Thursday, May 31, 2007

E-Medicine -Health 2.0 – The Mother of All IT Conferences by the Mother of All Health Care Bloggers

Matthew Holt of

On September 20 in San Francisco, Matthew Holt, creator of, is staging Health 2.0: A User-Generated Conference. By “user” I’m assuming he means all of you out there who actually “use” information for self and health care betterment. You can find out more by visiting www.

Why am I telling you this?

1) Matthew has risen to the top of the health care blogging pile, and I’m interested in how he does it so I can keep on slogging and blogging until I get there too.

2) Matthew has attracted the attention of the major media – The Wall Street Journal (the WSJ says he is “a must read”); and he’s been mentioned in ABC News,, FOX News, and Scientific American. I would like to know what kind of magnetism he generates to attract the media moths.

3) I recommend you read Matthew’s blog and attend his conference (all the big IT dogs and visionaries promoting use of IT by consumers will be there). I will have spies there to tell me what transpires.

4) Matthew is a damn good writer – conversational, funny, acerbic, topical, sometimes cynical, but always on the top of his game (to me he’s the Christopher Hitchens of the health care blogging world). I envy his style and his content and don’t mind saying so. In my case, jealousy is the mother of this fulsome flattery.

5) Matthew is out there in San Francisco – home of, a host of IT companies, and cheek to jowl with Stanford and Silicon Valley – from whence Google sprang and which has Microsoft scrambling.

6) Matthew has a clear, rapidly emerging sense of where the medical world is going ( his sense is akin to that of Alfred D. Chandler, Jr., the pre-eminent business historian who said the year before his death, “All I know is that the Internet will transform the world.” Matthew knows this too.)

Here, in his own words, is how the world, in this case, the health care world, is being transformed.

Social networks are redefining relationships within communities in unanticipated and previously unimaginable ways. MySpace, LinkedIn, Facebook and YouTube have grown far beyond niche phenomena. A similar transformation is starting to take place in the health care industry as consumers take more responsibility for their own health care.

By applying Web 2.0 tools like social media, blogs, wikis, podcasts, user-generated video and specialized search - a fundamental shift is rapidly taking place away from the
traditional flow of information as defined by payers, physicians, hospital systems, and suppliers.

It is absolutely clear that we are at the start of a big shift in the demand from consumers and providers for better information and easier ways to share experiences. All stakeholders in health care must immediately begin to confront the decision of how to interact with these new technologies and networks, and potentially adopt and integrate them into their business and technology strategies.

What is less clear is whether the emerging Health2.0 phenomenon is going to grow into an independent industry sector, be subsumed into the current health care system, or create a new hybrid landscape.

At Health 2.0: User-Generated Healthcare you will see exclusive live demonstrations of new information and collaborative technologies from cutting edge companies, and have the chance to discuss how they will redefine the practice and business of healthcare. Health 2.0: User-Generated Healthcare will include perspectives from start-ups that are connecting providers to each other and creating new online patient communities, health focused search engines and patient and consumer tools. You will also hear from traditional organizations such as pharmaceutical manufacturers and insurers who are experimenting with these new technologies.

Here’s Matthew’s self-bio:

I'm Matthew Holt. I've spent more than 13 years in health care as a researcher, generalist forecaster, and strategist. I've worked for renowned forecasting and survey research organizations. I've conducted in-depth studies about many aspects of health care for public release and private clients. I'm a well-regarded, amusing presenter, and I've delivered several keynote addresses. ..I'm a Senior Consultant with Professional Services Solutions, Inc.

And here’s what he says he can do for you:

I provide "soup to nuts" research-based strategic consulting.

I get you relevant information about problems and opportunities. I help you design your strategy, and execute on it.

I can provide "quick & dirty" market research, or manage significant research efforts. As a well renowned speaker I can educate--and entertain--your team, your executives or your customers. Using my wide network, I can connect you to helpful people in health care and technology, including bringing a full service virtual team for strategy and marketing projects. I can facilitate your internal decision sessions. I can even set up a marketing program for your organization. In a nutshell, I can help you get where you need to go more quickly and efficiently.

A final word of caution: Matthew, Brit with a hilarious and wicked sense of humor and humus, is getting married soon. We’ll see if that effects his sense of humility. I hope not.


Wednesday, May 30, 2007

Clinical Innovation - The Starbucks Example, Shaping “The Experience” Of A Medical Practice

Why do some doctor practices attract and keep loyal patients? Why do Starbucks customers in New York City return for coffee an average of 18 times a year?

In Starbucks case, Howard Schultz, founder of Starbucks, it’s the total “experience.” Starbucks a neutral place – neither home nor work – where one can meet friends, listen to music, use your laptop, find a date, conduct business, snack, enjoy various coffee concoctions, and even pick up coffee grounds for free for you roses. Yes, Starbucks is offering coffee grounds for free to feed your roses at home, as part of its “green” image.”

In a 2006 book The Starbuck Experience: 5 Principles for Turning the Ordinary into the Extraordinary, Joseph A. Michelli, PhD , says all of these possibilities flow from 5 principles Schultz uses to inspire and motivate his employees to do their level best to please Starbucks customers and to keep them coming back.

These five principles are:

• Make it your own- experiment on your own in your own way to give your customers a unique experience.

• Everything matters – It’s not only the big things – the layout of your café – but the details that your customers observe and talk about and tell others.

• Surprise and delight – Free coffee grounds for roses or a specially made coffee drink for a special customer are examples.

• Embrace resistance - If a customer resists, overcome that resistance with special attention and warmth.

• Leave your mark – Do something that your customer or the community where you serve remembers.

Why couldn’t these principles be applied to medical practices? My friend< Susan Keane Baker, author of Managing Patient Expectations: The Art of Finding and Keeping Loyal Patients, Jossey-Bass, says similar principles can be used to medical practices.

She says doctors can start by simply asking their staff members to ask three acquaintances these questions:

1. Have you ever visited our practice?

2. If yes, what was your experience like?

3. Have any of your friends ever mentioned our practice?

4. If ye, what did they say about it?

Or you can conduct a focus group asking:

1. Tell me what an ideal visit to a doctor’s office would be like.

2. What three or four words would you use to describe how you felt when your visited your doctors office?

3. How did you feel when you were with your doctor?

4. How did the doctor make you feel about yourself?

5. What does your doctor ‘s practice do that other practices do not?

6. How did you choose your doctor?

7. What to you like about your doctor’’ practice?

8. How could your doctor’s practice’s practice improve service for you?

9. How would you describe your doctor’s practice as a neighbor?

10. What would a doctor do to make you feel that you are well cared for?

Finally, Susan recommends doctors pay rapt attention to the “moments of truth” – those specific encounters where patients form their opinions of your practice and decide whether to return or go elsewhere.

1. Call your practice

2. Making an appointment

3. Receiving directions

4. Meeting the receptionist

5. Waiting in reception

6. Waiting in exam room

7. Meeting the clinician

8. Giving a history

9. Having an examination

10. Having an invasive procedure

11. Giving a lab specimen

12. Receiving discharge instruction

13. Leaving the practice

14. Obtaining lab results

15. Receiving a bill

I’m not suggesting doctors try to become another franchise like Starbucks, with a strategy for opening 10,000 offices worldwide. Doctor services are more complicated and less differentiated. The menu of services is much more diversified. Besides, except for a few isolated franchises – retail clinics, or practices specializing in Lasik, cataract, cosmetic, Botox, weight loss, skin care, fitness, spas, and ER/trauma services – most physician franchises have never caught on.

What I’m saying is: Look at the total experience of your practice through your patients’eyes. See through their lenses how your practice fits into the human condition and into the community as the place to go. This new perspective may pay dividends. It’s the total “experience,” and every detail that goes into that experience, that counts

Tuesday, May 29, 2007

Consumer-Driven Care: Boom, Bust, or Bouillabaisse?

Is Consumer-Driven Cure Just Another Bubble, or Is It An Important Piece of the Bigger Puzzle?

“There’s a huge boom going on in alternative renewable and new technologies, and it wouldn’t be happening without the bouillabaisse of incentives, mandates, subsidies, and the related group of ingredients.”

Daniel Gross, “With Help, Could Ethanol be the Next Internet? New York Times, quoting Daniel Yergin, chairman of Cambridge Energy Research Associates, May 27, 2007

I take my health care metaphors where I find them, even if I find them in the business section of the New York Times, and even they compare the alternative alcohol fuel boom to the Internet.

Why bouillabaisse as a health care metaphor? As Steve Martin, the American comedian, says, “Boy! Those French! They have a word for everything.” There’s got to be a word explaining what’s going on in American health care, and for me, Boullabaisse is it. It’s a French term for a rich soup made with fish, shellfish, vegetables, herbs, and saffron.

Boullabaisse is an apt metaphor for the rich soup of American health care. Our system mixes insurers, hospitals, academics, physicians, and consumers vying for control of health care. The soup is in a big bowl. And it’s rich. Health care consumes $2 trillion a year, bigger than the GNP of China.

At this point, consumer-driven health care is neither boom nor bust, but just a small part of the health system, part of the bouillabaisee. If you think of the system as a kettle of fish, consumer-driven care is a minnow, or perhaps a spice, adding flavor.

Influential people – Regina Herzlinger of Harvard Business School; Grace Marie Turner, president of the Galen Institute; and Greg Scandlen, head of Consumer for Health Choices – are pushing privately financed consumer-driven care as an alternative, in some cases, even a replacement, for the present system, now 47% paid for by government and 53% by the private sector.

On the other side are those who say health care is much too important to be left to the market, just as wars are too important to be left to generals. Sick people, consumer-critics assert, are too vulnerable, too subject to whims of unexpected illnesses, and too ill-informed to know what’s good for them . People, particularly the frail, elderly, the mentally ill, the poor, and the young can’t predict or control their health destinies, and therefore their care needs government subsidies, mandates, and oversight.

Proponents of market-driven forces like Rayola Dougher, senior economic analyst at the American Petroleum Institute, use this language,

“We think a reliance on market forces is the best way to satisfy any growing fuel requirement, and that any policies should reply a level playing field for all options. We just don’t think at this point that the government should pick winners or losers.”

“Alternative” as another word for “innovation.” I like to see alternatives played out in the market, rather than in the political arena, where these questions about cost and feasibility will be answered.

• Can the Medicare Drug benefit be fairly administered by competing drug companies and health plans? So far the answer is a qualified “Yes.”

• Will nurse-practitioner retail clinics satisfy a public need for convenience and lower costs enough to be in nail in the coffin of primary care? No one knows for sure, but I doubt it.

• Will baby-boomers embrace HSAs and high deductible plans enough to make them a force? Will they remain marginal. Will they cut costs sufficiently to ward off universal care enthusiasts? Or will politicians abort the consumer process by deciding for consumers?The answer is still up for grabs.

• Will large organized multispecialty groups replace independent physicians in solo practice or small groups? The answer thus far is a qualified “No.”

• Will physicians organize into groups or hospitals into systems providing integrated bundled care with predictable prices known in advance? Not yet, but it may be coming.

• Will the dream of a national system-wide information system linking all parties with ubiquitous EMRs and personal health cards ever become real? Or will it the dream become another burst economic bubble, like the dream of corporations like PhyCor and MedPartners, who thought they could organize doctors into corporate entities?

• Will the much touted chronic disease management industry, led by companies like American Healthways, transform health care for the elderly, cut costs, and improve outcomes? Many think so, and early evidence is promising. One thing is for sure. Given enough attention, the Hawthorne Effect, patients respond positively to preventive and wellness efforts.

• Will outbursts of market enthusiasm, and money spent on hype and promotion in hopes of economic and health gain, overcome the embedded problems inherent in an aging population.? Will this enthusiasm build enough public consciousness for taking care of yourself, looking for the best deals for choice and cost, spur consumer demand for make for a better and less costly health system? The jury is still out, but will render its decision within the next five years.

In a human endeavor as complex as health care, covering everything from soup to nuts, it’s important to cut through the clutter. It’s essential not only to seek the right answers, but to ask the right questions. Does this alternative, this option, this innovation address the concerns of people in their everyday lives? Does it fit their behavior? Does it offer convenience? Does it engage them? Does it speak to them in terms they understand?

Everything can be improved and sustained , if the right questions are asked and the right answers activated.

Monday, May 28, 2007

Military medicine - A Memorial Day Tribute to U.S. Military Medical Doctors

The training and accomplishments of doctors serving in the U.S. military has always impressed me. These dedicated physicians, with the help of medics and nurses, have steadily reduced death rates on the battlefield and speeded recovery times after injuries. Because of prompt care at injury sites, quick evacuation, and immediate surgery and medical support, our soldiers, sailors, and marines stand better chances of surviving than in any previous war.

In Iraq, improvised explosive devices and suicide bombers have caused an unprecedented number of amputations and traumatic brain injuries. These injuries place new demands on rehabilitation and long-term care.. The media has focused on the good and bad aspects of this care. News outlets tend to praise the doctors and blame the administration when care fell short of expectations.

One neglected aspect of military doctors and the entire military medical system is that its training system produces excellent medical leaders. This leadership stems from organizational skills honed from mobilizing teams of medical technicians, medical corps men, nurses, and other doctors to provide care.

Once the Vietnam conflict ended, the unused skills of medical corps men motivated Dr. Eugene Stead at Duke to conceive the concept of physician assistants, a relatively unheralded innovation now consisting of about 100,000 practicing physician assistants who have improved and supplemented American health care.

In my own circle of doctor friends who have trained and served in the military, I count these.

• George Lundberg, MD, Los Gatos, California, an eminent pathologist who organized and oversaw laboratories for the U.S. Army, became editor of the Journal of the American Medical Association, leader in world health organizations, and now editor-in-chief of Medscape’s General Medical Journal, the world’s largest online peer-reviewed journal. George has been active in international medical circles and is author of Severed Trust: Why American Medicine Hasn’t Been Fixed, Basic Books, 2001.

• Steve Barchet, MD, FACOG, CPE, FACPE, Rear Admiral, MC, , retired, Seattle, Washington. Steve completed over 27 years of military service, first an obstetrician and gynecologist. His final assignment was Deputy Surgeon General and Deputy Director of Naval Medicine. He served in Vietnam as a doctor running a field hospital. Steve is currently coordinator of the Health Plan for Life (Hp4Life), which is dedicated to the proposition that prevention and wellness are the best route to stabilizing health care costs.

• Dr. Michael Parkinson, Alexandria, Virginia, executive vice president and medical director of Lumenos, a consumer-driven plan now owned by Wellpoint. As a former career medical officer for the Department of Defense, and a student of “top-down” military care, he believes a consumer-driven system is the only antidote to the U.S. medical cost problem. He entered the military in 1980 as a flight surgeon, and learned that primary care in the military consisted of learning about environmental risk factors, occupational medicine, disease prevention, and behavior change.

• Dr. Jerry Reeves, Los Vegas Nevada, Jerry served for 20 years in the United States Air Force Medical Corps. Just prior to retirement, he served as Chief of Clinical Medicine at USAF Headquarters in Europe, where he was responsible for the health care delivered by 350 physicians plus medical support personnel at 27 Air Force medical treatment facilities throughout Europe. Jerry is currently the Chairman of the Board of Directors of WorldDoc, Inc, a leading source of health management systems empowering people to lead healthier lives and reduce health costs. In conjunction with his role as Chairman, Dr. also serves as President of Las Vegas Operations of the Hotel Employees and Restaurant Employees International Union Welfare Fund. Prior to his current positions, Dr. Reeves was Corporate Senior Vice President and Chief Medical Officer of Humana Inc. During his three-year tenure at Humana, he led the disease management, population health, and prescription drug programs for their 6.2 million members.

My hats off to Drs. Lundberg, Barchet, Parkinson, and Reeves and to all physicians who served and trained in the U.S. military and who are using their military experiences to make a difference in civilian health care.

Sunday, May 27, 2007

Government reform - Health Reform Revisited by Senator Clinton and Me

Clinton Proposals, Reece Reactions

Senator Hillary Rodham Clinton outlined a plan yesterday to reduce health care costs, in a speech at George Washington University.

Senator Hillary Rodham Clinton, who endured a major political setback as first lady when she tried to promote universal health care, revived that crusade yesterday but in a more measured way, offering a plan to reduce costs, through programs like disease prevention, to make universal coverage affordable.

Katherine Q. Seelye, “Clinton Revisits Health Care and Affordability,” New York Times, May 25, 2007

I see by The New Times that Senator Hillary Clinton is “revisiting” health reform. I wish her luck. She will need it. I trust she learned from her first visit in 1994-1995, when she organized a task force consisting mostly of think tank members and graduate students withoutincluding a single hospital administrator or a solitary practicing physicians, who together accounted for about 75% of health costs.

Now she proposes to lower costs, improve quality, and insure everyone at one fell swoop by,

• managing disease prevention
• coordinating treatment
• computerizing offices and hospitals
• substituting generic drugs for brand name drugs
• having Medicare negotiate drug prices with pharmaceutical companies.

Unfortunately, taken together, these sensible and laudable goals are unachievable all at once short of a worldwide depression, an international world war, a major political scandal (a Bush impeachment ), or a unprecedented natural disaster ( global warning with flooding of Florida and the East Coast.) Still I applaud her thoughts.

Her original intent back in 1994 was to micromanage the system through “managed competition” made up of interlocking managed care plans. She suffered an ignominious defeat at the hands of “Harry and Louise” and health industry lobbyists.

The notice of her “ revisiting reform” occasions me to revisit my book Voices of Health Reform, Interviews with Health Care Stakeholders, Options for Repackaging Health Care (Practice Support Resources, Inc, 2005). The book was based on 41 interviews with national health care leaders. From those interviews I made the following 11 conclusions, which I revisit now to see what has changed.

Eleven 2005 Conclusions about Health Reform Revisited

1) Fragmentation and conflicts among health care interest groups renders reform intractable, but collaboration is essential if we are to preserve the best of our present system.

The fragmented state of affairs hasn’t changed much. Some of the larger health plans have acquired smaller plans, some of America’s 5200 hospitals have consolidated into larger health systems, but perhaps 70% of America’s doctors remain in groups of 10 or less, and 40% of these are in groups of three or less. Vaunted collaboration efforts between health plans and doctors and hospitals and doctors have yet to materialize to any significant degree. Senator Clinton’s proposals contain little about consolidating the various industrial sectors or forcing them to collaborate. Consolidation is occurring, but collaboration remains in short supply. Collaboration with one’s competitors runs against the grain of human nature, which may be why RHIOs (Regional Health Information Organizations) have had such a slow start.

2)Single-payer backers, still committed, are seeing practical opportunities slip away.

The three major Democratic candidates – Clinton, Obama, and Edwards -- all preach the gospel of universal coverage at the national level, but for practical purposes, the only real action is occurring in the states. If you ask the public, “Would you like universal coverage,” at least 75% will say “yes.” But if you rephrase the question, “Would you like universal coverage if it raises your taxes, rations care, and causes you to wait for high tech cures, “ that 75% drops below 50%. I agree with Senator Clinton says insuring everybody must be accompanied by lower costs and improved quality. Unfortunately, the political hat trick – lower costs, better quality, and universal coverage – is an extremely difficult to pull off. The government can’t dictate costs and quality. Government cost control has never worked well, and quality control depends on measuring outcomes – still in its infancy.

3)Medicare, in its present form, is unsustainable.

Medicare, with social security, is the third rail of American politics. Right now the politicians are still trying to sort out what the elderly think the Medicare Drug bill, passed in late 2003, and what it will cost. So far 80% of seniors have signed on and most seem satisfied, and it is costing less than anticipated, which was in the neighborhood of $100 billion a year. Senator Clinton is foursquare for the government negotiating drug costs directly with pharmaceutical companies. But prospects for that are unlikely. Capitol Hill has more drug firm lobbyists than members of Congress. Drug companies contribute heavily to coffers of politicians on both sides if the political aisle. Medicare may be “unsustainable,” but Congress has bigger fish to fry – the Iraq War, Besides, 2017 when Medicare is scheduled out of funds should present trends continue, is still ten years away.

4)These days the consumer-driven movement occupies everybody’s minds.

When I wrote my book Voices of Health Reform in 2005, there were 1 million health savings accounts (HSA) holders. Today there are 4.5 million HSA holders, and the number is growing at roughly 40% per year. Project that out ten years, and the number would be 112 million. This HAS member hood , is unattainable, critics say, because HSAs punish the poor, the sick, and women. But HSA brokers can’t keep up with demand. Brokers say many firms are completely replacing HMOs and PPOs with High Deductible Plans linked to HSAs. A lot depends on how quickly baby boomers embrace HSAs, how effective Democrats are in criticizing and facilitating them, how motivated employers are in ditching present health costs, and how satisfied the current crop of holders are with them. Whether the free preventive care offered by most tax deductible plans and the tax-deferred income by not using them are sufficient incentives to grow them remain moot questions..

5)Regional ideological and geographic differences matter.

For the last 30 years, Doctor John Wennberg and associates at Dartmouth and now Harvard have been saying regional variation of health costs and practices are irrational, illogical, and untenable. Yet little has changed. More health care is still delivered at higher costs per episode or procedure, for example, in Miami, New York City, and Boston. Big multispecialty groups are still more common in the Midwest and Pacific Coast. Kaiser still thrives in California, the West Coast, and Denver, but languishes elsewhere. Hospitals and doctors still cater to their local constituencies, which may demand more specialists, centers of excellence, technologies, and specialists. Experimental universal coverage plans may be introduced in Blue States suffering from business stagnation or fast growing immigrant populations, but they are often anathema in most in fast growing, business-minded entrepreneurial Red States.. Nationalization of the system will not erase these regional and geographic differences. The U. S. is a huge continental nation, with marked regional differences and attitudes.

6)Hospital and physician collaboration is an “iffy” proposition

You might think hospitals and doctors, both being in the “cure” business,” would be warm bedfellows in most health care undertakings. You would be wrong, As Regina Herzlinger points out her latest book Who Killed Health Care? America’s $2 Trillion Medical Problem – and the Consumer Driven Cure, hospitals , which make up roughly half of health costs, are intent on maintaining control and building their empires– through mergers, consolations of services, vertical integration, charging high prices for the uninsured, and stopping doctor-owned specialty hospitals from getting off the ground. Herzlinger claims hospitals will stop at nothing to quash or stop competition. Senator Clinton says coordinated therapy and computerized medical systems will help lower and rationalize costs. She is no doubt right on these counts, but most hospital systems spent their money on internal computer systems, not “coordination” with physician systems. Physician systems may not communicate with hospital systems and are still in short supply at most small physician practices. About 20% of physician practices now have EMRs.

7)The consumer movement means different things to different health care stakeholders and opens up enormous opportunities for other community institutions.

When I speak to hospital audiences about the consumer movement, I generally get a collective yawn. Appealing to individual consumers, changing their billing systems to make them more “consumer-friendly, creating bundled bills so consumer will know in advance what they would be charged, are partnering with doctors to build ambulatory care centers removed from the hospital campus simply don’t jib with plans to build a centralized empire where consumers come to them rather than the other way around.

Physicians are also slow to change. The idea that “patients” are “cost-conscious consumers” who respond to lower prices, evidence of value, convenience, and consumer control is hard for some doctors to swallow. Along with Senator Clinton, they may agree that computerization of the office will help attract patients (but a $30,000 a year, many are reluctant to pay), that coordinated care is great (but reorganizing , relocating the office, or joining a larger group is too daunting a task for most), that disease prevention would be a good thing appeals to most (but when are Medicare and health plans going to pay for prevention). One thing doctors are willing to do, is to prescribe generics rather than brand name drugs to relieve patients of the expense of brand name drugs.

8)Many American physicians increasingly consider themselves a disenfranchised minority.

There may be some basis for this complaint: Physician income growth is flat, Medicare and health plans systematically cut reimbursement for doctors, insurers reject 10 to 20% of submitted claims for minor errors, and the papers are filled with stories about doctors accepting free lunches, gifts, and rebates from well-healed pharmaceutical and medical device companies. As a physician interviewed in Voices of Health Reform, said to me, “Why would any intelligent person choose a profession where income is guaranteed to fall 30% over the next five years, where your every action is second-guessed by government or health plans, where malpractice suits are a constant worry, and where you are blamed at every turn for the exorbitant cost of care? Why would an rational, business-minded physicians accept Medicare or Medicaid payment below their costs of doing business? Why indeed” These are some of the reasons why a 50,000 physician shortfall is expected by 2010 and a 200,000 shortage by 2020.

9) Medicare and managed care organizations are placing their reform bets on the pay-for-performance movement.

This bet is based on the proposition that there are “good doctors”, i.e. high performing frugal doctors with good outcomes, and “bad doctors, i.e. marginally competent or incompetent doctors who charge excessively and have poor outcomes and that you can use data to sharply separate the two. I am dubious on pay-for-performance for a number of reasons: 1) most doctors to see enough of a given category of disease to be judged; 2) those making the judgments on performance have never been in a physicians’ office and have scant knowledge of how many clinical diseases can be based on “evidence;” 3) patient satisfaction surveys don’t really discriminate on the technical and knowledge base of good and bad doctors; 4) most outcomes result from patient behaviors outside the office. But, of course, I could be wrong. At the very least we need more effective patient-based education programs – probably online and personalized – that can teach patients using simple language, animated illustrations, the truth and consequences of their behavior and why they should comply with the doctors’ instructions.

10) Health systems are difficult to manage because they are composed of individuals and independent organizations acting in their own best interests at the boundaries of care.

As John Naisbitt, first in Megatrends and now in Mind Set!, so vividly points outs in his books, we live in a ”bottom-up” not a top-down society. We respond to the environment around us and to innovations that meet and satisfy the demands imposed upon us and effect our daily lives, not to mandate imposed from above by politicians. Americans are creatures of our culture. When asked what Americans believe, Garry Orren, a professor of political science at Brandeis, who polls of the New York Times and the Washington Post, “ A good place to start is to remember we are pro-democracy and anti-government. It comes down to ideas that are essentially anti-authority, and tend towards self-regulation. If there were an American creed, I think it might begin.

One: Government is best that governs least.

Two” Majority rule.

Three: Equality of Opportunity.

That seems about right to me. It explains why Americans prefer local health solutions, why they reject federal government-mandated coverage with rationing, why they feel capable of making their own health care solutions, why they seek equal opportunity access to high technologies, why they prefer pluralistic payment systems, why they allow market-based and public-based institutions to co-exist, why they are reluctant to heavily tax the “haves’ for the benefit of the “have-nots,” and why they believe in self-responsibility and individual choice and control.

11) Information technologies are often seen as the Holy Grail of health care, but these technologies will not work if they ignore the Elephant in the Room, the reluctant of small physician practices to install electronic medical records

In the long run, I think Senator Clinton is correct that computerized systems and information technologies will shape the system. Information technologies will glue together health care innovations, reduce costs, ease use, and improve care and outcomes – not in time to influence the 2008 Presidential elections --but in the next ten years.

The breakthrough in information technologies, already upon us, pivots on three developments:

1) government financial incentives (read that as Medicare) and from health plans paying doctors for adopting and using IT systems for episodes of care (pay for use);

2) the realization among doctors that the introduction of HSAs on a large scale and the widespread use of smart care(containing information the patient’s medical history and HAS credit status make payment at the point of care) will make their practices more efficient and profitable;

3) a growing demand among consumers to seek out only those physicians who are able to meet their demands for transparency, information, and convenience at the point of care.

That’s about it. Once again, reform is more likely to occur from innovations initiated from the bottom-up, rather than the top-down; universal coverage is not in the immediate future although pressures for it will grow in individual states; consumer-driven care remains a lively alternative; and what happens next may well depend on what takes place in the marketplace rather than the government space

Saturday, May 26, 2007

Clinical Innovations - Hidden in Plain Sight: A Book Review

Innovative Insights in How to Respond
To Demands in Patients’ Everyday Lives

The other day I responded to an email from Michelle Morgan, publicist for the Harvard Business School Press. She was aware of and of my book Innovation-Driven Health Care and wanted to know if I would like to review Hidden in Plain Sight: How to Find and Execute Your Company’s Next Big Growth Strategy, 2007, by Erich Joachimsthaler, a business scholar who has spend 25 years advising companies on innovation.

Joachimsthaler is founder of Vivaldi Partners, an innovation straregy and marketing firm with headquaters in New York City, and offices in Munich, Dusseldorf, London, Zurich, Hamburg, and Buenos

I said, sure, I would be glad to since health care innovation is my beat. I've just completed the book, and I found its insights fascinating. Joachimsthaler’s basic thesis is that the most powerful innovations, the one’s that make you exclaim, “Now why didn’t I think of that?” rest on observing demands generated by how people behave what people do in their daily lives, not on extending any companies' current product line. Of this observation comes his theory of DIG (“Demand-first innovation and growth)/

DIG consists of:

• Creating the demand landscape – becoming an unbiased observer of what people do each day and how they live.

• Reframing the opportunity space – Making practical products relevant to the context of people’s lives and work.

• Formulating the strategic blueprint for action – challenging the organization’s fundamental beliefs and looking for radical and better solutions outside their usual way of thinking and beyond extending the usual product lines.

Joachimsthaler gives concrete examples. For instance, he talks of Starbucks. During a visit to Italy. Howard Schultz, Starbucks founder and CEO, during a visit to Italy, observed the café was part of Italians’ everyday lives. Upon his return to America, Schultz imagined a business that could create a “third place” – not home and not work- that would be welcomed and become part of people’s everyday regular lives.

Joachimsthaler also explains how GE’s Medical System’s Division creates growth platforms for responding to clinicians demands in the fields of advanced medical imaging, patient monitoring, anesthesia delivery, critical care, and information systems.

Why should doctors read such a book? Well, for one thing, I think we have a lot to learn from innovative commercial companies and retailers – from,

-- creating new sites and new services for medical care for convenience sake to fit the demands of patients; everyday lives,

--to making the patient-doctor encounter more productive and more satisfying at the point-of-care,

--to creating integrated and bundled services with prices known in advance,

--to partnering with hospitals to build “big boxes” to provide one-stop-shopping ambulatory services,

--to constructing doctor-owned home pages from which patient can gather informed and reliable health information created by their own doctor.

To the astute health care observer, many of these innovations are obvious -- but hidden in plain sight for those who care to see.

Friday, May 25, 2007

Costs - The Frail and Elderly: The Costly One Percent

One Percent of Patients Account for 20 Percent of Costs

This day I spoke to John Shard, MD, 66, who lives in Lakefield, Connecticut, a small hamlet tucked in the Northwest corner of Connecticut.

Shard heads up an organization Enhanced Care Initiatives, or ICI. Through contracts with managed care organizations, such as Tufts Health Plan and HealthSpring, Inc., a small managed care firm in Nashville, ICI provides and organizes care for frail and elderly patients, mostly over 75 and mostly with multiple chronic diseases.

Medicare, Medicaid, and health plan data indicates these patients, who represent one percent of patients, account for 20 percent of health costs. Four percent of these patients represent 40 percent of costs. Many fall through the cracks of traditional care. They tend to be socially isolated and depressed.

Shard says his organization seeks to establish ongoing relations with these patients. They do this through nurses, care coordinators, and regular community meetings bringing the frail and elderly together to discuss problems and solutions. These meetings break the isolation cycle and lift many patients out of depression. Many sessions open with jokes, which the patients bring. For subject matter, the meetings feature practical things patients can do to improve their health status, like simple exercise or dietary changes.

Another key ingredient in ICI’s success (it decreases hospitals by 33% and emergency room visits by 25%) is a meeting between ICI nurses and the patient’s doctors. Doctors respond positively to these meetings, which serve as a powerful intervention and improve accounts dramatically. The elderly, it turns out, aren’t helpless and passive. Given a modicum of attention, they adsorb advice greedily and are highly educable. ICI and the doctor together become potent advocates for the patient.

The nurses have a laptop containing an electronic medical record with clinical guidelines. With the EMR, ICI can track and document what nurses are doing and how the patients are responding. The ICI program is strictly a “hands-on” operation and depends heavily on personal contract, rather than telephonic follow-up, which many competing disease management firms emphasize.

Thursday, May 24, 2007

Health Care, General - One Trick Ponies

Medicine needs fewer one trick ponies, specialists who spend too much time with their fellow cronies. Too many doctors focus just on their specialty, as if it were the only normality in this complicated health care world.

These specialists may suffer from tunnel vision. They may be thinking only of their singular mission, rather than the patient’s or the health system’s overall condition. You might say these specialists are suffering from hardening of the categories, rather hardening of the arteries.

Give me gifted generalists, free-ranging wide-eyed realists. Give me doctors know more about the overall score. Give me physicians who innovate rather than simply operate.

Wednesday, May 23, 2007

Clinial Innovation - A Once A Year Drug to Treat Postmenopausal Osteoporosis

Why Not A Yearly Drug for Other Diseases Too?

Another Occasional Clinical Blog

“A once-yearly infusion of zoledronic acid during a 3-year period significantly reduced the risk of verterbral, hip, and other fractures.”

Dennis M. Black, PhD, and 20 co-authors, “Once-Yearly Zoledronic Acid for Treatment of Postmenopausal Osteoporosis, New England Journal of Medicine, volume 356, pages 1809-1822, 2007.

Sometimes asking “Why not?” is the essence of innovation. If the answer is ‘yes” and has elegant simplicity, it may even be a revolutionary step forward.

Such may be the case with using zoledronic acid as an annual single intravenous intravenous infusion to treat postmenopausal osteoporosis.

I don’t know who first asked “why not” about zoledronic acid as a once year dose to treat osteoporosis, but I do know:

• 21 authors in an international study found zoledronic acid reduced vertebral fractures 70%, hip fractures 41%, and non-vertebral, clinical fractures, and other fractures by 45%.
• 50% of postmenopausal women develop osteoporosis, the progression of which can now be prevented or minimized in many as one half to thirds of affected women.
• 50% of patients taking oral drugs for osteoporosis stop taking them within a year.
• Costs of medical care for osteoporosis are $18 billion yearly, the cost of which may due to failure to take oral drugs.

A Neighborly Chat

I was musing about these numbers when chatting with an 80 year widow in our town. I was telling her of the once-yearly infusion study and its astonishingly positive results. I thought she might be fascinated. She has suffered multiple vertebral fractures, has lost 6 inches in height, and wears a back support brace to prevent further fractures.

Her response surprised me, “ I don’t care what the doctors say. They just want to hand out, inject, or infuse another drug. I won’t do another damn thing until I research it on the Internet. Besides, I want to know what the drug costs. My doctor probably doesn’t know. ”

So much for baby boomers as the only demanding U.S. demographic group.

Three Concluding Thoughts

Her response led me to three thoughts.

1. An article in the April 23-30 American Medical News, “Costs vs. Compliance: Patients Often Fall to Follow Doctors’Orders Because They Can’t Afford The Medication. Talking With Patients about Money is One Step towards Changing That.” The author, Kevin O’Reilly, cited an article in the Archives of Internal Medicine, which stated 85% of patients are sometimes noncompliant, 50% skip drugs to save money, 35% didn’t discuss their noncompliance, 32% of patients suffer declining health because of noncompliance.
2. Doctors can decrease cost, in decreasing order of doctor preference, with 5.0 being top choice by:
• switching from brand –name to generic drug 4.34,
• giving drug sample 4.16,
• discontinuing drugs 4.03,
• switching to less expensive brand-name drug 3.96,
• prescribing higher dose and telling patient to split tablet 3.58,
• referring patient to drug assistance program 3.57,
• recommending over the counter substitute 3.21,
• referring patient to public aid or social worker 3.15,
• encouraging patient to see another doctor 1.86,
• doing nothing 1.47.

3. Wondering if once yearly intravenous drug infusions might be adapted to other treatments of other diseases. This is sheer speculation on my part and may be folly since I’m not acquainted with the potential pharmacologies or disease dynamics involved.

Nonetheless innocent and ignorant questions sometimes leads to stimulating more informed persons to pursuing research outside the usual mental framework to reach for answers in the sky where others have yet to venture. I’m reminded of these lyrics of a popular 2007 song by Hillary Duff.

Why not
Take a star from the sky
Why not
Spread your wings and fly
It might take a little
And it might take a lot
But…why not
Why not.


1. D. M. Black and others, Once-Yearly Zoldronic Acid for Treatment of Postmenopausal Osteoporosis, New England Journal of Medicine, volume 356, pages 1809-1822, May 3, 2007

2. J. Compston, Treatments for Osteoporosis – beyond the HORIZON . New England Journal of Medicine, volume 356. pages 1878-1879, May 3, 2007

3. Kevin O’Reilly, Costs vs Compliance, American Medical News, pages 7-8, April 23-30, 2007

4. Archives of Internal Medicine, September 25, 2006, and March 25, 2005.

Tuesday, May 22, 2007

Physician Practice Ideas - “Busyness” The Bane of Health Care Businesses

"The world is moving so fast these days that the one who says it can't be done is generally interrupted by someone doing it."

Harry Emerson Fosdick, 1878-1969

"It is not enough to be busy; so are the ants. The question is: what are we busy about?"

Henry David Thoreau, 1817-1862

Back-to-back meetings all day long are a sure sign of organizational backwardness and of failure to know one’s time, not of an individual’s importance. That’s the message I convey in this blog. Constant “busyness” leave little time for innovative thinking.

As a “connector,” a word Malcolm Gladwell coined in the Tipping Point (Little Brown, 2000) to describe individuals with wide social circles and broad connections, who seek to make the right things happen, I spend a lot of time on the phone trying to reach influential friends and health leaders.

It’s a frustrating experience.

• First, there’s those long interminable uninterruptible telephone menus, in English and Spanish, directing you to those eight departments you don’t want to reach, then reciting them again if you don’t push the right button.

The purpose of these menus, of course, is to direct traffic without human intervention and to protect the “busy” executive. One trick here is to push “0” before you get too entangled listening to the menu merry- go-round.

• Second, there is the protective bodyguard “associate” asking you to state and defend your reason for calling, your relationship with his/her imminence , and telling you the boss is “busy” now in meetings, on conference calls, or is out of the office and won’t return until he or she is good and ready to answer your call, which may be never.

• Third, there’s the “busyness” excuse. So-and-so is “terribly busy,” Or, Doctor Jones is a an “incredibly busy physician, “ Or, “Mr. Smith is busy, he/she’s in meeting all day, all week, and is booked solid for the rest of the month, “ unable ,presumably, to talk to ordinary mortals outside of the organization. Sometimes I feel like saying, “I’m terrible busy too,” But I hold my tongue.

I understand this is a busy world and busy executives have a lot on their plate and spend a lot of time at meetings.

But I maintain there’s a lot of unnecessary busywork going on out there and one can get so caught up in “touching base” to satisfy office politics and to coordinate the bureaucracy that one forgets the world is made up of people.

Others have said of meetings and phone calls.

• Peter F. Drucker (1909-2005) -- “Another common time waster is meetings. The symptom is an excess of meetings. Meetings are by definition a concession to deficient organization. For one either meets or one works. One cannot do both at the same time. If any executive in an organization than a fairly small part of their time in meeting, it is a sure sign of malorganization.” Drucker also said any organization in which executives or managers spend more than 25% of time in meetings is “dysfunctional.”

• Marshall Zaslove, MD, a physician productivity expert, wrote, ”Most doctors don’t like meetings, because we recognize intuitively that they’re not only an interruption, but usually a waste of our work time. On this point we differ from executives and managers, who love meetings and who will even boast to each other. ‘So-and-so gave me a meeting.’ The difference stems from the fact that as physicians we usually do our work one on one; that’s just the nature of our tasks. In contrast, managers are not rewarded for the work they do as individuals, but for how much work they can get groups of other people to do.”

• Robert C. Townsend, the legendary executive who launched Avis Car Rental’s campaign, “We Try Harder,” and who wrote Up the Organization: How to Stop the Organization from Stifling People and Strangling Profits,” said the best way to humanize the corporation was to have every employee, from executives on down, spend two weeks at a year at reservation desks answering phone calls. On a personal level, while on the road, he would call Avis headquarters, and ask for himself, “Try calling yourself up to see what indignities you have built into your own defense.”

So there, I’ve worked off my frustrations over “busyness.” One person I enjoy calling is Mike Martin, president and CEO of Practice Support Resources, Inc, an independent health care publisher in Independence, Missouri. His firm publishes 500 titles a year for physicians and hospital executives. Mike is always available to personally respond to calls. Mike is a refreshing touch of humanity.


1. Peter F. Drucker, The Effective Executive, Harper & Row, 1966

2. Marshall O. Zaslove, The Successful Physician: A Productivity Handbook for Practitioners , An Aspen Publication, 1998.
3. Robert C, Townsend, Up the Organization, How to Stop the Organization from Stifling People and Strangling Profits,, Mass Market Paperback, Fawcett, 1981.

Friday, May 18, 2007

Clinical Innovation, Hospice - The Hospice Innovation

The High Touch Part of High Tech/High Touch Medicine

Death be not proud, though some have called thee"

DEATH be not proud, though some have called thee
Mighty and dreadfull, for, thou art not so,
For, those, whom thou think'st, thou dost overthrow,
Die not, poore death, nor yet canst thou kill me.
From rest and sleepe, which but thy pictures bee, 5
Much pleasure, then from thee, much more must flow,
And soonest our best men with thee doe goe,
Rest of their bones, and soules deliverie.
Thou art slave to Fate, Chance, kings, and desperate men,
And dost with poyson, warre, and sicknesse dwell, 10
And poppie, or charmes can make us sleepe as well,
And better then thy stroake; why swell'st thou then;
One short sleepe past, wee wake eternally,
And death shall be no more; death

John Dunne

Juno Beach,Florida -- Most of us die before we reach 100. That's the nature of the human genome. Some of us die of "natural causes" at home or work; others die from the big killers - heart disease, stroke, cancer, obstructive lung disease- in hospitals; all of us die no matter what medicine's high tech tools have to offer.

For every high tech innovation, a corresponding high touch innovation crops up, For every mainstream theray, there's an alternative therapy. For every disease, there's a support group. And for every failed therapy, every disease, with every death across the Great Divide, there's a hospice.

My son, Spencer, who lives here in Juno Beach, has made my wife and me proud of his role in the hospice movement. He's training to be a hospice chaplain, one of those saintly souls who visit the dying, listen to their stories, commiserate with their spouses and relatives, prepare them to die in peace, comfort them, and cater to their spiritual needs.

Yesterday, with our son, my wife, Loretta, a fomrer Massachusetts General Hospital nurse, and I attended a session of session of a group training to be hospice chaplains. It was led by Philip Kittle, PhD, senior chaplain of the Hospice of Palm Beach County. The mission of the hospice is "to serve the spiritual needs of Palm Beach County."

The session opened with a white paper on the theological nature and structure of "sin," and was followed by a verbatim presentation by one of the aspiring chaplains. The "verbatim" consisted of a three page case study, written and read by one of the chaplain want-to-bes. The case for the day concerned a Jewish woman whose spouse of 25 years was dying of cancer. Her problems were two-fold: one, difficulty in talking to her husband about his imminent death; and two, conflicts with her husband's three sons from a previous marriage. The discussion swirled around the trainee's intraction with the wife, her dying husband, and the three sons. In a separate meeting, I was told, an interdisciplinary team- the chaplain, nurses, and doctors - would lay out the plan for the patient.

Our session with the trainees inspired my wife and me. It made us realize we are in this thing called life and death together. All of us need compassion and comfort and coming to grips with our mortality at the end.

The hospice movement, now about 30 years old in the United States, has become a major force in U.S. health care. Hospice tends to the dying in freestanding hospice units, in hospice hospital wings, in long-term nursing facilities, and in patients' homes. It is an inspiring movement. It has inspired our son, who has decided to become an Episcopalian priest, ministering to the needs of the dying. We are proud of him.

Thursday, May 17, 2007

Health Savings Accounts - Employers:Trust Your Employees, Give Them Health Care Choices

Death at the Hands of a "Choice" of One

From Who Killed Health Care: America's $2 Trillion Medical Problem - And the Consumer-Driven Cure, by Regina Herzlinger, McGraw Hill, 2007

Juno Beach, Florida --I have several friends with strong opinions about the employer's role in health care.

--One is John Burns, MD, who was vice-president of medical affairs at Honeywell (may not be exact title), about 10 years ago. John, an internist, felt all employees, from CEO on down, ought to have the same health benefits. This did not go down well with Honeywell executives, who thought rank had its privileges and therefore they ought to have their annual physical examinations at the Mayo Clinic while other employees could have their evaluations done elsewhere. John also felt strongly Honeywell should only pay for medical services that were based on evidence from the medical literature. Finally, John had his clashes with the Health Resources people who considered it their paternalistic and sacred duty to give employees as many health care benefits as possible and available..

-- The other is Brian Klepper, MD, president and founder of the Center for Practical Health Reform. Brian, too, is a believer in "evidence-based" medicine. He believes in care based on data on quality and outcomes and performance, as monitored by management platforms and as gathered in RHIOs, (Regional Health Information Organizations. Brian, like John, feels only business employers have the clout and leverage to reform health care.

Then, there's Regina Herzlinger, professor of business administration at Harvard Business School, senior fellow at the Manhattan Institute, and godmother of the consumer-driven health movement. You might think she would be sympathetic to the health costs plights of business. Health costs, after all, are said to be killing American business in the competitive global marketplace. GM, for example, spends $1500 for health care for each employee while Toyata is spending $110.

You might think this professor of business administration would put her emphasis on shifting of costs and risks to employees. These shifts could take the form of,

-- rewards for exercise and fitness
-- stopping smoking
-- losing weight
-- paying more to hospitals and physicians who adopt quality incentives
-- disease management at home and at work
-- tmanaging cost through HMOs, PPOs, and other forms of managed care.

But you would be wrong.

Instead she says: Businesspeople: trust your employees to make their own health care choices rather than relying on your Health Resources (HR) to narrow employee choices. Your employees, she insists, are just as capable of making intelligent informed choices about health care as they are of knowing what to do with their 401Ks, their cafeteria plans, and their private purchases of homes, cars, computers, and mutual funds. According to Herzlinger, HR personnel are paternalistic and bureaucratic rather being competitive and entrepreneurial. Like typical corporate bureaucrats, they do not believe in competition, choice, and entrepreneurship, and they mistrust employee's judgement in choosing between multiple plans. Instead they believe in making health consumers' choices for them. And they believe it is their duty to hire insurance plans to administer their employees' benefits.

If this approach fails, as it often does, they require employees to pay more for their premiums and elevates co-pays. If that fails, they further reduce the number of plans to one or two. They reduce the number of drugs available in the formulary. They reduce the number of hospitals or physicians in the network. The strategy is: narrow the choices, shrink the benefits, switch to generics, tightly manage use of health services to the sick.

Rarely do the HR types consider competition and different vendors. And so by 2005, this narrowing and shrinking process resulted in virtually all employeers offering only opne plan, typically a managed one. Only lately since 2004 have some employers began to switch employers to high deductible plans with health savings accounts (HSAs) and even a few have completely replaced HMOs and PPOs with high deductible plans.

Rarely have corporations turned to consumers and physicians to manage costs on their own. That would be their last stand. That might entail more individual responsibility, employees choosing between various plans based on costs, quality, and value. That would be radical, trusting employees to make choices, as they now do for cars, computers, pension funds, housing, and education. But giving consumers the option of spending their own money -- based on what they think they need and what they judge to be in their own best financial and health interest -- might also cure the health care cost crisis.

Wednesday, May 16, 2007

Hospitals and Physicians - General Hospitals in Transition from Dominance to Innovation

From Who Killed Health Care? America's $2 Trillion Medical Problem- And The Consumer-Driven Cure (McGraw-Hill, 2007)

I have some experience with hospitals. As a pathologist, I've worked inside of them. As the chairman of a PHO, I helped develop 150 "bundled bills" -- a combined hospital and physician fees -- to achieve "tranparency" for health plans and consumers. As a co-owner of an outpatient "commercial" clinical laboratory, I've competed with hospitals(Among other tests, we charged $6 for an SMA-12 while the hospital was charging $75. I was told this was necessary for "cross-subsidization" purposes to support money-losing hospital services.) And with a former hospital CEO, James Hawkins, I co-authored Sailing the Seven "Cs" of Hospital Physician Relationships: Competence, Convenience, Clairty, Continuity, Contro, Cash, and Competition (Practice Support Resources, 2006).

None of this makes me an expert on general hospitals, but as a consequence of these experiences, I read Regina Herzlinger's chapter on general hospitals with rapt attention.

Regina's message is: America's 5200 general hospitals had better move to innovate if they are thrive in a consumer-driven environment.

No longer can general hospitals sustain their dominance, if,

1. their costs continue to grow at a an 8% to 9% annual pace;

2. their costs exceed costs of general hospitals in other developed countries as much as 4 to 1 and in underdeveloped countries attracting medical tourists by as much as 10 to 1;

3. "adverse events" continue to occur on their premises, 400,000 times a year, marking them as dangerous places full of safety hazards;

4.they continue to consolidate with rivals to maintain their monopolies, further driving up costs by extracting fees from insurers who have no where else to go;

5. they persistently charge "outrageous" fees to the uninsured, thereby making a mockery of their "charitable," "not-fro-profit" and "church-affiliated" or "doing the work of the Lord" status;

6. block the building of physician-owned and/or operated specialty hospitals through heavy lobbying of Congress;

7. employ salaried doctors or setting up "centers of excellence" in the name of economies of scale or vertical integration, when in actuality they are more inefficient and less productive than their competitors.

8. Act in their own financial seelf-interest rather than the interest of consumers.

According to Herzlinger, these tactics, successful so far, will not work indefinitely because general hospital costs, already comprising about half of all health costs, will continue to rise. Her reasoning? Monopolies without competition will ultimately run afoul of federal anti-competitive laws, lawyers like Dickie Scruggs will stripe hospitals in some states of their charitable status. monoplies are inerently economically inefficient, consumers spending their own money will siimply get their care elsewhere.

Herzlinger argues general hospitals must see the clouds on the horizon and act to innovate, much like America's retail industry has done, by,

1. introducing more and more diverse consumer shopping sites for care;

2. stressing services and convenience to miminize time and travel expenses;

3. offering more choices of services and re-organizing them into more convenient care categories;

4. ceasing trying to be everything for everybody and subspecializing;

5. allowing more competition which will come anyway and will not be denied;

6. focusing on consumer needs that are more relevant and fit consumer needs, not the needs of the hospital;

7. offering integrated services for diabetes, cancer, AIDS, heart, lung, and bad backs.

8. giving physicians more latitude, control, and share of profits

9.becoming more transparent in pricing by offering upfront "bundled bills" for a range of services in advance.

10. moving to meet the threat posed by global competitors, who have already made many of the managerial innovations indicated above.

Herzlinger -The Health Insurers Are Killing Care

From Who Killed Health Care?America's $2 Trillion Medical Problem -- And the Consumer-Drive Cure (Regina Herzlinger, McGraw Hill, 2007)

Juno Beach, Florida --In her 304 page book, backed by 634 references, Regina Herzlinger, Harvard Businness School Professor, Senior Fellow at the Manhattan Institute, and Godmother of Consumer-Driven Health Care, asserts third parties are killing the system. They're killing it, she maintains, by bringing about too high costs, getting between doctors and their patients, acting in their own self-interests rather than those of health consumers, and showing a lust for empire building.

In her chapter on "The Health Insurers" she surprises me by focsing on the woes of Kaiser Permanente. This took me a little off guard because I have always thought of Kaiser as a progressive organization who could do no wrong. I have admired their Archimedes Project, their reduction of heart attack and stroke mortality, and their ambitious EMR project. Thirty years ago, when I was a student of Regina Herzlinger at a Harvard Business school advanced management course, Regina admired Kaiser.

Why the shift? Well, it isn't a complete shift, but she is critical of Kaiser's failed renal transplant program. In this program, she says Kaiser drifted away form its usual culture of scrupulously providing prepaid care. It was too intent on growing its system and left out its usual attention to details. It also learned too much "vertical integration" can be a bad thing. You can't be everything to everybody and do everything well. Some things are better off being outsourced. In her analysis of Kaiser, she carefully lays out the history of Kaiser -- its founding, growth, reaction to adversity, and declines. She says Kaiser strayed from its mission in the mid-1990s when it decided to adopt its culture to that of other HMOs - growth for growth's sake -- and instituted its fated and failed renal transplant program

She concludes:

At one time, the fabled HMO Kaiser exhibited a corporate culture that enabled it to offer high quality care at a reasonable price, and Kaiser still does a good job for many of its patients. But when Kaisers managers decided to grow the organization, they wore down the foundation of this culture and lost a fortune in the process.

In all human activities, God is in the details, especially wlhen it comes to care of seriously ill people. The management of the Kaiser HMO allegedly neglected these thousands of details in its kidney tranplantation program; it reportedly understaffed the program; fired orginal employees who complained about its quality progam and provided little suppor for those who remained. In 2006, after more than a hundred of patients awaiting kidney transplant died, Kaiser performed one mericual act; it closed the program

There is more to "The Health Insurers" chapter than Kaiser. Herzlinger comments on the fallacies of "Just-Say-No" policies, the unnecessarily high administrative costs, the use and abuse of doctors, the neglect of the needs of health care consumers, and other misguided policies.

Tuesday, May 15, 2007

Herzlinger - Who is Killing Health Care?

I'm in Juno Beach, Florida, and I've just completed reading Regina Herzlinger's latest book, Who is Killing Health Care? (McGraw Hill, 2007). The book is an all-out assault on the flaws of the present system. She puts the blame squarely on the shoulders of not-for-profit hospitals, managed care, employers, the academic community, Congress, and other self-serving third parties who know little about health care consumers. All of these third parties, she says, in one way another, adopt a paternalistic "Father knows best" attitude without basically knowing what they're talking about. Only they, the top-down gang, feels it knows what's good for patients when nothing could be farther from the truth.

The altitude and attitudes of the health care "fat cats," who are pocketing billions to serve their own narrow self-interests, bewilders and angers health care consumers. Consumers feel they have little choice, control, transparency, and information to make intelligent choices. And third party actions hog tie doctors. leaving little room for innovation and entrepreneurship. These two factors, Regina asserts, will the the life-blood and salvation of any workable, convenient, cost-saving, patient-serving system. Health care consumer, Herzlinger maintains, are very smart people who know what's best for themselves. More on this book and specific examples of what Herzlinger is talking about later.

Monday, May 14, 2007

Physician Mindsets - Two Solo Practice Mindsets

Do You Single or Mingle?

In Mind Set! (Collins, 2007), John Naisbitt, who wrote Megatrends, observes how you think about an issue depends upon your mindset.

Naisbitt puts it this way, ”Judgments in every area are driven by mindsets, from world affairs to personal relations.” If you think of the world as a clash of civilizations, all politicians as crooks, outsourcing to India as stealing American jobs, cats as the planet’s cleanest pets, global warning as a threat to civilization, husbands as faithful rather than as philanders, you receive the same information differently.

How one perceives the future of solo practice also depends on mindsets.

If you cherish your independence, want to be your own boss, seek a deep personal relationship with your patients, strive to reduce your overhead, and have information technology savvy, you may think a solo practice as the way to go.

Dr. Gordon Moore, a solo family physician in Rochester, New York, is such a person. In “Going Solo: One Doc, One Room, One Year Later” (American Academy of Family Practice, March 2002), Moore described how gratifying and rewarding solo practice can be.

Using a “lean” IT system with Internet access, Moore saw every patient on the day they called, delivered comprehensive care, took his own call, developed deep and personal relationships with patients by spending 30 minutes with each one, reduced his patient load from 25 to 30 to 12 patients a day, operated without support staff in a room of 150 square foot, averaged $65 a visit, and took home $155,000.

On the other side of the solo mindset divide is David Lawrence, MD, chairman emeritus of Kaiser Permanente. In his widely acclaimed book, From Chaos to Care: The Promise for Team-Based Medicine, Perseus Publishing 2002, Lawrence maintains solo practice is dying because one doctor, acting alone, can’t handle American Medicine’s demands..

Lawrence conveys his message in the form of a fictitious solo practitioner, Adam Landers, MD. He says Dr. Landers lacks the time, money, and organization to be a high quality physician and to deliver on the promise of modern medicine. Landers, Lawrence maintains, will fall further and further behind. These are Lawrence’s words, “For the simple and routine illnesses, he provides a valuable service. But for more complex and chronic conditions, neither he nor his colleagues in other solo or small group practices are prepared for what medicine now requires and patients demand. The forces are too strong and the changes too profound.”

According to a 2003 CDC survey of National Ambulatory Care, 38.5 percent of patients still go to solo practitioners for their care. This visitation rate may change over time. New physicians are much less likely to enter practice and more likely to work as salaried employees of group medical practices, clinics, hospitals, or health networks.

To those who say solo practice is dead as a dodo, I say, “Some Death, Some Dodo.” Solo practice may be dying, but patients haven’t recognized it yet.

Sunday, May 13, 2007

Health System - The New York Times Reports “Good News” About American Health Care

That’ll Be The Day

“All I know is just what I read in the papers.”

Will Rodgers,1879-1935

I await the day when The New York Times runs a series of “good news” articles about the state of American health care. The series might have these titles,

• Americans Trust Their Doctors
• Americans Have Greater and Quicker Access to High Tech Diagnostic and Curative Care Than Any Other Nation
• Foreign Physicians Flock to America for Training Unavailable in Their Country
• Record Numbers of Canadians Cross Border for Life-Saving Care
• America Achieves Unprecedented Longevity Gains in Last Decade
• Americans Receive 80 Percent of Noble Prizes in Medicine
• Research at American Pharmaceutical Companies Produces 90 Percent of the World’s New Drugs
• America’s Innovative Health System’s Variety and Choice the Wonder of The World

That’ll be the day.

The Times in 2005 and 2006 had a series of a dozen articles entitled “Being A Patient.” These focused largely on the perils of being a patient in America. Now The Times is embarked on a series on medicine and money, focusing on profit-mongering drug and medical device companies in league with greedy specialists to bilk the public.

It all comes down to altitude and attitude. From their lofty perch, The New York Time’s editorial staff has yet to tumble to the reality America is basically a conservative nation, distrusts centralized government, wants choices of care and providers, demands access to the wonders of high tech medicine, and believes a market-based system, with all its faults, such as profits for entrepreneurial and innovative health care companies and doctors, are worth the price and value received.

It is almost as though The Times denies the existence of entrepreneurial capitalism in American health care. Our health system blends innovative large and small firms striving for economic growth. Such a system entails risk – workers who lose jobs and health insurance, widening of gaps between winners and losers, competition with some jobs going to skilled workers abroad who have increasing skills, occasional bankruptcies among those unable to pay health care bills. American capitalism is imperfect. It requires oversight to reduce risks without losing entrepreneurial vigor. Unremitting accusations of bad faith and constant “bad news” stories don’t strengthen health care.

Read the The New York Times, and you’ll come away believing pervasive avaricious greed corrupts American health care and will break our already “broken” system.

From May 9 through May 11, The Times ran 10 articles on how drug companies deceived the public and entered into unholy alliances with doctors to sell more drugs to produce more revenue for doctors, how doctors willingly entered into these alliances solely for material gain, and how lobbyist-tainted and incompetent FDA failed to monitor new drugs and harmed patient safety.

The May 9 front page, right top column, the prime spot for highlighting news, featured these headlines,

Doctors Reaping Millions for Use of Anemia Drugs. Payments from Industry. Concerns over Safety – Critics See Incentives for Higher Doses.

The opening Section read:

“Two of the world’s largest drug companies are paying hundreds of millions of dollars to doctors every year in return for giving their patients anemia medicines, which regulators now say may be unsafe at commonly used doses.
The payments are legal, but very few people outside of the doctors who receive them are aware of their size. Critics, including prominent cancer and kidney doctors, say the payments give physicians an incentive to prescribe the medicines at levels that might increase patients’ risks of heart attacks or strokes.
Industry analysts estimate that such payments — to cancer doctors and the other big users of the drugs, kidney dialysis centers — total hundreds of millions of dollars a year and are an important source of profit for doctors and the centers. The payments have risen over the last several years, as the makers of the drugs, Amgen and Johnson & Johnson, compete for market share and try to expand the overall business.”

The Times
appears bent on publishing on its front pages “All the Bad News that’s Fit to Print about U.S. Health Care.” The May 9 article is part of a series of medicine and money, all decrying collusive relationships between big business and bad doctors. The Times series focus on the pharmaceutical industry and medical device industries , and how these industries reward specialists who overuse products for financial gain.

To The Times, the American health system has become a morality play,

• the good guys (The Times and other assorted elites and policy pundits) vs. the bad guys (profiteering health companies and doctors);
• the greedy (well-healed executives and “rich” doctors) vs. the needy (poor patients in the throes of cancer or kidney dialysis);
• the high brows (academics and journalists who know what’s right for the common good) vs. the low brow commercial types (who do almost everything wrong as long as it suits their own financial self-interest).

I don’t wish to pick a fight with a media outlet who buys ink by the barrel. I know “bad news” sells better than “good news.” I know The Times considers itself the Watchdog and Whistle-Blower against mean-spirited, profiteering conservatives. I don’t question our capitalistic system needs oversight to reduce abuses.

I’m simply seeking more balance in The Times reporting. For an example of this imbalance, in its May 9 piece, The Times dismisses America doctors’ overuse of anemia-correcting drugs for cancer and dialysis as a deliberate effort to make money. To make its case, The Times notes American doctors,

• prescribe more drugs than European counterparts ( Did it ever occur to The Times maybe, just maybe, European doctors “under-prescribe” and maybe their patients have less positive results? )

• conssciously endanger patients for profit when they know anemia drugs are unsafe (Has it occurred to The Times American physicians prescribing these drugs believe higher hemoglobin levels are “good” for improving health and alleviated distressing symptoms attributable to anemia.)

• Continued to prescribe drugs even after studies indicated hemoglobin levels above 12 might endanger patients ( Did it ever occur to The Times the studies indicating “possible” risk studies were far from conclusive and only appeared in March?)

Nor does The Times point out doctors themselves often criticize thenselves. For instance, on a May 11 blog, “The Doctors Weighs in on Cancer,” Dr. Dov Michaeli, an academic physician and biochemist who does cancer research takes the American Society of Clinical Oncologists (ASCO) to task for responding to the Times defensively (see epilogue to this blog for a reprint of ASCO letter to The Times).

Of the ASCO letter to the times (reprinted in epilogue), Dr. Michaeli acidly comments “ASCO makes that same argument that professional people make when colleagues are caught with their hands in the cookie jar: most of us are conscientious, hardworking people. Granted, but it turns a blind eye to the corrosive influence of pharmaceutical companies on the use of drugs. This is denial of how our health system ‘works’ on a daily basis.”

Michaeli concludes: “As the wheels are coming off our broken health system, more revelations of waste, abuse, greed and outright criminality are bound to surface. What are we going to do about it?”

Good question. I suggest we start with a more balanced view of the system.

• First, I reject the notion the system is “broken” – and constant reference by academic critics of greed by practitioners as a cause for this brokenness ( Michaeli, an academic researcher, shows some of this bias when he says, “ ASCO is led by academic clinicians and researchers, whose motivation and dedication is admirable. But many of the rank and file, community practitioners, are not beyond temptation.”

I doubt medical academicians, who compete for pharmaceutical company grants and who run clinical trials, are beyond temptation. I’m unaware academic physicians wear halos and only practicing doctors are vulnerable to “temptation.”

• Second, I believe critics ought to acknowledge health care is an innovate force in our economy, will soon represent 20 percent of the nation’s GNP, and is the nation’s largest employer. Professional managers, whose job is to maximize resources and revenues, run most health care enterprises - hospitals, medical practices, drug and device manufacturers. If overzealous pursuit of revenues and resources leads to excess, managers should be condemned, even fined and jailed, but it shouldn’t be assumed or taken for granted pharmaceutical and medical device companies and doctors are always seeking mutually beneficial arrangements are ipso facto evil doers.

What the media in general, and The New York Times in particular, needs is a more balanced view. An occasional dollop of good news, such as more than 50 percent of cancer victims are now surviving, more than 10 million cancer victims are living with their disease, and genetically engineered cancer drugs are contributing significantly to cancer cures, would help achieve that balance.

I’m pleased to report the May 12 issue of The Times contains a “good news” piece on Becton, Dickinson & Company. It’s buried on the third page of the business section. It’s titled “Medical Gear That Rarely Makes News.” It consists of an interview with Edward J. Ludwig, CEO of Becton and Dickenson, with revenues of $5.7 billion last year, on sales of syringes, diagnostic kits, lab equipment, and related gear.

The unifying theme behind the company’s success is its emphasis on safety in its products to protect doctors, nurses, and patients with shields, sliding clasps, and needle retracting into the device. Its ambition is to make a significant dent in the 2 million infections each year from antibiotic resistant staphococci killing 90,000 Americans each year and costing $6 billion yearly to treat. Toward that end, B &D has acquired a diagnostic system allowing them to quickly identify the offending bacteria. Use of this system to screen every patient. entering Evanston Northwestern Hospital reduced infections by 60 percent. Ludwig contend s private innovation will help the “broken” health system to heal itself by attacking safety problems, and improving care. What the media needs is a new more flexible mindset allowing them to become more innovative in reporting the “good news” of our resourceful and responsive health system.

Epilogue: In the interest of being “fair and balanced” (a term the mainstream media now considers anathema since Fox News adopted it as their slogan), I reprint six letters from the May 13, Sunday, New York Times. The Times deserves credit for publishing letters representing both points of view.

Best Drug, or Best Money Maker? (6 Letters)
1) To the Editor:

So two drug companies are paying hundreds of millions of dollars to doctors who prescribe anemia medicines that lack effectiveness and put a patient’s health at risk. This is not a surprise because it reflects our broken health system, a system driven by greed.

Although drug companies say their intentions are not to promote the use of more medicine for profit, there will always be the risk that some doctors will prescribe higher doses to gain that extra dollar.

As patients, we should work to eliminate the incentives to doctors and to raise patient awareness about them. We deserve the right to know the benefits of a medicine, both for us and for the doctors.
Luis Rodriguez
Daly City, Calif., May 9, 2007

2) To the Editor:

Medical care should be guided only by what is best for patients. But throughout the medical system, rebates and volume discounts are common and can create the perception of improper incentives.

Our organization has long advocated evidence-based guidelines, including those we produced in 2002 with the American Society of Hematology on erythropoietin use for chemotherapy-related anemia. With the appropriate use of erythropoietin, many thousands of patients have avoided potentially dangerous blood transfusions.
Oncologists care deeply about their patients, and the overwhelming majority treat them based on the best available evidence.

In the case of erythropoietin, recent studies prompted the Food and Drug Administration to issue a “black box” warning in March about the potential dangers of using erythropoietin to boost hemoglobin to levels higher than guidelines recommend. Early evidence suggests that doctors factored this new data into their prescribing decisions and have reduced erythropoietin use.

As a whole, the medical community needs to better determine the impact financial incentives may have on prescribing patterns and patient care, to ensure that patient needs continue to be at the forefront of medical decisions.

Allen S. Lichter, M.D.
Exec. V.P., American Society of Clinical Oncology
Alexandria, Va., May 10, 2007

3) To the Editor:

Many doctors appear dissatisfied with fees ethically garnered from clinical evaluation and management. They can and will prescribe for personal profit, and will readily reshape and expand diseases to suit the available reimbursement. Without disclosure, patients are typically the last to know there might be a problem.

The investigation of anemia drugs no doubt could expose the self-serving logic, unethical inducements and poor administrative surveillance that permit exploitation of the public’s soft financial underbelly. Unfortunately, there are plenty of other specialties of medicine where such professional betrayals occur. And adequate regulation is not likely to occur in the financial free-for-all of private medicine.

James H. Lampman, M.D.
Bismarck, N.D., May 9, 2007

4) To the Editor:

The discovery and development of growth factors that stimulate the bone marrow to produce red cells was a milestone in modern medicine. In the appropriate setting, these growth factors can improve blood counts and quality of life and spare patients time-consuming, expensive, short-lasting and risky transfusions.

In our practice the increasing use of these medicines is driven by the fact that they work so well. As with any new therapy, these medicines need to be used within established and developing guidelines to avoid serious side effects.

Since there are two competing and equally effective drugs, the drug makers are offering incentives for preferential use — the natural outcome of a free-market economy.

Deciding how regulators might control drug makers is an important undertaking, but it should not detract from the tremendous benefits of these drugs when used in the right situation.

Birjis Akhund, M.D.
Chief of Medical Oncology
Huntington Hospital
Huntington, N.Y., May 9, 2007

5) To the Editor:

America has the best medical care in the world. It is the most advanced and expensive. The first two qualifications are debatable, but the third is difficult to refute.

The great expense is complicated by the high cost of drugs and procedures of dubious benefit.

The likelihood of being prescribed drugs of dubious benefit is obviously increased by kickbacks to doctors. The kickbacks may be legal, but should they really be allowed? The cost of medicine is increased by this practice, and the quality is sure to suffer.

Alex Floyd
Lexington, Ky., May 9, 2007

6) To the Editor:

“Doctors Reaping Millions for Use of Anemia Drugs” (front page, May 9) was disturbing. I found it equally disturbing that the continuation of the article was in Business Day. In the past two decades, I have observed that news of important medical advances increasingly appears in, or is continued in, the business section.

This practice advances the thinking that health care is primarily a business in which providers reap riches, rather than a humane social endeavor in which providers earn their living.

Ira D. Feirstein, M.D.
New York, May 9, 2007

Saturday, May 12, 2007

Physician Patient Relationship - Patient-Physician Productivity Triple Play

Medfusion. Inc, EClinicalworks. Inc , and Primetime Software, Inc

In yesterday’s blog, I described how patients, given the opportunity to become emotionally and intellectually engaged in their own care through interactive online videos, improved the productivity, satisfaction, safety, and financial returns for all parties – the patient, the physician, and the hospital.

Today, I shall tell how various arrangements between three innovative information technology organizations – Medfusion Inc Eclinicalworks, Inc and Primetime Software, Inc – further advance and enhance these factors.

• Medfusion, Inc is a Raleigh, North Carolina company that has pioneered development of physician Web sites that offer such patient-friendly services as office location hours, physician credential, prescription refills scheduling an appointment, and patient education information. These self-service capabilities increase patient productivity by offering information without going through telephone menus, and physician productivity, by speeding workflow through reducing phone calls, allowing pre-registration and appointment scheduling, delivering lab results, prescription renewals, online, and reminders about annual appointments and preventive tests.
• Eclinical works is a Massachusetts-based EMR/PM (electronic medical record/practice management) company that offers medical practice software to over 10,000 practice physicians in over 50 states at a price of about $10,000 per physician, far below the industry norm. The Eclinicalworks EMR is easy for physicians in small practices to use, learn, and install than more expensive and cumbersome systems. Furthermore, users can customize the EMR and practice management systems for their use by working out the bugs in a transparent web site,
• Primetime Software’s product is the Instant Medical History, which explains its offering this way. “Instant Medical History interviews patients to begin gathering the subjective history prior to the encounter. Branching logic enables patients to progress quickly through adjustable questionnaires from an extensive medical knowledgebase. Sophisticated technology enables this information to transfer to EMRs. Physician productivity increases because as much as sixty percent of the medical data necessary to complete the visit note can be provided by patients and automatically documented in medical terminology through the Internet, in exam rooms, or in waiting areas before the encounter.”

Common Features

Medfusion, Eclinicalworks and the instant medical history have several things in common, they,
• enhance productivity in office practices, achieving gains of up to 60% to 80% in the typical primary care practice;
• reduce expense of data entry, by converting from paper to electronic charts, saving time in finding previous charts, saving space, and, in some cases, replacing personnel.
• make it feasible to structure and standardize the information exchange between patients and doctors, and to close the gaps between the subjective and objective, the evidence-based and non-evidence based, the quality and non-quality related, and the Science and the Art.
• represent the convergence and evolution of multiple IT technologies into one flexible and workable whole.
• demonstrate that IT systems, working together can engage the attention of both patients and physicians and serve as a humanizing influence by freeing up more face-to-face time between patients and doctors.
• Allow patients to leave the office visit with a complete record of the medical history, the physician findings, the treatment plan, and in the process, reduce future misunderstandings and disagreements that might end in malpractice actions.
• are all described or mentioned in my book Innovation-Driven Care: 34 Key Concepts for Transformation and are backed by case studies by those who developed these systems.

When Push Cms to Shove

When push comes to shove, these over-lapping and inter-mapping technologies are more about productivity than humanity, financés than nuances, and documentation than doctoring. They are more about power coding and data loading and restructuring and standardizing a longstanding cultural relationship. They may serve, directly and indirectly, as measures of performance, outcomes, and that elusive still intangible thing called quality.

But they don’t and can’t separate good doctors from bad doctors or more than superficially define the human dimensions of the patient-doctor relationship. Nor can they measure clinical judgment, depth of a physician’s cognitive thinking abilities, extent of patient compliance, final outcomes of a patient’s illness, or doctor and patient individualism and choice of courses of action. Human intelligence remains beyond artificial intelligence, virtually always, at least for now.

Friday, May 11, 2007

Consumer-Driven Care - “Engaged Patients" as a Catalyst for Change

When Patents Are Emotionally and Intellectually Engaged in Their Care Everyone Benefits and the Right Things Happen

A new idea, “engaged patients,” based on the proposition that patients emotionally and intellectually engaged in their care are worth the return on investment in educating them, is bursting upon the practice scene. In other words, “engaged patients” are intrinsically valuable because they bring about quantifiable financial returns.

“Engaged patients” propel consumer-driven care. Becoming engaged in their care is why patients visit websites like the,, and Engagement is why the patient education video industry is so robust. Furthermore, go to and you can view educational videos on almost any surgical procedure or disease. YouTube and educational videos are part of a larger phenomenon – a visual educational culture Visual education, often computer-driven, is faster to absorb, easier to understand, and doesn’t require verbal literacy.

Michelle Sobel, Chief Creative Officer for Emmi Solutions, Inc, a Chicago-based company that produces interactive patient education videos prior to surgical procedures, explains why videos expressed in plain language with a voice-over, are so powerful,

“The engaged patient is more than an informed patient. The engaged patient is activated. She understands information critical to her health, communicates effectively and confidently with her clinical team, complies with instructions related to here treatment, and is positively transformed by her experience with care.”

As patient engagement increases, so do top-line and bottom-line payoffs, to wit.

• Patient Loyalty -- Engaged patients who understand what’s at stake through patient education are loyal. A Georgetown Consulting study has demonstrated informed patients are loyal. Hospitals and doctors who rank in the top quartile on loyalty measures have 80% higher earnings than hospitals and doctors in the lower quartile, (1) For hospitals, engagement means greater market share, for doctors, engagement doctors higher patient retention and more referrals.

• Operational efficiencies - Engaged patients able to tell their whole story, even to a computer, create efficiencies. Dr. John Bachman, professor of primary care at Mayo in Rochester, has written computer interviewing saves 4- 8 minutes per patient, creates a record justifying higher codes, and generates claims less likely to be rejected.(2) Engaged patients follow directions. Cancellations of procedures when patient don’t comply with pre-op instructions cost $2188 -- the average cost of a cancelled procedure .(3)

• Patient Safety – Engaged patients, alerted to possible problems during hospitalization or after surgical procedures, are three times more likely to recognize complications, such as hospital-acquired infections, which cost $54,000 more than in patients who such infections than those who did not. (4)

• Risk Reduction – Most nuisance lawsuit result from misunderstandings, not negligence. These misunderstanding may be a failure to understand informed consent – 44% of patients don’t know the exact nature of the operation they’re undergoing; 60-70% don’t read the informed consent form; and claims in which misunderstood informed consent is an issue have average awards as much as $ 1 million. (5,6)


1. Gallup Consulting Study. Hospital Network: Employment Engagement, Patient Loyalty, and Leadership Development,, accessed March 2007.
2. Bachman, J, The Patient-Computer Interview, Mayo Clinic Proceedings, volume 78, pages 67-78, 2004.
3. Paul J. St. Jacques MD and Michael S. Higgins MD, MPH, Beyond Cancellations: Decreased Day of Previous Surgery Delays from a Dedicated Preoperative Clinic may Provide Cost Savings, Journal of Clinical Anesthesia, Volume 16, Issue 6 , September 2004.
4. Connolly, C. “Data Shows Scourge of Hospital Infections,” Washington Post, July 13, 2005.
5. What Did the Doctor Say?” Improving Health Literacy to Protect Patient Safety - A Joint Commission Whitepaper, February, 2007.
6. American Society of Closed Claims Project,, Accessed, April 27, 2007.