Category Archives: HPH Italia

Smokers will be asked to quit before undergoing surgery under new medical guidelines @Medici_Manager

Grant McArthur

SMOKERS will be asked to quit before undergoing surgery and be referred for help while on waiting lists under new medical guidelines.

A strengthened smoking policy from the Australian and New Zealand College of Anaesthetists will require all elective surgery patients to be asked if they smoke, and for tobacco users to be given referrals to help them quit before their operations.

The policy will not give practitioners the power to delay or cancel surgery. But ANZCA president Dr Lindy Roberts said the guidelines would offer smokers the best chance to avoid life-threatening complications by providing them with support.

The hope is to convince and help smokers to quit four to six weeks before surgery, while they are already on the waiting list, which can greatly cut the risks of serious complications during recovery.

“Smokers are at greater risk of complications such as pneumonia, heart attacks and wound infections,” Dr Roberts said.

“When you are coming into hospital for something like an operation, it does provide you with an opportunity to think about your health more generally, and the benefits of giving up smoking for your health are in the longer term as well as relating to surgery and anaesthesia.

“It may be that when presented with the risks for a certain procedure that the surgery is delayed to allow somebody to improve their health prior to the surgery.

“From time to time a decision may be made between the anaesthetist, the surgeon and the patient to delay the surgery if there is something that can be improved to make them fitter for surgery.”

The move follows the success of a Frankston Hospital program in which all smokers entering the surgery waiting list were sent a quit pack – prompting 13 per cent to act and contact Quitline. Australian Medical Association Victorian president Victoria president Dr Stephen Parnis said the college’s quit-smoking stance was a positive move, balancing the need to advise patients without discriminating.

“This is not about banning people, this is about giving them the best chance to benefit,” Dr Parnis said. “When you weigh into account the procedure they need and their health, if there is a benefit to delaying the procedure then we would do that.”

Approaching Illness as a Team @Medici_Manager @Doctor4Quality

The New York Times

Opinion Twitter Logo.

The Cleveland Clinic, long considered a premier medical system, is gaining new renown for innovation in improving the quality of care while holding down costs.

For Op-Ed, follow@nytopinion and to hear from the editorial page editor, Andrew Rosenthal, follow@andyr

In its most fundamental reform, the clinic in the past five years has created 18 “institutes” that use multidisciplinary teams to treat diseases or problems involving a particular organ system, say the heart or the brain, instead of having patients bounce from one specialist to another on their own.

The Neurological Institute, for example, provides both inpatient or outpatient care for those with strokes and brain tumors, as well as those with epilepsy, multiple sclerosis, depression and sleep disorders, among other conditions.

On a recent visit, we observed one such team, consisting of a neurosurgeon, a neurologist, a neuroradiologist, a neurologist with advanced training in intensive care, a physical and rehabilitation doctor, a medical resident, a physical therapist and a nurse. As they made rounds from patient to patient, they had a portable computer that displayed electronic medical records so that the whole team could see how the patient was doing and plan the course of care for the day.

This team approach can improve the quality of care because all the experts are involved in deciding the best treatment option, which can save time and money. The neurological team, by consensus, has been better able to determine which acute stroke patientsneed a risky and expensive treatment that involves threading a catheter through an artery in the leg up into the brain to destroy a clot. It cut the use of that treatment in half, reducing costs and deaths and improving outcomes.

The Cleveland Clinic has strong leverage to drive such reforms because its staff physicians are salaried and are granted only one-year contracts and subjected to annual performance reviews. Those reviews apply measures of quality, like patient improvement, patient satisfaction and cost reductions. It raises the pay of those who get high marks, reduces the pay of poor performers and even terminates some doctors who fall short. This approach could become more widespread as more hospitals and doctors move toward the salary-based model.

Data analysis to evaluate how well treatments work is also a big part of the medical practice. For instance, the clinic analyzed outcomes for heart surgery patients and found that those who had received blood transfusions during surgery had higher complication rates afterward and a lower long-term survival rate. As a result, it has adopted strict guidelines that limit the use of transfusions.

Such judgments about a treatment’s effectiveness are made by doctors, not by financial administrators, so they tend to be accepted. One analysis found that suturing could be done as well with a $5 silk stitch as with a $400 staple, leading to a big drop in the use of the staples. At the same time, the clinic has also carried out simpler reforms, like improving sterile conditions, which has reduced catheter-related bloodstream infections by more than 40 percent and urinary tract infections by 50 percent. All this has happened in a remarkably short time. Patients seem to like the treatment they get. A federal government survey of patient opinion last fall found that 80 percent of the patients gave the Cleveland Clinic a high rating over all and 84 percent would recommend it to others, well above the state and national averages in the 69 percent to 71 percent range.

Still, many patients are clearly unhappy. A series this year about confusing medical bills and unexpectedly high charges by The Plain Dealer of Cleveland elicited hundreds of patients’ complaints mostly directed against the clinic, because it had reclassified off-campus physician practices and health centers as hospital outpatient facilities and tacked on a “facility fee” for services previously billed at lower doctor’s office rates. The clinic says the added fees are justified because it provides better quality controls and health information technologies in its outpatient units than that available in a typical doctor’s office.

Medicare’s spending per patient at the clinic for an episode of illness that requires hospitalization is below the national median, suggesting that the clinic’s cost-cutting efforts are working. The University HealthSystem Consortium, an alliance of the nation’s leading nonprofit academic medical centers and teaching hospitals, gave the clinic one of its “rising star” awards in September for significant improvements over the previous year in quality, patient safety and clinical effectiveness, an indication that its quality efforts are taking hold.

The Cleveland Clinic’s progress in restructuring itself, said Michael Porter, a Harvard professor who analyzes health care delivery and organizational change, is “light speed” compared with other institutions. The clinic is “a model of where we need to go,” he said, “Not perfect, not done, but far along.”

A version of this editorial appeared in print on December 25, 2012, on page A26 of the New York edition with the headline: Approaching Illness as a Team.

The end of the hospital as we know it? @Medici_Manager

How profoundly do hospitals need to change and will there be a place for the hospital as we currently know it in the health system of the future?

I want to answer this question by reflecting on the current way in which the NHS thinks about this question in theory and acts on it in practice.

There is a growing chasm between what the NHS thinks should be done to change the hospital model and what it is actually doing on the ground.

Nearly every board or leading doctor or manager in the NHS thinks that the current model of hospital care should and will be radically different in the next decade. Most people would say that this has to happen if the NHS is not going to run out of money. So the driver for change is a powerful one. Change might take the form of:

  • developing integrated care pathways that have the bulk of the pathway outside of hospital moving some categories of outpatients and day surgery out of hospital, or
  • removing the demand for emergency beds out of the hospital.

Sometimes this is backed by the idea of developing whole new models of care; sometimes it is backed by specific restructuring of current models of care.
But all around there is talk of radical change in the way in which hospitals operate. Most hospitals agree with this theoretical vision.

If you look at the long-term vision of most hospital boards, it contains a lot of change. If you add up the commissioning intentions of clinical commissioning groups (CCGs), together they create very different models of care for England’s hospitals.

Change – very radical change – in the nature of hospitals is in the air. The problem for the NHS is that it might just stay there – in the air. For in many parts of the country the moment a CCG starts to put this into operation a very different set of motivations comes into play.

In some of the CCG authorisation sessions that I have heard about, the second or third question that the panel asks the CCG is why they aren’t more worried about the way in which their commissioning intentions might ‘destabilise’ the hospital. Under those circumstances CCGs are puzzled. They look at the commissioning intentions that have just been marked green by the panel. They will have been congratulated because they have developed radical new approaches to integrated care in the home and the community.

But the moment they actually DO something they are told they should be more worried about destabilising the hospital.

This is backed up the possible action by the hospital at the moment when any of these intentions are put into effect. Hospitals still say that if you move these clinics out of the hospital, the hospital will collapse and it will be your fault.

In some parts of the country the old strategic health authority (SHA) (now a part of a new cluster and soon to be a part of the brand new NHS Commissioning Board) will then challenge the CCG about whether they really know what they are doing in moving this work out of the hospital.

  • How would they cope if the hospital fell over?
  • What plans have they got to replace the entire hospital when this happens?

It takes a brave CCG to say ’Actually whilst of course we have an input into that, it is not our prime concern.’

The brave CCG points to the new architecture and says that luckily Monitor will have the responsibility to the public ‘to ensure the continued provision of services.’ It is Monitor that will have the responsibility to look at the whole of England and see which providers are becoming unsustainable. It will be Monitor whose responsibility it will be to have plans to ensure that those services are maintained irrespective of the nature of the organisation.

My point here is that the NHS has a pretty good analysis of how the question at the top of the page should be answered. Of course it could be better; of course we probably need more fluidity in the thinking and more knowledge from other jurisdictions.

But the theoretical answer is not the problem. The problem is the practice of making the vision happen. Practically there are real road blocks placed in the way of putting that vision into reality.

Great CCGs and great provider trusts can and will get round and through those road blocks. But to radically change the hospital model in the NHS we need more than heroines and heroes.

To change something this big the whole system needs to encourage the change so that ordinary organisations can make it happen.

Professor Paul Corrigan CBE is an an Independent Consultant and Executive Coach.

The positive side of physician burnout @Medici_Manager

by Kenneth H. Cohn

My 86-year-old mother, who values her privacy, would be upset to learn I am writing about her, but I suspect our situation is similar to that of many children trying to care for aging parents while living hundreds of miles away from home.

Last Friday, she developed painful leg swelling that turned out to be due to a blood clot. Our family arranged with her physician for visiting nurses to give her shots of Lovenox until she was anticoagulated on warfarin. Two days later, the visiting nurse contacted me that she seemed confused and out of breath; we arranged for an ambulance to take her to a nearby emergency room.

Within an hour, I received a phone call from the most pleasant emergency room physician with whom I have ever spoken. She explained my mother was experiencing a rapid heartbeat from atrial fibrillation. She outlined the tests she needed to run, estimated the time they would take and promised to call me back as soon as she knew the results. Her voice was professional and soothing. She spoke from experience and made my mother and me feel special.

She called me back hours before her estimate, reassured me that my mother had no evidence of a stroke, and arranged admission to a telemetry unit that would monitor her heart rate and rhythm continuously.

When I told her how easy it was to talk with her, she said she had been a heart surgeon until she began to experienceburnout after eight years in practice. Having spent a total of six months of my surgical residency on the cardio-thoracic surgical service, I could only imagine how difficult life had been for her. A thoracic surgeon I know wrote about surgery as an impairing experience in “Better Communication for Better Care.”

The happy ending for her and her patients is that this doctor has found her niche. She is the perfect cultural ambassador for patients and their families who come in through the ER.

When I mentor fellow physicians, I often hear them say it is easier to become a highly trained specialist than to figure out what to do with their lives after being in practice for several years (or decades). I could tell that my mother found the experience reassuring because, as she awaited transfer, she said to me, “Kenneth, I have just two words for you, ‘Don’t worry.'”

I welcome your input.

Ken is a practicing general surgeon/MBA and CEO, who divides his time between providing general surgical coverage and working with organizations that want to engage physicians to improve clinical and financial performance.


The Cost of Assuming Doctors Know Best @Medici_Manager @hesham_abdalla

Articolo pubblicato da The Atlantic (

The success of a hospital system in Washington state is a strong signal that patient decision aids are powerful quality-improving, cost-cutting tools — but change is stalled by bad financial incentives.


Group Health Cooperative, Bellvue, Washington (BenjaminBenschneider/AECOM)

In most industries, quality-improving and cost-cutting innovations don’t sit around for years while people keep muddling through with old technology. When an innovation is ready for widespread use, it disrupts the market, whether the market wants it or not. In the process, some entrepreneur usually makes a killing.

That process hasn’t worked in healthcare, though — and because of that, we have a whole set of rarely-used innovations that are ready for large-scale implementation, and that could start saving money today. Those technologies include simple things like broader use of generic drugs, which can reduce pharmaceutical costs significantly; and better hand washing, which reduces the transmission of disease within hospitals and doctor’s offices. They also include more complicated interventions like Lean management, which has been implemented successfully at hospitals like Virginia Mason Medical Center in Seattle and Thedacare in Wisconsin, to make their care processes more efficient by cutting out useless steps.

The habit of assuming the doctor knows best has created a system where huge numbers of patients aren’t getting the treatment they would have chosen if they were fully informed.

Then there’s shared decision making, which helps patients be better informed about their treatment choices and make better decisions — and might be the most promising of the bunch in terms of improving care and reducing spending.

Shared decision making is a way of dealing with the tough questions posed by “preference-sensitive conditions” — conditions where there are multiple treatment options, and none of those options is clearly better than the others. That includes conditions like arthritis in knees and hips, low back pain, stable angina (chest pain from heart disease), and early-stage prostate and breast cancer. (Obviously, it doesn’t include emergency conditions like heart attacks and hip fractures, or conditions where there is clearly only one treatment.)

Deciding on a treatment for preference-sensitive conditions involves weighing a variety of risks and possible benefits, and different patients will end up making different “right” decisions because they have different values and preferences. The best example here is women with early-stage breast cancer. They can choose lumpectomy (surgery that preserves the breast) or mastectomy (which removes it entirely). The two options are equally good in terms of reducing the risk of dying of breast cancer, but they require different kinds of follow-up and different women prefer one over the other.

Making such decisions means that patients must have the relevant information about all their treatment options, and doctors must understand their individual patients’ preferences — basically, what they want from treatment. But too often, patients only hear about one treatment option, the one the doctor usually uses — and doctors routinely assume they know what their patients want without actually asking them. And in many cases, the doctor is wrong.

This habit of assuming the doctor knows best has created a system where huge numbers of patients aren’t getting the treatment they would have chosen if they were fully informed. It also means that hundreds of thousands of patients are going through surgery that wasn’t really worth it, and that they wouldn’t have chosen had they understood their options.

Shared decision making is a process designed to ensure that patients are fully informed, and then use that information to get the treatment they want. A common though non-essential part of informing patients is a “patient decision aid.” Decision aids can be videos, websites, or pamphlets, and they present the available medical evidence on all reasonable treatment options — including the option to do nothing — in a way that patients can understand. Decision aids also help patients understand what they value and how much risk they’re willing to accept. Doctors can participate in the process, too, by clarifying things for the patient and helping make sure there’s a good match between the treatment and what the patient wants.

There have been more than 80 randomized controlled trials on the effects of patient decision aids, and the results are pretty clear. According to the Cochrane Collaboration, which reviews groups of studies, using patient decision aids improves the match between patients’ preferences, improves patients’ knowledge of the possible results of treatment, and reduces the number of patients who still don’t know what they want.

Here’s the icing on the cake in terms of health care spending: Patients also tend to choose less invasive (and therefore less expensive) treatment options.

Even after those impressive results, shared decision making hasn’t reached universal adoption. One reason may be that randomized control trials aren’t always able to be generalized to medical practice as a whole. In theory, they’re the scientific gold standard for measuring effectiveness, but the environment of the trial can sometimes skew the results (because patients or doctors in trials are different from their real-world counterparts, or because people behave differently when they’re being watched).

But a new study from a hospital system in Washington state should be a strong signal to other hospital systems that implementation is possible, and shared decision making and patient decision aids are just as powerful as we expected them to be. Soon patients will understand their effects, and hospitals that don’t use decision aids risk getting left behind.

The Washington legislature recognized back in 2007 that decision aids are a valuable tool for improving medical care by helping patients make better decisions. They passed a law providing greater legal protection to providers who use shared decision making, rather than standard informed consent, and that law required the state to study the effects of shared decision making. As part of that study, Group Health Cooperative (an integrated insurer and hospital system) gave all 660,000 of their patients access to decision aids when they were considering any of a dozen preference-sensitive treatments. They also made all of the doctors and staff watch the decision aids, and kept physicians informed of how many of their patients were choosing surgery.

The results were striking. The paper, published in the September edition of Health Affairs, covers two orthopedic procedures — knee replacement and hip replacement for arthritis of those joints. During the year and a half immediately after they introduced the decision aids, rates of hip replacement fell over 25%; knee replacement went down 38%. Total spending went down 21% on patients with hip osteoarthritis and 12% for knee patients — not just on those patients who skipped surgery, but for the whole study population. That amounts to well over $1000 a year in true medical savings — money that can be spent on something else entirely, and isn’t just shifted from one payer to another.

Allow us to reinforce something from that last paragraph: over a quarter of patients were choosing not to have surgery once they were better informed. Looking at that one way, it’s great news: We can save a ton of money and make patients better off, just by doing a better job of targeting elective surgery. But it’s also a vicious indictment of our current practices: every day we continue not using decision aids, our medical system knowingly puts patients at risk of a wrong-patient error.

If shared decision making is so wonderful, why aren’t we already using it in every hospital and every doctor’s office?

The answers are neither satisfying nor pleasant. The most important reason should be obvious: the way we finance healthcare is set up to reward doing more, rather than doing good. This is particularly the case when it comes to elective surgeries. Group Health was able to make money by using decision aids to improve care, because they’re an integrated insurer and delivery system. When patients spend less on unwanted surgery, Group Health doesn’t lose money. Similarly, all Group Health physicians are salaried, so their surgeons get paid the same amount whether their patients get lots of surgeries or not. Most healthcare organizations don’t work that way, though–doctors and institutions get paid based on some form of fee-for-service, meaning they take in more money when they do more procedures.

Changing that payment system will be tough, but it needs to be done, because fee-for-service payment isn’t just making us spend more money than we need to for good care — it’s actually making our medical system worse.

Shared decision making isn’t the only technology being held up by bad financial incentives. Lean management, as we mentioned earlier, has been incredibly successful in reducing both process waste and overuse in a number of hospital systems across the country. But the payment system still forces systems that eliminate duplicative tests and unnecessary treatments to risk losing needed revenue. It’s much easier to continue over-treating patients, and continue getting paid to do it. We need a system that rewards entrepreneurs for eliminating waste as well as it rewards them for giving us new options. We’re not taking full advantage of the technology we have until we only use it where it works.

SHANNON BROWNLEE & JOE COLUCCI – Shannon Brownlee is the acting director of the health policy program at the New America Foundation. She has written previously for The Atlantic,New York Times Magazine, and The New Republic, among others. Joe Colucci is a program associate in the New America Foundation’s Health Policy Program and editor of the program’s New Health Dialogue blog.

Health of a Nation bug

Medical providers, local communities, and the public wellness movement
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Doctors and hospitals produce health care, but what people want really want is health @Medici_Manager @HarvardBiz

What Business Are We In? The Emergence of Health as the Business of Health Care

On January 19, 2012, after 131 years of operation, the Eastman Kodak Company filed for Chapter 11 protection in U.S. bankruptcy court. No doubt some people were surprised by this filing, because they grew up at a time when bright yellow boxes of film accompanied every family vacation and celebration. Those who were paying more attention offered many explanations for the bankruptcy. Central among them was that Kodak was late to recognize that it was not in the film and camera business: it was in the imaging business. With the advent of digital imaging, Kodak was outpaced by other companies that could better achieve consumer goals.

This lesson has been repeated many times over. In 1960, the editor of the Harvard Business Review, Theodore Levitt, wrote that the failure of railroads could be explained in part by the myopic view that they were in the railroad business and not the transportation business, which left them vulnerable to competition from cars, trucks, and planes. Levitt argued that it’s always better to define a business by what consumers want than by what a company can produce. Kodak had built a successful enterprise producing cameras, film, and photographic paper and chemicals, but what people wanted was images, and so when a better way to get those images was found, its customers followed.

The analogous situation in health care is that whereas doctors and hospitals focus on producing health care, what people really want is health. Health care is just a means to that end — and an increasingly expensive one. If we could get better health some other way, just as we can now produce images without film and transport people and freight without railroads, then maybe we wouldn’t have to rely so much on health care.

To some of us, the point may seem both obvious and irrelevant. We might concede that even if people don’t intrinsically desire doctors’ visits, medications, surgery, and imaging, those services are still the way to get people the health they want. Although that may be true, the leaders of Kodak or the railroads may have had similar thoughts in their own day. Yet they seem to have missed some signals. What signals might we be missing?

One signal is that while much of recent U.S. medical practice proceeds as if health and disease were entirely biologic, our understanding of health’s social determinants has become deeper and more convincing. An enormous body of literature supports the view that differences in health are determined as much by the social circumstances that underlie them as by the biologic processes that mediate them. Examples include the Whitehall study of British civil servants that revealed that civil-service grade is more strongly associated with mortality than any broad biomedical measure; research conducted in the Veterans Affairs health care system and elsewhere demonstrating the persistence of health disparities even within fixed health insurance and delivery systems; and models of fundamental causes that provide a conceptual explanation of how such disparities can persist over time, following different pathways in changing circumstances.

None of this evidence suggests that health care is not an important determinant of health or that it’s not among the most easily modifiable determinants. After all, we have established systems to support the writing of prescriptions and the performance of surgery or imaging but have found no easy way to cure poverty or relieve racial residential segregation. But the evidence does suggest that health care as conventionally delivered explains only a small amount — perhaps 10% — of premature deaths as compared with other factors, including social context, environmental influences, and personal behavior. If health care is only a small part of what determines health, perhaps organizations in the business of delivering health need to expand their offerings.

A second signal is that whereas in the past there was some implicit presumption that doctors and hospitals provide health care of consistently high quality, that presumption is now being challenged, and we’re getting much better at identifying, measuring, reporting, and targeting health outcomes. For decades, health plans, states, and the federal government have been publishing quality data at the levels of conditions, populations, physicians, and hospitals. Some of these data reflect processes — for example, which hospitals are better at giving aspirin to patients with acute myocardial infarction — but more and more data reflect outcomes, not just for patients within hospitals but for the populations surrounding them. The Mobilizing Action toward Community Health project has been publishing ratings of county-level population health. Employers increasingly focus on employee wellness, on one side, and disease management, on the other. Research funding increasingly supports efforts to improve these measures and effectively communicate outcomes. Each of these approaches has advanced incrementally over decades. This trend reveals an interest in what ultimately happens to individuals and populations.

A third signal is that health care financing is testing these pathways too. Payment systems that will not reimburse preventable readmissions or that bundle payments for goals or episodes of care rather than visits reflect a population approach to health focused on outcomes rather than processes. Today’s standard approach of reimbursing for office visits and hospitalizations is likely to be displaced once better measures of outcomes can provide a substitute that’s more relevant to our key goals. If we can measure success, why pay for process? If we can get the images we want in a better way, why use photographic film, paper, and chemicals?

In the future, successful doctors, hospitals, and health systems will shift their activities from delivering health services within their walls toward a broader range of approaches that deliver health. Although we’re seeing the earliest steps in this shift toward accountability for health, we currently lack both good tools for moving forward in any substantial way and more established pathways for redirecting financing toward those outcomes. What do we need to move from a product-oriented industry to a customer-oriented one?

Surely, Kodak’s employees and shareholders lost something as their company lost business to other firms. But the world is at least narrowly better thanks to the ways photographs are now produced. Doctors and hospitals who pay attention to the business they are actually in — defined by the outcomes their “customers” seek — will leave the doctors and hospitals who don’t behind, captured in a Kodak moment.

This article first appeared in The New England Journal of Medicine and can be accessed along with additional information here.

More on: HealthInnovation
David A. Asch and Kevin G. Volpp


Both David A. Asch and Kevin Volpp are physicians at the Philadelphia VA Medical Center, Professors of Medicine at the Perelman School of Medicine at the University of Pennsylvania, Professors of Health Care Management at the Wharton School, and Scientific Advisory Board members of VALHealth. Dr. Asch is Executive Director of the Leonard Davis Institute of Health Economics and the Penn Medicine Center for Innovation. Dr. Volpp is Director of the Center for Health Incentives and Behavioral Economics.

Which hospital should I choose? How to use hospital rankings @medici_manager @drsilenzi @ashishkjha @kevinmd


After years of breaking down, my sedan recently died.  Finding myself in the market for a new car, I did what most Americans would do – went to the web.  Reading reviews and checking rankings, it quickly became clear that each website emphasized something different: Some valued fuel-efficiency and reliability, while others made safety the primary concern.  Others clearly put a premium on style and performance.  It was enough to make my head spin, until I stopped to consider: What really mattered to me?  I decided that safety and reliability were my primary concerns and how fun a car was to drive was an important, if somewhat distant, third consideration.

For years, many of us have complained about the lack of similarly accessible, reliable information about healthcare.  These issues are particularly salient when we consider hospital care. Despite a long-standing belief that all hospitals are the same, the truth is startlingly different:  where you go has a profound impact on whether you live or die, whether you are harmed or not.  There is an urgent need for better information, especially as consumers spend more money out of pocket on healthcare.  Until recently, this type of transparent, consumer-focused information simply didn’t exist.

Over the past couple of months, things have begun to change. Three major organizations recently released groundbreaking hospital rankings.  The Leapfrog Group, a well-respected organization focused on promoting safer hospital care, assigned hospitals grades (“A” through “F”) based on how well it cared for patients without harming them*.  Consumer Reports, famous for testing cars and appliances, came out with its first “safety score” for hospitals.  U.S. News & World Report, probably the most widely known source for rating colleges, released its annual hospital rankings, but this time with an important change in methodology.  While others have also gotten into this game, these three organizations bring the highest amount of care, transparency, and credibility.

What is particularly striking, though, is how differently the hospitals come out in the recommendations.   Just like the different car rating websites that emphasize different things, these three have also taken approaches very different from each other.  If we want to understand why some hospitals get an “A” on Leapfrog or are rated one of America’s Best Hospitals but get an abysmal score on Consumer Reports, we have to look “under the hood.”

It is worth noting that there are important similarities across the rating systems.  They each include hospital infection rates, though to varying degrees.  All three incorporate hospital mortality rates, though they weight them differently.  In accompanying blogs, colleagues from the Leapfrog Group andConsumer Reports each explain their methods and approach in far greater detail than I can, so I highlight what each emphasizes, and focus on their differences.

Let’s start with Leapfrog, whose primary focus is ensuring that when you walk into the hospital, your chances of being hurt or killed by the medical care you receive (as opposed to dying from the underlying condition that brought you in) are minimized.  Each year, as many as 100,000 people die in U.S. hospitals due to medical errors, a stunning number that has changed very little over the past decade.  The most common causes of death and injury in hospitals are medication errors and healthcare-associated infections, though there is no shortage of ways that you can be injured.  Leapfrog creates a composite safety score, emphasizing whether a hospital has computerized prescribing, how well it staffs its intensive care units, and what its rates of infections are.  Your chances of being injured in the hospital are generally lower at an “A” hospital than a “C” hospital.

Consumer Reports (CR) also calculates a “safety score,” but its focus is very different.  First, CR also incorporates infection rates.  It also emphasizes three areas not incorporated by Leapfrog.  The first is “double” CT scans (which, thankfully, are rare) and represent un-necesary radiation.  The second is patients’ reports on how well their providers communicated about medications and how well providers explained what would happen after discharge.  I’m a huge fan of patient-reported measures (it’s the one chance we consumers get to rate hospitals).  The challenge is that it captures both patientexpectations as well as hospital performance.   The latest evidence suggests that patients’ expectations, including their tendency to give high scores, vary a lot based on who they are and where they live.  A final area of emphasis is readmissions, a very complicated metric.  The best evidence to date suggests that only a small proportion of readmissions are preventable by hospitals.  In fact, good social support at home and the ability to get in and see your primary care physician probably matters much more than what the hospital does.  The other factors in the CR score that are emphasized less (including mortality) can be found here.

U.S. News has been rating hospitals for a while, though they made a very important methodological change recently.  Three things make up their score:  mortality (1/3), reputation (1/3) and other stuff (1/3).  The other stuff is a collection of safety and technology indicators.  The reputation score comes from a survey of specialists in each field and is meant to capture the intangible knowledge about hospital care that the rest of us don’t have.  Finally, and most importantly, they now emphasize mortality rates, which in many ways are “the bottom line” for a hospital’s performance.  Their risk-adjusted mortality rate captures both how well the hospital provides the right treatments (a.k.a. “effectiveness”) and how well it avoids harming patients (a.k.a. “safety”).

Implications:  Who wins and who loses?

Different approaches lead to different winners and losers (see table below).  In the Leapfrog scores, there aren’t large variations by hospital type (i.e. size, teaching status).  There aren’t large regional variations either – in every part of the country, there are lots of winners and losers.  It is worth noting that safety-net hospitals (as we have previously defined) generally do worse on Leapfrog (19% of those who got an “A” were safety-net hospitals, compared to 31% who got a “C”).

Because CR emphasizes infections but also patient experiences and readmissions, big “winners” on their score are small, community-based hospitals with very few minority or poor patients.  Hospitals in the Midwest do particularly well.  Major teaching hospitals do extremely poorly (three times more likely to end up in the worst quartile).  These worst quartile hospitals also have a lot more minority and poor patients – most likely because hospitals that care for poor patients have higher readmission rates (remember, poor social supports at home likely drive this) and worse patient experience scores.

U.S. News top-ranked hospitals are usually big, academic teaching hospitals.  On this metric, at least, it’s nearly impossible for a small community hospital to be rated as one of the best in the country.

What’s a consumer to do?

If you’re lucky enough to find a hospital that gets rated highly by all three organizations, I’d take that in a heartbeat.  It’s like finding a car that drives well, looks stylish, is reliable, and safe!  No brainer.  Unfortunately, those hospitals are rare.  In Boston, Massachusetts General Hospital was ranked the #1 hospital in the country by U.S. News.  It got an “A” from Leapfrog. It was near the bottom of Massachusetts hospitals in the CR rating, receiving a score of just 45 out of 100.

It can be easy to decide if the safety, or the style, or the performance of a car is most important to you. Unfortunately, choosing what’s most important in health care can make us ask difficult and seemingly unreasonable questions. Is my primary goal to survive my hospitalization, avoid infections and medication errors, or have a reasonably good experience?  Every individual has to decide what matters most.  If a low mortality rate is most important, U.S. News is your best bet.  If you care most about patient safety, then Leapfrog is the way to go.  Consumer Reports emphasizes infections, unnecessary radiation and patient experience.  If those matter most, CR is your best bet.

My personal list ranks mortality as most important (by far), followed by safety, with patient experience an important but distant third.  Others will make different choices. This is why we need different lists and different types of hospitals. It’s time for consumers to use this new information to make better choices.  I know that there is little precedent for consumers choosing healthcare providers based on quality.  I’ve always believed it is because they lacked good data.  In an era of greater transparency, if consumers vote with their feet, it’ll make hospital care better for everyone.

*Please note that I served on a blue-ribbon panel that advised the Leapfrog Group on their methodology.  I received no financial compensation for this effort.  The final choice of metrics and the scoring methodology for the Leapfrog Safety Score was made by the Leapfrog Group and not by the blue-ribbon panel.

Here’s how the rankings break out:

Which hospital should I choose? How to use hospital rankings

Ashish Jha is an Associate Professor of Health Policy and Management, Harvard School of Public Health.  He blogs at An Ounce of Evidence and can be found on Twitter @ashishkjha.

Strengthening public health services and capacity: an action plan for Europe @Medici_Manager

The WHO European Region faces new challenges in public health including epidemiological and demographic changes, an increase in lifestyle-related chronic diseases and the application of new technologies that push the boundaries of what can be achieved through health interventions. The Region’s countries are also burdened with disparities in the health threats they face and in their capacities to overcome them.

The aim of public health professionals, organizations and services is to protect health, prevent disease and promote the health and well-being of the whole community. This begins with an effort to understand why some communities are healthier than others, or why some communities have a greater prevalence of some diseases. Some public health problems are relatively new, such as widespread obesity and diabetes, and they interplay with the dynamic factors affecting public health, including health inequalities, lifestyle risk factors, demographic change, globalization and technological advances.

WHO/Europe supports Member States in evaluating the effectiveness and performance of their public health services and in devising strategies for reform. It also gives support and guidance for the development of public health laws, conducts stakeholder dialogues about public health, and works with relevant networks to support public health activities.

One such network is the South-eastern Europe Health Network (SEEHN). This was founded in April 2001 and today comprises representatives from the ministries of health of its ten member countries and five partner western European countries as well as five intergovernmental organizations. For the past nine years, SEEHN has been instrumental in promoting development in south-eastern Europe in the areas of mental health, communicable diseases, food safety and nutrition, blood safety, tobacco control, information systems, maternal and neonatal health, public health services and health systems.

The WHO European Region faces new challenges in public health including epidemiological and demographic changes, an increase in lifestyle-related chronic diseases and the application of new technologies that push the boundaries of what can be achieved through health interventions. The Region’s countries are also burdened with disparities in the health threats they face and in their capacities to overcome them.

The aim of public health professionals, organizations and services is to protect health, prevent disease and promote the health and well-being of the whole community. This begins with an effort to understand why some communities are healthier than others, or why some communities have a greater prevalence of some diseases. Some public health problems are relatively new, such as widespread obesity and diabetes, and they interplay with the dynamic factors affecting public health, including health inequalities, lifestyle risk factors, demographic change, globalization and technological advances.

WHO/Europe supports Member States in evaluating the effectiveness and performance of their public health services and in devising strategies for reform. It also gives support and guidance for the development of public health laws, conducts stakeholder dialogues about public health, and works with relevant networks to support public health activities.

One such network is the South-eastern Europe Health Network (SEEHN). This was founded in April 2001 and today comprises representatives from the ministries of health of its ten member countries and five partner western European countries as well as five intergovernmental organizations. For the past nine years, SEEHN has been instrumental in promoting development in south-eastern Europe in the areas of mental health, communicable diseases, food safety and nutrition, blood safety, tobacco control, information systems, maternal and neonatal health, public health services and health systems.

Why Hospitals Don’t Deliver Great Service @Medici_Manager @helenbevan @LaureenLMP

by Scott Simmons and Christie Fraser

Hospitals try to deliver the best health outcomes. That’s a given. But many also aim to deliver high levels of customer service. On that latter goal, healthcare systems are falling short. Here’s why: Truly improving service demands a culture that intentionally champions a focus on the patient.

Managers must be equipped to drive employee engagement in their departments.

What healthcare systems urgently need are clear intentions and strategies at the leadership level. These will determine whether a service mindset can exist within a hospital. What’s more, getting employees engaged and connected to this mission will ultimately determine whether they live out that mindset each day.

Gallup has found that a service-centered culture requires:

  • a committed leadership team that champions a philosophy that is aligned with service
  • employee commitment to providing outstanding service and quality
  • the strategic alignment of the organization’s plan, policies, and procedures with the goal of being service-focused
  • an established process to document and disseminate organizational knowledge and efficiencies
  • an ongoing commitment to improving performance and using proven tactics

It’s difficult to execute any vision for change in a service-oriented industry — even when leaders clearly communicate it to the organization — without an engaged and motivated workforce. Healthcare systems with a strong service-oriented culture recruit and hire people who fit that culture and begin sharing the vision during the recruitment phase and through orientation and onboarding.

A healthcare system must implement regular feedback mechanisms in the early stages of a healthcare professional’s tenure. The organization should check in with new hires after 30, 60, and 90 days, using these opportunities to assess whether the recruit is adapting to and thriving in the organization’s culture. The healthcare system should also continue to provide ongoing training and development, giving refresher courses about the vision and culture every 12 to 18 months. With leadership’s support, these engaged employees become ambassadors for the patients’ priorities.

After proper onboarding, a healthcare system must align its human resources policies to encourage service excellence and hold employees accountable to the standards. Managers must be equipped to drive employee engagement in their departments and held accountable for action planning and knowledge sharing. Aligning these activities with the hospital’s larger strategic plan and organization-wide goals is crucial and should be transparent from leadership down to the front line. One of the greatest challenges in any modern and multi-location system is that pockets of excellence exist, but best practices are rarely shared across units. Maintaining open and intentionally structured communication is a means to spread great customer service across an organization.

As in other service-based industries, consistency is key. A patient may interact with many areas of a hospital over the course of an inpatient stay, a series of tests, or a surgery. Receiving fantastic service in one area and mediocre service from another lowers a patient’s perception of the overall experience he or she has had.

Finally, every hospital must have a built-in mechanism for improving performance. Building performance improvement teams and using the Plan, Do, Check, Act model can help ensure that performance improvement is an understood and respected part of the culture.

What strong service cultures do right

Improving the patient experience is about changing a hospital’s culture.

Healthcare systems that can achieve a patient-focused service culture take improving the patient experience as seriously as improving financial and clinical outcomes. Gallup’s studies of healthcare systems that have built a strong service culture yield some dominating themes:

  • Strong and visible leadership that not only is committed to the patient experience but also is able to instill that commitment in the rest of the organization. There are typically two strong leaders involved in the process — a managing director or CEO who sets the vision and a head of nursing who helps execute the strategy.
  • A clear mission, vision, and values and a set of behavior standards that capture the intent of the organization and create accountability for service among staff members. These are not simply words on a page. Rather, hospitals must reinforce these beliefs and behaviors at orientation, staff meetings, and daily huddles. Ideally, facilities use real patient examples to ensure that the mission, vision, and standards resonate throughout the hospital.
  • Consistency across all messages so that managers and staff see the patient experience as a strategic objective that is as important as other financial and clinical outcomes. It’s essential that healthcare systems consistently communicate what constitutes the proper patient experience not only in the strategic plan but also in job descriptions and performance evaluations.
  • Buy-in from key constituencies, including physicians and the broader patient community. Negative relationships with either group can adversely affect a healthcare system’s change effort. Physicians are particularly sensitive when they don’t feel they have been involved in a significant directional shift. The general public — which includes past patients and their families as well as potential patients — also can form perceptions about a healthcare system’s brand based on their or others’ previous experiences. So hospitals must be deliberate in their messaging to overcome any lingering problems.
  • A family atmosphere that cuts across unit and departmental lines in every hospital. Creating this type of environment starts by recruiting and hiring people who fit the kind of culture that provides the best possible patient experience. Leaders and managers must make a point of stressing the sense of family and unity from orientation forward. The facility should instill a sense of common purpose in employees to the point where they start holding each other accountable.
  • A defined performance improvement approach that goes beyond service recovery. Service recovery can add to patients’ perceptions, but the organization must take proactive measures to identify and address ongoing problems, particularly those that extend beyond the unit level. Healthcare systems often create so many special teams and committees that each group’s responsibilities and role are not clear. The best performance improvement teams have a defined mandate or charter and clear communication channels, and they provide constant communication on their progress to others.
  • A proficiency in baseline tactics such as rounding, using whiteboards for pain management, and establishing “no pass zones.” Gallup finds these efforts necessary but not sufficient for improving the patient experience. For example, rounding can be even more effective when the information is trended and used as a performance improvement tool. Hospitals also can take a more comprehensive approach to discharge planning. Facilities can focus on process or discharge materials, for example, without factoring in elements such as wait time or the attention staff members pay to the patients between the time they are told they are discharged and the time they actually get to leave the hospital.

Senior leadership’s responsibility

Improving the patient experience is about changing a hospital’s culture, and this change is the single most powerful and legacy-defining step a leader can take to improve the care for a community. Senior leadership must not only take responsibility to make the patient experience a priority but also must allocate the necessary time and resources to make this focus a reality. Without this backing and accountability, any efforts to improve the patient experience will not succeed.


Overtreatment Is Taking a Harmful Toll @FLAHAULT @LeapfrogGroup @drsilenzi


When it comes to medical care, many patients and doctors believe more is better.

But an epidemic of overtreatment — too many scans, too many blood tests, too many procedures — is costing the nation’s health care system at least $210 billion a year, according to the Institute of Medicine, and taking a human toll in pain, emotional suffering, severe complications and even death.

“What people are not realizing is that sometimes the test poses harm,” said Shannon Brownlee, acting director of the health policy program at the New America Foundation and the author of “Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer.”

“Sometimes the test leads you down a path, a therapeutic cascade, where you start to tumble downstream to more and more testing, and more and more invasive testing, and possibly even treatment for things that should be left well enough alone.”

Have you experienced too much medicine? As part of The New York Times’s online series The Agenda, I asked readers to share their stories. More than 1,000 responded, with examples big and small.

Some complained that when they switch doctors they are required to undergo duplicate blood work, scans or other tests that their previous doctor had only recently ordered. Others told of being caught in a unending maze of testing and specialists who seem to forget the patient’s original complaint. I heard from doctors and nurses, too — health professionals frustrated by a system that encourages these excesses.

Terrence Power of Breckenridge, Colo., said that after his wife, Diane, learned she had Wegener’s disease, an uncommon autoimmune disorder, the couple found it difficult to refuse testing recommended by a trusted doctor. The doctor insisted on office visits every three weeks, even when she was feeling well. He frequently ordered blood tests and X-rays, and repeatedly referred her to specialists for even minor complaints. Even when tests came back negative, more were ordered, and she was hospitalized as a precaution when she developed a cold. During one six-month period, she had 25 doctor visits. The couple was spending about $30,000 a year out of pocket for her care.

“He was convincing enough that we felt we needed to have it done,” said Ms. Power, 60, who recalls being sedated before an endoscopy procedure, one of the last tests she allowed her doctor to perform. “When they were getting ready to knock me out I was thinking, ‘Why am I doing this?’ But we felt like the doctor knew what to do and we trusted him.”

After several years of physical suffering and near financial ruin from the medical costs, the couple began questioning the treatment after consulting with other patients in online support groups. Mr. Power spoke with his own primary care doctor, who advised him to find a new specialist to oversee Ms. Power’s care. “It’s a really hard thing to determine when they’ve crossed the line,” Mr. Power said. “You think she’s getting the best care in the world, but after a while you start to wonder, what is the objective? He seemed caring, but he didn’t really consider my wife’s time and the suffering she was going through having all these tests done.”

Under the new doctor’s care, the regular testing stopped and Ms. Power was finally able to achieve remission. Now she sees the doctor only four or five times a year.

Sometimes the toll of too much medicine is brief, but emotional. Kara Riehman, 43, of Atlanta was vacationing in California when she lost a struggle with an ironing board in her hotel room and ended up with a black eye.

As the bruising peaked around 10 days, she called her doctor to make sure everything looked normal. But instead of seeing her, the doctor, through a conversation with the nurse, ordered a CT scan. She had no symptoms other than a bruised eye, but the doctor never spoke with her or examined her. The scan came back with an ambiguous finding, and the nurse told her it could be a tumor. She was then given an M.R.I. and for two weeks while she waited for the results, she worried she had brain cancer. The nurse called to tell her the M.R.I. was fine.

“It was really terrible,” she said. “It was only two weeks, but there is a lot of cancer in my family. I never actually talked to my doctor through this whole thing.”

The total cost to her insurance company was about $7,000. “It did change how I think about interacting with the medical system,” Ms. Riehman said. “It made me much more of a questioning consumer.”

Jim Donohue, a Brooklyn bank examiner, had to intervene on behalf of his father, now 79, who had a stroke in March 2007. Doctors in Florida put him on several medications, including two antidepressants, and soon after the man began hallucinating and showing signs of dementia. Mr. Donohue began researching the drugs, and learned they were associated with cognitive problems. He persuaded his father’s doctors to change the medication, and his father quickly improved. He has since recovered, and has been living on his own for four years.

“All the medical professionals seeing him along the way, the hospital, twonursing homes and nobody thought of this,” said Mr. Donohue, who said his father never should have been given a diagnosis of depression in the first place. “I don’t know if we have too many specialists and every one is trying to practice their specialty, but it should not have happened.”

When Kathryn Gullo, a teacher in the Los Angeles area, gave birth to twinsjust 25 weeks into the pregnancy, she was thrust into the intense medical care of the neonatal ward that saved her children’s lives. But when her daughter, Grace, was 3 months old she was transferred to a different hospital, where the doctors insisted on subjecting her to a battery of tests for symptoms that other doctors had dismissed as normal for her condition. “We felt like we were being bullied,” Ms. Gullo said. “I had enough faith in her previous doctors that it was then easy to say no.”

The family switched hospitals and their daughter, now 5 and living with mild cerebral palsy and some vision and feeding issues, continues to require specialized care. But recently, when doctors suggested an M.R.I. that would require that their daughter be anesthetized, Ms. Gullo and her partner, Katie Ingram, said they asked two key questions: “What new information will this give us?” and “Will it change what we are doing?” After talking to the doctor, they declined the M.R.I.

“Not every mystery has to be solved, and not every problem has to be addressed,” Ms. Gullo said. “That’s hard to get your brain around.”

The series is part of a larger New York Times project called The Agenda, which focuses on critical issues facing the next president and Congress. Join the conversation at The Agenda.


Healthcare 2020 – Bain & Company @drsilenzi @agnescheer @muirgray

By George Eliades, Michael Retterath, Norbert Hueltenschmidt and Karan Singh

We have been talking about healthcare costs for more than 40 years, but the worldwide financial crisis and subsequent climate of austerity are finally catalyzing change. Payers are searching for all available tools to stunt the growth of a sector that has successfully resisted cost containment for decades. Adding to the urgency for action is an anticipated global surge in demand precipitated by several factors: an aging population with chronic care needs, population and income growth in emerging markets and the potential for insurance coverage expansion due to health reform in the US and around the globe.

An increase in demand—even one accompanied by cost pressures—is generally good for companies supplying products to the healthcare sector. But in this case, it is concomitant with a precipitous decline in research and development productivity for pharmaceutical and medical technology companies, leading to a more than $100 billion loss in product exclusivity by 2015.1 Despite ongoing medical need across many diseases, these players can no longer depend on their innovation engine and pricing power to drive ongoing profit growth. The net result will be an unprecedented decline in the share of the overall healthcare profit pool captured by innovation-driven companies in favor of lower-margin sectors like generic manufacturers and providers.2

We do not suggest that healthcare will be less innovative over the coming decade, but rather that the focus of innovation will shift from the product arena to healthcare delivery. A demand surge in an environment of fiscal constraint and slower product innovation will create a climate that favors investment in new ways of delivering care, in part by applying the power of information technology—long overdue in healthcare, relative to other sectors. Indeed, the shift in emphasis from managing inputs, like the rate of adoption of new products and the number of physician visits, toward delivering outputs, like patient satisfaction, clinical outcomes and overall system savings, is already well underway.

Going forward, the critical question for companies will be how they can evolve their business model and thrive in a world of shifting profit pools by focusing on delivering better outputs, rather than by simply generating more inputs—more products, more procedures and ultimately more cost to the payers.

All of these disruptive changes will have two significant implications for the global healthcare market:

  • There will be radical changes in the relative size and growth of the various parts of the global healthcare profit pool. In the past, growth by sector has been relatively consistent, but by 2020 and beyond, growth rates across sectors and geographies will diverge.
  • The basis of competition in the marketplace will change as well. Different therapeutic areas will be affected in distinct ways by two significant trends: growing consumer engagement and increasing standardization of care (“protocolization”).3

How will you compete as global profit pools shift?

Even though the global profit pool will expand over the next 10 years, most players will need to develop new business models to win. We believe the total profit pool will grow at a compound adjusted growth rate (CAGR) of 4%—from $520 billion in 2010 to $740 billion in 2020—but lag overall healthcare expenditure as profitability declines in aggregate worldwide4 (see Figure 1).

Your business plans for the next decade will require a deeper understanding of the sector and regional shifts embedded in these global figures. For example, most of the growth in the global profit pool will come from increased volume in the delivery of care, while another significant source of growth will come from smaller sectors like contract research or manufacturing and nutrition, which are experiencing significant growth from a smaller base, particularly in the emerging markets.

Pharmaceutical companies will see low growth and some decline in margins over the coming decade. Brand-name pharmaceuticals will grow only 1%, and the market will become increasingly fragmented, as the main source of revenue growth will be smaller items like targeted oncology products.5 In the US the situation will be even worse, as the forecasted 1% growth rate will depend on substantial growth in the second half of the decade, overcoming patent expirations and pricing pressures. At the same time, generics will grow by 7%, driven by those same patent expirations as well as increased volume in emerging markets (and a few underpenetrated developed markets).

healthcare-2020-fig-01A_embedClick to enlarge

healthcare-2020-fig-01B_embedClick to enlargeGlobal medical technology products will grow 3%, but with lower profit margins due primarily to worldwide pricing pressure. The slowdown will come mainly from peak penetration of products, such as stents, in developed markets and competition everywhere from “good enough” products. In China there is already fierce competition from locally produced stents, and this pricing pressure will continue as the Chinese and others develop cheaper alternatives.6

New healthcare value chain players will expand the overall profit pool to some degree. While margins in almost every other sector will slow, the growth in these sectors will be dramatic. Contract research, manufacturing and sales companies and healthcare IT companies will see significant volume growth as pharmaceutical companies outsource more functions and the demand for data accelerates.7 Contract research organizations will expand through greater use of strategic alliances and risk-sharing arrangements with pharmaceutical companies. Contract manufacturing organizations will see 8% CAGR, in part due to their expansion into China and India.

Because of the uncertainty of health reform in the US, payers are not likely to experience the growth they have experienced in the past. Even if there is more insurance coverage, there will be lower margins because of pressure on premiums. In fact, the traditional business model of US health insurers is increasingly coming into question with the rise of accountable care organizations (ACOs). The net result is that the expansion in worldwide insurance coverage will come largely from emerging markets, with growth in Europe remaining fairly stagnant.

Providers of care worldwide will see the largest volume gains, but not necessarily any increase in their overall margins. These volume increases will drive 30% of the overall profit pool growth (about $70 billion), but profitability will be flat or will decline. In fact, the overall profitability of healthcare players is expected to decrease by about 1% by 2020.8 The slower growth in US and European markets will be offset to some degree by expansion in emerging markets like China and India, specifically for generic drug products. Rapid economic growth and the rise of chronic diseases will produce substantial gains for price-sensitive generic products, but weak medical insurance and gaps in delivery capability in rural areas will remain challenges for these economies.

China’s healthcare profit pool will grow from about $22 billion in 2010 to $113 billion in 2020, a CAGR of 18%, 9 suggesting appealing opportunities for new investments, but hospitals and other providers will drive 40% of that growth (see Figure 2).10 Those providers will benefit from an aging population and a rising middle class, and there are also some signs of government policies that are favorable to private investment in the sector. Pharmaceutical and medical technology companies will continue to realize attractive earnings before interest and tax (EBIT), but brand, generic and over-the-counter products will shrink by one percentage point because of government-enforced price cuts and the increasing purchasing power of distributors.

Likewise, in India, the delivery of care and pharmaceutical sales will make up most of the fragmented $65 billion market.11

healthcare-2020-fig-02_embedClick to enlarge
Disruptive changes will alter the basis of competition, creating new opportunities to redefine business models and enter new markets

The sheer size of emerging markets makes them attractive offsets to more stagnant growth in other regions of the world. But to be successful, companies will need new business models to take advantage of the opportunities there (see Figure 3). Profit pool shifts and the lack of access to healthcare in many countries, for example, may spur some pharmaceutical and medical technology companies to meet the challenge by opening clinics in the developing world, or even entering the private insurance market.

In the developed world, providers and payers are already entering the device or drug market. Companies like Fresenius Medical Care, which started out producing dialysis machines, have emerged to “own” an entire segment of care—vertically integrated with machines, clinics and drugs. With global government spending estimated at about $50 billion for dialysis products and services, but with shrinking reimbursement per treatment, the vertically integrated model may be an effective path to capture a very specific part of the profit pool.12

healthcare-2020-fig-03_embedClick to enlarge
While the specificities differ by market, the overall trend is that companies are seeking incremental growth in new profit pools that tie to disease knowledge or market know-how.

On what basis will you compete? If you can no longer depend only on increased volume or control pricing, where can you most profitably operate in the newly configured global market? This is where the acceleration of twin trends—consumer-driven demand and standardized and protocolized care—comes into play. These two trends are powerful and have the capacity to facilitate the shift to outputs over inputs, stimulating new opportunities for profitable growth, if you can adapt your business model.

  • With more information about treatments available to an increasing number of consumers or patients around the globe, every company with a product to sell must understand how best to engage with consumers, in a way that speaks to their individual needs and patient experience. Search engines have produced a vast engaged patient population we could not have imagined even 10 years ago: 80% of Internet users now search for health information online, and more than half look for specific information about a medical treatment or disease.13 The demand for more engagement is not limited only to the US and Europe. Mobile phones and Internet access are now available in most emerging economies. While there will continue to be cultural differences in the way consumers engage with their care, the degree of engagement itself will only intensify globally. More than one-third of Indians, for example, currently use the Internet to search for health information, with similar percentages of younger, more educated people seeking health information online in Brazil, Mexico and China.14
  • Along with the trend toward increased consumer engagement is an increasing professionalization of medical care processes. We call this trend protocolization because physicians and other providers are accepting and using more standardized protocols and guidelines for treating their patients. US providers have been somewhat slower to embrace clinical protocols than their European or Asian counterparts, but there is little doubt about the direction of this change. No longer will the individual physician be the lone decision maker. The cottage industry of medical care is being industrialized, as payers and providers increasingly align their businesses—and results—which may be threatening to some, but may well produce better care at lower cost.

Protocolization and consumerism will not affect all therapeutic areas equally

There are at least four “landscapes” where healthcare companies will have to make strategic decisions in order to survive and win (see Figure 4).15

On one axis of Figure 4, we included the conditions and diseases for which consumer engagement will be the main market driver; on the other, we have shown the degree to which standard protocol will guide treatment decisions. In some areas of treatment, both consumer engagement and protocolization will be in play, leading to an opportunity for patient-provider “teaming.” Both of these trends translate into reduced autonomy and decision-making control for physicians for established conditions.

Where there is a high degree of consumer engagement but low protocolization, the patient experience will impact the outcomes most strongly. Such treatment options are often cash-based or lifestyle therapies, like breast implants or erectile dysfunction. Brands will initially rule for these types of procedures because of their familiarity and marketing clout, but prices may be forced down over time as the experience curve is applied to these markets. The degree of protocolization for these therapies will start out weak, but will increase with competition, especially for treating conditions like infertility, where buyers perceive proprietary protocols to be an advantage.

healthcare-2020-fig-04_embedClick to enlarge
The more routine, protocol-driven therapies, such as for conditions like hypertension or procedures for knee or hip replacement, involve processes of care that are generally well accepted, but result in less physician discretion and patient choice. Manufacturers of products for these conditions will need to have good data to accurately price their products and ensure that they are included in any protocols being developed to guide treatment. Whatever patient marketing exists for these types of conditions will largely focus on adherence because care management, not just the specific product, results in better outcomes.

Where there is a high degree of consumer engagement along with a high degree of protocolization for diseases like breast cancer or Type 1 diabetes, manufacturers will need to be sure that they shape the protocols being used and target their marketing to those preferred therapeutic options. The “teaming” between providers and patients will be a significant challenge for payers and manufacturers. In the area of breast cancer alone, the existence of multiple effective patient advocacy organizations will inform patients of their options, and they in turn will put pressure on doctors to find the optimal treatment regimen. Payers will attempt to control the protocol development in this area in order to control costs.

The physician-driven quadrant, with its lower degree of consumer engagement and protocolization, is a “business as usual” state, and there is unlikely to be significant growth in those types of markets. Therapies for migraines or attention deficit hyperactivity disorder (ADHD), for example, have fewer accepted protocols, and thus payers will continue to struggle to control utilization beyond mere cost shifting. New physician-driven therapies will, of course, continue to emerge, but the overall trend is clearly away from full physician control as markets mature and consumers become more involved in their own healthcare.

Over time, more diseases will move up and to the righthand side of Figure 4. Protocolization and consumerism will increase, and payers will demand and use better data about outcomes. Although these changes will not guarantee increased revenue, good outcomes should result in a better share of the profit pool for players that can shape the protocol development by demonstrating how their products create value.

Where can you play—and win—by 2020?

Only transformational business models will enable future winners to capitalize on the disruptive market changes at play (see Figure 5). The models identified in Figure 5 are very different from the business models being discussed in boardrooms today. Becoming a consumer marketing powerhouse, a disease population manager or a successful integrated care company will require different organizational capabilities. For example, for treatments and conditions where the degree of consumer demand is high, like health and wellness programs, or for treatments with high brand recognition, a consumer powerhouse approach can help produce differential growth and market share. For conditions with a high degree of protocolization like hypertension, a population- manager approach may be the answer. The most challenging model of all will be to create integrated care solutions that manage the full suite of products and services across the patient journey. This approach will require deep expertise in patient-centered care and the tools that support that care, such as real-time feedback, secure communication and digital technology to enhance patient participation.

These new approaches require a fresh look across the profit pool for each condition. Here are a few examples to think about:

  • For businesses in the more traditional, physician-dominated quadrants of Figure 4, winners will build the capabilities to deliver risk-sharing models, potentially partnering with payers and providers— or even directly becoming more involved in the delivery of care.
  • If you are operating in the top right-hand quadrant of Figure 4, patient-provider teaming, then you may need to partner or develop capabilities in data sharing and coordination to ”wrap around” the patient and manage a population for a payer or provider organization.
  • If you operate more in the consumer world, you may need to move beyond branding the product and start branding the procedure by forming alliances with certified providers that can perform the procedure or provide medication, such as exclusive, branded and certified botulinum toxin clinics.

healthcare-2020-fig-05_embedClick to enlarge

  • Where the various components of the profit pool have created silos, with products and patients being passed around among them, the trend toward protocolization and consumerization will break down barriers and create a more integrated approach for a given medical condition or procedure. Firms like Fresenius and DaVita are already doing this, and other healthcare companies will either participate in this trend or risk becoming mere commodity suppliers.
  • The industry’s metrics will need to change. Using annual budgets and per person savings will not reflect value adequately for either private or government payers. Can payers stay involved for long-term gain when paying for chronic diseases? Public payers may not be able to resist the pressures to simply reduce their costs. Private payers will need to identify ways to reduce cost and demonstrate improved quality. For providers, it will be a choice of joining the rush to become an integrated care company or trying to find room to be a branded provider of choice.

For a select few, the old models could work—breakthrough innovation will still drive profitable growth, but few, if any, have proven the ability to sustain this over time. Cost pressures will force nearly every company in the industry to rethink how and where it will grow moving forward. Good strategic choices will still yield growth. A profit pool that is growing at a breakneck pace will no longer shelter poor choices. Executives and investors can and must know where the profit pools are shifting—and how they will change course to successfully compete.

George Eliades is a partner with Bain & Company based in San Francisco and a leader in the firm’s Global Healthcare practice. Michael Retterath is a Bain partner based in New York and a leader in the Global Healthcare practice. Norbert Hueltenschmidt is a partner based in Zurich and the head of Bain’s Global Healthcare practice. Karan Singh is a partner based in New Delhi and head of Bain’s Asia-Pacific Healthcare practice.

  1. IMS Institute for Healthcare Informatics, “The Global Use of Medicines: Outlook Through 2015,” May 2011.
  2. The methodology Bain used for developing this profit pool analysis is based on detailed health sector revenue and EBIT margin analysis for US and global sectors. The sector revenues are based and triangulated on latest market reports; the sector margins are based on company annual reports; the 2010-2020 CAGRs are based on market reports, where available, and Bain estimates; and the margin changes from 2010 to 2020 are based on proprietary Bain analysis.
  3. The term “protocolization” refers to the application of proven standards of care and consistent protocols and guidelines to reduce variation in the delivery of healthcare.
  4. Sources: Bain analysis, IMS, Datamonitor, Business Insights, Freedonia, annual reports, analyst reports, Centers for Medicare and Medicaid Services (CMS), OECD
  5. Sources: Datamonitor; based on top 50 branded pharma companies
  6. Sources: Business Insights, Datamonitor, analyst reports, Bain analysis
  7. Sources: Business Insights, Datamonitor, Parexel, analyst reports, Bain analysis
  8. Sources: IMS, Datamonitor, Business Insights, Freedonia, annual reports, analyst reports, CMS, OECD, Bain analysis
  9. Sources: IMS, BMI, Espicom, annual reports, analyst reports, China Health Yearbook, National Bureau of Statistics of China, Bain analysis
  10. Sources: IMS, BMI, Espicom, annual reports, analyst reports, China Health Yearbook, National Bureau of Statistics of China, Bain analysis
  11. Source: Bain analysis
  12. Fresenius Medical Care, “Forward Looking Statements,” 2009, p.31.
  13. Susannah Fox, Pew Research Center’s Internet & American Life Project – Health Topics, February 1, 2011,
  14. “Indians Increasingly Use Internet for Their Healthcare Needs,” Express Healthcare,
  15. Sources: International Guideline Library, National Guideline Clearinghouse data, National Health Service in UK, Medtech Insight and proprietary Bain analysis The methodology for determining the degree of consumer engagement and protocolization in Figure 4 was developed by collecting all the protocols on each disease from a variety of sources, scoring the current level of protocolization on a scale of one to 10 and then adjusting for prevalence and total spending on the disease. For consumerism, we monitored the presence of topics for each disease on a variety of patient websites and corrected for prevalence.

David Pencheon: Don’t always put patients first. @Richard56 @drsilenzi

26 Jul, 12 | by BMJ Group

David Pencheon

Patient health, patient experience, and health outcomes for individuals and populations should always be at the heart of the NHS. But the best way to actually achieve this most effectively might be to address it more obliquely.

Do you remember when some cabinet ministers (and their papers) emerged from 10 Downing Street and were caught on camera? One of the ministers had scribbled words to the effect of “we must put people first.” I thought this was rather good until Ian Hislop rightly pointed out that one really shouldn’t need to be reminded of this after so many years in public service and elected office. Similarly, although I can understand why we must strive towards a genuinely patient-centred health service (where the needs of patients should always come first), I wonder if that constant reminder doesn’t come at the cost of many staff feeling as though their needs come necessarily second. I heard the previous chair of the John Lewis Partnership, Sir Stuart Hampson, speaking recently at the NHS Confederation’s Annual Conference say much the same thing. (Some people in our family have a close association with said partnership and some with the NHS, and one works for both, so I am always keen to exploit this at the supper table.) Sir Stuart told countless inspiring stories of customer service; but when he was was asked how staff were trained to do all these outstanding tasks, he said they weren’t actually trained to do them. He ascribed such behaviour to a strong value base and culture in the staff and to deep seated “employee engagement;” all clearly borne out of the fact that the enterprise is genuinely a partnership.

Now, other than faith groups, there cannot be many organisations in the UK who have such a socially minded and ethically based set of values as the good ship NHS (despite the fact that such values are easier to espouse ritually than to deliver 24/7). I wonder therefore if there are some better ways towards improving patient care. Not by blindly putting the needs of patients above the needs of staff, but by acknowledging that meeting staff needs is an integral part of meeting the needs of patients—in fact we should acknowledge it is an essential part of high quality patient care.

This is an especially fertile time for re-establishing values: with the NHS Mandate at the consultation stage, the NHS Constitution being reviewed, and the establishment of numerous other national and local bodies, from Health Education England to local Clinical Commissioning Groups. Crises are far too good to waste, especially if one is interested in change for good. We could perhaps improve patient care most by investing more in staff needs and staff development.

None of this is new of course. Angela Coulter, perhaps one of the most perceptive observers, commentators, and actors on the stage of healthcare policy and practice has long espoused the fact that happy staff make happy patients. We should therefore reconsider trying to attain our goals too directly, and take counsel from the like of John Kay (of Obliquity fame) and remember that some of the most important goals in life (and perhaps of the health service) can be reached more efficiently, more ethically, more sustainably, and more fairly, by taking the more indirect approach.

David Pencheon is a UK trained public health doctor and is currently director of the NHS Sustainable Development Unit (England).

Posted in Guest bloggersNHSNHS reform.

How can primary care be a policy leader? @Medici_Manager @muirgray @drsilenzi @agnescheer

by  | in POLICY

The dream of reason did not take power into account – modern medicine is one of those extraordinary works of reason – but medicine is also a world of power.
-Paul Starr, The Social Transformation of American Medicine, 1984

How can primary care’s position be reasserted as a policy leader rather than follower? Even though it is a linchpin discipline within America’s health system and its larger economy – a mass of evidencecompellingly demonstrates that empowered primary care is associated with better health outcomes and lower costs – primary care has been overwhelmed and outmaneuvered by a health care industry intent on freeing access to lucrative downstream services and revenues. That compromise has produced a cascade of undesirable impacts that reach far beyond health care. Bringing American health care back into homeostasis will require a approach that appreciates and leverages power in ways that are different than in the past.

But primary care also has complicity in its own decline. It has been largely ineffective in communicating and advocating for its value, and in recruiting allies who share its interests. Equally important, it has failed to appreciate and protect primary care’s foundational role in US health care and the larger economy, as well as the advocacy demands of competing in a power-based policy environment.

The consequences have been withering constraints that have diminished primary care’s value, and that have thwarted its roles as first line manager of most medical conditions, and as patient-advocate and guide for downstream services. Combined with fee-for-service reimbursement and a lack of cost/quality transparency, primary care’s waning influence has precipitated a cascade of impacts, allowing health industry revenues to grow at more than four times the general inflation rate for more than a decade, with unnecessary utilization and cost that credible estimates suggest is half or more of all health care spending.

These impacts have been catastrophic not only for primary care physicians, but for patients, who are routinely exposed to unnecessary medical risks, and for purchasers, who for decades have borne an unnecessarily onerous economic burden. It seems unlikely that these groups’ prospects can improve without a meaningful change in the strategy pursued by primary care’s leading organizations.

The state of primary care

Primary care is a demoralized medical specialty. Recent Medscape data show that, on average, generalists make about half what their specialist colleagues do. Other surveys are more pronounced. A 2010 Graham Center study calculated a $3.5 million career income difference between primary care and specialist physicians.

None of this is lost on medical students. Faced with skyrocketing training debt, few now opt to make significantly less, so the percentage selecting primary care has plummeted. Between 1990 and 2007, the percentage of internal medicine residents becoming generalists dropped by 80%.

Then there’s office visit duration. Lower reimbursements and changing health status dynamics have translated to significantly shorter visits with more complex patients. Complicated patients who warrant thorough work-ups will often require more time than is allocated, meaning that they may cost more than they generate. This at least partly explains why specialty referrals have doubled in the last decade. Traditional primary care patients have increasingly become specialty cases, exposed to excessive specialty visits, diagnostics and procedures.

The growing inability of primary care physicians to succeed in private practice has precipitated a wholesale flight to health systems, where many doctors become “feeders” for outpatient and inpatient services. In 2010 the Medical Group Management Association reported that the share of practices owned by physicians had dropped from two-thirds to half in only three years. That trend continues.

Many of these dynamics are rooted in the relationship between the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association’s specialist-dominated Relative Value Scale Update Committee (RUC), which formulates recommendations for the value of medical services. This controversial and opaque process – former CMS Administrator Tom Scully recently described it as “highly politicized” and “not objective” – has overvalued specialty services at primary care’s expense, and inhibited primary care’s ability to hold specialty care accountable. Still, despite the RUC’s ongoingdisregard for primary care’s interests and value, primary care societies continue to argue that “being at the table” means having a say.

The need for a new organization

Primary care’s second rate status in the US results from organizational structures that are not constituted to cope with American health policy’s power dynamics. Generalists stand no chance against a far larger, wealthier and more influential health care industry that can field billions of dollars to promote ever-increasing health care spending.

At the same time, no single organization represents primary care professionals’ overarching interests. Nor is there one that aggregates their many groups (and their collective influence) to effect policy change that values primary care as medicine’s foundation. Generalists have diluted their modest influence, which derives from about 30 percent of American physicians, by scattering loyalties among six different medical societies. Several of these societies also advocate for sub-specialist interests that, contrary to their protests, may conflict with those of primary care.

Nor does primary care’s policy agenda meaningfully acknowledge that it isn’t only about them. Within health care, primary care’s competitors are the rest of the health care industry, comprising nearly one-fifth of the US economy. But outside the industry, one group, non-health care business, makes up the other four-fifths. Much larger and more influential than health care, non-health care business has suffered significant harm from American health care’s egregious inflation and waste. It should be primary care’s most powerful ally.

A new primary care society could reinvigorate the debate about what kind of health system our children will inherit. It could broaden primary care’s power base by being inclusive, acknowledging non-physician professionals and other groups in service to primary care’s larger missions, unifying it as a specialty, and embracing a 21st century vision of what medicine can be. Support from non-health care businesses and institutions could extend that power base further, re-establishing primary care in policy as the basis of a medical system built around evidence, appropriateness, efficiency, quality, safety and value.

A new primary care organization would not replace existing medical societies. Instead, it would become strong by convening and emphasizing other societies’ most positive attributes, providing a counterweight to the sub-specialists’ perspective. Ironically, the exemplar for this approach is the American Medical Association, which brought together all medical societies in its House of Delegates, then evolved to advocate against primary care and for specialists. This fact is evidenced by its insistence on disproportionate sub-specialist voting representation on the RUC, American health care’s most influential federal financial advisory panel.

Primary care is in decline because it is fragmented, inwardly focused, and structurally incapable of protecting its mission and value in the face of far larger forces. Within the ferocious world of influence, a new society would seek to drive policy that invests in America by investing in primary care’s capabilities.

Success will require primary care to amass much more power, pooling its resources, aligning with other more powerful groups and developing a unified voice under the umbrella of a new society. Only then could primary care’s value be feasibly reestablished within American health care.

Brian Klepper is Chief Development Officer of WeCare TLC and blogs at Care and Cost.

HEIDI Wiki (Health in Europe: Information and Data Interface)

Heidi – Health in Europe: Information and Data Interface – is a comprehensive search tool for European health information and data. It contains information about health status, determinants, diseases, health systems, trends, institutional and policy aspects – and much more.

Whether you want to know more about tobacco control or learn about the cancer burden in Europe, Heidi can help you!

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A way to provide palliative care globally @Richard56

25 Jun, 12 | by BMJ Group

Richard SmithPalliative care globally lacks funding, professionals, and medicines (particularly morphine) and suffers from policy neglect, said David Praill, chief executive of Help the Hospices, opening a meeting in London on global palliative care. Palliative care should cover all patients, all diseases, all nations, all settings, all dimensions (physical, psychological, social, spiritual), and begin earlier, said Scott Murray, professor of primary palliative care in Edinburgh, closing the meeting.

At the moment 42% of 234 countries have no palliative care services, and very few countries have palliative care services that are integrated into mainstream care. In almost all countries the services are patchy, and even in Scotland, which along with the rest of the UK has some of the best services in the world, only 29% of patients die with a care plan in place. (Almost unbelievably, a recent survey showed that third of British GPs had never initiated a conversation with a patient about his or her end of life wishes.)

A series of studies shows that over 60% of people in all communities want to die at home, said Barbara Gomes from King’s College, London; yet only a minority do—21% in England, 23% in Belgium, 30% in Canada, 34% in the Netherlands, and only 17% in  Norway. (Scotland has no data remarkably, and in Africa people are carried from hospital when terminally ill because it’s five times more expensive to transport a corpse than a (just) living person.) Deaths at home in the US have increased since policies were introduced to encourage the switch from curative to palliative care. In England deaths at home declined progressively until 2004 but have since increased.

Some 80% of people in the world lack access to morphine, and, as Anne Merriman, a pioneer of palliative care in Africa, says “Palliative care without morphine is only supportive care.” The point was made forcefully at the meeting that “Lack of access to morphine is torture.”

Only 12 countries have an end of life strategy, of which England is one.

A palliative care service run entirely by health professionals is not only logistically impossible for most of the world but also undesirable, suggests WHO. Libby Sallnow, a research fellow from Edinburgh University, described the remarkable Neighbourhood Network in Palliative Care in Kerala, which is based on the concept that “chronic and incurable diseases are social problems with medical complications.”

The network was started by doctors in 2001 and employs doctors and other clinical staff, but it belongs to the community and is staffed primarily by 12 000 volunteers. The network cares for 15 000 patients, and the provision of home based palliative care in the state has increased from 2% to 70% in 10 years. Provision in the rest of India is still around 2%. Almost all (90%) of the funds to support the network are raised locally, and 70% of the contributions are under 20p. This demonstrates the deep community roots of the project, and the network is endorsed by many local organisations, including the state government and the police.

There are, said Sallnow, two challenges for palliative care services: access and providing meaningful care. Britain has not solved the problem of access, and it may be, suggested Sallnow, that care by a multidisciplinary team has replaced existing care networks and is not meaningful care. Atul Gawande, the American surgeon writer, who was also quoted at the conference says. “In the past few decades, medical science has rendered obsolete centuries of experience, tradition, and language about our mortality, and created a new difficulty for mankind: how to die.”

Kerala seems to have overtaken Britain with both access and provision of meaningful care, and its model is beginning to spread. Bury St Edmunds, for example, is creating something along similar lines, and Bangladesh, which at the moment has no palliative care services, hopes to learn from Kerala.

Critics wonder if it will be possible to create a similar model outside Kerala, which is recognised by all to be a special state with a strong history of social activism. Challenged with this question, Sallnow pointed out that the network had begun among Muslims and people had said it would work only among Muslims. Then as it spread people said that it would work only in one part of the state—but it has spread across the state.

The Kerala model does provide a feasible way of achieving Murray’s vision of palliative care covering “all patients, all diseases, all nations, all settings, and all dimensions.” It’s hard to see how it will be achieved in another way.

Competing interest: RS is a friend of some of the leaders in palliative care and spoke at the conference on “Embracing death in all its glory.” He wasn’t paid and didn’t need expenses.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.

Posted in Richard Smith.