Tag Archives: Competizione

Una lettura obbligatoria: Exponential Organizations di Salim Ismail @WRicciardi @leadmedit

Una lettura estiva (forse sarebbe meglio dire uno studio estivo) di un libro affascinante: Exponential Organizations di Salim Ismail, edito da Marsilio nella collana Nodi.

Che cos’è un’organizzazione esponenziale? Essa è un’organizzazione il cui impatto (o output) risulta notevolmente superiore – almeno dieci volte – rispetto ai competitor, grazie all’utilizzo di nuove tecniche organizzative, che fanno leva sulle tecnologie in accelerazione.

Gestire organizzazioni esponenziali focalizzate sui clienti e non sui competitor esterni e sulle strutture interne tradizionali richiede una svolta epocale, paragonata a una nuova “era cambriana”. Richiede una nuova cultura e nuove e più dinamiche competenze.

Ho raccolto alcune frasi che mi hanno particolarmente colpito! Buona meditazione a tutti noi perché molti dei temi trattati riguardano anche la sanità!

  1. L’unica costante del mondo d’oggi è il cambiamento, e il ritmo del cambiamento sta aumentando.
  2. L’accelerazione (del cambiamento) è costituita dalle 6 D: digitalized, deceptive (ingannevole), disruptive (dirompente), dematerialized, demonetized, democratized.
  3. L’utilizzo di strumenti lineari e di tendenze del passato per fare previsioni su di un futuro in accelerazione è deleterio (vedi i casi di Iridium e Kodak).
  4. Gli esperti, in quasi tutti i campi, messi di fronte ad una crescita di tipo esponenziale, continuano sempre a pensare in un’ottica lineare, ignorando l’evidenza davanti ai loro occhi.
  5. Il vecchio detto secondo cui un esperto è “qualcuno che ti dice perché qualcosa non può essere fatta” è oggi più vero che mai.
  6. Nessuno degli indicatori tradizionali quali l’età, la reputazione e le vendite attuali possono garantire la sopravvivenza di un’azienda.
  7. La legge di Moore afferma che il rapporto prezzo/prestazione della potenza di calcolo raddoppia ogni diciotto mesi.
  8. “Le nostre organizzazioni sono fatte per resistere ai cambiamenti che arrivano dall’esterno” piuttosto che per accoglierli, anche quando sono utili (da John Hagel).
  9. Le strutture organizzative aziendali esistono proprio per annientare i fattori dirompenti di cambiamento.
  10. La maggior parte delle organizzazioni complesse si basa sulla cosiddetta “struttura a matrice” … Questa struttura è efficace nel garantire il controllo, ma è disastrosa in termini di individuazione delle responsabilità, di velocità e di propensione al rischio … Con il tempo, le funzioni orizzontali acquistano sempre più potere … Per le grandi organizzazioni con struttura a matrice attuare il cambiamento rapido e dirompente è qualcosa di estremamente difficile. Quelle che ci hanno provato, infatti, hanno sperimentato che il “sistema immunitario” dell’organizzazione tende a rispondere alla minaccia percepita attaccando.
  11. Le organizzazioni esponenziali hanno la capacità di adattarsi a un mondo in cui l’informazione è pervasiva e onnipresente e di convertirla in vantaggio competitivo.
  12. I tratti comuni delle organizzazioni esponenziali sono: il Massive Transformative Purpose (Mtp), cinque caratteristiche esterne denominate Scale e cinque interne denominate Ideas. Per essere un’organizzazione esponenziale, un’azienda deve avere il Mtp e almeno quattro caratteristiche.
  13. Il Mtp non è la missione: il Mtp è aspirational. Il fuoco è su ciò che si aspira a raggiungere.
  14. Scale: staff on demand; community and crowd; algoritmi, leveraged asset; engagement
  15. Ideas: interfacce; dashboard; experimentation; autonomia; tecnologie sociali.
  16. Il concetto di autonomia non implica non rendere conto a nessuno delle proprie azioni. Secondo Steve Denning, “In un network esistono ancora le gerarchie, ma esse tendono ad essere basate sulle competenze, e fanno affidamento più sull’accountability tra colleghi che su quella dovuta all’autorità, cioè sul dover rendere conto a qualcuno perché sa qualcosa e non per il semplice fatto che occupa una determinata posizione indipendentemente dalle competenze. Il ruolo del manager si trasforma, non viene abolito”
  17. Un’organizzazione esponenziale tende a essere una zero latency enterprise cioè un’azienda in cui si annulla l’intervallo tra ideazione, approvazione e realizzazione.
  18. In passato il lavoro si concentrava principalmente sull’importanza del quoziente intellettivo (QI), oggi il quoziente emotivo (QE) e quello spirituale (QS) stanno diventando indicatori sempre più rilevanti.
  19. Un secolo fa, la competizione si giocava principalmente sulla produzione, Quarant’anni fa, invece, il fattore decisivo divenne il marketing. Oggi, nell’era di internet, in cui produzione e marketing sono diventati merci e sono stati democratizzati, tutto ruota intorno a idee e ideali.
  20. Il piano strategico quinquennale è in sé uno strumento obsoleto … Esso è un suicidio per un’organizzazione esponenziale … L’unica soluzione è stabilire un Massive transformational Purpose (Mtp), costruire la struttura aziendale, adottare un piano (al massimo) annuale e osservare la crescita, con aggiustamenti progressivi e in tempo reale a seconda delle necessità.
  21. Nel mondo delle organizzazioni esponenziali, lo scopo (Mtp) è più importante della strategia e l’execution ha la precedenza sulla pianificazione.
  22. Arianna Huffington ha detto: “Preferisco lavorare con una persona meno brillante ma che sa fare gioco di squadra ed è chiara e diretta, piuttosto che con qualcuno molto brillante ma dannoso per l’organizzazione”.
  23. In un’organizzazione esponenziale, la cultura (con il Mtp e le tecnologie sociali) è il collante che garantisce la tenuta del team nonostante i salti quantici della crescita esponenziale. Secondo Chip Conley “la cultura è ciò che accade quando il capo non c’è”. E secondo Joi Ito “la cultura si mangia la strategia a colazione”.
  24. Sta diventando sempre più facile acquisire potere, ma è sempre è più difficile mantenerlo.
  25. Consiglio ai CEO delle grandi aziende di affiancare a chi occupa posizioni di leadership i venticinquenni più brillanti, per colmare il gap generazionale e tecnologico, per permettere a questi giovani di crescere più velocemente e per innescare un meccanismo di mentoring al contrario.
  26. Se siete un manager di Amazon e un dipendente viene da voi con una grande idea, la vostra risposta di default deve essere : Se volete dire di no, dovete motivare questo rifiuto con una relazione di due pagine spiegando perché non ritenete l’idea valida.
  27. Jeff Bezos (Amazon) ha detto: “ Se sei focalizzato sui competitor, devi aspettare che siano loro a fare la prima mossa, prima di agire. Concentrarsi sui clienti, invece, consente di essere dei pionieri”.
  28. Il miglior modo per definire questa macrotransizione verso organizzazioni esponenziali è considerarla un passaggio dalla scarsità all’abbondanza … Secondo Dave Blakely “queste nuove organizzazioni sono esponenziali perché prendono qualcosa di scarso e lo fanno diventare abbondante”.
Annunci

Il CV efficace: lo ha inventato Leonardo Da Vinci! Copiate! @drsilenzi @redhenry88

Tempo fa, sui social, Roberta Zantedeschi che si occupa di ricerca e selezione di personale e diformazione e orientamento professionale, ha pubblicato un interessante post su come stendere un CV efficace prendendo Leonardo da Vinci come testimonial.

Eccolo: interessante!

Quel gran secchione di Leonardo Da Vinci tra le varie cose è fautore pure del CV efficace.

Quel CV cioè che non descrive ogni singola esperienza lavorativa (quello che hai fatto in passato) ma che mette in evidenza le capacità maturate (ciò che potrai fare presso chi ti assumerà).

Un CV non autoreferenziale ma concreto, pragmatico e rivolto ai bisogni e ai problemi di chi legge.

La lettera è indirizzata al Duca Ludovico Sforza detto Il Moro in occasione del trasferimento dello stesso Leonardo a Milano e pare proprio una moderna domanda di assunzione.

Eccola tradotta in Italiano corrente:

Avendo constatato che tutti quelli che affermano di essere inventori di strumenti bellici innovativi in realtà non hanno creato niente di nuovo, rivelerò a Vostra Eccellenza i miei segreti in questo campo, e li metterò in pratica quando sarà necessario. Le cose che sono in grado di fare sono elencate, anche se brevemente, qui di seguito (ma sono capace di fare molto di più, a seconda delle esigenze):

1- Sono in grado di creare ponti, robusti ma maneggevoli, sia per attaccare i nemici che per sfuggirgli; e ponti da usare in battaglia, in grado di resistere al fuoco, facili da montare e smontare; e so come bruciare quelli dei nemici.

2- In caso di assedio, so come eliminare l’acqua dei fossati e so creare macchine d’assedio adatte a questo scopo.

3- Se, sempre in caso di assedio, la fortezza fosse inattaccabile dalle normali bombarde, sono in grado di sbriciolare ogni fortificazione, anche la più resistente.

4- Ho ideato bombarde molto maneggevoli che lanciano proiettili a somiglianza di una tempesta, in modo da creare spavento e confusione nel nemico.

5- Sono in grado di ideare e creare, in modo poco rumoroso, percorsi sotterranei per raggiungere un determinato luogo, anche passando al di sotto di fossati e fiumi.

6- Costruirò carri coperti, sicuri, inattaccabili e dotati di artiglierie, che riusciranno a rompere le fila nemiche, aprendo la strada alle fanterie, che avanzeranno facilmente e senza ostacoli.

7- Se c’è bisogno costruirò bombarde, mortai e passavolanti [per lanciare sassi e ‘proiettili’] belli e funzionali, rielaborati in modo nuovo.

8- Se non basteranno le bombarde, farò catapulte, mangani, baliste [macchine per lanciare pietre e ‘fuochi’] e altre efficaci macchine da guerra, ancora in modo innovativo; costruirò, in base alla situazione, infiniti mezzi di offesa e difesa.

9- In caso di battaglia sul mare, conosco efficaci strumenti di difesa e di offesa, e so fare navi che sanno resistere a ogni tipo di attacco.

10- In tempo di pace, sono in grado di soddisfare ogni richiesta nel campo dell’architettura, nell’edilizia pubblica e privata e nel progettare opere di canalizzazione delle acque. So realizzare opere scultoree in marmo, bronzo e terracotta, e opere pittoriche di qualsiasi tipo. Potrò eseguire il monumento equestre in bronzo che in eterno celebrerà la memoria di Vostro padre [Francesco] e della nobile casata degli Sforza.

Se le cose che ho promesso di fare sembrano impossibili e irrealizzabili, sono disposto a fornirne una sperimentazione in qualunque luogo voglia Vostra Eccellenza, a cui umilmente mi raccomando.

Che cosa fa Leonardo?

Per prima cosa sintetizza le sue competenze in un elenco numerato, così facendo facilita l’organizzazione dei contenuti e la lettura da parte di chi riceve la missiva.

Inoltre, e ancora più importante, contestualizza la lettera citando soprattutto le sue competenze in ambito bellico. Lui, che era prima di tutto un artista e pure pacifista, scrive un CV promuovendo una gamma ben specifica di abilità, quelle che ritiene possano servire al Duca. Delle sue qualità di artista ne accenna solo al decimo punto, senza forzare la mano.

Da Vinci docet quindi, il CV moderno l’ha inventato lui, e non ha niente a che fare con il formato europeo.

È invece un CV lean, contestualizzato, funzionale, che punta dritto all’obiettivo facendo leva sui bisogni di chi dovrebbe ingaggiarlo. Funziona così anche oggi: chi assume lo fa perché ha un problema e sceglie la persona che ritiene possa risolverlo nel migliore dei modi.

Quando scrivete un CV chiedetevi sempre: che problemi ha il mio interlocutore? In che modo io posso contribuire a risolverli? E poi scrivete di questo! Tutto il resto che vi verrà voglia di inserire nel CV potrebbe essere inutile, pensateci bene prima di occupare spazio con parole e informazioni che non portano valore aggiunto.

E strutturate il testo perché sia immediato e fluido, gli elenchi puntati sono i vostri migliori alleati.

Costi standard in sanità: i documento del Convegno N.I. San. @Medici_Manager

Ecco i documenti del II Workshop Nazionale sui Costi Standard tenutosi il 18 Ottobre 2012 aSan Giovanni Rotondo, a cura del N.I.SAN.

http://bit.ly/YmOKuR

Private healthcare: the lessons from Sweden @Medici_Manager

On Kungsholmen, one of the islands on which the Swedish capital Stockholm is built, stands what some consider to be the future of National Health Service under David Cameron: St Göran, a six-storey redbrick hospital that makes profits from the state by treating patients.

Emblazoned with the name of its corporate manager, Capio – rather than the Swedish state, which constructed it – the hospital has for a decade been the mascot of pro-market Scandinavian policies that are widely admired by the coalition in Westminster.

Despite its reputation as a leftwing utopia, Sweden is now a laboratory for rightwing radicalism. Over the past 15 years a coalition of liberals and conservatives has brought in for-profit free schools in education, has sliced welfare to pay off the deficit and has privatised large parts of the health service.

Their success is envied by the centre right in Britain. Despite predictions of doom, Sweden’s economy continues to grow and its pro-business coalition has remained in power since 2006. The last election was the first time since the war that a centre-right government had been re-elected after serving a full term.

As the state has been shrunk, the private sector has moved in. Göran Dahlgren, a former head civil servant at the Swedish department of health and a visiting professor at the University of Liverpool, says that “almost all welfare services are now owned by private equity firms”.

Thanks in part to the outsourcing of the state, Sweden’s private equity industry has grown into the largest in Europe relative to the size of its economy, with deals worth almost £3bn agreed last year. The key to this takeover was allowing private firms to enter the healthcare market, introducing competition into what had been one of the world’s most “socialised” medical systems.

Business-backed medical chains have sprung up: patients can see a GP in a centre owned by Capio, be sent to a physician in the community employed by Capio, and if their medical condition is serious enough end up being treated by a consultant in a hospital bed in St Göran, run by Capio. For every visit Capio, owned by venture capitalists based in London and Stockholm, is paid with Swedish taxpayers’ cash.

The company’s Swedish operation now has 4,500 employees, with a turnover of about £500m. Westminster wonks have monitored Capio’s success closely ever since St Göran was allowed to be taken over in 2000. There are now six private hospitals funded by the taxpayer in Sweden, about 8% of the total.

In Britain the coalition has mimicked this approach. Circle, backed by private equity firms, runs Hinchingbrooke hospital in Cambridge. Serco, a FTSE 100 company, is eyeing the George Eliot hospital in Nuneaton, and two hospitals may be privatised in south London as a result of bankruptcy.

Dahlgren says: “The difference between Sweden and England is thatprivatisation of a hospital was only considered when you had big financial problems. St Göran was considered one of the best when it was sold.”

Capio’s executives dispute that they have simply “made the best better”. They say they focus on improving standards, arguing that only by attracting more patients and managing costs can they make money from healthcare.

During an hour-long presentation to the Guardian, St Göran’s chief executive, Britta Wallgren, says the 310-bed hospital, serving 430,000 people, outperforms state-owned rivals inside and outside the country.

She says emergency patients see a doctor within half an hour, compared with A&E waits of up to four hours in the NHS. “We took an A&E department that dealt with 35,000 patients a year and now treats 75,000,” Wallgren says. “As admissions grow and we have an increasingly elderly population so must our performance improve.”

Capio stresses that St Göran has low levels of hospital-acquired infections, and patient surveys record high levels of public satisfaction. It has also produced year-on-year productivity gains – something the state cannot match. Thomas Berglund, Capio’s president, says the “profit motive works in healthcare” and companies run on “capitalism, not altruism”.

He adds: “We have just won the right to run the hospital again and will have to reduce costs by 120m Swedish krona [£11.2m] over 10 years. That’s our profit gone unless we keep reducing costs here.”

At the busy entrance to the hospital, Swedish patients appear resigned to the end of state ownership in health, once a cornerstone of the country’s generous welfare system.

“I am one of those Swedes who do not agree that private hospitals should exist,” says Christina Rigert, 62, who used to work as an administrator in the hospital but resigned “on principle” when it was privatised a decade ago.

Now back as a patient after gastric band surgery, she says: “The experience was very good. I had no complaints. There’s less waiting than other hospitals. I still do not think there should be private hospitals in Sweden but it’s happening.”

Since 2010 private companies have had the right to set up large GP-style services anywhere in the country – and to be paid for it out of taxpayers’ money. Corporates have set up 200 healthcare centres in two years, although critics point out that the majority have been in wealthier urban areas.

Dahlgren says that inequalities are growing, adding that the law is “fundamentally antidemocratic”. Sweden, he explains, has a long history of local governments deciding where GPs should be sited to ensure poor or rural areas do not lose out.

“The local councils can now neither determine the number of for-profit providers to be financed by taxes nor where these tax-financed services are to be located,” he says. “This is determined by the private providers on the basis of profitability rather than the health need for these tax-financed services. It is remarkably antidemocratic.”

There are distinct differences between Sweden and Britain. Swedish political culture is much more consensual than in Britain, and strongly centred on people choosing where to get healthcare.

Leftwing governments in Sweden, who ran the country for 65 of the last 80 years, promoted patient choice between state-owned hospitals. The real shock was when centre-right governments argued in the 1990s that for patient choice to work, competition and privatisation in healthcare were needed.

The Social Democrats, the main Swedish opposition party, have given up the idea of renationalising the health service and instead argue that profits should be capped and quality of care more tightly regulated. With hardline opposition to private healthcare limited to the far-left parties, Swedes are likely to see more changes.

In Stockholm, more than 500 beds are being removed from the country’s best known health centre, the Karolinska University hospital, and the services are being moved into the community to be run by private companies, a policy that in England would almost certainly lead to demonstrations.

Pro-marketeers argue that companies can improve patient experience at a reduced cost, and expand provision at a time when the state cannot afford to do so. This view was challenged last year when a business-backed research institute, the Centre for Business and Policy Studies, looked at the privatisation of public services in Sweden and concluded that the policy had made no difference to the services’ productivity. The academic author of the report, who stood by the findings, resigned after a public row.

There have also been scandals involving claims of shocking treatment of some patients. Last year Stockholm county council, which controls healthcare for a fifth of the Swedish population, withdrew contracts from a private company after staff in a hospital were allegedly told to weigh elderly patients’ incontinence pants to see if they were full or could be used for longer.

Stig Nyman, a Christian Democrat member of the council instrumental in ushering in a pro-market health policy for 20 years, says he still believes private business is necessary.

Over coffee and biscuits in his modern office amid the 19th-century neoclassical columns of the council building, Nyman dismisses the allegations of mistreatment. “We have hundreds of contracts with private firms. In this case journalists found five or six mistakes. It’s not a big deal.

“In healthcare, companies drive up standards. We pay 5,000 Swedish krona [£465] a patient on average. We force people to compete on the quality of service and treatment.”

Perhaps most damaging for private investors drawn by the potential profits to be made from the state has been the probing of their affairs by tax inspectors. The industry has been under scrutiny since 2007, when a spate of high-profile deals, including the buyout of Capio, led to investigations into financiers.

The charge is that private equity firms siphon profits out of the state’s coffers while avoiding their fair share of taxes. Berglund, of Capio, says: “It is always thrown about that we are not paying taxes but it is not true.”

Swedish tax authorities are, however, taking some companies to court because pay in private equity groups is often linked to the profits made on deals and has been incorrectly taxed for years, it is said, at rates lower than that required for income in Sweden.

Earlier this month one of Capio’s owners, a private equity firm called Nordic Capital, lost a court case against the Swedish tax agency, leavingit with a bill of 672m Swedish krona [£63m]. The authorities, it is reported, will also slap a tax bill collectively of 2.6bn krona on another 34 individuals.

“There has been a strong reaction in Sweden. These people have been paying themselves enormous sums of money,” says Dahlgren. “It should be a worry for every health system where you have competition and private firms arriving.”

http://www.guardian.co.uk/society/2012/dec/18/private-healthcare-lessons-from-sweden

Medici meno esperti spendono di piu’ per cure e diagnosi @Medici_Manager

Roma, 5 nov. (Adnkronos Salute) – (EMBARGO ALLE 22.00) – Inesperienza e incertezze dei medici ‘nemiche’ della spending review. Secondo uno studio pubblicato su ‘Health Affairs’, infatti, le caratteristiche del medico influiscono direttamente sulle spese sanitarie. Infatti i camici bianchi con meno esperienza tendono a spendere molto più denaro nel trattamento dei pazienti, rispetto ai colleghi più navigati, spiegano i ricercatori della Rand Corporation e dell’Università di Pittsburgh.

Secondo gli studiosi questi risultati potrebbero avere implicazioni significative per i decisori in tempo di crisi, al momento di ‘disegnare’ reti di specialisti o di mettere in piedi programmi che premiano gli operatori sanitari che forniscono cure di qualità a un costo inferiore. “Questi risultati sono provocatori, e occorrono ulteriori esami” su questo tema, spiega Ateev Mehrotra, associato presso l’Università di Pittsburgh School e ricercatore della Rand Corporation, istituto di ricerca senza scopo di lucro. “Ma è possibile che un elemento guida dei costi sanitari stia nel fatto che i medici appena formati tendono a praticare una medicina più costosa”. In pratica, prescrivendo più esami diagnostici, o medicinali più cari, magari proprio perché meno esperti e sicuri rispetto ai colleghi che hanno alle spalle più anni di pratica.

Per disegnare l’identikit del medico più costoso per il servizio sanitario, i ricercatori hanno utilizzato i dati relativi a oltre un milione di persone residenti nel Massachusetts dal 2004 al 2005, costruendo i profili di ‘spesa sanitaria’ dei pazienti di oltre 12.000 medici dello stato americano. I costi sono stati valutati attraverso 600 tipi di “episodi di cura”, includendo la patologia di una paziente, la sua gravità e le procedure eseguite. Ebbene, la forbice più ampia nei costi si ha paragonando i dati dei ‘novellini’ con gli operatori con la maggiore anzianità di servizio. Si è visto che i medici che avevano meno di 10 anni di esperienza hanno costi complessivamente superiori del 13,2% rispetto ai colleghi con 40 o più anni di servizio.

Invece gli operatori con 10-19 anni di lavoro alle spalle hanno profili di costo più alti del 10% (rispetto ai colleghi più maturi), percentuale che per i medici con 20-29 anni di esperienza scende al +6,5% e per quelli con 30-39 anni del +2,5%.

Nessuna associazione è stata trovata, invece, tra i costi e le altre caratteristiche dei medici, come ad esempio una segnalazione per negligenza o azioni disciplinari, o ancora le dimensioni della struttura in cui un medico ha lavorato. I ricercatori sostengono che la differenza rilevata dallo studio non suggerisce che i medici meno esperti, spendendo di più, finiscano per fornire una migliore assistenza medica. Anzi, sembrerebbe proprio che le cose non stiano così. “I nostri risultati non possono essere considerati definitivi, ma si sottolineano la necessità di comprendere meglio gli approcci della pratica medica e che cosa influenza questo comportamento,” dice Mehrotra.

Secondo gli studiosi sono diversi i fattori che possono spiegare i risultati ottenuti dalla ricerca. I medici appena formati possono avere più familiarità con nuove modalità di trattamento, più costose e high tech, rispetto ai vecchi medici. Inoltre, è possibile che la mancanza di esperienza e le incertezze dei ‘novellini’ si traducano in un approccio più aggressivo nella cura, fino a sfociare a volte nella medicina difensiva. Infine non è detto che, via via che i medici acquistano esperienza, il loro atteggiamento cambi: è possibile che le differenze rilevate dallo studio restino tali per tutta la carriera dei medici più giovani, dicono i ricercatori, convinti che nella formazione dei camici bianchi non possano più mancare elementi per renderli coscienti della responsabilità di essere anche buoni amministratori delle risorse sanitarie.

IOM Report Focuses On $750 Billion In Inefficient Health Care Spending @drsilenzi @agnescheer @KHNews

By Ankita Rao

SEPTEMBER 6TH, 2012, 1:42 PM http://capsules.kaiserhealthnews.org/index.php/2012/09/iom-report-focuses-on-750-billion-in-inefficient-health-care-spending/

“If home building were like health care,” says a new Institute of Medicine report, “carpenters, electricians, and plumbers each would work with different blueprints, with very little coordination.”

With physicians, hospital administrators and insurance companies on often diverging building plans, the idea that the health care system could fall apart like a badly built house is not surprising, according to committee members at a press conference on Thursday. They called for collaboration across different sectors of the industry.

The cost of an inefficient system is no small burden: the institute, a nonprofit that advises the government, estimated that $750 billion was wasted on inefficient spending and care in 2009.

But the solutions, according to the report, are not strictly financial. In that report, “Best Care At Lower Cost: The Path to Continuously Learning Health Care In America,” a group of public health experts, physicians and scientists propose a strategy to make health care cost effective based on examples of best practices in health technology, leadership and administration.

The 382-page report exhorts physicians to keep up to date with technology, hospitals to improve their management, patients to learn about the system to make more informed decisions and scientists to use stricter standards to evaluate their research.

Eugene Litvak, one author of the report and head of the Institute For Healthcare Optimization, said that hospitals have not been maximizing their productivity. He cited Cincinnati Children’s Hospital, a case study in the report, and one of his organization’s clients, as a success story.

By staggering the surgeons’ schedules more, for example, the hospital was able to decrease its physicians’ overtime and use more of the costly patient beds that were often left empty. The adjustment spared the hospital the need to spend $100 million on new beds.

“These methods of operations management exist in every other industry – it’s only health care and education where they don’t,” Litvak said.

The report also supports the highly debated use of financial incentives to motivate doctors and others to be more efficient. The authors said the new federal Center for Medicare & Medicaid Innovation should take the lead in evaluating  payment systems.

A graph in the report shows that $210 billion was wasted on excess services in 2009, which the authors said could have been avoided by rewarding physicians and hospitals who cut down on unnecessary procedures and treatment.

But the incentive model has met resistance in the health care industry, and some researchers have found that value-based incentives do not significantly affect  the cost of services.

John Goodman, head of the National Center For Policy Analysis, said in an interview that rewarding physicians in this way was not an appropriate method to address the issue. He said that health care providers should be able to choose how to run their own programs.

“I don’t think that the demand side should try to tell the supply side what to do,” Goodman said.

The IOM committee said that the U.S. was spending up to 17 percent of its GDP on health care, a far higher proportion than other developed countries, and with very little additional benefit. That not only affects spiraling government spending on health care, but also siphons off resources that they said should be used for other public services such as education.

Litvak said that the larger problem with the health care system was stubborn adherence to the status quo. “It’s not a shortage of resources,” he said. “It’s the shortage of leadership and willingness to change.”

Changing health care delivery at academic medical centers @kevinmd @drsilenzi @agnescheer

by  | in POLICY http://www.kevinmd.com/blog/2012/08/changing-health-care-delivery-academic-medical-centers.html

At academic medical centers (AMCs) all over the country, health care delivery and payment reform are becoming reality. AMCs need to think in a new way about the markets they serve. Timing for AMCs transforming care delivery is critical. We need to find the perfect middle ground, or what I like to call the “Goldilocks Factor.” AMCs need to transform delivery, definitely not too slowly, but not too fast for their markets either.  And finding “just fast enough” is not easy.

The services we provide are, now more than ever, about comprehensive care and population management to achieve the “Triple Aim” of improved quality, improved health, and controlled cost.  Primary care is key to successful care of defined populations under payment models such as Patient Centered Medical Homes, capitation, and shared savings. But some highly subspecialized services will likely remain fee-for-service, at least for a time and maybe indefinitely, while value-based payment covers increasing fractions of AMCs’ total care.

We have to learn how to balance managing population risk and health along with continuing  to provide subspecialized care paid fee-for-service. If we reduce utilization of subspecialized care by populations quickly without replacing this fee-for-service volume, we will reduce our revenues and get in financial trouble.

If we are too slow and do not learn how to manage market risk, and then the market changes abruptly to heavily risk-based contracting, we won’t be ready for it and will get in financial trouble.

We have to build comprehensive care for populations while reaching regional or even national markets to “backfill” subspecialized care that will decrease for defined local populations. This will require competing to provide these services on the basis of cost, quality and patient satisfaction.  So, just like the porridge in “Goldilocks and the Three Bears,” we have to be just right.

At the University of Utah School of Medicine, we have been working to redesign primary care delivery to improve efficiency and quality and lead us to the care model that is just right for our patients. Our primary care system includes eight production-oriented clinics in various neighborhoods and communities of northern Utah plus two teaching sites for family medicine faculty and residents. The clinics together deliver about 1/4 of all outpatient visits provided by University of Utah Health Care.

One of our initiatives, the University of Utah Community Clinics’ patient centered medical home model, “Care by Design,” has had substantial success in implementing a team-based model of care that increased the ratio of medical assistants (MAs) per provider to 4-5:2 with expanded MA roles, enhanced access, and prospective care management for chronic conditions and prevention.

We had to find a way to balance the two sides of the equation. The primary care and specialty sides must work together to provide quality care at a controlled cost. Investment in primary care builds institutional capability for population management.  Investment in controlling utilization and cost of fee-for-service specialty care prepares the organization to compete in a transformed payment environment. AMCs should become “medical neighborhoods,” incorporating advanced medical homes and a continuum of coordinated services including highly subspecialized care.

For the future of academic medicine, we need to think about what services to provide defined local and regional populations, and what services to provide patients who may travel from surrounding states or beyond. Going forward, everyone is going to have to diversify their care delivery methods and explore new opportunities not just to stabilize revenue and reduce costs, but to improve patient experience and health of populations, while also supporting the full range of academic missions of the AHC. It will not come overnight, and it will take work, but we will eventually find our “just right” bowl of porridge.

Michael K. Magill is Chairman, Department of Family and Preventive Medicine, University of Utah School of Medicine.  He blogs at Wing of Zock.

Learning from European and U.S. health care. @HealthyDebate @muirgray@drsilenzi

By Jason Sutherland & Nadya Repin –JULY 24, 2012
There’s been a seismic shift in health policy taking place in Canada that has been largely ignored by the mainstream media and gone unnoticed by the general public.  Provinces are starting to change the way they fund hospitals.  This is no small change and will directly affect the care patients receive — potentially improving access to hospital care.

Ontario and British Columbia, for example, have announced initiatives to fund hospitals partially based on the services they provide and the characteristics of the patients they treat.  It seems intuitive to pay hospitals for what they do, but our rural-urban divide, how we arrange specialty care in big cities, and limits to the amount we want to spend on hospital care, complicate the issue.

Under the current ‘global budget’ approach used in all provinces, hospitals receive a fixed funding amount, regardless of the types of patients they treat.  The value of this approach is the power to restrain growth in hospital spending.

So what’s the problem?  In a word, inertia.

Since exceeding budgets is penalized in the traditional hospital funding model, hospitals typically avoid adding services that may increase costs, which means hospitals don’t aggressively attack wait times for fear of running up a deficit.

The belief was that, in order to improve care and reduce wait times, we needed to increase staff and hospital beds.  This is the most expensive option and such a move would empty provincial coffers quickly.

It’s also unnecessary.

We now have good data that indicates we are not using our current hospital beds effectively.  We have too many patients in beds that can be safely discharged home — in some regions, above 15% of beds are currently occupied by those who no longer need to be in hospital — translating into thousands of “extra” hospital beds.

The changes to hospital funding in Ontario and B.C. tackle inertia head-on and employ approaches used around the world.  Known as activity-based funding (ABF), hospitals are paid for the kind of care they deliver and the complexity of the patients that are cared for.  This approach is ‘equal pay for equal work,’ and creates incentives for hospitals to discharge patients more quickly, since new patients generate additional revenue for the hospitals.

There are legitimate concerns among stakeholders that under the ABF model patients will be discharged “quicker and sicker.”

This particular phrase was borrowed from early evaluations in the U.S. that indicated that elderly patients were discharged sooner under the ABF model.  The same concerns are now echoing across the Canadian health care landscape in response to ABF policies in Ontario and B.C.

First, do the financial incentives of ABF shorten patient hospital stays?  While not all patients stay a shorter time in hospital under this system, there is good evidence from many countries that, on average, the duration of hospitalization shortens.  This results in more patients treated per bed and improved access to hospital care.  A panel study of 28 countries that moved from global budgets toABF reported a reduction of 3.5% in average length of hospital stay.

The evidence regarding the effectiveness of ABF is consistent — health systems that implementABF for hospital funding tend to experience shorter lengths of stay which lowers wait times in the system.

That’s ‘quicker,’ but what about ‘sicker’?

A criticism leveled against ABF is that it creates incentives for hospitals to shorten lengths of stays to the point where patients’ safety and quality of care are jeopardized.  In other words, patients being discharged from hospital before they are healthy enough to go home.

Canada, as a late-comer to this type of hospital funding, can learn from the evidence from other countries that have adopted similar policies.  Evidence from the U.S. indicates patients in ABFhospitals are discharged in less stable condition, but that processes of care have improved and mortality rates are unaffected.

Findings from the U.K. and other European countries are more positive: there is no association with increased mortality in the ABF model, and even some reports of lower mortality.  Recent work is even suggesting that ABF may encourage hospitals to provide higher quality care to reduce costly complications or readmissions.

So, while some patients are discharged earlier and possibly in less stable condition, patients do not appear to return to hospital more often (readmissions) or die prematurely.

“Quicker,” yes, but “not sicker.”

Hospitals provide the most expensive type of care in our health system and are hungry for new sources of funding.  While this change is one successfully used elsewhere to expand access, in Canada we will still have to make sure that quality of care doesn’t suffer — nor should priority access be granted to ‘profitable’ patients.

Other provinces are vigilantly watching the experiments in Ontario and B.C.  It’s been decades since the status quo has been challenged.  If access improves, quality is unaffected, and cost growth is moderate, other provinces will surely be tempted to follow a similar path.

Jason M. Sutherland is an Assistant Professor at the Centre for Health Services and Policy Research, University of British Columbia.

Nadya Repin is a research coordinator with the Centre for Health Services and Policy Research, UBC.

This guest post is provided courtesy of the EvidenceNetwork.ca and is reproduced under a CreativeCommons Attribution No-Derivatives license.

Cure Your Company’s Allergy to Change @Medici_Manager @HarvardBiz

by Brad Power  |  10:00 AM August 30, 2012 http://blogs.hbr.org/cs/2012/08/cure_your_companys_allergy_to_change.html

Many organizations suffer from a tragic pattern: The chief executive officer launches a new change program with great fanfare and intentions, only to shelve it a few years later with little to show for great expenditures of time and consulting fees. How can you break this cycle?

Consider a health insurance company that has been struggling with change programs gone haywire for quite some time. A few years ago, the chief operating officer launched a customer quality initiative to improve six core processes and assigned executives to “own” each process. But in the budgeting process, the initiative got little funding. Only a few of the six processes were assigned staff, and each claimed credit for the work of colleagues. The initiative fizzled.

But this wasn’t the only improvement initiative to peter out in the company. The CEO recently drove a cultural change program, and did so earnestly. He appointed vice presidents to run teams to recommend process changes. At several off-sites, they talked about culture, and people spoke their minds. After four months of meetings, the VPs surfaced even more issues. For example, employees wanted more transparency and say in project prioritization. But the CEO and his deputies heard things they didn’t want to hear, so they pulled the plug. None of the recommendations were implemented, and there were no results for the significant time invested.

This company has demonstrated a repeated pattern of 3- to 5-year cycles where it launches a change program, takes awhile for managers to get behind it, and then more time to get it funded. A program gets funded for a year but then everyone loses interest, and it gets defunded and dies. Recently they’re failing faster; the three- to five-year cycle is moving to two to three years. But they’re not failing fast to learn. They’re just failing more. It’s definitely not a learning organization.

How do companies get trapped in such tragic change cycles? The health insurer’s bugaboos speak volumes.

Just about everyone in the company agrees the culture is dysfunctional, with various layers to the problems. Some point to politics in the C-Suite, especially to competition between the COO and CFO. They blocked each other’s progress. If the COO launched a large, cross-functional improvement program, the CFO would underfund it. Another problem lay with the CEO, who had a way of questioning and stress-testing people that discouraged risk-taking. The result: a “play it safe” mentality.

The company has very polite and gracious people who like to follow rules, value process over results and contracts over trust. They often depend on consultants to take the lead in proposing major process change. Executives also want quick wins, so they scope projects to be done in a year. Most change programs at the company need multiple years to complete. As a consequence, by the time a program extends beyond the first year, executives move onto the “new initiative.”

A fourth problem was narrow scope for a change program: Anything outside a department or function required the CEO’s seal of approval; otherwise it couldn’t get anyone else’s attention. In such a hard-siloed organization, no one has an end-to-end view of any process.

Lack of ambition was a fifth problem. When confronted by problems, directors say, “I need to protect my department. I don’t want to do extra work.” Finally, they liked to report rosy numbers. For example, customers reported that the website performance was poor, but the internal department was using numbers that showed everything was okay.

Are there some countermeasures that can break a tragic change cycle like this?

Several lessons on how to achieve meaningful cultural change and associated operating performance improvements run through successful efforts at health insurance companies Aetna andBlue Cross Blue Shield of Michigan:

  • Organizational realignment — The structure of an organization determines the incentives that drive identity, behavior, and employee understanding of roles and responsibilities and priorities, as well as a sense of ownership and accountability. Blue Cross Blue Shield of Michigan’s organization had been structured around health insurance products. It then tried a more traditional functional management structure but then found it lost customer focus. So it appointed leaders to run market segments with profit and loss responsibility, and put pressure on them to change the product mix and improve profitability. By organizing by customer, cross-functional changes became much easier to implement, and there was a dramatic turnaround in business results.
  • Improvement methods — Irrespective of whether an organization is focused on growth or cost reduction, it must have a platform for doing work nimbly and at low cost. Adopting improvement methods such as “agile” or “lean” can change the culture as employees are empowered to make changes in their work and results and trust are prized over process and contracts. At Blue Cross Blue Shield of Michigan, tactics such as daily huddles drove immediate wins and helped entrench a culture of empowerment.
  • Employee engagement — Employees fundamentally want themselves and the company to be successful, so successful change agents listen to their needs and help them transition. At Aetna, a recent article describes how new CEO John Rowe and other members of the senior team “sought out employees at all levels — those who were well connected, sensitive to the company culture, and widely respected — to get their input on the strategy as well as their views on both the design and execution of intended process changes.” Executives at Blue Cross Blue Shield of Michigan went into the field to gather input and communicate their commitment to change. And employees were trained in improvement methods (“Lean”), with every employee going through two sessions in accountability training.

Have you seen organizations break a tragic change cycle?

More blog posts by Brad Power

President Obama Calls for Better Payment System for Primary Care Physicians @Medici_Manager

http://www.aafp.org/online/en/home/publications/news/news-now/government-medicine/20100609obamasgr.html

President Obama has called for changes in the nation’s physician payment system to better compensate primary care physicians and thus encourage more medical students to pursue careers in the primary care field.

Photo of President Obama during a town hall meeting in Maryland

During a town hall meeting for senior citizens in Maryland, President Obama points out that reforming the Medicare payment system to encourage preventive care and to better compensate primary care physicians likely is “the single most important thing that we can do” to ensure good health care.
“This issue of primary care physicians is absolutely critical, and it has the promise of making such a big difference in the overall health of everybody, from children to seniors,” said Obama during a June 8 town hall meeting in Wheaton, Md.

“It used to be that most of us had a family doctor,” said Obama. “You would consult with that family doctor. They knew your history. They knew your family. They knew your children. They helped deliver babies.” Consequently, more people got regular checkups, making it easier to anticipate medical problems, according to Obama.

“Now in these big medical systems, so often, what happens is that you’re shuttled around from (sub)specialist to (sub)specialist,” said Obama. “Oftentimes, people don’t have a primary care physician that they’re comfortable with, so they don’t get regular checkups. They don’t get regular consultations. Preventable diseases end up being missed, and you don’t have the kind of coordination that’s necessary between all these different specialists.”

Obama’s remarks were made during the give-and-take portion of the town hall meeting and not from a prepared statement. The president told the audience of senior citizens that one of the main goals of the newly enacted health care reform legislation is to increase the number of primary care physicians and to give them more power so that “they are the hub around which a patient-centered medical system exists.”

“And the first step is getting more primary care physicians,” he stressed. “Sadly, a lot of young medical students, they’d love to go into primary care, but primary care physicians don’t get paid as well as (sub)specialists. So, they say to themselves, ‘You know what, I don’t want to — I’ve got all these medical school bills that I’ve got to pay. I’ve got to become a plastic surgeon or something.'”

Obama pointed out that the health care reform law creates new loan forgiveness programs and strengthens existing ones to make primary care more enticing for medical students. He also said that changing the payment system to encourage preventive care and to better compensate primary care physicians is “probably going to be the single most important thing that we can do to assure that you and those of you who have good primary care physicians continue to get that kind of care.”

“Right now you’ve got a situation where if a primary care physicians says to a patient, ‘You know what, you need to lose some weight because you’re at risk of diabetes, and I’ve got a good exercise program that makes sense, and here’s a dietitian that you should talk to,’ sometimes Medicare may not reimburse that consultation,” Obama said.

But, he noted, Medicare will pay $30,000 for a foot amputation that results from the ensuing diabetes.

“That doesn’t make sense,” said Obama.

The president also assailed the sustainable growth rate, or SGR, formula, saying it is something that has to be fixed. The SGR governs Medicare physician payment rates and regularly calls for a reduction in those rates. Congress recently failed to pass a patch to the system, thus allowing a 21.3 percent reduction called for by the SGR formula to take effect on June 1.

“What we shouldn’t do is have this guillotine hanging over (physicians’) heads every year where they’re having to figure out, ‘Am I going to get reimbursed or is, suddenly, my income going to drop 20 percent?'” said Obama.

It is imperative, he added, “to make sure that your doctor is getting reimbursed so that they can stay in business and keep their doors open.”

“My administration has worked very closely with doctors to try to see if we can get this fixed short term, but ultimately, we’re going to have to get it fixed long term,” he added.

In the meantime, the AAFP, along with the American College of Physicians and the American Osteopathic Association have again urged Congress to replace the SGR with a payment formula that more accurately reflects the work performed by physicians.

In a June 4 letter to House and Senate leaders, the organizations expressed their members’ “deep frustration with Congress’ inability to agree on a framework to eliminate the endless cycle of Medicare physician payment cuts created by the unworkable SGR and to recommend an approach to move to a permanent solution.”

“Although stabilizing payments is essential, it is not enough for Congress to substitute a temporary positive update for the 21 percent cut that went into effect on June 1 unless it leads to a better payment framework,” says the letter.

The organizations call for a framework that will

  • provide stable and predictable updates that reflect increases in physician practice expenses;
  • allow for more realistic and achievable spending growth for physicians’ services than the current SGR formula;
  • provide for higher growth targets for primary care visits and preventive services; and
  • account for the costs of providing “stable, predictable and fair updates in payments to physicians, rather than hiding the costs by assuming a bigger ‘cliff’ in future years.”
In the letter, the AAFP and the other groups said higher growth targets and updates for primary care visits and prevention are essential because demand for primary care and prevention will continue to grow as the population ages and more Americans become eligible for Medicare.

The letter points out that “primary care and preventive services are undervalued by Medicare and other payers,” which has led to a growing shortage of 35,000 to 44,000 primary care physicians for adult patients.

For health care to be better, doctors must lead the change @drsilenzi @muirgray @kevinmd

by  | in PHYSICIAN http://www.kevinmd.com/blog/2012/08/health-care-doctors-lead-change.html

Recently New Yorker staff writers and best-selling authors Malcolm Gladwell and Atul Gawande addressed the question of whether the problem in health care is that patients are too reliant on doctors and don’t have the ability to make decisions. In reading between the lines, is that the reason health care is not affordable and care not commoditized or consumer driven like other industries?

At a conference for America’s Health Insurance Plans, Gladwell argued that patients or consumers have been unable to be more empowered because doctors, as the intermediary, held the power of knowledge much the same way chauffeurs did for the early days of the automobile and Xerox technicians did in the early days of photocopying. A person was needed to guide and assist the individual to get the job done. At some point, however, the technology became simpler. People began to drive their own cars and make their own photocopies. The mystique of the chauffeur and technician was lifted. Now everyone could drive. Everyone could make photocopies.

Is it possible that for health care and the health care system, which for many people is a system they interact with rarely and in an area (health / illness) where the uncertainty and stakes many be too “high,” that individuals willingly to defer the responsibility to someone else? Gladwell hints that might be a possibility.

“A key step in any kind of technological transition is the acceptance of a temporary deficit in performance at the beginning in exchange for something else,” said Gladwell. That something else can eventually include increased convenience and lower cost. He offered a number of examples, including the shift to digital cameras where early pictures were not as good as film and the advent of the digital compression of music, which he contends has made the quality of music worse.

The changes in film and music were accepted, he said, in exchange for new opportunities to arrange, manipulate, and personalize our pictures and music. “In healthcare we don’t have the same stomach for that period of transition. That’s striking to me.”

The disruptive innovation that Gladwell is hoping for has yet to affect healthcare. It is possible that as more Silicon Valley start-ups focus on making medical care more convenient, worry-free, hassle-free, more personalized, and more accessible that the majority of individuals won’t adopt them because doctors don’t approve. The shift to a “temporary deficit in performance” may not be as acceptable even if less expensive and more convenient. As Gladwell notes in the case of dialysis, despite being around for over seven decades, patients in general still don’t self-administer treatment, which would be less expensive, but rather continue to go to facilities which are overseen by doctors.

His colleague, Dr. Atul Gawande, countered that other industries, like “teaching, firefighting, and police work” still have intermediaries that do the work on behalf of the individuals. Gawande believes that the real issue is that the care we provide as doctors isn’t integrated. We focus on optimizing each part of the health care system without looking across the entire experience of care. Extending this analogy to building the best car and using the best manufacturer for each part, Gawande notes:

… building a car with Porsche brakes, a Ferrari engine, a BMW chassis, and a Volvo body. Put it all together and what you have is an expensive pile of junk that doesn’t go anywhere because the pieces don’t work together.

Nowhere was the need for doctors to lead change and think about the entire experience for the patient more clear than a recent New York Times piece by health reporter Tara Parker-Pope, titled “Too Much Medical Care.” She chronicled her experience as an educated patient and parent of a daughter who suffered an ankle injury at camp. She started first with:

Pediatrician. Initial visit.

One month later, still not better so she takes daughter to sports medicine specialist. MRI ordered.

Referral to pediatric orthopedic surgeon. Another MRI. Blood work.

Slightly abnormal blood work.

Referral to eye specialist.

Referral to pediatric rheumatologist. More blood work. Another (3rd) MRI. X-ray of hands.

Five months after original injury, daughter notes that her ankle still hurts.

Finally, Parker-Pope takes back control. She consults with the sports medicine specialist who reviews the case with the pediatrician. The focus in back on the patient and pain relief. Soon, the daughter is back to resuming her activity.

In retrospect, what is most surprising is how long the entire process went and still the daughter’s problem hadn’t been solved. Three MRIs for an ankle injury. Four specialists.  Many blood vials drawn. X-ray of the hands, though the ankle was the injured joint. It’s not that Parker-Pope is naive or uneducated. She is a health reporter for the New York Times and has talked to many doctors and written many stories. The fact that she and her daughter were caught up in the health care system illustrates the challenges facing the public.

Solving the health care crisis will require both points of view offered by Gladwell and Gawande. We need both patient engagement as well as a more coordinated integrated health care system. It is however increasingly clear, particularly based on the New York Times piece, that empowered patients alone won’t be able to bend the cost curve. Despite the easy availability of information via the internet and self-diagnosis, there is value to the “expert” in determining the right course of action. As both Gladwell and Gawande note in their previous works there is a need for 10,000 hours of deliberate practice to become expert and that even the experts need coaching for continuous improvement, respectively.

The real problem is whether the “experts” are willing to make the judgement calls that our training provides? When to refer? When not to refer? When to get the MRI? When not to get the MRI? When to prescribe antibiotics? When to hold ground and sympathize when it is a virus? When to comfort, empathize, and heal when it means stopping chemotherapy when treatment is futile? When to do surgery? When to hold off? Are we willing to have others observe us in action so we can be even better? If not, why not?

For health care to be better, doctors must lead the change. No one else can. Insurers and employers have exhausted strategies to make patients more accountable. Increasing deductibles and co-pays indefinitely won’t work. Despite the unprecedented access to information, empowered patients and other patient advocates will never be able to fully close the knowledge gap. That difference in knowledge, as Gladwell points out in his book, Blink, is what allows an expert to distinguish between an authentic piece of artwork and a very good looking fake.

It is also the difference between stopping a number of unnecessary referrals and the cascade effect of subsequent imaging, blood work, and appointments and instead focusing on the patient.

Who will shape health care? Doctors, patients, and insurers and in that order.

Or entrepreneurs who partner with doctors to solve our challenges so we can go back to focusing on healing patients.

Davis Liu is a family physician who blogs at Saving Money and Surviving the Healthcare Crisis and is the author of The Thrifty Patient – Vital Insider Tips for Saving Money and Staying Healthy and Stay Healthy, Live Longer, Spend Wisely.

How much does surgery cost? About $147 a minute @drsilenzi

Interessante valutazione dei costi di procedure complesse in ospedale.

by  | in PHYSICIAN Nate Johnson is a medical student who blogs at Costs of Care

The patient had a large abscess surrounding his spleen. On a large screen in the middle of the operating room, I watched a surgeon drain the fluid collection and remove the organ with small metal tools.

I remember the surgeon navigating the complex anatomy with alacrity, handling the laparoscopic equipment with expert finesse, and quickly and confidently answering the battery of questions from the assisting medical student. To a young and reverent observer, this surgeon seemed to know everything.

So at the end of the case I asked how much the procedure would cost the patient.

“I’m not really sure. It’s … kind of complex,” the surgeon vaguely responded.

Indeed, surgical procedure charges are confusing and consist of many different fees. There are fees for medications, instruments, and devices, there is the “initial” operating room fee, the recovery room fee (billed per hour), the anesthesia fee, the surgeon’s fee, and the operating room fee (billed per minute), among others.

But at the time I was surprised and a little disappointed that this surgeon – who expertly performed the surgery and had an incredible breadth of medical knowledge – had no idea what the patient would be charged. It just seemed like such a simple question. I decided to look into it myself.

As it turns out, the total charge to the patient in this case was $43,226.18. The patient was in the operating room for 3 hours and 31 minutes and was charged a $30,966 operating room fee. That’s just under $147 per minute! A closer look also revealed that, from incision to surgery end, the procedure lasted 2 hours and 35 minutes. This leaves 56 minutes of non-surgical operating room time.

Of course, this time is not squandered. Before the surgery begins, for example, anesthesiologists need time for induction, the sterile surgical field must be set-up around the patient, instruments have to be prepared, checklists have to completed, and the surgeons have to scrub in.

Yet the question must inevitably be asked: did all of this additional work require almost an hour? At $147 per minute, the question deserves serious consideration. And the answer should be anything but vague.

Cataract surgery may prevent efficiently hip fractures in elderly which is huge cost for Medicare 10bn$/yr @FLAHAULT @drsilenzi

Quando l’analisi economica ha un punto di vista societario e non si esaurisce in una valutazione d’impatto sul budget di un singolo ospedale!

http://jama.jamanetwork.com/article.aspx?articleid=1273017

ABSTRACT

Context  Visual impairment is a known risk factor for fractures. Little is known about the association of cataract surgery with fracture risk.

Objective  To determine the association of cataract surgery with subsequent fracture risk in US Medicare beneficiaries with a diagnosis of cataract.

Design, Setting, and Participants  Retrospective study of 1-year fracture incidence in a 5% random sample of Medicare Part B beneficiaries with cataract who received and did not receive cataract surgery from 2002 through 2009.

Main Outcome Measures  One-year incidence of hip fractures. Analyses were adjusted for age; sex; race/ethnicity; US region of residence; systemic comorbidities, including Charlson Comorbidity Index (CCI) score; ocular comorbidities; cataract severity; and presence of physically limiting conditions. Adjusted odds ratios (ORs) of hip fractures were calculated using logistic regression modeling.

Results  There were 1 113 640 US Medicare beneficiaries 65 years and older with a diagnosis of cataract between 2002 and 2009 in the 5% random sample; of these patients, 410 809 (36.9%) received cataract surgery during the study period. There were 13 976 patients (1.3%) who sustained a hip fracture during the study period. The most common fracture-related comorbidity was osteoporosis (n = 134 335; 12.1%). The most common ocular comorbidity was glaucoma (n = 212 382; 19.1%). Compared with 1-year hip fracture incidence in patients with cataract who did not have cataract surgery, adjusted OR of hip fracture within 1 year after cataract surgery was 0.84 (95% CI, 0.81-0.87) with an absolute risk difference of 0.20%. Compared with matched subgroups of patients who did not receive cataract surgery, patient subgroups that experienced lower odds of hip fracture after cataract surgery included patients with severe cataract, patients most likely to receive cataract surgery based on propensity score, patients 75 years and older, and patients with a CCI score of 3 or greater.

Conclusion  In a cohort of US Medicare beneficiaries aged 65 years and older with a diagnosis of cataract, patients who had cataract surgery had lower odds of hip fracture within 1 year after surgery compared with patients who had not undergone cataract surgery.

Fractures secondary to falls are a significant cause of morbidity and mortality in the elderly population,accounting for more than 60% of expenses resulting from fall-related injuries and costing the United States more than $10 billion in the year 2000.Visual impairment has been found to be strongly associated with an increased risk of fractures,– with reports of increased fracture incidence in patients with poor visual acuity,depth perception,contrast sensitivity,and visual field loss.7

Specifically, vision plays an important role in providing a reference frame for postural balance and stability, and cataract-induced changes in vision have been found to be associated with postural instability.A systematic review found that patients who wait more than 6 months for cataract surgery had an increased rate of falls.Furthermore, cataracts have been found to be the most common cause of fracture-related visual impairment,10 with untreated cataract causing up to 49% of visual impairment in patients with femoral neck fractures related to decreased vision.10

Despite the association of poor vision and cataracts with increased fall and fracture risk, only a limited number of studies11 – 15 have examined the influence of cataract surgery on fall incidence in visually impaired adults, and only 2 of these studies11 – 12 examined the incidence of fractures secondary to falls. These 2 studies examined the relationship of first and second eye cataract surgery with fall and fracture risk in the same population of women in the United Kingdom older than 70 years, with sample sizes of fewer than 350 patients in each study. To our knowledge, no other studies have examined the association of cataract surgery and fracture incidence in visually impaired adults. This study examined the association between cataract surgery and fracture incidence in a cohort of US Medicare beneficiaries.

Interesting blog via @innovate on large companies & disruptive innovation. Do same principles apply to large NHS orgs? @helenbevan @drsilenzi

Disruptive Innovations and Large Companies

A few weeks ago I gave a seminar at an executive management class for a large, global company.  The class consisted of up-and-coming executives, roughly in their late 20s and early 30s with 5 – 10 years in the company.   The subject of my seminar was Managing Technology-based Disruptive Innovations.  I used my personal experiences at IBM, the development of the Internet strategy in the mid-late 1990s in particular, as a springboard for discussing two major subjects: why companies, no matter how big and successful, need to embrace disruptive innovations that will likely have a major impact in their industry;  and why doing so requires an entrepreneurial approach quite different from their more typical operational culture.

Given my long career at IBM, as well as my more recent involvement with Citi, it is not surprising that I am particularly interested in entrepreneurship and innovation in large companies.  While I’ve been involved withstartups, the bulk of my experience has been with large, global companies, not just IBM and Citi, but many others I’ve interacted with as part of my work.

Quite a few people think that entrepreneurship in large companies is an oxymoron.  In March of 2009, The Economist published a very good special report on entrepreneurship.  Its lead article defined  the term as: “somebody who offers an innovative solution to a (frequently unrecognised) problem.  The defining characteristic of entrepreneurship, then, is not the size of the company but the act of innovation.”

It further added:  “Many entrepreneurs are sworn enemies of large corporations, and many policymakers measure entrepreneurship by the number of small-business start-ups.  This makes some sense.  Start-ups are often more innovative than established companies because their incentives are sharper: they need to break into the market, and owner-entrepreneurs can do much better than even the most innovative company man.”

A good innovative idea is necessary, but not sufficient, to succeed in an entrepreneurial endeavor.  The innovation game is played in the marketplace, so you need to figure out how to best bring your innovation to market and nurture it along.  To succeed, you need to leverage whatever advantages you have in what is likely to be a tough competitive battle.

Focus and speed are the key competitive advantages of a startup.  Startups are generally organized around one central innovation.  They can thus focus all their energies on developing the ensuing offerings, getting them to market as quickly as possible, and continuously improving them based on actual customer feedback.

It is different with large companies.  Over the years, the company has amassed a number of valuable assets.  It has built an extensive organization, the bulk of which is dedicated to managing their assets, – continuously improving their products and services; supporting their customer base and channel partners; growing revenue, profits and cash; nurturing the brand, and so on.

For a startup, a disruptive innovation is an opportunity to take on established companies with new products that offer significantly better capabilities and/or lower costs.  That’s what creative destruction is all about.  Not surprisingly, an established company under attack will often reject and fight anything that threatens its market dominance and profits.  The company is already consumed with managing its existing operations, – a highly complex and demanding task.  It may see the new innovation as more of a distraction than an opportunity.

This is generally a mistake, sometimes a very costly one.   First of all, the company needs to identify and acknowledge the disruptive innovation as early as possible.  Disruptive innovations, most of which are technology-based by nature, take years to develop, come to market, and build up enough momentum to threaten existing products and services.  Like watching out for asteroids, most such technologies can be identified and carefully tracked years before the broad marketplace notices that something new has now appeared on the horizon.  In all likelihood, universities and research communities, as well as entrepreneurs and VCs are already working on developing the new technologies and figuring out their marketplace implications.

Once the company is convinced that sooner or later change is inevitable, it needs to analyze the potential consequences and come up with a plan of action.  This is often really difficult, especially if the actions require different business models and significantly lower cost and expenses.  The company will likely go through a period of denial, where it hopes that the change will not happen, or that it is so far out in time that it can leave it to the next generation of leaders.

But, once it’s clear that major changes are inevitable, whether you like it or not, it’s time for important strategic decisions.  How will your industry change over time?  What are the implications for your company, and what should you do about it?  How quickly should you move?  The answers to these questions and the ensuing actions you take are critical to the future of the business.

Large, established companies cannot possibly compete with startups on focus and speed.  Instead, the companyneeds to figure out how to best integrate the new disruptive innovation with its key core assets.  This will make it easier to then embrace the innovation as a way of rejuvenating and transforming the company and its various products, services, processes and business models. It will be a major competitive advantage over both established competitors and fast moving startups.

The company’s financial strengths will enable it to hire the the necessary talent to develop and bring to market the new offerings.  Or, given the time-to-market pressures in an increasingly competitive environment, the company may decide to embrace the new innovations by acquiring a startup that already has a product in the marketplace, rather than waiting for the time it takes to start a new group and develop the product in-house.

In the case of IBM’s Internet strategy, which I often use to illustrate these points in seminars and classes, we came up with the concept of e-business which we succinctly defined as Web + IT, that is, the combination of the industrial-strength IT infrastructures being widely used in business and government with the new universal reach and connectivity of the Web.  Any institution, by integrating its existing databases and applications with a web front end, could now reach its customers, employees, suppliers and partners at any time of the day or night, no matter where they were.  Anyone with a browser and an Internet connection was now able to access information and transactions of all sorts.

Our point of view was quite different from what many dot-com startups and Internet analysts were saying at the time.  Many were claiming that in the Internet-based new economyborn-to-the-Web startups had an inherent advantage over existing companies, whose legacy assets, including IT infrastructure and customer base, were no longer relevant, would slow them down and make it hard for them to compete.

We took a very different position.  Every business, we were convinced, would benefit from embracing the universal reach and connectivity of the Internet, not just startups.  We believed that the brand reputation, installed customer base and IT infrastructures that companies had built over the years would be even more valuable assets when combined with the new capabilities offered by the Internet.  Our position was not always popular during the dot-com bubble, but once the bubble burst a few years later, it was clear that we had developed the right strategy and had given our customer the right advice.

With few exceptions, the assets that have made a company successful over the years are invaluable if properly deployed – from their products, services and loyal customer base to their brand reputation and financial strength.  Those companies that can properly leverage their assets and integrate them with up-and-coming innovations stand the best chance to be around for many years to come.

5 TED Talks That Will Change Your Life @drsilenzi

Written by  http://www.pickthebrain.com/blog/5-ted-talks-that-will-change-your-life/

A great, free Internet resource for anyone who loves to learn online is the websitewww.TED.com (Technology, Entertainment, Design). TED  provides fascinating discussions and lectures about important and interesting topics – for free. TED offers us many wonderful opportunities to expand our knowledge base and change our lives. Below are five TED talks in a broad range of topics that we think are truly life changing, and are, in the words of TED, ideas worth spreading.

  1. SteveJobsHowtoLiveBeforeYouDie: At a commencement address he gave at Stanford University in 2005, Steve Jobs urged graduates to pursue their dreams, and to view the setbacks that we have in life as new opportunities for advancement. This even includes death itself. This brilliant talk by Jobs will change your life because you learn a bit of how Jobs took some serious challenges thrown at him by life, and still become one of the most influential businessmen and innovators of the last 50 years.
  2. DaphneKollerWhatWereLearningFromOnlineEducation: Daphne Koller gives a fascinating talk about the future of online education. She believes that in the near future, many universities will begin to place much of their best courses online at no cost. This will serve not only as a service to millions of people who could not otherwise access such education. It also will serve as a great tool to learn how people learn. Every keystroke, quiz and discussion conducted online can be mined to discover how people process knowledge and learn.
  3. JillBolteTaylorsStrokeofInsight: Brain researcher Jill Bolte Taylor had a highly unusual and amazing opportunity in the world of science: She got to study her own stroke as it occurred in her own body. As the aftermath of the stroke progressed, she had a ringside seat as her brain functions ceased one by one: speech, motion, memory and self-awareness. Taylor spent eight long years learning how to think, walk and talk again.
  4. NeilPasrichaThe 3 AsofAwesome: Neil Pasricha’s has a blog called 1000 Awesome Things, which encourages us to enjoy some of the most simple pleasures of life. These can include clean sheets, free refills, and much much more. In this talk, Pasricha talks about the three secrets of life that lead to an awesome life. He began his blog about five years ago to just provide small reminders to people of the many free, simple joys of life that make it worth living. Today his blog has millions of readers from all over the globe.
  5. RandyPauschReallyAchievingYourChildhoodDreams: Carnegie Mellon professor Randy Pausch was dying of pancreatic cancer in 2007 when he delivered this legendary lecture about how you can truly achieve your dreams from your childhood. This is one talk that you really should not miss. Millions of people around the planet have been inspired by The Last Lecture.

Hopefully these five jaw-dropping TED talks left you feeling inspired and a bit more knowledgeable about our world.

Joseph Pickett is a freelance writer for MPHProgramsList.com, where he enjoys writing about science and the art of protecting and improving the health of communities through education and smart healthy lifestyles. More recently he highlighted 10 Public Health Careers sure to address upcoming shortage of public health workers. He invites feedback on this and his other articles.