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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

A great, free Internet resource for anyone who loves to learn online is the (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, 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.

Tasse e Regioni: chi ci guadagna e chi ci perde

Quali sono le Regioni che spendono più di quanto raccolgono? E quali le più virtuose?
Scoprilo in questa infografica di Yahoo! e Linkiesta:

Tasse e regioni, chi ci guadagna e chi ci perde – Infografica

Is rationing necessary to reduce health care costs? @GIMBE @drsilenzi @kevinmd

by  | in POLICY

Healthcare costs keep rising. Your insurance premiums go up, your deductible and co-pays go up, pharmacy benefits go down. Despite the high cost you get little time with your physician, insurance statements are complex beyond belief and “customer service” seems to be a foreign concept. To combat high costs we are often told that rationing will be necessary. Is that true?

Why are costs so high in this very dysfunctional healthcare delivery system?

There are many reasons. New technologies and drugs are often cited as major culprits. There is some truth to this of course but the real culprit here is inappropriate use. Think of the stomach acid blockers for reflux (heartburn). Good drugs for sure but maybe some lifestyle changes such as less caffeine, less alcohol, raising the head of the bed and waiting a few hours after dinner before going to sleep will work just as well with no cost whatever.

Worst yet is when an expensive test is ordered when diagnosis could have been figured out through a careful history. Did you need an endoscopy with its negative results when the reflux would not abate? Or did you really need a careful history that figured out you were sensitive to gluten? A dietary change solved the entire problem; no pills or procedures needed.

Our lifestyles are a major reason for the escalation of costs. As a society we eat a non-nutritious diet and far too much of it, we are sedentary, we are chronically stressed and 20% still smoke. The results are complex chronic illnesses such as diabetes, cancer, heart disease and stroke. These are lifelong once they develop, difficult to manage and expensive to treat. The real answer is to adjust our lifestyles and to prevent the epidemic of obesity which is a precursor to many of these illnesses. But until we do, costs will escalate rapidly as more and more individuals develop these chronic illnesses – which are where about 70+% of health care claims paid go.

The population is aging as well and with aging come problems such as visual and hearing impairments, joint dysfunction and Alzheimer’s disease. These too incur substantial expense.

There remains in healthcare delivery far too many preventable errors with probably 100,000 individuals dying each year and an equal number dying of hospital acquired infections. Dealing with these two problems will not only markedly improve quality but will also save billions of dollars each year.

And at end of life, often there is a decision made by either patient (or patient’s loved ones) or recommended by the physician to “do one more thing.” All too often this is a mistake with no real benefit to the patient and often more time spend with distress. It is much better to have a realistic discussion between patient (and or loved ones) and the physician and from that a realistic plan for care. This, I hasten to add, is neither a “death panel” nor does it mean no more care and attention. What it does mean is that the care going forward will be just as complete and compassionate but with the more realistic goal of best quality of life possible for as long as possible. Here again, quality ends up costing less.

These are just some of the most notable reasons for rising costs. Many, perhaps most with the exception of those that come with aging, could be addressed with changes in lifestyle, good preventive medicine, attention to quality and more emphasis on patient-physician interaction rather than on testing and referrals to specialists. Add to this good palliative care at the end of life and a very substantial amount of money could be saved while providing better quality.

Physicians can take the lead by agreeing to eliminate those tests and procedures that are often done but which have not been found to add much to the care of the patient. A good approach to this has been presented by Dr. H Brody in the New England Journal of Medicine which was followed up in the oncology field by Smith and Hillner also in the NEJM . The basic concept was that each specialty society create a “top five list” of those tests or procedures that offer little or no benefit to most patients. In Smith and Hillner’s article they suggested – just one of their  examples to reduce costs in medical oncology -that no patient (other than certain well defined exceptions) should receive chemotherapy if he or she was unable to walk into the clinic unaided, there being good data that such patients rarely benefit but often suffer adverse consequences.

Rationing is not necessary. We need to correct the dysfunctional delivery system so it can offer higher quality care at a reasonable cost. It is not impossible to do and no rationing is required.

Is rationing necessary to reduce health care costs?

Stephen C. Schimpff, MD is an internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center and consults for the US Army, medical startups and Fortune 500 companies. He is the author of The Future of Medicine – Megatrends in Healthcare andThe Future of Health Care Delivery, published by Potomac Books. 

Innovation in Healthcare Leadership: The Time is Now @HarvardSPH_ECPE

Hospital Review
Written by Alan M. Zuckerman, FACHE, FAAHC, President, Health Strategies & Solutions | July 11, 2012
Healthcare organizations had a great run. The past four decades, post-implementation of Medicare and Medicaid, have been a boom time. As healthcare spending grew rapidly, all parts of the industry flourished. Just trying to keep up with growing demand was a major challenge for many organizations.
In a booming economy, the need for innovation is low. Organizations prosper just by fulfilling needs, providing adequate quality and customer service, and by avoiding doing the wrong things, like severe mismanagement and taking major unfounded risks. Most healthcare organizations, especially non-profits, pursued strategies that were incremental — follow the money and play between the lines. Reinforcing this posture were organizational cultures that were risk averse and committed to the view that success was found in the tried and true and by not making errors, large or small. Even the job title for our industry’s executives for most of this period — administrator — suggests an overseer or steward rather than a leader and active manager.

New era/New imperatives

So, what has changed? Mostly the economy and healthcare reform, but an emerging oversupply of certain profitable services played a part as well, fueling hyper competition in many markets. The 2008 recession dealt the final blow to the old healthcare economy, removing the artificial support that allowed spending to grow without limit. With the economy stalled out, spending increases above the rate of inflation become unaffordable to governments and private buyers alike, setting the stage for healthcare reform. Reform’s principal emphasis, both that of the federal government, but also the less obvious reform of the deficit-riddled states and struggling private businesses, is to get their costs under control. We are entering an era of no- or low-growth reimbursement. Like many other industries, the call to action is how do we do more, or even the same, with less? And with the artificial prop of 5 to 10 percent increases in rates and spending no longer guaranteed, how do we maintain the vitality of our organizations?

A healthy shake-up

As unsettling as the last four years have been for healthcare leaders, there is an upside. The rules of the game have changed. Opportunities to be bold are emerging and innovation in healthcare organization management and service delivery, when executed well, will be rewarded. Slowly reacting and adapting to scientific and payment/regulatory modifications won’t be enough. Busting the status quo, challenging long-held assumptions, envisioning the possibilities when uncertainty is converted to action and forging a new path – that’s what true innovation in healthcare could look like.

Getting started

How can innovation be fostered? How does the industry move to a culture where innovation is valued? Where will innovation come from? These questions lie at the heart of successful adaptation to this new era of healthcare.

First, healthcare executives must recognize that their organizations’ cultures are at odds with this new posture and work to reshape the cultures to make them more adaptable, flexible and risk-bearing. Second, every executive must accept the responsibility for innovation as part of their core role, moving this from the periphery of leaders’ concerns to the center. Third, then, how do we operationalize the search for innovative opportunities and successfully implement them?

Healthcare organizations can look to other industries for guidance on how to identify and implement innovative opportunities. Peter Drucker’s Harvard Business Review article, “The Discipline of Innovation,” identified seven sources of innovation, four that are internal — unexpected occurrences, incongruities, process needs, and industry and market changes — and three sources that are external — demographic changes, changes in perception and new knowledge. He suggests that “an innovation has to be simple, and it has to be focused. It should only do one thing…Above all, innovation is work rather than genius.”

5 actions to launch the innovation journey

Here’s what the agenda for innovation could look like at your organization.

1. Rally senior leaders. Beyond the case for change, clarify the importance of individual and organizational innovation as a critical element of success in the future.

2. Reexamine and begin to modify your organization’s culture to be more risk-bearing. Recognize and reward innovation, encourage experiments and pilots and create a non-punitive environment.

3. Make innovation a theme of day-to-day operations. Building on #2, support, highlight, emphasize and celebrate innovation in daily operations.

4. Consider structural changes to support innovation. For large organizations, a chief innovation officer would be a symbolic and substantive commitment to progress; for any organization, an ad hoc committee or subcommittee of a board or senior management group could be charged with keeping innovation visible and moving forward.

5. Just do it. Don’t study and discuss innovation to death; accelerate implementation of small- (and larger-) scale innovations and demand that all senior leaders visibly support such changes.

Isn’t it time we got to the hard work of innovation in healthcare organization leadership and service delivery and move it to a central role in organizational growth and development?

Alan M. Zuckerman, FACHE, FAAHC, is president of Health Strategies & Solutions, Inc., a national health care strategic planning firm headquartered in Philadelphia. During his 35-year tenure as a management consultant, he has developed strategic and business plans for over 150 providers, including many of the top health systems and academic medical centers in the country. A nationally recognized author and speaker, he is actively involved in researching emerging trends in health care strategy.

More Articles on Healthcare Innovation:

HHS Gives $123M to 26 Healthcare Innovation Award Winners 
Spurring Innovation in Healthcare Delivery: 5 Best Practices of Health System Leaders 
7 Noteworthy Developments for Healthcare Innovation During 2011

Global Budget Payment Model lowers medical spending, improves quality @Pqr9ap

2 years post-launch, the Blue Cross Blue Shield Alternative Quality Contract provides a viable model for moving beyond fee-for-service

A new study suggests that global budgets for health care, an alternative to the traditional fee-for-service model of reimbursement, can slow the growth of medical spending and improve the quality of care for patients.

Researchers from Harvard Medical School’s Department of Health Care Policy have analyzed claims data from Blue Cross Blue Shield of Massachusetts’s Alternative Quality Contract (AQC), a global budget program in which 11 health care provider organizations were given a budget to care for patients who use BCBSMA insurance. Such a model contrasts with widely used fee-for-service systems, where providers are reimbursed for each medical service they deliver.

The Alternative Quality Contract predates, but is similar to, the Pioneer Accountable Care Organization contracts that Medicare began this year through the Affordable Care Act, an initiative in which Medicare will reward groups of providers based on improved outcomes and lower health care spending.

The researchers looked at the first two years of data from the AQC and found that the program has, in fact, succeeded in lowering total medical spending while simultaneously improving quality of care.

On average, groups in the AQC spent 3.3 percent less than fee-for-service groups in the second year, the study showed. Provider groups who entered AQC from a traditional fee-for-service contract model achieved even greater spending reductions of 9.9 percent in year two, up from 6.3 percent in the first year. Compared to those groups, groups that entered from contracts that were already similar to the AQC achieved fewer savings in both years. The researchers also found that the improvements in quality of chronic care management, adult preventive care and pediatric care associated with the AQC grew in the second year.

“Moving away from fee-for-service models is high on the agenda of those looking to establish a fiscally sustainable, efficient health care system,” said Michael Chernew, professor of health care policy at Harvard Medical School and senior author on the study. “It is likely that this type of new payment model will grow rapidly in coming years in the nation as a whole, and particularly in Massachusetts. By analyzing this program, we’re studying the future before it gets here.”

“Both challenges and opportunities lie ahead,” said Zirui Song, a student at Harvard Medical School and recent graduate of the Harvard PhD Program in Health Policy, and lead author on the study. “With global budgets, provider organizations must divide not only dollars, but authority and autonomy among its member physicians and hospitals. While this transition is likely challenging, it represents a real opportunity to align incentives to coordinate care and keep patients healthy. The AQC teaches us that a successful start is possible, and that supportive payer-provider partnerships are critical.”

These findings will be published July 11 in the journal Health Affairs.

In 2009, Blue Cross Blue Shield of Massachusetts launched the Alternalitve Quality Contract. In addition to the global budget, participating groups were also eligible for bonuses if they met certain quality or financial targets. Conversely, groups took on financial risk for any spending over the budget.

Initially seven groups entered the program, followed by four more in 2010. Last year, Song, Chernew and colleagues analyzed data from the program’s first year and published the findings in theNew England Journal of Medicine.

While the first year analysis also demonstrated reduced spending with increased quality of care, the numbers were even more striking for the second year. Overall savings in year one were 1.9 percent, as opposed to 3.3 percent in year two.

For both years, reduced spending was attributed largely to physicians referring patients to lower-cost facilities. For the second year, lower utilization of medical services among some groups also contributed to the savings.

Quality of care improvements were also greater in the second year than in the first.

The researchers noted that while the AQC reduced medical spending, the overall dollar amount paid by BCBSMA did not decline. This is because the AQC was designed to include incentives for lower spending and improved quality that may offset reductions in medical spending.

Chernew, however, does not consider this a weakness of the program.

“The intent of the AQC was to achieve savings over the five year duration of the contract,” said Chernew. “It was not designed to reduce BCBSMA spending in the first two years. Yet success in the long run requires a change in the culture of medicine in Massachusetts. This study shows that the culture can and will change. For example, in the second year of the AQC, we found both changes in utilization and referral patterns, which suggest physicians are beginning to think and act differently. This study suggests that the delivery system is on a trajectory to be successful, and ultimately it’s the trajectory that matters. Continued transformation of delivery systems is crucial and we have to continue to monitor the impact of these cutting edge payment systems. One way or another, providers need to learn to live in a more fiscally constrained environment.”

“Historically physicians have felt that when money gets tight, the cavalry—in the form of more money—will arrive. We’ve reached the point where it’s unlikely there will be any cavalry,” Chernew added.

“These results are vitally important,” said David Cutler, Otto Eckstein Professor of Applied Economics at Harvard University. “We have known there were better organizations—high quality and low cost—and worse organizations. But we haven’t known how to help organizations get better. These results show us a key path to quality improvement and cost reduction.”


This research was funded by The Commonwealth Fund, the National Institute on Aging and the Charles H. Hood Foundation.


Health Affairs, July 11, 2012, “Web First” online publication

“The ‘Alternative Quality Contract,’ Based on a Global Budget, Lowered Medical Spending and Improved Quality” by Song et al.

Harvard Medical School <> has more than 7,500 full-time faculty working in 11 academic departments located at the School’s Boston campus or in one of 47 hospital-based clinical departments at 16 Harvard-affiliated teaching hospitals and research institutes. Those affiliates include Beth Israel Deaconess Medical Center, Brigham and Women’s Hospital, Cambridge Health Alliance, Children’s Hospital Boston, Dana-Farber Cancer Institute, Harvard Pilgrim Health Care, Hebrew SeniorLife, Joslin Diabetes Center, Judge Baker Children’s Center, Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital, McLean Hospital, Mount Auburn Hospital, Schepens Eye Research Institute, Spaulding Rehabilitation Hospital, and VA Boston Healthcare System.

Ten Things You Didn’t Know Were In The Affordable Care Act @KHNews

By David Schultz and Christian Torres

JUL 12, 2012

So you think the Supreme Court upheld a law that requires most people to buy health insurance? That’s only part of it. The measure’s hundreds of pages touch on a variety of issues and initiatives that have, for the most part, remained under the public’s radar. Here’s a sampling:  

Postpartum Depression (Sec. 2952)
Urges the National Institute of Mental Health to conduct a multi-year study into the causes and effects of postpartum depression. It authorized $3 million in 2010 and such sums as necessary in 2011 and 2012 to provide services to women at risk of postpartum depression.
Abstinence Education (Sec. 2954)
Reauthorizes funding through 2014 for states to provide abstinence-only sex education programs that teach students abstinence is “the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems.” Federal funding for these programs expired in 2003.
Power-Driven Wheelchairs (Sec. 3136)
Revises Medicare payment levels for power-driven wheelchairs and makes it so that only “complex” and “rehabilitative” wheelchairs can be purchased; all others must be rented.
Oral Health Care (Sec. 4102)
Instructs the Centers for Disease Control and Prevention to embark on a five-year national public education campaign to promote oral health care measures such as “community water fluoridation and dental sealants.”
Privacy Breaks for Nursing Mothers (Sec. 4207)
Requires employers with 50 or more employees to provide a private location at their worksites where nursing mothers “can express breast milk.” Employers must also provide employees with “a reasonable break time” to do this, though employers are not required to pay their employees during these nursing breaks.
Transparency on Drug Samples (Sec. 6004)
Requires pharmaceutical manufacturers that provide doctors or hospitals with samples of their drugs to submit to the Department of Health and Human Services the names and addresses of the providers that requested the samples, as well as the amount of drugs they received.
Face-to-Face Encounters (Sec. 6407)
Changes eligibility for home health services and durable medical equipment, requiring Medicare beneficiaries to have a “face-to-face” encounter with their physician or a similarly qualified individual within six months of when the health professional writes the order for such services or equipment.
Diabetes & Death Certificates (Sec. 10407)
Directs the CDC and the HHS Secretary to encourage states to adopt new standards for issuing death certificates that include information about whether the deceased had diabetes.
Breast Cancer Awareness (Sec. 10413)
Instructs the CDC to conduct an education campaign to raise young women’s awareness regarding “the occurrence of breast cancer and the general and specific risk factors in women who may be at high risk for breast cancer based on familial, racial, ethnic, and cultural backgrounds such as Ashkenazi Jewish populations.”
Assisted Suicide (Sec. 1553)
Forbids the federal government or anyone receiving federal health funds from discriminating against any health care entity that won’t provide an “item or service furnished for the purpose of causing … the death of any individual, such as by assisted suicide, euthanasia, or mercy killing.”
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La classifica dei sistemi sanitari

Gavino Maciocco, L’Unità, 15 luglio 2012

Su 34 sistemi sanitari europei quello italiano si trova al 21° posto. Siamo superati non solo dai nostri tradizionali concorrenti (Germania, Francia, Regno Unito, al primo posto in classifica l’Olanda), ma anche da paesi dell’ex Europa orientale come Repubblica Ceca, Slovenia e Croazia.

Destò scalpore – e fu accolta in Italia con grande soddisfazione  – la classifica dei migliori sistemi sanitari del mondo predisposta dall’OMS e pubblicata nel 2000 nel suo Rapporto annuale “Health Systems: Improving Performance”.  Al primo posto la Francia e subito dopo l’Italia.  Colpiva il fatto che ai primi posti vi fosse una forte concentrazione di paesi mediterranei e che nazioni come Spagna, Portogallo e Grecia surclassassero nazioni con solidi e ben più rinomati sistemi sanitari come Regno Unito, Svezia, Germania e Canada.

Tre i criteri utilizzati per misurare la performance dei diversi sistemi sanitari e allestire la graduatoria:

1)    Il buono stato di salute della popolazione – good health – (la durata della vita in buona salute);

2)    L’equità del finanziamento – fair financing – (nessuno dovrebbe andare in rovina a causa di una malattia);

3)    La capacità del sistema di rispondere ai bisogni dei pazienti –responsiveness –  (il rispetto della dignità, della riservatezza e dell’autonomia, la tempestività nella risposta, la scelta del luogo di cura, il comfort ambientale, la possibilità di parenti e amici di essere vicini a un paziente ricoverato).

Particolarmente sul punto 3) – la responsiveness – si aprì una discussione, e alla fine una critica serrata, sul metodo di rilevazione delle informazioni utilizzato dalla ricerca dell’Oms. Infatti le domande non erano state rivolte agli utenti o ai pazienti (come sembrava naturale, quasi ovvio), ma a degli “esperti”.  E quando – successivamente – la ricerca fu ripetuta avendo come bersaglio pazienti  ricoverati e pazienti ambulatoriali,  pazienti poveri e pazienti anziani,  i risultati sono stati molto diversi. E paesi come Spagna, Portogallo, Grecia e – ahimè –  l’Italia si sono trovati in fondo alla classifica (dei paesi più industrializzati).  Per questo motivo la classifica dell’Oms ha perso valore e credibilità.

Se dopo l’esperienza del 2000 l’Oms ha cessato di stilare classifiche di valutazione dei sistemi sanitari, questo compito ha deciso di assolverlo – limitatamente ai paesi europei –  l’Health Consumer Powerhouse, agenzia indipendente, nata a Stoccolma nel 2004 allo scopo di promuovere la cultura della valutazione e della trasparenza in campo sanitario, partendo dal punto di vista dei cittadini-utenti. La filosofia dell’iniziativa è che la valutazione comparativa sulla qualità dei sistemi sanitari genera un circolo virtuoso: per gli utenti una migliore informazione crea la migliore piattaforma per scegliere e agire; per i governi, le autorità sanitarie e i produttori di servizi il focus sulla soddisfazione dei cittadini e sulla qualità dei risultati li aiuterà a introdurre i necessari cambiamenti nei confronti delle aree critiche o insufficienti.

Il primo prodotto è stato lo Swedish Health Consumer Index, che dal 2005 è diventato Euro Health Consumer Index (EHCI), con la valutazione di 34 sistemi sanitari europei, giunto nel 2012 all’ottava edizione (per scaricare il Rapporto clicca su questo sito). Vengono esplorate e valutate attraverso una serie d’indicatori – con un punteggio massimo complessivo di 1000 punti potenziali – le seguenti aree: 1) Diritti e informazione dei pazienti; 2) Tempi di attesa per ricevere i trattamenti; 3) Risultati di salute; 4) Gamma e accessibilità dei servizi offerti; 5) con particolare riferimento ai farmaci.

Nel Rapporto 2012 in testa alla classifica, con 872 punti, c’è l’Olanda, mentre l’Italia, con 623 punti, si trova al 21° posto (vedi Figura 1).

Figura 1. EHCI 2012. Punteggio complessivo dei 34 sistemi sanitari europei

A pag 14 e 15 del Rapporto c’è una tabella riepilogativa dei risultati: in verde sono segnati gli indicatori positivi, in giallo gli intermedi, in rosso i negativi.  Per quanto riguarda l’Italia i punti verdi riguardano soprattutto i risultati di salute (es. mortalità infantile, mortalità evitabile, sopravvivenza da tumori e da infarto), per il resto predominano i colori giallo e rosso.

Una perfetta impudenza: l’Italia del “tutti innocenti”


Il Corriere della Sera 13 luglio 2012

Sosteneva Schopenhauer – un bilioso connazionale della signora Merkel vissuto circa un paio di secoli fa, al quale evidentemente non eravamo troppo simpatici – che tra tutti i popoli d’Europa gli Italiani rappresentavano l’esempio di «una perfetta impudenza». Esagerava, certamente. Ma resta il fatto che da un po’ di tempo chi vive in questo Paese non può fare a meno di chiedersi dove mai erano negli ultimi trent’anni gli attuali protagonisti della scena pubblica italiana, che cosa allora essi dicevano e facevano, addirittura se abbiano mai detto o fatto qualcosa. O forse, invece, erano ancora in troppo tenera età? O magari tutti all’estero e si occupavano d’altro?
Oggi, infatti, nessuno sembra essere stato responsabile di nulla. Una «perfetta impudenza», appunto. Debito pubblico cresciuto a livelli vertiginosi? Spesa pubblica oggetto di sprechi di ogni tipo e misura? Un’amministrazione di inefficienza conclamata? Le professioni preda del più turgido spirito corporativo? La lottizzazione partitica dominante dappertutto? Un welfare costruito a tutela dei più forti? Reti e servizi organizzati in forma oligo-monopolistica e sempre in danno del consumatore? Banche inefficienti e abituate ad angariare la clientela? Un’industria privata spesso variamente foraggiata a fondo perduto dallo Stato? Una giustizia di cui i cittadini diffidano? Carceri in condizioni orripilanti?

Sì, questo è il panorama vero e angoscioso dell’Italia di oggi. Ma è un panorama orfano di padri: per la parte che ciascuno vi ha avuto nel generarlo nessuno se ne vuole fare carico. Tutti innocenti. A cominciare dai partiti che fino a novembre dell’anno scorso hanno governato in ambito locale e nazionale. Quei partiti, quegli uomini e quelle donne, che per decenni hanno preso tutte le decisioni che oggi sappiamo sbagliate, quasi sempre senza preoccuparsi del domani ma solo del consenso dell’oggi; che hanno deliberato spese sconsiderate e hanno approvato leggi sempre più rivelatesi mal pensate e peggio ancora applicate. Per non dire dei sindacati, propugnatori abituali di vincoli rivelatisi soffocanti e, specialmente nel pubblico impiego, sostenitori di ope legis rovinosi, di mansionari e organici fuori dalla realtà, portatori di abiti ideologici implacabilmente ostili al merito, alla gerarchia, all’efficienza. Quei sindacati che per bocca di Susanna Camusso ancora oggi rivendicano come un merito indiscusso la prassi della concertazione «tra le parti», senza neppure un dubbio sulle evidenti conseguenze che una tale prassi ha avuto per decenni ai danni dell’interesse, non «delle parti», ma di quello generale, di cui deve pur essere garante il governo.

Mettiamoci pure, come è giusto, il sistema dell’informazione. Sì, troppo a lungo l’informazione indipendente si è mostrata eccessivamente indulgente verso il potere politico ed economico e i suoi rappresentanti. Non solo: troppo rispetto a priori anche verso i tabù culturalmente consacrati, verso l’autorità delle grandi corporazioni, verso tante discutibili pretese dei corpi dello Stato. Esattamente come la medesima indulgenza, il medesimo conformismo, però, ha avuto l’informazione ideologicamente orientata, ogni qual volta si è trattato di coprire le contraddizioni, le inadeguatezze o le vere e proprie magagne della propria parte.

C’eravamo, ci siamo stati tutti, insomma, nell’Italia degli ultimi trent’anni, se non sbaglio. E ognuno con la sua piccola o meno piccola parte di colpa; anche se oggi in molti fingono di esserselo dimenticato. Soprattutto c’erano, ci sono stati, gli Italiani (ha fatto bene Giuseppe Bedeschi ieri a ricordarlo). Gli Italiani: nella loro maggioranza implicati in mille modi – contro una minoranza di veri poveri e di senza diritti – nei meccanismi perversi che ci hanno portato alla drammatica condizione attuale: come elettori, come evasori fiscali, come finti invalidi o finti intestatari di quote latte, come viaggiatori a sbafo, come fruitori della spesa pubblica, di condoni edilizi, di pensioni d’anzianità, come membri di qualche piccola o grande corporazione di privilegiati. Più o meno i medesimi, c’è da giurarci, intenti a recitare oggi la parte dei superindignati contro la «casta».

È questo il massimo ostacolo che paralizza il Paese e gli impedisce di riprendere qualsiasi cammino, è la sua cattiva coscienza: l’oblio generalizzato e autoassolutorio della società nazionale in genere, e la mancanza della benché minima autocritica dei partiti maggiori, che di conseguenza li rende tutti non credibili nei loro propositi per il futuro, destinati quindi a suonare fastidiosamente patetici. L’Italia non potrà avere alcun futuro finché non riuscirà a disporre di una narrazione del passato che la renda consapevole degli sbagli trascorsi, delle loro cause e dei loro responsabili. Così come dopo la catastrofe della guerra potemmo risollevarci solo dopo esserci sforzati di capire gli aspetti oscuri della nostra storia che si riassumevano nell’errore del fascismo, allo stesso modo oggi andremo avanti solo se faremo i conti con la vicenda grigia e piena di difetti della nostra democrazia.


Doctors’ basic errors are killing 1,000 patients a month @SEEdPublisher @GIMBE

Biggest ever study of errors in British hospitals finds one in ten patients affected

Almost 12,000 patients are dying needlessly in NHS hospitals every year because of basic errors by medical staff, according to the largest and most detailed study into hospital deaths ever performed in the UK.

The researchers from the London School of Hygiene and Tropical Medicine and colleagues found something went wrong with the care of 13 per cent of the patients who died in hospitals. An error only caused death in 5.2 per cent of these – equivalent to 11,859 preventable deaths in hospitals in England.

Helen Hogan, who led the study, said: “We found medical staff were not doing the basics well enough – monitoring blood pressure and kidney function, for example. They were also not assessing patients holistically early enough in their admission so they didn’t miss any underlying condition. And they were not checking side-effects… before prescribing drugs.”

In one case a middle-aged man who had a cyst on his neck removed developed an infection. He was treated with antibiotics but medical staff did not realise he was not responding until it was too late and he died.

In another case, a 40-year-old obese woman was in hospital for three weeks while doctors investigated symptoms including vomiting and weight loss before discovering she had ovarian cancer. She was never given preventive treatment for blood clots – a risk of prolonged bed rest – and died of a clot on the lung.

The study was based on analysis of 1,000 deaths at 10 NHS trusts during 2009. Previous estimates have suggested up to 40,000 deaths a year are caused by errors in care but these have been based on international studies and have not directly linked the errors with the cause of death.

Dr Hogan added: “Hospitals must learn from careful analysis of preventable deaths and make every effort to avoid [them].”

Most of the patients who died were elderly and frail and suffering from multiple conditions. But some were in their 40s and 30s. More supervision by senior consultants was required to ensure junior doctors carried out proper assessment on admission and liaised with GPs and social services.

International evidence suggests one in 10 hospital patients suffers harm as a result of errors in their care, ranging from short-term effects from a wrong prescription to severe harm resulting from an operation on the wrong limb.

But the new study, published online in BMJ Quality and Safety, found errors of omission were more frequent than active mistakes.

Dr Hogan said: “The NHS in the future is going to have to look after very frail elderly patients as their numbers increase. Our systems are not robust enough to ensure we avoid harming them.”

The authors say the quality of hospital care should be assessed on the basis of harm caused by errors, rather than on deaths. “If 95 per cent of deaths in hospital are not due to preventable poor care, the scope for hospitals to demonstrate reduction in their mortality rate is limited,” they say.

A Department of Health spokesperson said it was an important study which revealed a picture of preventable deaths.

“Patients have a right to expect the very best care from the NHS. Any preventable death in hospital is unacceptable and we expect the NHS to ensure patients receive high-quality, safe and effective care. We know that data like this can help hospitals to improve services,” said the spokesperson.

Man who died of dehydration was killed by hospital neglect

Neglect by medical staff led to a man dying of dehydration in a hospital bed, a coroner has ruled. Medical staff at St George’s Hospital in Tooting, south London, did not give Kane Gorny vital medication to help him retain fluids. The 22-year-old, who was a keen sportsman, even phoned police from his hospital bed as he was so desperate for a glass of water, the inquest heard. Deputy Coroner Dr Shirley Radcliffe told the hearing: “A cascade of individual failures has led to an incredibly tragic outcome.”

She recorded a narrative verdict at Westminster Coroner’s Court and said Mr Gorny had died from dehydration contributed to by neglect. Dr Radcliffe said: “Kane was undoubtedly let down by incompetence of staff, poor communication [and] lack of leadership, both medical and nursing.”

James Stevenson, the solicitor for Mr Gorny’s family, said they were “devastated by the number of missed opportunities” to prevent his death.
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Sanità. The first cut isn’t the deepest. @chicago_blog

Alberto Mingardi su Chicago Blog dà spunti interessanti sulla sanità, anche se non cita un fatto molto importante: l’erogatore privato sceglie l’ambito del suo intervento e non è necessariamente obbligato a “produrre” servizi poco o punto remunerativi (es. pronto soccorso, terapie intensive, ecc.) perché non tariffati! Inoltre, sarebbe bene ricordare l’enorme variazione nord-sud della qualità dei servizi sanitari pubblici e privati.

 La “spending review” è uno strumento di importanza cruciale, se pensiamo che anche la spesa pubblica non sfugga alla regola del conoscere per deliberare: è necessario capire dove e come effettivamente lo Stato spende, per potere tagliare con efficacia.

L’obiettivo di lungo periodo dovrebbe essere quello di una spesa più leggera e quindi più sostenibile, coerente con una riduzione del raggio d’azione del pubblico. L’obiettivo di breve del governo è mostrare risultati tangibili nei prossimi mesi. I due collidono.

Nel caso della sanità, la parte del leone nei tagli la fanno gli acquisti. Governo ed esponenti politici paiono convinti che spendendo di meno si possano garantire le stesse prestazioni. Da una parte, si fa leva sul potere di mercato del monopsonista pubblico: dal momento che sono il tuo unico compratore, fai i prezzi che ti dico io.

Dall’altra, l’idea curiosa è che beni simili di prezzi diversi siano in realtà identici. Pare che in sanità una Porsche e una 500 valgano solo in quanto l’una e l’altra sono automobili. Ci siamo spesso sentiti dire, per esempio quando chiedevamo l’ampliamento del circuito distributivo per i farmaci non rimborsati dallo Stato, che la salute delle persone non può essere lasciata in balia delle forze del mercato. Vietato “mercificare” la sanità. L’alternativa alla mercificazione, in tutta evidenza, è il socialismo: cioè il rifiuto dogmatico dell’idea che i prezzi dicano qualcosa. Secondo logica, invece, il prezzo trasferisce informazioni – anche sulla “qualità” di un certo prodotto. Abbassandolo artificiosamente, si obbligano i produttori a fare economie. Qualcuno potrà pensare di stare “espropriando gli espropriatori”: ma è improbabile che chi incassa di meno produca come se stesse incassando quanto prima.

L’ostilità al motivo del profitto segna puntualmente le “manovre” dei governi italiani in tema di sanità. I giornali scrivono che si pensa anche a tagliare del 2% le prestazioni erogate dalle strutture di diritto privato che operano all’interno dell’SSN. Queste strutture curano il 25% dei malati, costando il 15% della spesa ospedaliera.

Non è che tagliando del 2% ci sarà il 2% di malati in meno. Quelle stesse persone dovranno andare a farsi curare nei nosocomi pubblici. I quali costano di più al servizio sanitario nazionale. Questo è particolarmente evidente in Lombardia, dove fra erogatori di diritto privato ed erogatori di diritto pubblico c’è la concorrenza (relativamente) più aperta e trasparente. Laddove il privato regge economicamente in virtù delle prestazioni che svolge e gli vengono pagate, il pubblico ha costantemente bisogno di essere ripianato a pie’ di lista. Non serve Sherlock Holmes per capire chi dei due contribuisca al dissesto delle finanze regionali.

La sanità è un tema complesso, ma proprio per questo solo interventi lungimiranti ed ambiziosi possono avere impatto nel lungo periodo.

L’Olanda ha scelto di canalizzare la spesa attraverso una intercapedine fatta da assicurazioni private in concorrenza: le assicurazioni sono probabilmente pagatori più accorti (ed esigenti) delle amministrazioni dello Stato. La Germania ha visto una diminuzione degli ospedali pubblici ed un aumento importante di quelli privati, non per amor di mercato ma semplicemente perché questi ultimi assicurano maggiore efficienza gestionale e, quindi, minori costi.

Il vero costo è la rendita politica che si annida nella sanità, ma non è estirpabile immaginando che le migliori meningi della nazione vengano spremute a dovere per decretare quanto deve costare il servizio-mensa, a Milano o a Reggio Calabria. La stessa polemica contro i piccoli ospedali è stucchevole: chiama le leadership nazionali ad un impossibile sforzo di volontà, contro atteggiamenti ben radicati nelle loro constituencies, che nell’ospedale manifestamente inefficiente magari non ci vanno ma si beano al pensiero di averlo sotto casa.

L’unica via sensata è smetterla di essere presuntuosi. Smetterla ad esempio di pensare che possa essere Roma a “sapere” quale è il numero e la dimensione ottima degli ospedali in Italia. La rete va “razionalizzata”? Certo, ma non per arrivare a una pianificazione diversa, potenzialmente altrettanto errata dell’attuale.

Si lascino fallire, se non le Regioni, almeno gli ospedali i cui conti non tornano – grandi e piccoli. Si lascino fallire: non ne si decreti l’estinzione. In qualsiasi processo fallimentare, un compratore può farsi avanti: sia una libera cooperativa di cittadini, un privato, un privato sociale. Se alla porta non bussa nessuno, sarà chiaro che l’offerta era insostenibile.

Ridurre la spesa implica, come tutte le cose nella vita, un processo di apprendimento. Anche da parte degli elettori-pazienti. La scorciatoia del dettato degli illuminati ci porterà semplicemente a doverci porre di nuovo gli stessi problemi, tempo di un paio di vertici europei.