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.

People often ask if my kids are pursuing a career in medicine.  As it turns out, neither of my sons is going into anything even remotely related.  They’ve never really had the inclination, and I’m certainly not the type to push them into anything.  But when someone learns that my boys aren’t following in my footsteps, the follow up statement is often something along the lines of “I hear a lot of doctors are pretty unhappy with how things are going, and say they wouldn’t do it again. I guess it’s not surprising you would discourage your children from being a physician.”

That’s when I get defensive.  I actually love what I do!  If anyone has an interest in medicine, I would absolutely encourage them to pursue it.  After a number of these conversations, I started to wonder if I was crazy.  But now there is data to suggest I’m not alone.  A recent survey, the Gallup-Healthways Well-Being Index, shows that physicians rank highest or all occupations in terms of overall well-being.  (It’s like we’re the Denmark of occupations.)  The findings are based on over 170,000 interviews in 2012 with working Americans.  Physicians had the highest overall well-being index (78.0 on a scale of 100), followed by teachers at 73.5.  The survey includes 55 items measuring respondents’ physical, emotional, and fiscal well being.  Physicians scored highest (95%) in their belief that they “use their strengths to do what they do best every day” (followed by nurses at 92.7%), and near the top in being treated by their supervisors as a partner.  Physicians also scored at or near the top in measures of physical health, such as exercise, healthy food consumption, obesity.

This is not to deny that physicians are under a great deal of stress as we move through as rapidly changing healthcare environment.  Moreover, dissatisfaction appears to be particularly high in certain specialties, where changes in work patterns and reimbursement may be leading to lower pay and more difficult working conditions.  But overall, the evidence is that for the large majority of us, we still find that being a physician remains a rewarding way to fulfill our goals of making a difference in people’s lives.

I’m not disappointed that my kids are following different paths – I’m thrilled they have passions and they are pursuing them.  But I’m certainly not sorry with the path I’ve chosen, and I’d gladly do it again.

If medicine is a team sport, then integrity is the force that holds the team together.  In our statement of core values, integrity is characterized as “We build confidence and trust in all interactions.”  Integrity is often defined in terms of trust or honesty.  But it is really much more.  The word derives from the Latin root integer, meaning whole, or complete.  Integrity embodies the concept of consistency, the parts being in harmony with the whole: for example, consistency between words and actions.  In that sense, the link to honesty is clear, and is exemplified in the associated behaviors “I follow through on commitments,” and “I give and receive feedback honestly.”

But how does this notion of integrity as honesty explain “I listen to others to gain understanding,” or “I am committed to service excellence”?  This follows from a more expansive view of consistency, not only between words and actions, but between our actions and our inner principles, beliefs, and values.  Integrity is the pillar that supports our other values of purpose, collaboration, health, and innovation.  If we act with integrity, then what we do is motivated by our devotion to these other values, by our vision of the children in Wisconsin being the healthiest in the nation.

We cannot collaborate if we do not listen for understanding, if we do not assume good intent.  When we fail to assume good intent, then our action is not consistent with our values – we lack integrity.

A key behavior is “I treat others with dignity, compassion, and respect.”  Doing this, in turn, requires understanding those with whom we interact.  It means trying to put ourselves in their place, trying to see the world through their eyes.  This is particularly critical for our patients and families.  Acting with integrity requires empathy.  For a compelling look at approaching others with empathy in a health care setting, see this Cleveland Clinic video.

Integrity doesn’t just apply to us as individuals.  Our organization must also have integrity.  Patrick Lencioni, in his book The Advantage: Why Organizational Health Trumps Everything Else, states “An organization has integrity – is healthy – when it is whole, consistent, and complete, that is, when its management, operations, strategy, and culture fit together and make sense.”

For us as individuals, and collectively as an organization, integrity is absolutely critical.  Lack of integrity leads to failure – it is, literally, dis-integration.  “A house divided against itself cannot stand.”  But we can also look at this more positively.  When we have integrity, we are whole, we are healthy.  As Gandhi said: “Happiness is when what we think, what we say, and what we do are in harmony.”

For some time now, those interested in promoting safety in healthcare (such as our recent visitors from the Solutions for Patient Safety collaborative) have recognized that creating a high reliability environment and a culture of safety require a focus on the systems within which people operate, rather than on the individuals themselves.  Checklists, hard stop alerts, pre-filled syringes, all are examples of system design that “nudge” us (gently or firmly) away from things that might harm patients.

But when it comes to the effectiveness domain of quality, we still tend to focus on individual solutions – e.g., publishing systematic reviews or clinical guidelines, education – in the hope that providers will do the right thing. In reality, though, translating research into practice tends to be slow, sometimes painfully so.  Some recent publications shed some light on some of the barriers.  Pediatrician and New York Times columnist Pauline Chen wrote about barriers to clinicians acting on comparative effectiveness research results.  Citing a study in Health Affairs, she notes several factors that impede the ability of such studies to change practice: financial incentives that promote the status quo; limited applicability of study results to real world populations; ambiguity of study results (e.g., conflicting studies, subgroup differences); cognitive biases (e.g., the belief that more care or more expensive care equals better care); and limited use of decision support tools.

Changes in the health care payment environment may alter the financial incentives, and ongoing efforts to improve the design and conduct of comparative effectiveness research, such as those sponsored by the Patient Centered Outcomes Research Institute, will address the second two points.  Another recent article in Health Affairs sheds some light on the issue of cognitive biases.  Drawing on experience with behavioral economics, the authors discuss the two cognitive systems that affect behavior – the automatic and the reflective.  While the latter is driven by rational thought, the former is driven by heuristics, mental short-cuts that allow us to react rapidly to an onslaught of multiple, simultaneous inputs.  While they often serve us well and keep our brains from being overwhelmed, these heuristics are subject to a variety of biases and errors.  One example is “availability bias,” where things we have encountered most recently assume greater importance than they warrant based on actual probability.  The point of the article is that, if we hope to change clinical practice behavior, we cannot rely strictly on education – which utilizes the reflective system of processing – and instead use approaches that acknowledge and account for the biases inherent in the automatic thought processing we all use in our day-to-day practice.  For instance, behavior is often driven by perceived norms; we want to do what others in a similar situation would do. (“I believe most people would get a CT in a patient with a new onset seizure.”) The problem is, we don’t always know what those norms really are. (How often are CT’s actually done in such patients?)  If we knew what the norms are, we might be more inclined to change what we do to conform.  Another example is how our perception is altered by the messenger.  They cite a study where 82% of physicians said they trusted a guideline from their professional organization, while only 6% supported the same guideline said to come from an insurer.

One particularly important behavioral promoter of change is making the desired activity the default.  Enrollment in retirement plans and organ donation are both dramatically higher when someone has to opt out rather than opt in.  Similarly, generic prescribing is higher when that is the default.  This is a system change that can be used to drive evidence-based practice.  So is decision support, the fifth barrier to translating research into practice.  Building the evidence into the same tools we use for documenting and ordering is an important way to promote the use of that evidence.  Taking a systems approach will help as we attempt to improve quality in all of its domains, including effectiveness and efficiency as well as safety.

I’ve never been one of those people who really bought into the “baseball is a metaphor for life” thing.  But the longer days, melting snow, and opening day have got me thinking about one aspect of baseball that does resonate: teamwork.  While individual accomplishments are recognized, everyone on the winning team gets a World Series ring, even the guy with the lowest batting average, or the third left-hand reliever on the list.

As a team sport, even baseball pales in comparison to medicine, especially academic medicine.  Nothing we do can be done by one individual acting alone.  This is why one of our core values is Collaboration: “We work together to care for children and families.”  To be a team means more than just a group of people working in the same area.  Among the important things that transform a group into a team are common purpose, mutual respect, and collective responsibility.  All the members of the team are working toward the same goal – the health of a child, meeting the needs of a family, understanding a disease.  Sometimes it means putting off one’s own goals, at least temporarily, like a sacrifice bunt to advance another team member into scoring position.  It means each team member doing what she or he does best to lead to the shared outcome, regardless of the “credit” that may be given.  In turn, each team member respects the unique contribution of the others.  On a functioning team, diversity (of skill, talent, background, perspective) is a core strength.  An all-star team composed entirely of pitchers will never win.  In the end, all the team members share in the credit for success, or the responsibility for failure.  Members of teams don’t hog the limelight and they don’t point fingers.

Because we work in such a complex environment, we recognize the many teams each of us is on.  It might be the group of care providers in the clinic or OR.  It might be the individuals working on a research project.  The leadership team of a service line.  The members of a committee.  Leaders from our various campus partners like MCW, CHW, CSG.  The partnership between a family and a provider.  The list is nearly endless.  But all of these are teams, and all have in common those key features of collaboration: common purpose, mutual respect, collective responsibility.

So while I have always been terrible at baseball (I was actually held back in Little League!), I am grateful for the spirit of teamwork and collaboration I have found in academic pediatric medicine, and in particular here at Children’s Hospital of Wisconsin and Medical College of Wisconsin.

The tone of the debate over healthcare reform in Congress was predictably partisan.  But the tone of the public discourse over healthcare costs is taking a different, more visceral, and frankly darker tone.  If you haven’t yet read the recent cover story called “Bitter Pill Why Medical Bills Are Killing Us,”, I urge you to do so.  (If, like me, you get most of your news from The Daily Show with Jon Stewart, you can watch the interview with the author, Steven Brill.)  It’s not so much because of its original insights (you probably already realized a lot of what is reported), or because it is so factually accurate (a little more on that below).  But the article is a stark reflection of how the majority of Americans view the absence of value in our healthcare system.

The 38-page article documents the stories of six people’s medical bills, the associated sticker shock, and the apparent arbitrariness and irrationality of charges and payments for medical supplies and services.  As I read the article I found myself getting a bit defensive.  Don’t people understand about the need to subsidize care for uninsured or underinsured patients?  How can they complain about salaries in the healthcare field – have they seen what people on Wall Street get paid?  And, as documented by others (e.g., Joanne Conroy in the Huffington Post), some of the facts are a bit distorted.

But in broad strokes, this article makes a case that many others have made before – healthcare in this country is very expensive, and while some of it is because we utilize a lot of it, much of the reason is that hospitals and medications and tests and yes, physicians, cost a lot.  A recent blog in the Washington Post called health care prices “ludicrous.”  And as healthcare consumes an increasing and unsustainable portion of our economy, and individuals find they can’t afford the care they need, there is going to be a backlash.  We can rationalize and explain, but more and more people are just fed up.  This is why we all need to read and pay attention to this article; what I sensed was anger, more than anything else.  I’ve heard that anger in some of our families who complain about their bills.  I’ve heard it in conversations at parties.  I’ve heard it from business leaders talking about their healthcare costs.  I’ve heard it among commentators both serious and comic (Jon Stewart was in rare form about this).  To those who wonder if all the talk about change in the healthcare system is overwrought, and think it will all blow over in a few years like HMOs did in the 1990s, I would say this feels very different.  If we want to play a meaningful role or even drive the reforms, we need to acknowledge the passion, the frustration, the rage, before it is turned on us.

“Value” has become the new buzzword in healthcare, and for good reason.  But for a long time, those of us in the caring professions have emphasized our values, which really define us as professionals.

Children’s Hospital of Wisconsin has elaborated a set of core values.  Arising from our culture enhancement work, this represents a simple statement of who we are, why we do what we do, and how we act in our work.  It’s been really gratifying to see how our attention to our culture and our values is improving our ability to carry out our missions and to advance the health of children.

Our first value is Purpose: “We act in service of children and families.” This is about our passion and commitment to our missions – providing the best and safest care, advancing and disseminating knowledge, and advocating for those we serve.  Anyone who spends more than 5 minutes with our physicians and other providers can see that strong sense of purpose.  I see it in the physicians who put in endless hours making our EHR work, in the APPs who stay way beyond the end of their day (or evening) to avoid having to hand off the care of a child to another provider, in the speakers at our Best Practices conference who spent their weekend passionately sharing their expertise with over 370 community providers.

It’s also about recognizing that our patients and families are at the center of all of our activities, and our accountability to them for providing care that is effective, safe, efficient, timely, and equitable.   Finally, it is about our accountability to each other and to the organization, including our responsibility for being stewards of our resources so that we and those who follow us will be able to serve our patients, families, and community for a long time to come.

Having had the privilege of working in several other children’s hospitals, I think our commitment and passion really distinguish us – this is one of the most purpose-driven organizations I’ve ever seen.  And there is real value in that.

That was the old Midwest Airlines motto.  I’ve been traveling a bit lately, which often makes me reflect on the parallels that have been drawn between the aviation industry and health care, and the notion that we in medicine can learn from what has been done to maximize safety in commercial flying.

This time, I was also pondering what we might learn from the service and efficiency aspects of aviation and the hospitality industry.  Yes, airlines hardly have a reputation for customer service, but then again, neither does health care.  Consider the following:

– Self-service check in.  I’ve seen airport-style kiosks used successfully for families to register at another children’s hospital with a very busy orthopedic clinic.  Families were highly satisfied, the process was timely, and fewer registration personnel were needed.  How could we make the check in process more efficient and user friendly?

-Text reminders.  On my last flight, I got text reminders of flight status and gate locations.  Could we use text messaging or other means to remind families of appointments, notify of delays, prompt for feedback, etc.?  We also need to think about using available technology to communicate more broadly with families – e.g., test results, questions, etc.  MyChart will be a step in this direction, but how can we make it as accessible as possible?

– Scheduling.  Twenty years ago the only way to book a flight was through a travel agent.  Airline scheduling was supposedly so complicated only a professional could do it.  When was the last time you spoke with a human to book a flight?  True, clinic scheduling algorithms can get complicated, but the vast majority could be computerized and automated to allow families to make appointments at their convenience.

-Customer loyalty programs.  We often (and sometimes pejoratively) refer to patients who have a lot of contact with us as “frequent flyers”.  Frequent flyers on airlines get certain perks.  What could we do to encourage or reward our frequent flyers?  The same is true of those who refer patients to us.  A complaint I’ve heard from our CMG physicians is that they get no tangible benefit from being part of our system in terms of facilitating patient referrals.  Perhaps we can explore expedited access or other incentives for our most loyal customers?

-Training.  People who work in service industries have to be skilled at what they do – pilots need to be highly competent at flying, maintenance workers have to know how to keep the machinery operating, chefs better be able to create delicious meals.  But they also receive specific training on how to provide excellent service. I’m not suggesting we sacrifice the effectiveness domain of quality for family-centeredness.  But the best care does both. What do we do to make sure that everyone who has contact with patients and families is not only skilled at her or his job, but can also make the experience a satisfying one?

Being able to provide not only the most effective and safest care, but also care that is efficient, timely, and patient- and family-centered is important for several reasons.  First, for a lot of our services, families have other options for providers that, if we are honest, we can’t always differentiate ourselves from on the basis of effectiveness or safety.  We will need to compete on other aspects – cost and service – to attract them here.  Second, even in those instances where we provide care that is clearly more effective, poor service can create enough of a barrier that families may seek care elsewhere.  Finally, if quality care is defined as the kind of care you’d want for yourself if you needed it, think about the times you’ve been a patient or parent of one.  Let’s face it – service matters!

OK, time for me to go through security.  At least we don’t have the TSA in our lobby.