Wednesday, June 18, 2014

A Purpose Driven Company

I admit that I have great pride when I see my children quoted.  However my reason for sharing this particular article which references the second of my four children, is about the message that he gives and how it applies to my own company, Accolade, and to all organizations involved in health care. 

Accolade was built as a purpose driven company, with a goal of helping people through the complexity and confusion of health care by creating a new profession – the profession of Health Assistant.  We were built with the vision that every person in the United States will someday have a Health Assistant and that Accolade Health Assistants will be the best in the world supported by the best systems and the best organization. 

In this particular article, Rob is quoted as saying about Good Eggs, his company, “we’re a company full of folks who are doing this because [we] want to make the world a better place.”  That also describes all of us at Accolade and it describes how all people building new health care organizations should approach the tasks before them. 

In CSR Wire, the Corporate Social Responsibility Newswire, Rob describes eight lessons on how to build and run a purpose-driven company.  All of you who are trying to build health care organizations, either as new entities or within established organizations should think about these lessons as you approach your missions of helping those in need.

Monday, June 16, 2014

Medical Myths and Asking the Right Questions

Last week, I started my blog post with the statement that “Doctors are people.”    There are many medical myths and the one I was addressing in that post was the myth that physicians have some supernatural power that makes them more than just people.  Dr. Robert Pearl, the CEO of the Permanente Medical Group, in the latest installment of his “medical myth” series of blog post in Forbes attempts to prove  that the statement “medicine is an art, not a science” is a myth.  The fact is that medicine when practiced optimally must be both. 

He starts by asking the question whether medicine as an art or a science saved more lives.  His answer is that science has saved more lives and therefore medicine as an art must be considered a myth.  Whenever you have the opportunity to ask the question in the way you want, you can always produce the result you want.  Just ask any pollster.  The question he asks is written from a population health management point of view, not an individual patient care point of view.  The answer becomes more nuanced when the question is changed.  Let’s look at the three examples he gives. 

His first example is treating people with stroke and he rightly points out that when guidelines developed by the American Heart Association in conjunction with the American Stroke Association are used by hospitals to standardize admitting orders, then the outcomes are better.  Science therefore triumphs.  However a major factor in the use of those guidelines calls for patients to get to a center that can effectively treat them in a very short time.  Delay, in this case, kills.  Quick action demands faith in one’s doctor and in the health system and also demands that the access to care is simple and perceived by the patient as helpful.   A different question to ask in this case is whether art or science will help people access care at the right time and at the right place in order to take advantage of the best practice protocol.  The art of medicine requires that patients know their doctors and other health professionals, trust them, and therefore reach out in a timely manner when care is needed.  That is a precursor in this instance to using the right protocol once someone is in the hospital.  Unless physicians pay attention to the art of medicine, gain people’s trust, and give them the confidence to reach the right facility soon enough, the scientific efforts are worthless.   

The second example he talks about is the use of beta-blockers, ACE-inhibitors, aspirin and statins after a heart attack to reduce the risk of future heart attacks.  He cites the fact that “the best doctors prescribe these medications 98 percent of the time.”   However he neglects to mention, that when a physician prescribes a medication, that is only the start of the challenge of ensuring that the patient takes the medication.  A different question therefore is whether the art or science will help the patient take the medication as prescribed.  The patient may hate taking any medication and may not believe that the beta-blocker will help.  A friend may have told them of a bad experience with the same medication and they may be afraid to take it.  The patient may have a benefits plan which requires a co-payment that they cannot afford.   The art of medicine requires that the doctor know the context of the person’s life, their values and beliefs towards the therapy, and the potential barriers that are present that may affect the patient carrying out the doctor’s instructions.  It requires the doctor to think past the protocol and help address the life issues in a way that respects the patient’s beliefs and values. 

His last example is the setting of protocols for the operating room.  Again those protocols are necessary and the science behind them is compelling.  However an experienced, knowledgeable surgeon, who is able to react to the changing situation in the operating room, using experience and the art of medicine, is often necessary.   A different question therefore in this case is whether the art or science will help in assessing any surprises in the OR.  In his editorial in the WSJ entitled, “The Bureaucrat Sitting on Your Doctor’s Shoulder”, Dr. Zane Pollard from Scottish Rite Children’s Hospital in Atlanta tells of a case in which in the operating room, he had to change his surgery due to findings that were unexpected.  He was not paid and was cited for performing a surgery that was not part of the protocol that was approved even though he clearly did what was right for the patient.

The best medical care never makes a choice between the art and science of medicine but rather uses both to benefit the patient. Dr. William Osler, considered to be the father of modern scientific medicine said, “The good physician treats the disease; the great physician treats the patient who has the disease.”  He also said, “Variability is the law of life, and as no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike under that abnormal conditions we know as disease.” 

Dr. Pearl’s examples and questions to prove his point are all about populations and disease.   If the questions we ask, and the metrics we use, are only about the populations and about disease and not about the “patient who has the disease” in Osler’s words, we will miss major aspects of care.  If they are only about what goes on in the doctor’s office and in the hospital and not what happens before someone arrives at the hospital and after they leave, we may actually cause harm to the patient even if we improve our population numbers.  We must practice both science and art: we must follow scientific protocols diligently and use the communication skills, the assessment skills and the trust building skills that are all part of the art of medicine.  We must partner with people and understand how the disease impacts their lives, and how their lives impact the treatment of the disease.  The real myth is the belief that medicine is either art or science when it must be both.

Monday, June 9, 2014

Physicians as Stewards of Health Resources

Doctors are people.  While I want all physicians to rise above and be totally selfless in helping those in need, I know that all people work within a broader milieu and are sensitive to incentives, economics and the metrics on which they are judged.  As part of the health care consolidation that is ongoing in our society, doctors are increasingly employees of large organizations rather than private professionals answering only to their patients.  That tendency in healthcare to organize more effectively is necessary as medicine is increasingly a team sport that requires many different professionals, using complex equipment often available only in sophisticated facilities, working together.  Large organizations can often combine these resources more effectively.  However organizations that are large can also lose the focus on the individual who is in need of care.  It can lead to systems in which health professionals are judged more on their effective use of organizational resources and their contribution to the well-being of the organization, rather than the well-being of the patient.  Ultimately, because physicians and all health professionals are people, judging them as stewards of health resources rather than as fierce advocates for their patients puts them at risk to be less focused on the values and needs of the specific individual they are helping in the moment. 

Two articles this week shed light on this issue.  In the Journal of the American Medical Association, an article entitled “Guidelines, Online Training Aim to Teach Physicians to Weigh Costs of Care, Become Better Stewards of Medical Resources.”  It intermingles two points, benefit to the patient and benefit to society, as if they were the same and those two related but critically different points can result in danger for patients.  Lowell E. Schnipper, MD, chair of the American Society of Clinical Oncology’s Value in Cancer Care Task Force speaks of the need to raise physician awareness of the financial effects of medical care on their patients.  That is critically important as the physician must know their patient, and must know the factors that will affect that patient’s care.  Financial considerations are an important part of anyone’s life and a doctor must be sensitive to those factors.  Schnipper however later states, “The dollar amount isn’t the driver; it’s the degree of benefit the patient and society get.”  That statement makes me nervous.  A doctor’s focus must be on the benefit the patient receives and not the benefit for society.  Doctors who are “stewards of medical resources” rather than stewards of their patients’ needs and values can harm the trust needed between a doctor and patient. 

Dr. Charlotte Yeh voices my own fears quite well in her article “Nothing is Broken: For an Injured Doctor, Quality Focused Care Misses the Mark” published in Health Affairs.  She tells her own story of being in an accident, then taken to the ER and ultimately admitted.  She felt alone, isolated, and ignored.  She did not feel cared for.  At one point, after being in the Emergency Room for 14 hours, a physician said to her, “There’s no medical reason to admit you but if you can’t walk, we’ll just have to.”  That callous statement made her feel embarrassed and guilty.  Yet the physician was following medical scientific protocols and trying to be a good steward of the expensive resource of a hospital admission.  Dr.Yeh laments the “uneven nature of my care, marked by an overreliance on testing and a narrow focus on limited quality metrics” and states that it “fostered an inattention to my overall well-being.”  She points out that patient-reported outcomes are critical and that the “North Star” guiding all care must be “providers using any means possible to know the patient, hear the patient, and respond to what matters to the patient.”

If I, as a patient, believe that my physician is more focused on a broader societal good, and not as much on my own benefit, then I will not have the trust I need in the physician.   Part of that trust is a physician understanding the financial impact of any care on me and my family.  There is a slippery slope however in focusing on societal and organizational goals rather than the patient and family goals.  It could lead to physicians thinking more about the society and deciding, for example, that it is not worth helping a healthy alert 80 year old get the care needed, as his or her life expectancy on a cost benefit analysis would not bring enough value.  If you practiced in a prison setting, a focus on being a steward of societal resources could cause you to decide that someone serving a life sentence should be allowed to die of disease because the price to society of both the cost of care and the cost of maintaining that person in a prison is too high.
I say all this as a person who works, and has worked for the past twenty-five years in some very large organizations.  I have built and managed many of the policies and programs of those organizations.  Yet I have always done so with the knowledge that any metric, any policy, and any organizational design will not fit 100% of all the people they are meant to impact.  I design these with the knowledge, and the proviso that smart people, using judgment, must be allowed to override the process in order to help a person in need.  I do this design work in the hope that caring health professionals will battle the design when they must to maintain the sacred patient trust that is part of being a Health Professional, and especially part of being a Physician.  I want the dynamic tension that comes from caring people, with different frameworks of healthcare, occasionally arguing for different approaches because that leads to better results for all.  Once, when I was Chief Medical Officer of an organization that covered 11 million lives, I was called because a 9 year old girl needed a type of therapy for a rare cancer that was not approved under the medical policy of the health plan for that particular cancer.  It was covered for other types of cancer however no one had foreseen the potential of using it for the particular rare cancer this young girl suffered from.  The mother of the patient had been fighting with the health plan for three weeks before it came to my desk.  I immediately approved payment for the treatment, called the mother directly and listened to her cry with relief.  Money was a factor and this family could not have afforded the treatment had it not been covered.  I was later taken to task by my organization for going against the medical policy.  I still wear that decision, and the price I paid organizationally, as a badge of honor. 

While doctors are people, and will work towards incentives as people, I still want the practice of medicine and all health professions to be callings; sacred missions to help people and not just jobs.  People are able to rise above their own incentives and their own concerns if they are trained and imbued with the responsibility that a calling entails and given the proper protection if they fight the system.  What is needed is more education to physicians about all aspects of a patient’s life impacted by illness, including finances.   What is needed is a culture in which doctors are encouraged to know their patients, and care more about their patients, and not necessarily the broader society.  Physicians must be given the tools and time to return to the caring role they traditionally have held.  A physician should be focused on listening to the patient, learning who they are and what their values are, and following a solemn oath to be true to the patient’s needs and values while practicing the best scientific care in partnership with that patient.  Only then will physicians be true stewards of the trust that their patients place in them. 

More on the VA System

I want to thank those of you who commented, in a variety of venues, on my blog post on the VA system.  The Health Assistants I work with brought valuable perspective from having loved ones who receive their care from the VA in their comments.  In that post, I spoke of my work consulting for the VA system in the 1990s.  During that era, Dr. Kenneth Kizer, as the Undersecretary of Health in the Department of Veterans Affairs implemented reforms that improved quality, access and efficiency.  I was an admirer of Dr. Kizer and his efforts at that time. This week, in the New England Journal of Medicine, Dr. Kizer in collaboration with Dr. Ashish Jha, wrote about restoring trust in VA Health Care.  Their analysis and suggestions are ones that should be followed.  They point to three main causes of the health care problems now besetting the VA Health System.  “…an unfocused performance-management program, increasingly centralized control of care delivery and associated increased bureaucracy, and increasing organizational insularity.”  They propose a few first steps. 
  1. Refocus its performance-management system on fewer measures that directly address what is most important to veteran patients and clinicians – especially outcome measures.
  2. Conceptualize access to care in terms of a “continuous healing relationship” drawing on modern information and communications technologies to facilitate caregiver-patient connectivity and that uses personalized care plans to address patients’ individual access needs and preferences. 
  3. Engage in more private-sector health care and form learning and improvement partnerships with outside entities, while making performance data broadly available. 

To the three that they mention, I would add one that would be required even before starting – leadership of the quality that Kenneth Kizer brought to the organization in the 1990s.  

Sunday, June 1, 2014

VA Health Care, Good Intentions, and Unintended Consequences

In the mid-1990s, I had the experience of consulting for VISN (Veterans Integrated Service Network) 11 of the VA system which includes Michigan, Indiana and parts of Illinois.  I was asked to help them develop a strategy to bring more primary care to communities that had no VA facilities. Even then, the problem of access to care, and especially access to high quality primary care, was seen as a major issue for veterans.   I visited communities in northeast Indiana and helped the VA system develop options to either build a contract system to use independent primary care doctors as an arm of VA care, or to actually have VA employed doctors work in community based outpatient facilities with the major VA medical centers reserved for referrals from those community based practitioners.   My job was to deliver the options in a way that could facilitate decision making and be made operational.  The experience I had was consistent with the revelations now receiving media coverage and congressional scrutiny.  I saw excellent clinical care and horrendous service which significantly limited access to care. 

I am not the only one to recognize that these problems are not new.  A Wall Street Journal editorial entitled “The VA’s Bonus Culture” starts by saying “It must feel like Groundhog Day at the Veterans Affairs Office of Inspector General.  On Wednesday it issued an interim report – its 19th since 2005 – documenting excessive wait times at VA hospitals.”  The lack of public attention to all of the previous reports is a sad fact. I will not attempt to explain it except to say that there is constant competition for public attention as problems are plentiful.  That is part of our contemporary world. 

The persistent nature of the problems is the result of a flawed system of flawed incentives.  I don’t doubt that the implementation of the current VA system was done with the best intentions.  In the 1980s and 90s, there was a persistent belief amongst the architects of this system that the effective use of technology, and the use of state-of-the-art electronic medical records would result in a better quality of care. The belief ran that these approaches in turn would drive ‘care efficiency’ by instituting best-practice protocols embedded in the use of this technology. This ‘efficiency’ would allow for more care to be given to more veterans at a lower cost and in a timely manner.  Twenty years ago the VA system also instituted the use of specific metrics in assessment of its employees to properly reward those who met their metrics and punish those who did not.  The career-advancement incentive for these VA professionals became the following of proper protocols and meeting their “numbers” rather than an incentive system based on individual patient progress, veterans’ satisfaction with their care and improved quality of life for people using the system. Again, I do not question the good intentions of those who instituted this system, but looking at the current situation of the VA in turmoil and with my thirty years of experience in the world of Health Policy, I can confidently point to these efforts as inadvertently leading to the major underlying problems of VA healthcare.

We are now seeing the logical consequence of a system designed and executed poorly.  In individual VA networks and hospitals, this poor incentivization made it so that the administrator who challenged this system was likely to be replaced while the one who accepted it as is and perpetuated its broken bureaucracy was likely to be promoted.  Of course, back then the elected officials in the legislative and executive branches did not know that computers would not be the entire answer, and that the incentives they put in place would drive creativity of the wrong type – creativity in manipulating the system to gain raises, bonuses and promotions with little regard for the care of the patient.  We have now found ourselves with a system that was never designed to expose and correct resulting problems or respond to the changing needs of veterans.

Health care, even when consistent with best science and greatest public policy, is greatly affected by the context of our lives that make each of us unique: our values, our beliefs, our family, our culture, our finances, and our work.  Inflexible systemic ‘solutions’ in the provision of care, curated either by government or by private industry, can handcuff us to programs and policies that, though driven by a desire to improve the world, end up creating incentives that bear little relationship to those initial good intentions.  We need small solutions built for each person carried out by people whose only incentive is tied to how they help that human being in their care. We need to acknowledge that part of the responsibility of health care providers is to be caring and compassionate to all aspects of the lives of their individual patients.  Illness is isolating and being thrown into a big bureaucracy only adds to the isolation.  No person, let alone our veterans, should walk through illness alone.  When on the actual battlefield, it is sometimes said that you do not fight for country, or for your cause, but for your buddy next to you.  When you spend time at a VA facility, broken as its administrative system may be, you see the buddy system in full force as veterans stand outside, share stories and experiences, and remember the tremendous camaraderie of their unit, and their team. If only the system were built to incentivize its workers to more fully appreciate the importance of those stories, experiences, and camaraderie in the implementation of care.

All answers, especially large scale answers, always have unintended consequences and any answer we develop today in reaction to this crisis is likely to have flaws. We need to build a system that is flexible and able to innovate on the go as we learn more about the unique ails and lives of our soldiers. We need people, our medical professionals and administrative staff, to be trained and incentivized to be interested in what is best for individual veterans.  We need a system that assesses all VA employees on the human connections they make with veterans and their families and on their successes in helping our veterans access the care they need and deserve. We need professionals who listen and make themselves part of the military unit that provides care. 

Programs to lower cost and improve quality of care must be driven by individual patient needs, as determined by patients and health professionals working together.  The sacred trust of a caring relationship cannot thrive in a world that tries to shoehorn people into systems that fail to adjust and innovate to the changing science, changing values, changing populations, and changing realities of the people being served. Illness is a battlefield and, as healthcare providers, it is our duty to make those battling illness feel as though we have their backs.  Let’s build dynamic, flexible systems that acknowledge all the veterans’ needs including the need to have someone they trust at their side.