cleveland Clinic is one of two medical centers worldwide that has implemented all six, beginning with integrated practice units, which we call “institutes.” A patient-focused institute combines medical and surgical departments for specific diseases or body systems. All of our institutes are required to publish outcomes and measure costs. With bundled payments, we combine all the services provided before, during, and after a complex procedure like joint replacement, into a single charge. We have integrated care through shared protocols and the electronic medical record at all of our 75 care-delivery sites. And our expansion across Northeast Ohio into Florida, Nevada, and overseas allows broad geographic access to our services.

What makes Cleveland Clinic different stretches back to our founding 92 years ago as a physician-led group practice that runs a hospital – not a hospital that employs doctors. This distinction is important. Decisions from the CEO on down are made by physicians based on what is best for the patient.

Mining Data

As a leader in the electronic medical records, we have a wealth of data that can tell us what’s working and what’s not. For instance, we were able to comb through data of heart-surgery patients to find that those who received blood transfusions during surgery had higher complication rates and lower long-term survival rates. This finding – mined from our own data – changed the way we do things; we now have strict guidelines in place to limit transfusions.

We’ve made similar strides in many other clinical areas, using data to drive quality. By collecting data on provider performance and making that data transparent, central-line infections have decreased by more than 40%, while urinary-tract infections have dropped 50%.

Data can help identify variations in clinical practice, utilization rates, and performance against internal and external benchmarks, leading to improved quality and a sustained change in culture. Last year, we established a values-based care team, which seeks to eliminate unnecessary practice variation by developing evidence-based care paths across diseases and to improve comprehensive care coordination so that patients move seamlessly through the system, reducing unnecessary hospitalizations and ER visits.

Lowering Costs Without Compromising Quality

American health care is on an unsustainable path. Health care spending topped $2 trillion in 2011. The Centers for Medicare and Medicaid Services predicts that without major change, it will account for more than 20% of GDP by 2021, up from 5.2% percent in 1960. What that means is that if we continue on our current path, $1 in every $5 spent in the U.S. economy will go toward health care.

We can choose a different path, though. At Cleveland Clinic, we’ve been engaged in an ongoing effort to trim costs across the entire system. Through a concerted focus on our supply chain, we use rigorous value-based purchasing protocols, market intelligence, and business analytics to examine every purchase from the standpoint of value, utility, and outcomes. Over the past two years, this has resulted in cost savings of more than $150 million.

Our electronic medical records are also programmed with a “hard stop” function to reduce unnecessary duplicate tests. This led to a 13% reduction in blood-gas determinations, generated $10,000 in monthly savings for laboratory tests, and resulted in savings of $117,000 in just the first month for genetic testing.

A key part of the cost solution is to educate all caregivers, including doctors, about what items cost. Earlier this year, we created a Cost Repositioning Task Force to work with all caregivers across the entire Cleveland Clinic system to assess everything we do and everything we spend. Now, as part of the purchasing process, dozens of doctors gather to discuss the merits of certain products: Which ones provide the best outcomes for patients? How many are needed? How much does it cost?

Traditionally, knowing the cost of a stitch or a catheter or a bone screw — or any of the thousands of other supplies used during surgeries — hasn’t been part of doctors’ medical consciousness. To remedy that, we’ve taped price lists to supply cabinets in some ORs. In others, posters remind everyone to choose supplies carefully, stressing this message: “Without compromising quality, consider cost-effective alternatives.”

As health care reform kicks into high gear, providers are facing a difficult challenge: being paid less to produce better outcomes. We must view this as an opportunity, not a burden. After all, the providers who make the transition early will be rewarded with more satisfied patients, lower expenses, and pride in a job well done.

Follow the Leading Health Care Innovation insight center on Twitter @HBRhealth. E-mail us athealtheditors@hbr.org, and sign up to receive updates here.

Science alone can’t make tough decisions for us @kevinmd @Medici_Manager @pash22

by   http://bit.ly/1bjVWDk

On April 14, The United States Preventive Services Task Force concluded that women with an elevated risk of breast cancer – who have never been diagnosed with breast cancer but whose family history and other medical factors increase their odds of developing the disease–should consider taking one of two pills that cut that risk in half. The Task Force is an independent panel of medical experts who review the medical literature to estimate the pros and cons of preventive interventions. This is the same Task Force that in recent years raised questions about the benefits of mammograms in 40 to 50-year-old women, and PSA tests for men of all ages, tests that screen respectively for breast and prostate cancer. Despite the popularity of both of these tests, the Task Force concluded that their harms often outweigh their benefits.

The irony now is that with this report on breast cancer prevention pills, the Task Force has switched from rejecting something patients believed in to endorsing something most patients will reject.

The seemingly strange way the Task Force ping-pong’s between popular and unpopular recommendations is inevitable, because these kinds of recommendations must necessarily go beyond the medical facts – it is impossible to decide what preventive measures people need without making value judgments.

To understand the way facts and value judgments get mixed together in these kinds recommendations, let’s take a closer look at these breast cancer prevention pills.

For many years now, doctors have been prescribing tamoxifen as secondary prevention to women who have already undergone treatment for breast cancer, in an attempt to thwart any breast cancer cells remaining in their body. In women whose breast cancer cells express “estrogen receptors”, tamoxifen reduces the chance that this cancer will recur, by attaching itself to those receptors, in effect crowding outestrogen. In breast cancer cells, any estrogen landing on these receptors will spur that cell to divide and multiply. But when tamoxifen lands on these receptor sites, it does not stimulate cell growth.

Raloxifene is a close cousin of tamoxifen, which has primarily been used to treat women with osteoporosis. Like tamoxifen, it competes with estrogen for the attention of estrogen receptors. Also like tamoxifen, it slows down breast cancer by preventing estrogen from stimulating cell growth. As it turns out, both raloxifene and tamoxifen also have the strange property that when they collide with bone cells, they don’t fight against estrogen, but seem to mimic estrogen, and thereby improve bone health. (Because these drugs and sometimes act like estrogen and other times act like anti-estrogen, they are called selective estrogen blockers.)

Two very similar drugs, then. Both slow down breast cancer cells while stimulating bone cells. Each drug has been shown to cut the risk of a first breast cancer in half for women with a high risk of experiencing this disease. In what is known as the P1 trial, for example, women who faced an average five year risk of breast cancer of 6% saw that risk drop to 3%, if they took tamoxifen.

Sounds like a good deal, yes? Take a pill for five years, and cut your risk of breast cancer in half. But keep in mind, most women do not face a 6% chance of breast cancer in the next five years. Women with this kind of risk are generally retirement age or beyond, and usually have a bad combination of family history, early onset of menses, and late age of first pregnancy. It is these women the Task Force believes should talk with their doctors about whether to take these medications. And how did the Task Force reach this conclusion? By determining that for some women, at least, the benefits of these pills outweigh their harms. Before looking at this harm benefit ratio more closely, let’s put this Task Force conclusion into context.

The Task Force essentially produces three kinds recommendations, which I have taken the liberty to name.

  1. NADA: When it concludes that the harms of an intervention outweigh the benefits, the Task Force recommends that doctors and patients avoid the intervention. Think: ultrasound screening for pancreatic cancer.
  2. OUGHTA: When the Task Force concludes that the benefits outweigh the harms, it pushes to make the intervention standard of care. For example: routine screening for colon cancer in people 50 years or older.
  3. UP TO THE INDIVIDUAL: When the Task Force concludes that the benefits of an intervention potential outweigh the harms, depending on the patient’s individual preferences, it leaves the decision up to individual patients and their doctors to weigh. This is the recommendation the Task Force made both for mammography in 40 to 50-year-olds, and for tamoxifen and raloxifene to prevent breast cancer.

When making NADA or OUGHTA recommendations, the Task Force essentially makes its own value judgment. It looks at the risks and benefits of an intervention, and concludes that no sensible person could decide differently from the Task Force. In this third type of recommendation, however, the Task Force concludes that reasonable people could make different choices, based on how they weigh the risks and benefits of the interventions.

In the case of tamoxifen and raloxifene to prevent a first breast cancer, I expect the vast majority of women will conclude that the risks of the pills outweigh the benefits.  In the past two years, I have collaborated with a team of researchers at the University of Michigan (led by Angie Fagerlin, a decision psychologist in their medical school), to help women decide whether to take either of these pills. We developed an Internet-based decision aid, a tool designed to help patients weigh the pros and cons of their medical alternatives. (I write about the history of decision aids in my book, Critical Decisions.) Our decision aid provided women with individualized estimates of their odds of developing breast cancer in the next five years. We only directed women to the decision aid whose risk was high enough to have qualified for the P1 trial.

In the decision aid, we described the benefits of both drugs – the reduced risk of breast cancer and the strengthening of their bones. We also laid out the risks – a very small chance of endometrial cancer, a slightly larger chance of heart attack or stroke, a modest risk of cataracts, and finally a very strong likelihood of experiencing menopausal symptoms such as irregular menstrual bleeding and hot flashes. We actually provided them with precise numerical estimates of these side effects, with pictures illustrating the risks to make them easier to comprehend.

Women pondered the pros and cons and concluded, almost unanimously, that the side effects of these drugs outweighed the benefits.

The decision whether to take tamoxifen and raloxifene is no doubt a personal one, and the right choice will vary depending on how a given person weighs the respective risks and benefits of these medicines. For a woman with an extremely high risk of breast cancer over the next five years – say 10% or more – cutting that risk in half might very well be worth the hot flashes and the chance of experiencing blood clots. But very, very few women faced a five year risk is highest.

Consider, instead, a woman with a 3% chance of developing breast cancer over the next five years. That risk is much higher than average – most women face a five year risk of less than 1% – but is it high enough to justify taking one of these pills? For such a woman, tamoxifen and raloxifene only reduce that risk by 1.5%. Over five years. Five years with possible hot flashes. For a cancer women have not experienced yet. These modest benefits simply do not loom large enough to interest most women in these pills.

You might wonder at this point whether our decision aid biased women against these medications. As a physician trained in behavioral economics, I’m constantly on the lookout for decision biases. In the case of our study, however, we designed our decision aid in a manner that allowed us to test for well-known behavioral economic biases. For instance, research has shown  that when people face a choice between three options and two of the options are similar, they often opt for the more different alternative even if the other options are better. In other words, a person might believe that A > B, and A’ > B, but still choose B over A and A’, because they cannot decide between A and A’.

Aware of this problem, we created several different versions of our decision aid. In one version, we presented women with a choice between tamoxifen, raloxifene or no pill. Three choices in other words, two of which – the two medications – are quite similar to each other. In another version of the decision aid, we simply presented women with the choice between pill or no pill. We thought this simpler choice would increase women’s interest in these pills, by minimizing the difficulty of choosing between the two of them. But instead, this reframing of the decision did not increased women’s interest in either of these preventive medicines.

We also designed our decision aid to take account of another well-known decision bias, what are known as recency effects. When people learn about the risks of a medication and then learn about its benefits, that order of information leads them to look favorably upon the medication, because the information they remember best, the last information they receive, is about the pill’s benefits. By contrast, people who receive the same information about this medicine, but in the opposite order, like the pill less, because the last thing they learn about are the pill’s risks, and this information sticks in their minds. To make sure this recency effect was not influencing women’s decisions, we varied the order of information across women. We discovered that this did nothing to change their willingness to take either of these medications, mainly because whichever order women received information in, they did not like the idea of taking either pill.

If these pills are so unpopular among well-informed women, why would the Task Force come out in favor of them? It comes down to judgment. The Task Force concluded that a reasonable person could look at these risks and benefits and decide that the hot flashes and blood clots are acceptable prices to pay to reduce the chance of breast cancer. The majority of women don’t have to agree with this view for the Task Force’s recommendation to be correct. Even if only a small percentage of women decide these pills are worth taking, at least they have the freedom to make that choice. And at least they know that medical experts have concluded that such a decision is a reasonable one to make.

The same goes for whether to start mammograms before the age of 50 in women at normal risk of breast cancer. The Task Force never said that women shouldn’t start mammograms at this earlier age. They just said that it was a tough judgment call, and that some women, perhaps the majority even, might conclude that the harms of early screening – the anxiety caused by false negative tests, the pain caused by unnecessary biopsies – aren’t worth the modest benefits of screening at this age.

If the Task Force is going to leave all these tough decisions up to individual patients and their doctors, why should we care about their recommendations? For starters, you will have a hard time finding a more thorough and levelheaded evaluation of the pros and cons of these kinds of interventions. These people are very good at what they do. In addition, anyone reading through Task Force reports will be forced to recognize that science alone can’t make tough decisions for us. Ultimately, science can only provide us with the facts. The rest of us eventually need to make tough judgment calls. In effect, the Task Force is doing us a huge favor, by showing us which judgments are close calls, and which ones are no-brainers.

Peter Ubel is a physician and behavioral scientist who blogs at his self-titled site, Peter Ubel and can be reached on Twitter @PeterUbel.  He is the author of Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together.

Cosa significa Governance per @Treccani? @leadmedit @Medici_Manager @WRicciardi

GOVERNANCE http://bit.ly/1e4aJ3Q

Governance, tutti insieme aziendalmente

Nell’accezione di ‘insieme dei princìpi, dei modi, delle procedure per la gestione e il governo di società, enti, istituzioni, o fenomeni complessi, dalle rilevanti ricadute sociali’, il sostantivo aziendalistico-imprenditoriale governance, dritto dritto nell’italiano e nelle altre lingue europee del cosiddetto mondo economicamente più sviluppato, si impone, trasvolando l’Oceano Atlantico, a partire dagli inizi degli anni Novanta del Novecento (il GDU, diretto da Tullio De Mauro, certifica il 1988 come data della prima attestazione nell’italiano scritto).
L’anglicismo, che propriamente vuol dire ‘modo di dirigere, conduzione’, inizialmente ha battuto e ribattuto sulle pagine della stampa italiana le piste del mondo dell’impresa, soprattutto perché abbinato all’aggettivo (anglosassone pure lui) corporate‘aziendale’, nella locuzione corporate governance (in italiano dal 1994), che vale, «nel linguaggio aziendale, il metodo e la struttura organizzativa con la quale si distribuisce il comando tra i dirigenti di un’impresa» (Treccani.it).
L’orizzonte s’è allargato
Insomma, prima di togliersi, almeno un poco, di dosso le stimmate aziendalistiche, governance ci ha messo qualche anno, almeno a giudicare dai referti archivistici del quotidiano «La Repubblica»: a partire dalla prima attestazione nelle pagine del quotidiano, che è del 1994, nei tre anni successivi devono allinearsi l’una dopo l’altra 26 attestazioni sì, certo, di governance, ma soltanto come secondo elemento della locuzione corporate governance (usata metà delle volte al maschile, metà al femminile: e ancor oggi una sentenza definitiva sul genere non c’è), prima che, finalmente, compaia una governance“scorporata”, libera del marchio a fuoco delle regole e procedure organizzative relative alla distribuzione del comando e alle buone pratiche dirigenziali in azienda che l’aggettivo corporate porta con sé: nel 1997, alfine, si scrive degli «organi della governance economica internazionale» (vedi il primo esempio). E sia, sempre nell’ambito dell’economia restiamo, ma perlomeno l’orizzonte s’è allargato, la governance s’è significativamente traslata altrove: dal grattacielo coi vetri a specchio siamo passati ai consessi degli organismi che tengono (o credono di tenere) il pallino dell’economia internazionale nelle loro mani.
In questa accezione allargata di ‘governo, direzione’, governance finisce ormai da tempo, nel nuovo millennio, col riferirsi a fenomeni di più ampio e generale momento (sempre inquadrabili, in prima istanza, da un angolo visuale economico), fenomeni-cornice, si potrebbe dire, come certifica questo attacco di articolo del 2011, tratto dal «Corriere della sera»: «Il governo Sarkozy aveva dato grande rilievo alla definizione di un set di regole per la governance globale di Internet» (vedi l’ultimo esempio).
Le locuzioni in corporate
Va detto, comunque, che la configurazione dell’azienda (verrebbe da dire: dell’azienda-sistema e dell’azienda-struttura), come entità centrale nelle logiche e nei flussi di contrattazione (interni ed esterni) del denaro e del potere è caratteristica del pensiero economicistico contemporaneo e ha evidenti ricadute sul lessico, che, come si sa, tende a farsi carta assorbente delle ideologie dominanti. Basti un esempio: l’aggettivo cruciale di cui sopra, corporate ‘aziendale’, entra in composizione, negli ultimi trent’anni, in un numero crescente di locuzioni nominali anglosassoni, che poi si impongono nel linguaggio economico e aziendale delle principali lingue di cultura tradizionali, italiano compreso. Ecco allora, nella nostra lingua, arrivare una serie di locuzioni sostantivali, femminili e maschili, come corporate finance ‘complesso di princìpi, metodi e procedure per la gestione finanziaria di un’impresa’ (dal 1986); corporate bond ‘obbligazione emessa da una società privata’ (dal 1987);corporate identity ‘area della comunicazione d’impresa che stabilisce l’identità e la mission dell’azienda’; corporate communication ‘comunicazione d’impresa’ (1998); corporate image ‘reputazione di cui gode un’impresa presso i consumatori’ (1987), corporate strategy ‘strategia mirata alla creazione di valore d’impresa’ (1994). Oltre, ovviamente, al(la)corporate governance di cui già si è detto.
La gubernantia di Boezio
Il bello delle lingue, specialmente se omogenee o reciprocamente permeabili per via di radici in parte comuni e a causa della fittezza di scambi economici, sociali, culturali (per non dire di rapporti politici diretti, fatti di dominio e sottomissione, nel passato) intrecciati tra le comunità parlanti, è che spesso fanno circolare tra di loro parole che appaiono, si impongono in una forma e significato, poi scompaiono da una parte, permangono in altre, ma forse un po’ modificate nell’aspetto o nel senso, poi – come si dice colloquialmente – “ricicciano” dopo decenni, o magari secoli, da un altro punto dell’ecumene e rientrano nel vocabolario in forme in parte nuove e, ancora, in accezioni specifiche diverse rispetto all’origine. È il caso di governance, che – non senza una inusitata sapienza etimologica – il programma di correzione automatico del computer sul quale è stato scritto questo articolo cambia subito in governante. Già, perché l’etimo, evidentemente ha gli stessi lontani natali: governante dagovernare, da governogovernance (inglese) già nell’antichità dal francese gouvernance, a sua volta dal latino medievalegubernantia di Boezio (a sua volta dal verbo, del latino classico, gubernare, da cui il nostro governare). Di questa storia di trasmigrazioni e mutazioni, fortune e sfortune di parole apparentate nella vecchia Europa, scrive Tullio De Mauro nel lemmagovernance del suo godibile Dizionarietto di parole del futuro (Laterza, Roma-Bari 2006, p. 40). L’antico francesegouvernance «ebbe vita modesta e si usava per precisare meglio ciò che parole come governogovern o go(u)vernmentdicevano già benissimo: governo non solo come istituzione politica, ma come modi di regolare la vita sociale, economica ecc. di un’impresa, istituzione ecc.». Succede poi che verso il 1985 la parola inglese “riciccia”, rilanciata virtuosamente dalle istituzioni economiche internazionali. Il successo del “cavallo di ritorno” è immediato. In particolare, scrive ancora De Mauro, «[i]n tedesco e italiano l’anglismo pare senza alternative e piace anche a imprenditori nella locuzione corporate governance, governo d’impresa».
Il lemma
governance ‹ġa’vnëns› sostantivo ingl. (propr. «modo di governo, conduzione, direzione»), usato in italiano al femminile – A partire dal linguaggio aziendale, in cui indica maniera, stile o sistema di conduzione e di direzione di un’impresa (in particolare nella locuzione sostantivale corporate governance, propr. «governo, direzione dell’impresa»), il significato del sostantivo si è rapidamente allargato all’accezione di insieme dei princìpi, dei modi, delle procedure per la gestione e il governo di società, enti, istituzioni, o fenomeni complessi, dalle rilevanti ricadute sociali.
Elaborato dalla redazione di “Lingua italiana” del Portale Treccani
Esempi d’uso
Che se questo Paese ha recuperato negli ultimi anni qualcosa nella considerazione mondiale della sua essenza statale, questo è dovuto all’azione giudiziaria contro la corruzione pubblica e contro la criminalità di stampo mafioso. Gli organi della governance economica internazionale hanno infatti assunto questi due disvalori (corruzioni, crimine organizzato) come parametri universali di un giudizio che pesa su tutto il resto.
Andrea Mazzarella, «La Repubblica», 26 luglio 1997
Il quarto argomento è quello della governance della mondializzazione.
«Il Foglio», 24 agosto 2000 (citato in G. Adamo – V. Della Valle, Neologismi quotidiani. Un dizionario a cavallo del millennio, Leo Olschki ed., Firenze 2003, s.v. governance).
La più parte di essi ritiene che le risposte ai guasti della globalizzazione debbano essere apprestate dai singoli stati nazionali attraverso risposte politiche interne, e non da strumenti di governance sovranazionale.
«Il Manifesto», 28 agosto 2001 (citato in GDLI. Supplemento 2009, diretto da Edoardo Sanguineti, s.v. governance).
Il Ministro dell’Economia sulla costruzione della carta – «All’Ue non serve l’egemonia di un solo pensiero politico» – I pericoli vengono da una antidemocratica e tecnocratica «governance» – Con il «metodo comunitario» i Parlamenti e i governi delegano il potere d’intervento.
Titolazione da «La Stampa», 28 febbraio 2002
Il governo Sarkozy aveva dato grande rilievo alla definizione di un set di regole per la governance globale di Internet, presentato come un tema di rilievo dell’agenda del G8 di Parigi. Dire che la montagna ha partorito un topolino suona perfino ottimistico: le velleità francesi sono naufragate di fronte all’opposizione unanime delle altre potenze.
Carlo Formenti, «Corriere della sera», 1° giugno 2011
Silverio Novelli

“Dove e come mi curo”: trasparenza e informazione anche in Italia @Medici_Manager @WRicciardi

Walter Ricciardi http://bit.ly/19Urpbh

Dal 25 ottobre scorso – in virtù della direttiva europea 2011/24/UE – ogni cittadino dell’Unione Europea può decidere liberamente di ricevere assistenza sanitaria in ciascuno dei 28 Paesi membri.

È chiaro che, per scegliere il luogo dove curarsi, un cittadino dovrebbe avere accesso ad informazioni chiare, rigorose e tempestive sulla qualità dei servizi offerti, sia ospedalieri (quelli che giustificano il sacrificio di spostarsi da casa propria per avere cure adeguate), sia ambulatoriali e domiciliari. Proprio per questo motivo la direttiva UE raccomandava ai Paesi membri di attivare strumenti, soprattutto su internet, per informare i propri cittadini: in Inghilterra, ad esempio, questi dati sono disponibili da anni e, addirittura, dallo scorso luglio, sono disponibili on line i dati relativi ai singoli professionisti.

In Italia mancava finora un database informativo destinato ad orientare le scelte dei cittadini in ambito sanitario.

Questo sito ‘Dove e come mi curo’ nasce proprio per riempire questo vuoto e aiutare gli italiani a trovare le migliori strutture sanitarie cui rivolgersi per una certa patologia, ma anche per rendere tali strutture attrattive per gli stranieri.

Esso è il frutto di oltre due anni di difficile lavoro di un gruppo di ricercatori, supervisionati da un Comitato Scientifico di assoluto valore internazionale, che ha raccolto, elaborato e spiegato in modo semplice i complessi – spesso incomprensibili ai non addetti ai lavori – dati ed indicatori sanitari per permettere di scegliere dove e come curarsi in modo adeguato.

È un primo passo verso un sistema sanitario più trasparente e verso una partecipazione più attiva ed informata dei cittadini a quello che è ancora uno dei Servizi Sanitari migliori del mondo, ma ha al suo interno enormi diversità che rendono difficile per il cittadino orientarsi.

Ad oggi, è stato possibile includere soltanto alcune problematiche per cui erano disponibili dati ed informazioni pubbliche, ma vi sono ancora tante situazioni che interessano milioni di italiani che non hanno strumenti per scegliere in modo adeguato il proprio luogo di cura.

Confidiamo che la futura collaborazione sia con singoli cittadini, sia con le più importanti associazioni di pazienti che svolgono un lavoro importantissimo in merito, sia con le stesse organizzazioni sanitarie, possa ulteriormente ampliare e migliorare il sito, per la salute dei cittadini e per il bene del nostro Servizio Sanitario Nazionale.

Making Sense of Geographic Variations in Health Care: the New IOM Report @Medici_Manager @pash22 @goranhenriks

By ELLIOT FISHER, MD & JONATHAN SKINNER   http://bit.ly/173olKS

Since 1973, when Jack Wennberg published his first paper describing geographic variations in health care, researchers have argued about both the magnitude and the causes of variation.  The argument gained greater policy relevance as U.S. health care spending reached 18 percent of GDP and as evidence mounted, largely from researchers at Dartmouth, that higher spending regions were failing to achieve better outcomes.   The possibility of substantial savings not only helped to motivate reform but also raised the stakes in what had been largely an academic argument.   Some began to raise questions about the Dartmouth research.

Today, the prestigious Institute of Medicine released a committee report, led by Harvard’s Professor Joseph Newhouse and Provost Alan Garber, that weighs in on these issues.

The report, called for by the Affordable Care Act and entitled “Variation in Health Care Spending: Target Decision Making, Not Geography,” deserves a careful read. The committee of 19 distinguished academics and policy experts spent several years documenting the causes and consequences of regional variations and developing solid policy recommendations on what to do about them.  (Disclosure: We helped write a background study for the committee).

But for those trying to make health care better and more affordable, whether in Washington or in communities around the country, there are a few areas where the headlines are likely to gloss over important details in the report.

And we believe that the Committee risks throwing out the baby with the bathwater by appearing, through its choice of title, to turn its back on regional initiatives to improve both health and health care.

What the committee found

The report confirmed three core findings of Dartmouth’s research.

First, geographic variations in spending are substantial, pervasive and persistent over time — the variations are not just random noise. Second, adjusting for individuals’ age, sex, income, race, and health status attenuates these variations, but there’s still plenty that remain. Third, there is little or no correlation between spending and health care quality. The report also effectively identifies the puzzling empirical patterns that don’t fit conveniently into the Dartmouth framework, such as a lack of association between spending in commercial insurance and Medicare populations.
The committee also confirmed earlier work by Harvard investigators showing that, for the commercially insured population, variations in the prices paid by private health plans explain most of the variations in private insurance spending.  The committee deserves considerable credit for deepening our understanding of this irrational world of pricing commercial health care services.  Yet as the report finds, even in the commercially insured population, there are substantial differences in utilization rates across regions.  We would therefore argue that for commercial populations both price and utilization deserve attention, especially because in many regions, avoidable utilization may be easier to address than price.

It is Medicare spending growth, however, that represents arguably the greatest risk to the financial health of the U.S Treasury, and in Medicare, variations are almost entirely the consequence of utilization of services, not prices.  The report finds that the single largest component of the variation in Medicare spending across regions that remains after risk and price adjustment is due to post-acute care (including skilled nursing facility services, home health care, hospice, inpatient rehabilitation and long term acute care). These services have also been a major source of growth.

But this focus on post-acute rather than acute hospital and physician services misses the key point that dysfunctional regional health systems are characterized both by hospitals providing fragmented and expensive care and by a large and thriving post-acute care sector ready and eager to absorb the discharged patients.  For example, Joan Teno and colleagues at Brown University have established the strong association of inpatient treatments with no medical benefit, such as feeding tubes for people with advanced dementia, with high rates of regional resource use.

Which brings us to…..

The IOM committee’s policy recommendations: Where they hit the mark …

The committee makes five policy recommendations — and we agree with all of them.  First, they call for making more and better data available, on both Medicare and commercial populations.  Second, they recommend that CMS continue to test new payment models that encourage clinical and financial integration.  Third, they call for timely and iterative evaluation of current and new payment reforms so that improvements can be made to the models.  Fourth, they call on Congress to grant CMS the flexibility to accelerate the transition to value-based payment models as successful approaches emerge.

The fifth recommendation focuses on whether Congress should adopt a geographically based payment adjustment. When the committee was first mandated by Congress in the midst of health care reform in 2010, congressional members from regions with lower costs espoused a “Value Index” in which Medicare would reward low-spending regions with higher reimbursements, at the expense of high-spending regions. The committee concluded that payment mechanisms should not be tied to region, but instead targeted to individual providers, rightly criticizing the Value Index approach as not providing institutions and systems with the right incentives to reduce costs and improve quality.

… and where they fall short:  Geography does matter

We believe, however, that the committee, by subtitling the report “Target Decision-makers, Not Geography,” will confuse the media and casual readers (for example, those who don’t make it to page 3-3 in the full report) by appearing to cast doubt on the promise of geographic and regional efforts to improve the quality and efficiency of U.S. health care.

As the late Nobel-Prize winning economist Elinor Ostrom has emphasized, successful management ofcomplex social problems can best be achieved through sustained collaboration among diverse stakeholders, often across traditional political boundaries.  She demonstrated that cooperative agreements are often the most effective approach to solving the kinds of problems we face in health care. Among these are the natural instincts of physicians and hospitals within local health care systems to protect their financial health by expanding capacity and defending market share, whether by opening new cardiac centers when the one at the nearby hospital is perfectly adequate, or by buying proton accelerators that will be used to treat conditions where they offer no demonstrated benefit.

The rationale for a geographic focus on health care reform is strong:  the factors that determine population health are largely local, rooted in the environmental, social, economic, and behavioral determinants of health.  Many of the factors that influence health care quality and costs are also local, including local supply, pricing behavior, and the relative emphasis of providers on profit.  For example, in the widely cited New Yorkerarticle by Atul Gawande, Medicare utilization in McAllen was found to be nearly twice as high as that in another Texas border town, El Paso, despite the existence of multiple hospitals in both McAllen and El Paso, nearly identical Medicare prices, and common Texas malpractice laws.

Many regional multi-stakeholder initiatives have been established.   Although most began with a focus on quality, many are beginning to act more broadly to both improve health and lower costs: Three examples include Pueblo Colorado (Regional Triple Aim),  Akron, OH (Accountable Care Community), and the Atlanta Regional Collaborative for Health Improvement (focused on driving provider transitions to global payment, capturing savings, and reinvesting in strategic population health initiatives).

While the IOM Committee is exactly right to call for improved financial incentives for health care providers, we should also remember that both health and health care are local.  Geography matters.

Elliot Fisher, MD, MPH and Jonathan Skinner, PhD are professors at Darmouth’s Geisel School of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice.  Fisher is a  principal investigators, and Skinner is a senior scholar of The Dartmouth Atlas Project.

Fisher, Elliot S. & Skinner, Jonathan S., Making Sense of Geographic Variations in Health Care: The New IOM Report, Health Affairs Blog, 24 July 2013. Copyright ©2013 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.

The Importance of Teaching Value-Added Care @Medici_Manager @muirgray @WRicciardi @pash22

By Richard M. Schwartzstein, M.D. and Grace Huang, M.D. http://bit.ly/15Ww2hN

Richard M. Schwartzstein, M.D., Executive Director of the Carl J. Shapiro Institute for Education and Research, Vice President for Education at Beth Israel Deaconess Medical Center, and Faculty Associate Dean for Medical Education at Harvard Medical School

Grace Huang, M.D., Director of Assessment at the Shapiro Institute and Assistant Professor of Medicine at Harvard Medical School

No topic is more timely or relevant to the current political climate than cost-effective care. We at the Shapiro Institute for Education and Research prefer to frame the concept as “value-added care,” which incorporates patient-centered outcomes, including potential harm and discomfort from diagnostic testing. In the face of data that demonstrate wasteful testing and treatments contribute significantly to our rising health care costs, practicing physicians are under pressure to be part of the solution.

The lay public clearly is attuned to this crisis as expressed in the popular press and media reports and is demanding to know why physicians are not taught to consider the value and cost of the tests and treatments they recommend. Changing physician behavior, however, requires more than knowledge-based instruction; rather, we must identify and address the cultural factors that contribute both to patients’ demands and expectations and to physicians’ actions.

Our historical model for training physicians has neglected to incorporate contemporary principles of resource utilization, harm from diagnostics, and cost considerations into medical education curricula. The medical, physical, and emotional consequences of false-positive testing are not real to medical students. Even in the hospital environment, where trainees become increasingly aware of delivery issues—such as readmission rates, observation status, and case management—they still operate under assumptions that tests and services are fully reimbursed and that hospitals are profitable. Consequently, when residents enter the workforce, they are unprepared for the economic realities of our health care system and typically lack the tools necessary to navigate an optimal patientcentered, cost-conscious approach to the evaluation and management of their patients.

Topics such as epidemiology, evidence-based medicine, and diagnostic reasoning represent the cornerstones of the preclerkship curriculum for medical students. But the hidden curriculum and test-ordering practices of attending physicians (who often drive the ordering decisions of trainees) hinder the effective application of these theoretical principles during actual clinical experiences. Most faculty members are neither trained in high value care nor able to identify “best teaching practices.” Academic doctors, particularly those practicing in tertiary medical centers, strive to teach their students and residents the breadth and depth of medicine. The longer and more intricate the differential diagnosis, the better, and supervising physicians often are loath to stifle the curiosity of their trainees.

Patient expectations fuel excessive testing. The fear of malpractice litigation may incentivize health care professionals to pursue diagnostic certainty even at the cost, both financial and human, of multiple tests and procedures. Physicians may assume that patients will seek alternate care if their doctor is reluctant to pursue whatever test the patient thinks is necessary, regardless of the cost. Physicians also may opt for the perceived “easy way out” by giving the patient what he or she wants, rather than entering into a thoughtful, but timeconsuming and potentially difficult, conversation about the reasons for avoiding that diagnostic pathway.

There have been positive steps to reduce waste and contain costs. Campaigns such as Choosing Wisely at the American Board of Internal Medicine have spurred professional societies to highlight unnecessary tests for their specific specialties, while the High-Value Care Curriculum at the American College of Physicians (ACP) provides the knowledge elements and tools to deliver content. But these initiatives, although incredibly valuable starting points for these discussions, may not sufficiently address our medical culture, which demands diagnostic certainty. One key question remains: If we want to influence the actions of future physicians, how do we optimally teach these principles to our current trainees?

In this context, the Shapiro Institute convened an invitational Millennium Conference on Teaching Value-Added Care, co-sponsored by the AAMC and in partnership with the ACP. This spring, teams from six medical schools—Drexel University College of Medicine, Dalhousie University Faculty of Medicine, Geisel School of Medicine at Dartmouth, Case Western Reserve University School of Medicine, Penn State College of Medicine, and Mayo Medical School—joined the Harvard/Shapiro team to consider challenges of the learning environment, propose best instructional practices, and engage in a structured dialogue to build consensus on how to teach value-added care across the medical education continuum.

We will detail our findings in future proceedings. A preliminary summary includes the following highlights.

Value is not strictly about cost; it comes from the patient’s perspective. As such, we must teach and serve as models for the behaviors that elicit patient concerns and preferences about the many nonmedical factors that influence their perceptions of health care. To explain why a particular study highlighted in the media does not apply to an individual patient requires not only knowledge of study design and biostatistics, but also the ability to translate that information to a patient who may not fully understand the study results. Discussing the complications of testing, particularly the consequences of false-positive findings, is challenging and requires a range of communication skills.

Teaching value does not necessarily require significant amounts of extra time.When a test of questionable value is ordered, ask the student or trainee, “How will the results affect what we will do with this patient?” At the end of patient rounds, consider adding questions that foster appropriate test ordering, such as, “Is there anything we ordered today that the patient does not need?” During the traditional morbidity and mortality conferences, add a discussion of hospital costs incurred.

Tackle the hidden culture head-on. The clinical learning environment is typified by routine daily labs, unnecessary diagnostic evaluations, and repeat imaging. Foster a reward system that values cost-effective care by discouraging extensive differential diagnoses that include diseases that are obscure and have a low probability of producing the patient’s clinical picture. Train a core faculty with demonstrated expertise in teaching these topics. Incorporate practice audits of ordering behavior into the teaching competencies of faculty.

The deliberations and recommendations of the committed faculty who attended the Millennium Conference 2013 are only the beginning of our efforts to enhance the teaching of value-added care. We hope our findings will stimulate additional initiatives across the United States and Canada.