Archive for the ‘Health Forum Journal’ Category

The Old Course and the MRI

Sunday, July 6th, 2003

In 2001, I had a serious problem requiring a medical intervention: my golf game had collapsed. For a Scot, this is the end of healthy living. I have played since the age of seven, not well, but I could usually get round most courses in the 80s or low 90s. In 2001 I went through a miserable spring of golf, unable to break a 100. I lost fifty yards off the tee, and could hardly swing through the ball. This agony was compounded by having the opportunity to play some of the world’s great courses (as a guest, too) including Mid-Ocean in Bermuda and the hallowed Pebble Beach. I had injured my neck lifting luggage (the macho one-handed garment bag catch it in the air from the overhead bin trick). I guess two million frequent flier miles and thousands of scrums as a hooker in rugby had taken its toll. But, I was trained that one ought to be conservative in treatment and so I had dutifully turned up for physiotherapy and had traction (what medieval torturers called the rack). The conservative approach resulted in only modest improvement in the symptoms, (tingling in the fingers, weakness in the legs and a constant neck tick resembling Tourette’s) and the golf game.

My wife (a former critical care nurse) finally, prodded me to return to my primary care physician. He suggested that I have an MRI. What a thrill for a Scottish-Canadian to have an MRI! It is easier for Canadians to win an Olympic Gold Medal in figure skating than it is to get an MRI. No one in Canada has ever had one and I was the toast of my extended family in Scotland and Canada.

The MRI showed a significant herniated disk in my neck at c5-c6 and some spinal cord damage. My neurosurgeon explained what he could do. This is not what he said, but it is what I heard. “First, we cut your throat, push the throat stuff aside, we go in, take out the disc, replace it with a piece of bone from Dead Uncle Frank, and screw it all back together with a titanium plate.” This did not sound very appetizing and like a dolt I went for a second opinion to a neurologist (as I recounted in a previous column “There’s No Screen). The neurologist referred me for a second MRI and back for surgery immediately.

My care at Stanford was fantastic and fast: in on the Monday out on the Tuesday, very little pain and very professional and caring staff. Although, even as a non-clinician I did detect enormous opportunities for error, what with the constant handing over from one nursing team to another and the myriad of people who seemed to come and see me, and lots of toing and froing and form filling in various places in the hospital. This led me to the unkind characterization of my patient experience at Stanford as “islands of clinical excellence surrounded by the Department of Motor Vehicles”.

Over a year has passed and the golf game is on the mend. Not brilliant, but enjoyable again. On a visit to Scotland last summer with a whole party of Canadian and American friends, we had a magical day playing the Old Course at St. Andrews in a forty mile an hour wind. I made an eagle on the par 5, 14th hole thanks to the following gale and a brilliant read on a 50 yard putt from my caddie, Willie Campbell. I was back, literally and figuratively, courtesy of American healthcare.

At a recent family wedding in Canada I asked my visiting Scottish doctor friends what would have happened to me if I was still back in Scotland. They said that the surgery was done in cases with serious clinical indications. When asked whether my clinical conditions would have warranted such surgery, they argued that shooting a hundred was not classified as a disability in Britain, indeed Dr. Calum said “Och, they would have told you to play from the white tees and putt better!”

I am deeply grateful to my doctors, to Stanford, and to my health insurers, for restoring my ability to enjoy what is an important part of my life. My story is a metaphor: American healthcare distinguishes itself from other systems internationally by delivering such quality of life improvement albeit at significant cost. Moreover, the quality of life can be improved only if you are well-insured and can come up with the diagnostic down-payment. But should the healthcare system pay for it all? Are there more deserving uses of the scarce resources? And who decides all this? As I have said in this column before, what Americans want is a decent floor for all Americans and the right to trade up with their own money. We need to figure out how to bring this about, with freedom and justice for all. No one should have to give up golf.

Ian Morrison is an author, consultant and futurist based in Menlo Park, California. This column was published in the Summer 2003 Issue of Health Forum Journal.

The End of the Community Hospital

Thursday, March 6th, 2003

The community hospital has had a good run. A century or so is a good innings (call it a half century really because hospital care and medical care generally in the pre-World War II era was apparently pretty miserable). Non- Profit community hospitals, competing with one another to build better services in their local communities across a wide range of clinical conditions may become a thing of the past. Why?

The Atrium of Dreams. The Field of Dreams effect is “if you build it they will come” (historically it was Roemer’s law: a built bed is a filled bed). Hospitals are investing millions in technology and facilities upgrades to attract the well-heeled and the well-insured. As Uwe Reinhard of Princeton University has always argued, the atrium is both the symbol and the key to economic success for hospitals. But the combination of a medical arms race and the Four Seasoning of the facilities has made hospitals a big source of cost inflation in healthcare once again, and the payers know it.

Tiered Networks. Many private payers and CMS (which thinks and acts more like a private payer every day) will push for networks that make hospital prices more transparent to consumers. Perversely, this will favor those hospitals with the best atriums (the best insured have light diseases and high incomes), but if you have an ugly lobby, indifferent quality, and a low-end clientele, you are toast.

Economic Evisceration of the Cost Shifting Engine. Entrepreneurial proceduralist physicians armed with imaging technology, catheters, and laser devices are fueling the economic evisceration of the community hospital. Doctors see the opportunity to take the hospital’s most profitable lines of business in cardiac catheterization, orthopedics, and cosmetic surgery and start competing in stand-alone surgical facilities and clinics. Healthy competition, eh? Maybe, but the result is the complete undermining of the economic cost shifting engine that powers most hospitals: profitable DRGs and per diems subsidize unprofitable ones. There are no physicians opening stand-alone clinics and hospitals for the unprofitable DRGs unless these doctors are do-good lefties with a big trust fund.

Swamped by the Undercovered. Basket case community institutions with a bad patient mix will be swamped by the undercovered over the next two years. The perilous state of Medicaid and state budget’s for health care will mean that cuts in both eligibility and payment rates are an inevitability. Can Medicare be far behind?

Government funded ICUs. Taken to the logical conclusion these trends will make many community hospitals government funded ICUs, only the sickest and the poorest will be left as inpatients. The well-heeled ambulatory patients will drive-thru their surgeries and be oblivious to the plight of St. Elsewhere.

How to respond? Two ideas: wherever you can become a benevolent monopolist, own everything in a 30 mile radius, and convince your medical staff that together you can do better than in a battle over the outpatient environment. If monopoly is impractical like in New York or Los Angeles, then build Community Care Cartels with enough local scale, clout and cross subsidy to keep the community-based institutions in the phone book.

Ian Morrison is an author, consultant and futurist based in Menlo Park, California. This column was published in the Spring 2003 Issue of the Health Forum Journal.

Wary of Choices

Sunday, October 6th, 2002

“The health care consumer needs to have skin in the game” is a phrase you hear frequently in health care. For those of you who don’t play poker, it means we consumers ought to pay at the point of care, which will motivate us to make more informed, value-conscious choices. Every health plan CEO I know, and almost all large employers, see this as the big new theme for health care. Consumer responsibility for payment will be sold to us consumers bundled with choice and couched in terms of empowerment. (Remember, when you hear the word empowerment, it’s code for “you’re on your own, pal!”)

At the same time, we have increasing variation in health care. A recent Institute of Medicine report calls attention to the huge disparities in care based on race and socioeconomic status. Physician John Wennberg’s research over the last 30 years has pointed to enormous variation in medical care across the country and across very small geographic areas. The patient safety and quality measurement gurus tell us that there are enormous differences in the quality of care between institutions and within institutions. Efforts to standardize care have been thwarted by a lack of enthusiasm among providers. Indeed, practice guidelines and evidence-based medicine are viewed by most doctors as one step away from communism.

How will the newly empowered, value-conscious consumers make out in this highly variable world?

If I go to that happy place inside (or listen to my most optimistic colleagues at the purchasing coalitions and health care foundations across the country), I can imagine the value-motivated consumer forcing a recalcitrant provider community to work on the big problems of clinical redesign and process improvement. We consumers, armed with new performance data at the provider level, will have the information and incentives to kick clinical butt and make choices that keep providers on their toes and take the American health care system to a new level of quality and accountability. But when I allow my natural Scottish cynicism to rise, I hear myself saying: “Most costs are incurred by the sick or the unconscious. They are not in a good position to kick anyone’s butt, let alone their doctor’s. And we Americans already have more skin in the game than anyone else in the developed world, with little measurable improvement in the value of health care we receive.”

In truth, both of my inner voices are correct in their own way. Fine-grain performance metrics in the hands of motivated consumers will have positive effects on the way care is organized and delivered. Providers should not resist such metrics, but embrace them. At the same time, the most disadvantaged among us-the poor, the elderly, the uninsured (or underinsured) with chronic illnesses, or just those of us who are medically illiterate-will struggle mightily because they haven’t the resources, knowledge, or support to navigate through this new world.

Ian Morrison is an author, consultant and futurist based in Menlo Park, California. This column was published in the October/November 2002 Health Forum Journal.

The Twenty Percent Solution

Thursday, June 6th, 2002

I was always taught that America spends too much on healthcare and we could reallocate resources to cover the uninsured, increase wellness and health promotion activities, and improve the quality of clinical care. That may well be true, but, as we have found out over the last thirty years it is simply impossible to achieve in the American political context. To reallocate requires someone’s income has to go down, not going to happen.

In my rattling around American healthcare I have come to realize that the only thing that unites doctors, hospitals, drug companies, the elderly, academic medical centers, the safety net, the public health community, health plans and medical equipment manufacturers is that they all want more money spent on them. So that’s the answer, let’s build a coalition of all the actors who want MORE. Can you imagine drug companies, doctors, hospitals and the AARP unleashing their enormous lobbying power, marching arm in arm to the Capitol singing kumbaya?

Here’s how it would work. Let’s assume we are spending $1.5 trillion on health care this year and it’s about 15% of a $10 trillion economy. The new MORE coalition demands that we increase health spending immediately by 20 percent, approximately $300 billion a year, and we make it a national goal to have healthcare account for 20% of GNP within five years (or two trillion in today’s dollars). Hey we will be there anyway in 2020 so why not start now, we need the practice.

How would we spend the money? We would pay people to eliminate disparities and variation in healthcare. We would cover prescription drugs. We would improve long term care. We would cover the uninsured. We would invest in public health infrastructure and we would embark on redesigning healthcare finance and delivery from the ground up for when we baby boomers really need it, twenty years from now.

If we spend two-thirds of the increment on labor costs that’s $200 billion worth of new jobs. You could have half a million jobs at $100,000 a year, 2 million at $50,000 and 2 million jobs at $25,000 a year. Or you could give invasive cardiologists a big raise.

Ok, you’ve spotted the problem, where does the money come from? Let’s assume there are 100 million tax-paying households (there’s actually more, but I don’t know how to work the calculator on my laptop so the math is easier this way). Ultimately, they pay whether in taxes, as part of wages, or as out of pocket costs. It comes to about $15,000 per household already spent on healthcare by all the actors (business, government, and households), we are just asking for $3,000 more per household per year. The top third of households by income would pay for the bottom third ($6,000 versus zero), seems fair. What else would you spend it on anyway, Britney Spears albums and dinner out.

Crazy idea, eh? No crazier than spending $1.5 trillion on a system of uneven quality and huge disparities , having 40 million uninsured, and nobody doing anything meaningful about it.

Ian Morrison is an author, consultant and futurist based in Menlo Park, California. This column was published in the June/July 2002 Health Forum Journal .

The Median and the Edge

Thursday, June 6th, 2002

We often compress the future. We look ahead, see a large, inevitable future, and presume it is close. I have called this premature extrapolation. It is part of a larger problem in long-term forecasting and strategy development: we lack discipline even about the emerging reality. More specifically, we fail to distinguish between the median (the mainstream or the norm) and the edge (the 3 percent early adopters, leaders, harbingers, or just plain flakes who may or may not become the median of the future).

You see it in corporate strategy: early adopters are assumed to be mainstream, and corporate bets are made as if those early adopters represent the norm. The new, new thing takes on an air of inevitability as the mainstream even though it has hardly begun. (Broadband to the home is a good example.)

In health care it is incredibly important to distinguish between the median and the edge. We have run into this trap many times. Forecasts that capitation would take over health care were rife in the early 1990s, even though less than 10 percent of doctors were in the group practices capable of absorbing capitation and the rest showed remarkably little interest in it. The problem wasn’t just with the forecast but with the strategic behavior of decision makers such as hospital CEOs: they behaved as if capitation were the mainstream by buying doctors, vertically integrating, and all that good stuff. Similarly, we have prematurely extrapolated Medicare+Choice enrollment, physician practice management, and the electronic medical record (a permanently emerging technology).

Sometimes the edge becomes the median. For example, managed care in various forms virtually eliminated unfettered fee for service. Internet to the home has become the median, and the average American uses it as a source of health information, although not for e-health services and transactions, which remain an edge phenomenon.

So what do you do? First, be honest and clear in your language and in your thinking about the future. Try to distinguish between the median and the edge. Futurists and forecasters use terms such as early adopters, wildcards, and harbingers to talk about edge phenomena, and terms like key driving forces, megatrends, and structural shifts to describe changes in the median.

Second, develop good metrics of the emerging reality. I am a big believer that if something is going to be a big deal in the future, it’s got to start sometime. That’s why surveys are so useful in measuring the real progress toward a new future, a new median. I have had a partnership with pollsters Harris Interactive for more than 15 years because most forecasting is based on a good understanding of the present.

Third, learn to look for what Malcolm Gladwell calls tipping points – the points at which phenomena start to grow or decline exponentially. (Others have termed this discontinuous change or inflection points.) Surveys will help you measure the diffusion curve of new trends. Once you have a few data points, you can do the math.

But you have to have a nose for the emerging trends to even ask the right question in surveys. That’s why the final tip is to keep a good ear to the ground. Conferences, networking with experts and peers, and reading this journal can alert you to candidates for the edge and give you a better sense of the mainstream.

Ian Morrison is an author, consultant and futurist based in Menlo Park, California. This column was published in the June/July 2002 Health Forum Journal.

Chief Example Officer

Saturday, April 6th, 2002

Lead by example. It’s cliché but true. Like most of management theory it’s stuff your mother told you in grade school. But increasingly, the CEO must be the Chief Example Officer. Why? Because every year, three powerful factors make the CEO’s job more difficult:

Skeptical followers. The typical employee of today and tomorrow is not a passive, “Tell me what to do, Boss” type. Employees are educated, sophisticated, and have a thirst for meaning at work. They want to be motivated, inspired, and moved to action, but they are deeply skeptical. They want an explanation for everything, and they need to be told why things are changing-not just how. They will perform if they believe. But what makes them believers? More and more, employees pay attention to the leader’s behavior. Your mom was wrong when she said, “Do as I say, not as I do.” In the best organizations, leaders inspire followers by their actions and behavior much more than by their speeches. After all, we grew a little weary of Bill Clinton’s lip biting even if we loved him.

Short tenures. CEOs are in a high-risk role. They don’t last long. Whether in the corporate world, the health care industry, or public agencies, the heads of organizations are under enormous pressure to perform. They are paid a good deal of money to succeed, and they’re canned when they don’t. The recession, the demise of, and the relentless pressure from Wall Street to deliver the numbers has made the corporate CEO’s role more hazardous than at any time in the last 20 years. Health care leaders, too, have experienced the same performance pressures. To make a difference as a leader fast, you cannot rely on high-falutin’ vision and mission statements or elaborate strategic planning processes. You need to model the behaviors you want the organization to have. Leaders set the tone, and the tone can be changed. While corporate culture changes at the speed of glacial erosion, leaders can make changes quickly by setting clear directions and demonstrating the behavior that will get the organization there.

Viral leadership. In a hyper-connected world, leaders can be infectious. Their behavior can be amplified by the power of connections. Bill Gates does it through e-mail, others through video-conferencing , others still by wandering around. Regardless of the medium, the message is that the leader’s example can be seen, heard, read, and felt by many. Tools and technology can amplify the presence of the CEO in the life of the organization and extend the range of the Chief Example Officer.

Leading by example can be exhausting if it’s all an act. To make it work you have to be yourself. The values and behaviors and positions have to connect (it’s what the scholars call authenticity). If you are going to lead by example, you’d better be comfortable with who you are and be confident that you are the right person for the job.

Ian Morrison is an author, consultant and futurist based in Menlo Park, California. This column was published in the April/May 2002 Health Forum Journal