Starting With Curious

Not too long ago, I was recommending an ultrasound for a child with suspected appendicitis, when the father asked me what it was going to cost.  I no longer find this terribly surprising, as it seems to occur more and more (albeit still pretty infrequently).  But as usual, I had no idea.  Not only because in general I’m unaware of what our standard charge is for most procedures and treatments.  But also because even if I did, it wouldn’t answer his question – I’d still have no idea what it was going to cost him.  To answer that, I’d need to know what his insurance is, what our negotiated rates are with that insurer, his deductible and co-pay, etc.  I couldn’t answer his question even if I wanted to.  So I basically pleaded ignorance.

There has been a lot of publicity lately about the disconnect between the so-called “chargemaster” price and what insurers and individuals actually pay, as well as the huge variation in both standard charges and actual prices between hospitals even in the same city.   This has generated call calls for more transparency, in response to which providers have typically done what I did, citing the complexity of answering that for a given individual.  But that is increasingly unacceptable to our families, who have to pay increasing out-of-pocket costs.  A few things on the horizon are making it harder for us hide behind that excuse.  A hospital in Miami announced recently that it would publish not only its sticker price, but also its negotiated rates with various payers.  Insurers are also making it easier for individuals to look on line to see what it will actually cost them to have various procedures from different providers.  In our own region, United Healthcare has billboards advertising their health cost calculator, and the GE Health Choice plan (their AACN product) has a similar Web site.

I’m not a huge fan of rank consumerism in health care.  But we have to start being prepared to think about how we’re going to answer that question “What’s this gonna cost?”

Some days we feel like we can conquer the world and make it a better place; others, we’re lucky to get out of bed and take care of our basic bodily needs.  To get through life, we need aspirations – lofty things to drive toward – while at the same time having a sense of reality so we aren’t crushed every time we don’t quite get all the way there.

Our organization’s vision is lofty: that the children in Wisconsin will be the healthiest in the nation.  But our strategies for getting there are pragmatic and measured.  We can’t get there overnight, and we can’t get there alone.  But that doesn’t stop us from trying.

Similarly, our organizational values are a mixture of lofty and more mundane.  Patrick Lencioni, in The Advantage: Why Organizational Health Trumps Everything Else, talks about three types of organizational values.  Core values are those that describe the behavioral traits actually inherent in an organization.  Our examples might include Purpose and Collaboration.  I believe that we are truly mission-oriented, and that virtually all the people who work here share that sense of purpose and work together to achieve it.  Permission-to-play values are the minimum behavioral standards required to be a part of the organization.  Those who don’t share these values should not be brought into the organization, or may need to leave.  Integrity would fall into this category.  Then there are aspirational values, the characteristics an organization wants to have and believes it needs, even if it isn’t quite there yet.  For us, that value is Health, characterized as “We Are At Our Best.”

This one has generated a lot of discussion.  Some of the feedback has been that this is not a value we consistently live up to and embrace.  If we look at the guiding behaviors listed under this value, one can certainly argue that is true.  How many of us can say we have harmony in our work and personal life, or that we lead a healthy lifestyle?   Most of us probably wish we could do better.  Does our organization really provide the most support possible for that kind of health?  While it does a lot to promote the health of our people, honestly, it could also do better.

The fact that Health is more of an aspiration rather than a core value does not diminish its importance, nor does it argue for taking it off the list.  Indeed, Lencioni suggests every organization should have at least one aspirational value, because by definition they need to be purposefully cultivated.

This value is one that is especially personally important to me.  For one thing, I am serious about my own health.   There is a growing body of evidence that a healthy workplace with a healthy workforce is more effective.  Finally, if we think about the shadow we cast for patient and families, we need to model our own health if we hope to promote theirs.

So what would Children’s look like if health moved from being an aspiration to being a core value?   Perhaps we would promote physical activity by making stairs more visible and accessible, organizing more group exercise opportunities like today’s walk around campus, or incentivizing people to bicycle to work.  (FYI, it’s national Bike to Work Week.)  We would promote rest and rejuvenation – which have been shown to increase effectiveness and productivity – through breaks and vacations (real ones, no email).  We would increase our efforts at sustainability, since a healthy environment is critical for healthy people.

Sure, this sounds a little pie-in-the-sky.  That’s what it means to be aspirational.  We’ve laid out a strategy to work toward the healthiest children in the nation here in Wisconsin.  What would it take to have the healthiest workforce in the nation here at Children’s?  I’ve shared a few thoughts – what are yours?

As adherents to evidence-based practice, we are used to paradigms changing.  From leeches to surgery for low back pain, the medical literature is filled with things that seemed sensible and theoretically sound, but that on rigorous study turned out not to be correct.  This is why providers need to keep up on the literature.  But there are caveats.  First, we must balance an openness to changing practice when the evidence supports or even demands doing so, with a healthy skepticism and critical evaluation of the evidence to be sure we draw the right conclusions from what are often imperfect studies.  We can all think of examples of papers that at first blush appeared to be true landmarks, only to have substantial flaws revealed, or be contradicted by subsequent data.  In addition, data are merely facts; to become information, data must be interpreted, and those interpretations can be subjective.  Finally, most progress in health care is at best incremental.  It is rare that any one study singlehandedly changes what we do.

A recent paper in the New England Journal of Medicine has been hailed by at least some commentators as one of those rare solo game changers.  In my mind, though, I believe its data are being widely misinterpreted.  I am referring to the study of the Oregon Medicaid Experiment.  Briefly, in 2008, Oregon was expanding its Medicaid coverage for childless adults.  However, there was less funding available than originally intended, so they allocated the coverage to the applicants using a lottery.  This was the holy grail of health services research – a randomized controlled trial (albeit a naturally occurring one) of insurance vs. no insurance.  Such rigorous study designs almost never occur in the area of health policy.  This was a rare opportunity to answer the question of how insurance coverage affects utilization of services and, most importantly, health, without the confounding and other flaws that occur when, for example, comparing different states with different levels of coverage.

The authors found that when comparing those who were randomly selected to get coverage with those who remained uninsured, those with Medicaid used more health services.  This is perhaps not terribly surprising.  But after two years of follow up, while the newly insured had lower rates of depression and less financial stress, there were no differences in several measures of health status including prevalence of diabetes and hypertension, cholesterol levels, or hemoglobin A1c levels in diabetics.  These results are consistent with one of the only other RCTs of insurance coverage, the RAND study of the 1970s.  All subjects in that study had coverage, but with varying levels of cost sharing.  Better coverage led to more utilization, but without any clear overall difference in health status.

Some commentators, particularly those opposed to the Medicaid expansion included in the Affordable Care Act, have touted these studies as proving that comprehensive health insurance in general, and Medicaid in particular, do not work.  Many others have pointed out specific flaws with the study that might limit this conclusion.  But I think there are two additional major errors of interpretation here that we might heed.

What if the proper conclusion is not that health insurance doesn’t improve health, but that heath care does not improve health?  After all, in both studies there were more doctors visits, prescriptions, etc., but no better health status.  That might be a leap, but we do know that not all medical interventions (tests and treatments) are beneficial.  Moreover, medical care is but one determinant, and a minor one at that, of a person’s health.  Finding that having insurance by itself does not decrease the rate of diabetes isn’t terribly unexpected.  But one potential lesson to draw from the Oregon study – and, I believe, and important one – is that health insurance is being spent on the wrong things.  If health coverage, and health care, are to have a positive impact – if they are to have value – what we do may need to be more focused on prevention, on promoting adherence on the part of both patients and providers to proven management strategies, and on care coordination.

The second thing to keep in mind is that health is not merely the absence of disease.  The World Health Organization, among others (including the American Academy of Pediatrics) support a more holistic view of health: a positive state of physical, mental, and social well-being.  Yes, the lucky people who received Oregon Medicaid had similar rates of several measures of physical health.  But they had lower rates of depression and of economic stress.  If we had some composite measure of the comprehensive meaning of health, insurance would undoubtedly have been shown to improve it.

Surely at least a few of those who pay for health care will look at this study and draw a similar conclusion.  If they pursue evidence-based policy making, they will develop ways to move models of care and payment in that direction.  Fee-for-service may become the bloodletting of the health payment world.