Skipped a Thrive post? Here’s what you missed…

A report published in the behavioral nutrition research journal Appetite found kids who were served fruit in a “visually appealing” way ate twice as much as those who were served fruit in a more traditional setting. Thrive spoke with Suzanne Rostler, MS, RD, LDN, of Children’s Hospital Boston’s Optimal Weight for Life (OWL) Program, who says moms and dads of picky eaters should try to replicate the study’s findings at home and offered tips.

Lois K. Lee, MD, MPH of Children’s Hospital Boston’s Emergency Department Injury Prevention Program will be featured on ABC’s Nightly News later this week as part of a segment on the dangers of ‘button batteries.’ In an effort to better inform our readers, Lee wrote a Thrive post specifically detailing the dangers these tiny batteries pose to kids, and offers tips for parents on how to help keep their children safe from accidentally ingesting of one.

Claire McCarthy, MD, is a primary care physician and the medical director of Children’s Hospital Boston’s Martha Eliot Health Center, this week on Thrive she addressed the concept of parental responsibility and proposed laws regulating fast food marketed at kids.

Current data shows that close to 7 percent of all kids in the United States have food allergies, well over double the number reported a decade ago. Dale Umetsu, MD, PhD, of Children’s Hospital Boston’s Allergy Program and Professor of Pediatrics at Harvard Medical School weighed in on the increase, its possible causes and tips for parents on better educating themselves about food allergies.

Thrive covered a sister blog- Healthy Family Fun website, which is part of a Children’s Hospital Boston campaign to provide families with information on how everyone can eat better, get more exercise and do it all on a budget.

Prom season is almost upon us, and data shows injuries sustained by teenagers due to alcohol increase dramatically around this time of year. In an effort to keep kids safe during this potentially dangerous time, Children’s Hospital Boston’s Center for Adolescent Substance Abuse Research(CeASAR) launched teen-safe.org, a website designed to educate and support parents. Thrive linked to video advice provided by CeASAR’s director, John Knight, MD, who answered parents’ questions about teen drinking, its dangers and their role in preventing it are answered.

In this installment of her monthly injury prevention column Lois Lee, MD, MPH of Children’s Emergency Department Injury Prevention Program, discusses the dangers of leaving windows open in homes with small children.

Every generation has its werewolves. Today, of course, there’s the Twilight phenomenon, which has given us Jacob Black and his brotherly pack of lycanthropes. But, as you’ll see in the news clip below from KENS5 in San Antonio, there’s a group of Texas teens who are taking the obsession with wolfmen one step further, transforming themselves into real-life werewolves – complete with fake tails and teeth.

In the fight against underage drinking kids need parents not pals. So says CeASAR director John Knight in our continuing coverage of how to keep your teen safe this prom/graduation season.

By BOB WACHTER You probably saw yesterday’s hospitalist piece in the New York Times, arguably the best lay article on the movement to date. It hit all the right notes, and did so with uncommon grace and fairness. The piece,…

By Matthew Holt While Yahoo!’s most recent notable public moment has been its CEO telling some (other) ex-pat British blogger to “Fuck Off”, this British ex-pat blogger has been waiting for a long time for Yahoo! to re-emerge in health…

The current political debate in Massachusetts about rising health care costs and insurance company premiums is a striking case of denial. The most thorough evaluation of the underlying causes of inflation was presented by the state’s Attorney General this past winter. She found that the long-standing and current disparities in pricing in the Massachusetts market contribute mightily to the growth in health care costs and insurance premiums in the state. As noted in this Boston Globe story, her staff put in thousands of hours studying the issue:

The report, the result of legislation that directed Coakley to investigate why medical costs are rising so rapidly, is based on tens of thousands of contracts and other documents subpoenaed from insurers and providers and depositions from more than 30 key health care executives.

In light of the AG’s conclusions, you would think that policymakers would be spending their time to design measures to reduce the disparities in reimbursement rates. But, as noted below, the policies being ordered by the Administration and the actions being taken by the insurers tend to do just the opposite.

In this kind of situation, where does one find the leadership to deal with these problems? The insurers have been willing or forced participants in creating the current situation. Can we expect them to change their stripes and take firm action against dominant providers?

During the hearings on these matters held by the state’s Division of Health Care Finance, the witness from Blue Cross Blue Shield said that even his company, the largest in the state, did not have the market power to offset that of the dominant provider group and individual hospitals with special geographical advantages. That such was the case with smaller insurers was demonstrated years ago when Partners Health Care forced Tufts Health Plan to bend, but whether the same would apply to the dominant insurer remains an untested proposition.

We certainly cannot expect those providers who have benefited from higher rates to voluntarily accept cuts that would take them to the statewide average in a timely fashion. For one thing, their cost structures have been built on the expectation of greater revenues.

I believe the leadership has to come from the business community, those firms whose payments of insurance premiums — or whose self-insurance arrangements — validate the current reimbursement patterns. Their goal has to be to support market shifts to higher value providers. The business community needs to demand that the state government use its existing authority to expand upon the AG’s work and present a clear picture of the current situation.

The “moral outrage” that would support value-driven market shifts will not come until the state chooses to publish actual rates paid to hospitals for commonly used services, and until the state also publishes clinical outcome data in a clear and up-to-date manner. Once these numbers are seen, employers and individual subscribers will discover that they are paying way too much to certain providers for services than can be delivered just as well by lower priced providers.

Once this information is freely available, the market will respond, with employers demanding and offering tiered products that more people would find acceptable. Consumers would then turn to providers who offer greater value, just like they do in other service industries.

For reasons I do not understand, neither the Administration nor the insurers have endorsed this kind of transparency, much less implemented it. Instead of being honest brokers in a transition to a more value-based health care system, they remain in steadfast denial of the AG’s well researched and thoughtful conclusions.

Over the coming weeks, we should measure parties’ commitment to change by the degree to which they advocate and adopt the kind of transparency that exists in virtually every other segment of the economy. If they do not, we will have to assume that they are motivated instead by self-protection of their owned perceived political and economic interests.

A small study showed that kids with asthma who did art therapy felt less anxious about their condition that kids with asthma who didn’t encage in a creative, therapeutic outlet.  

Though there is a popular belief that getting several vaccinations in a short time could have negative consequences for babies— some people thin it could over stress the immune system, for example— the medical community has always denied the possibility. Researchers recently did a test to scientifically disprove the idea and found that receiving as many as 10 different shots — including flu and whooping cough — had no impact.

Children and teenagers living in the most-rural parts of the U.S. are equally as likely to die by gun violence as those in big cities, a new study shows. The rates on the type of death tend differ with each area (i.e. accident, suicide or homicide) but the overall numbers of children who loose their lives to guns are almost exactly the same regardless of an urban or rural surrounding.

The number of young people hurt by their walking aides— cruthes, wheelchairs or walkers— is on the rise. Research shows that the amount of kids hurt by their own walking aides rose 8 percent annually between 1991 and 2008, with more than 3,000 people aged 19 or younger to the emergency room for injuries related to walking aides in 2008.

Originally thought to be too young and lacking the cognitive comprehension to experience depression, a new study shows little ones as young as 3 could be diagnosed as depressed.

Michael Rich, MD, MPH is Children’s media expert. He is the director of Children’s Center on Media and Child Health. Take a look at his blog archiveor follow him on Twitter @CMCH_Boston.

Michael Rich, MD MPH

Last week he answered your questions on if feelings of control in video games can translate to real life feelings of frustration/helplessness. This week he addresses a parent’s question about peer role modeling and healthy media use.

Q: Much of the discussion on kids’ media use centers, appropriately, on parent involvement. I’m wondering, though, are there ways kids and teens can help each other use media and technology—from cell phones to the Internet—safely and wisely? Peer support seems like an important angle, given how much kids influence each other as they get older and how much less savvy (and less interested in media) adults are.
-Kids Can Do, in Suburban Chicago

A: Dear Kids Can Do,

Your question gets at something I firmly believe: that kids are experts on media. In fact, in a seminar I conducted at the Harvard School of Public Health, I asked a group of high school students (with whom I’d previously done media literacy work) to teach the entire critical media use component for exactly this reason. Having kids teach about media is a powerful idea partly because they are the true experts. In addition—and perhaps even more importantly—youth tend to listen to their peers and especially to slightly older kids (who they look up to and want to be like) far more than they will listen to their parents. 

So how can kids can help each other, and how can we as adults best prepare them for it? First of all, we know from research that the ways that media are used at home will shape how children understand media’s role in their lives. Not only are parents setting examples for their children at home, but older children are setting examples for younger siblings. For example, when an older brother turns on the TV to watch a specific show, and then turns it off when the show is over, he’s teaching his little sister that media is used for a specific purpose, rather than as something to passively consume.

But there are also more focused ways that kids and teens can teach each other to use media and technology safely and wisely. For example, if kids really enjoy YouTube, they can find videos that give a “behind the scenes” look at how ads are made and then post them to their Facebook profiles to get a conversation going with their friends. Here are two of our favorites: 

• How do they make that burger look so good?

• What does it take to make a regular person into a model? 

Another conversation starter for kids and teens is song lyrics. Even something as simple as asking friends “Have you really listened to the words to this song?” is a good way to talk about paying more attention to media content, since songs are often about topics like relationships, what people do for fun, and how they treat each other.

This approach recognizes that, sooner or later, these young people will be solely responsible for their behaviors, actions, and time management, and it helps them build their broader media literacy skills and self discipline. But this isn’t to say that adults are off the hook—even peer-to-peer support can benefit from adult assistance. Teens can offer adults an open-minded, innovative sense of how media can be used and adults can offer teens wisdom from life experience and the foresight to think about consequences. Taken together, these perspectives create a powerful foundation for the kind of critical media use that best serves youth.

Enjoy your media and use them wisely,
The Mediatrician®

—according to this report:

Guess what girls — don’t be envious of the most beautiful women in the world.

Look at Elin, look at Sandra Bullock, look at Halle, Britney,JLo, Reese, Julia Roberts, Jessica Simpson — they’ve ALL been cheated on!

But what I want to know is, do they cheat more often? I mean, would this song be so funny if it didn’t have a ring of truth? Just askin’.

New Breed of Specialist Steps In for Family Doctor.

DB linked to the article and noted:

Of course, even the Times cannot write a nuanced article about either primary care or hospital medicine. Since I have spent much time working in both fields, I can see the omissions and flaws in their articles.

If they must simplify this issue, then what happens in their other articles.

Who could have ever guessed that the United States of America would fall so far behind in education, childhood death statistics,  scientific research, manufacturing jobs, and even healthcare?  Yes, of course, we are still a wonderful strong country with incredible resources, but somewhere along the line the train seems to have jumped off the track just a little, or is that like being a little pregnant?  No one would ever would have conceived that a spark plug would be worth more than GMC stock, but that’s exactly what happened last year.   Or how about the fact that large investment banks responding to the mandate to increase home sales by spreading the risk internationally could have helped put this entire world on the verge of a national depression?

For years now I’ve written about the need to provide some type of safety valve for the uninsured, underinsured, and those struggling to make it from layoff at age 58 to Medicare at age 65.  Now we have it, and, not unlike the Kennedy Ketsenbaum bill, you know, that HIPAA bill that was just meant to provide health insurance portability, we have healthcare reform legislation.  The really challenging thing about this new bill is that it was primarily written by policy wonks, fifty percent of whom will not be working in Washington D.C. in a few years, and worse than that, it will be interpreted by policy wonk lifers who will be there long after we are all dead. 

So, the Healthcare Oil Spill has been addressed.  What will it mean?  What does it mean?  How will it impact all of us?  That remains to be seen.  The good news is that 30 million more people will finally have a safety net. The bad news is that there are still two wars going on that are draining our treasury.  There is still financial chaos among the countries lovingly referred to by the EU as the PIIGS (Portugal, Ireland, Italy, Greece, and Spain), and, along with this group,  spending in the United States  has been out of control for at least nine years.  

What will happen is any one’s guess.  How things will be interpreted is any one’s guess.  How the law will be enforced is every one’s guess, but in  a recent round table discussion at the Mid-State HFMA meeting, we heard four CFOs discuss the challenges that they currently face and will continue to face as life becomes even more complex.  After that session, I’m thinking that lots of mud pushed in the head of the well might just be the cure!  Goodness knows there was enough mud thrown around during this last election cycle.  Maybe we could redirect it back to the source?  I do know for sure that one thing is clear.  CHANGE is INEVITABLE, the train is back on the track, and it’s coming straight toward our physicians, hospitals, and nursing homes.

How do we cope with that change?  Make sure that every ounce of fat is cut from the system.  Take a look at the list below and contact SunStone Consulting for the next steps:

Charge Process (CDM)

Compliance

Documentation Accuracy Program

Inpatient Coding and Compliance

Outpatient Claim Analysis

Pharmacy Revenue Cycle

Pricing

RAC Assessment

Reimbursement & Financial Analysis

Revenue Cycle

Transfer MS-DRG Review

Workers’ Compensation Recovery

Employee Health Insurance Advocacy

You probably saw yesterday’s hospitalist piece in the New York Times, arguably the best lay article on the movement to date. It hit all the right notes, and did so with uncommon grace and fairness. The piece, written by the Times’ Jane Gross, profiled Dr. Subha Airan-Javia, a young hospitalist at the Hospital of the University of Pennsylvania. While Dr. Airan-Javia spends about half of her time in administrative, largely IT-related roles (like many of my faculty), the article (and an accompanying…(read more)

By Matthew Holt As we get closer to Health 2.0 Goes to Washington on June 7 (Monday) we’ll be ramping up coverage of all kinds of things, and one is a big chance for you all to get to know…

By ROGER COLLIER The Patient Protection and Affordable Care Act, signed into law by President Obama in March, is a significant step towards a more equitable health insurance system, potentially making coverage available to millions of the currently uninsured. Unfortunately,…

This large retrospective analysis of >84,000 patients hospitalized with COPD confirms the benefits of antibiotics; antibiotic treated patients had lower risks of mechanical ventilation, inpatient mortality, and COPD readmissions (although higher Cdiff readmission rates). This large analysis confirms guideline recommendations for antibiotic therapy in patients hospitalized with COPD exacerbations (abstract)

In this large trial, >2500 patients with carotid stenosis were randomized to either stenting or endarterectomy. There were no differences at 2.5 years in the rate of the primary outcome between the groups (composite of stroke, MI, or death), but at 4 years follow-up, the stent group had significantly higher rates of stroke/death (6% vs 5%). Carotid endarterectomy remains the procedure of choice for most patients requiring carotid revascularization (abstract)

Memorial Day Weekend is just days away and your plans most likely include outdoor activities From water-skiing to backyard barbeque, we’re into the high sun exposure season. The National Council for Skin Cancer Protection has designated this Friday, May28, as “Don’t Fry Day” to encourage Sun Safety Awareness.
A “Suntelligence” study released this week from the American Academy of Dermatology reveals that many of us may have false assumptions about  sun safety. This morning we discussed what the study revealed, and what we can do to keep ourselves and our families “sun safe” this summer on The Denver Channel.

First of all, let’s review the study that was conducted.
The study polled 7,000 people in an online survey asking true and false questions about sun safety to determine how many correct answers the average person got to some basic sun safety questions. Overall, the results were not encouraging – there was only one question that was answered correctly by more than half of the respondents. This means that many of us are not protecting ourselves as well as we could.

What are some of the facts that were most often misunderstood?
1. There are no Ultraviolet rays that are safe for skin. Both UVA and UVB rays can cause harm – and did you know that UVA rays can penetrate glass to affect you?
2. Getting a “base tan” will not protect you skin – you may not burn – but you still get the UV exposure which ages your skin and accelerates the risk of skin cancer
3. Tanning beds are not more safe than outdoor sunlight. In fact – tanning beds have been listed as a known carcinogen
4. Did you know that SPF 30 keeps out only 4% more UV rays than SPF15?

So what is the difference between UVA and UVB rays?

Physically, UVA rays are longer wavelengths than UVB. In terms of effects on our skin – UVA rays do not cause sunburn, but they do cause harm and are thought to be a key factor in aging of the skin and have also been linked to melanoma. These rays tend to decrease the ability of our skin to fight off skin cancer.
UVB rays are shorter, and are the ones that give us sunburn. These rays are associated with skin cancers such as basal cell, and again, play a role in the development of melanoma.

So let’s concentrate on sun protection and SPF ratings – is there more we should know when choosing a sunscreen?
A few additional hints will help you choose the best protection for your family
• Remember – there is no sunscreen that produces 100% protection. It is also important to remember that sunscreens absorb the rays, while sunblocks physically deflect the rays. In either case, putting it on 20 minutes before getting into the sun, and having frequent reapplications while out in the sun is very important. SPF ratings are for UVB protection and some brands do not have good UVA protection, which is the PPD rating – so be sure and check the label to find a product with both UVA and UVB protection.

What else can we do to protect ourselves?
It is advised to avoid being out in the sun between 10 a.m. and 2 p.m. to avoid the strongest sunlight of the day. Wearing a hat and protective clothing is very effective in limiting sun damage – and best of all stay in the shade. And, remember to protect your eyes with sunglasses that provide UVA/UVB protection! In addition, the CDC has put together a Sun Safety Toolkit for youth that is available on their website.
Finally, if you have a mole that is unusual or changing, be sure to get it evaluated by your health care provider.

If you would like more information, here are some sites you might want to try:

CDC Youth Sun Protection Toolkit

Sunscreen Ratings by Consumer Group-

National Skin Cancer Protection

Good Health!

Dr. Dianne

Every generation has its werewolves. Today, of course, there’s the Twilight phenomenon, which has given us Jacob Black and his brotherly pack of lycanthropes. If you’re my age, you grew up watching the incredibly hokey Teen Wolf and Teen Wolf Two movies, plus the slightly less hokey An American Werewolf in London. And if you’re a bit older, you likely went to the local Strand Theater to watch Lon Chaney and Claude Raines in The Wolf Man or Little House on the Prairie star Michael Landon in I Was a Teenage Werewolf.

But, as you’ll see in the news clip below from KENS5 in San Antonio, there’s a group of Texas teens who are taking the obsession with wolfmen one step further, transforming themselves into real-life werewolves – complete with fake tails and teeth.

So what do you think, moms and dads: Is this type of self-expression a good thing, or a sure sign that these kids need to spend less time under the full moon?

It was reported yesterday that a toddler in Lowell fell out of a second-story window and had to be rushed to Children’s Hospital Boston for emergency care. Falls from windows are very dangerous for toddlers and small children, and as the weather gets warmer the number cases involving kids tumbling through windows that are only screened in are expected to rise.

In this installment of her monthly injury prevention column Lois Lee, MD, MPH of Children’s Emergency Department Injury Prevention Program, discusses the dangers of leaving windows open in homes with small children.

Lois Lee, MD, MPH

As the hot weather approaches, there is yet another preventable injury that I know we will see in Boston this summer—a small child falling from a window or a deck.  Children can be severely injured and can even die from falling out of a window on a second story or higher.  They can break their bones, damage their internal organs or sustain severe bleeding in the brain.

Falls are the leading cause of injury for children 5 years and younger. When the weather gets hot, families need to open the window, especially in homes without air conditioning.  But window screens DO NOT keep children from falling out of the windows. The good news is—window falls ARE preventable.

Here are some safety tips from the Boston Health Commission’s, “Kid’s Can’t Fly” brochure.

1.  Lock all unopened windows and doors.

2.  Keep furniture or anything a child can climb on away from windows. 

3.  Open windows from the top, not the bottom.

4.  Install child safety window guards if you have children under 7 years-old in the home.

5.  Be sure children are always supervised.

Window guards are an important part of preventing window fall injuries. They are aluminum or steel bars that installed on the bottom half of a window.  They can withstand up to 150 pounds of pressure—so a child pushing their hardest against a window guard still won’t fall through if it is properly installed. When purchasing window guards, parents may want to keep in mind that operable window guards have an emergency release mechanism so the window can still be used to escape in the event of a fire. Fixed window guards can not be quickly removed in an emergency. 

Some areas have programs to provide window guards for those in need. In the city of Boston you can contact the Boston Public Health Commission, Injury Prevention Program at 617-534-5197 (injuryprevention@bphc.org).

Dear Scott,

I understand the Senate confirmation process in Washington, DC, and how the appointment of individuals gets hung up for a variety of political reasons. I don’t particularly like it, but I understand it.

But I don’t understand how with regard to the appointment of Don Berwick as head of CMS, the Medicare agency, this can be the case, as reported recently in the Boston Globe:

Senator Scott Brown, a Massachusetts Republican, has not decided how he will vote, a spokesman said.

That Don Berwick is an internationally renowned expert in health care delivery is not in doubt. That he is an honest, hard-working, and thoughtful person is also clear to the thousands of people in the health care professions with whom he has worked. That his primary focus has always been on reducing harm and medical errors is likewise the case. He is also interested in reducing costs in the health care delivery system when such costs represent waste and inefficiency.

Scott, the issue here is not whether the recently passed health care bill was right or wrong for the country. I respect your opinion on that matter. But that vote has been taken.

The issue here is whether you want someone who knows enough about the delivery of health care, whose passion is making that safer for patients, to be in charge of the agency that potentially has the largest single impact on that goal.

As a State Senator, you were always incredibly supportive of us at BID~Needham Hospital in our desire to offer safe and efficient health care to your constituents. Please know that Don Berwick and the people working with him at the Institute for Healthcare Improvement taught us how to do that.

Please don’t stand by as his appointment is delayed. Please talk to your colleagues and help Dr. Berwick be confirmed as head of CMS.

With warm personal regards,

Paul

As you have seen in examples below, BIDMC is engaged in adopting the Lean philosophy to enhance our effectiveness in taking care of patients. An underlying premise of Lean is a respectful work environment for our staff, valuing each person and empowering him/her to call out problems and participate in improving things.

This approach raises a question, though. What leadership characteristics are appropriate to support the approach that characterizes a Lean company?

Yesterday, Gene Lindsey (CEO of Atrius Health) and I shared a podium in a session for human resource professionals, and he drew on the work of Robert Greenleaf to offer his view. Greenleaf set forth the concept of “servant leadership.” Here’s an excerpt:

“The servant-leader is servant first… It begins with the natural feeling that one wants to serve, to serve first. Then conscious choice brings one to aspire to lead. That person is sharply different from one who is leader first… The difference manifests itself in the care taken by the servant-first to make sure that other people’s highest priority needs are being served. The best test, and difficult to administer, is: Do those served grow as persons? Do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servants?

Coincidentally, this kind of approach was recently reflected to a group of our senior leaders by Mike Hoseus, Executive Director of the Center for Quality People and Organizations. (Mike is the co-author of Toyota Culture.) He presented an inverted organizational pyramid. Instead of the usual pyramid showing the CEO atop, this one shows the CEO at the bottom, followed by the vice presidents, senior managers, and group leaders. At the very top are the suppliers, team members, and customers. Nonetheless, without the energy and commitment of the CEO to the Lean endeavor, it will fail.

An audience participant at yesterday’s HR session skeptically raised the question of the sustainability of the Lean approach in a corporate setting. Citing previous management fads like re-engineering, six sigma, and the like, what assurance is there that the lessons of Lean will take hold and persist beyond the term of a given CEO? We answered that there is no concrete assurance. Each CEO employs his or her own management philosophy.

But I have a feeling that, properly implemented, Lean is remarkably subversive in this respect: Once you teach staff to be “wiser, freer, more autonomous,” a successor CEO is going to find it pretty hard to undo those characteristics. Indeed, a Board of Directors would find itself compelled to search out candidates who have a similar underlying philosophy.

This is not to say that there is an inevitable persistence to the use of Lean in an organization. Like physical systems in which entropy takes over, consistently applied energy is necessary to maintain the process improvement system that we call Lean.

If the goal of the current health care system is to drive away every primary care physician then it has been and still is doing a bang up job. Dr. Li writes about why she left.

Pediatricians’ pay took a tumble. Hospital nurses questioned why we took on so much responsibility and worked such long hours for paychecks significantly smaller than theirs. Insurance companies kept ratcheting back both on our reimbursements and on the level of patient care until there was little left.Patients naturally became disgruntled. They got angry about the insurance denials and took out their frustration on our office staff. We needed to see more patients to make ends meet, so the waiting room became more crowded and waiting times increased. I had nightmares about running hours behind, patients yelling at us to “hurry up!” There were days when we would skip basic necessities like eating lunch or going to the bathroom; we didn’t want patients to wait. Days “off” were often spent seeing patients, catching up on paperwork, and calling back families who had questions too lengthy for regular office hours. Lunch was typically spent tackling the accumulated stacks of charts and callbacks to patients from the morning, in addition to holding office staff meetings or attending meetings at the hospital. A typical call night would entail the beeper going off every five to 10 minutes throughout dinner, and my often spending a good part of the night at the hospital. In the morning we’d arrive at the office and try to smile through another full day of patients.

Sounds like a dream job. Yep, and a great investment: spending 7 years of medical training to make less than what an RN makes with 2 years of training (kudos to the happy RNs who figured this out before it was too late).

Dr. Li encountered the paradox of traditional high volume primary care. Insurance reimbursement rates fall so the provider sees more patients but higher volume means higher overhead costs and more non-reimbursable obligations (phone calls, medication refills, paperwork) and therefore less take home pay. Too bad Dr. Li didn’t consider changing to a concierge medical practice model.

Dr. Kirsch at MD Whistleblower has written about his recent unpleasant experience with malpractice litigation. Despite having full access to the patient’s chart and medical records, the plaintiffs attorney chose to include Dr. Kirsch in the suit . . apparently . . just because . . he had seen the patient.

In Ohio – where this case was filed – a plaintiff in a medical malpractice case is required to obtain an “affidavit of merit” from and “expert” witness essentially stating that the case is legitimate from a medical standpoint. Apparently, the plaintiffs attorney was unable to locate a physician to sign an affidavit. Maybe it was because . . I don’t know. . the case had no merit?

The plaintiff was granted two 45 day extensions as they searched the Ohio country-side in vain for a medical professional to certify the case. After several months, Dr. Kirsch was dropped from the suit and according to Dr. Kirsch’s malpractice insurance company, the cost of “defending” this suit on behalf of Dr. Kirsch came to $9,120.85.

And like other health care costs, this one does not evaporate into the ether. This cost – and who knows how many thousands of other cases like this each year in the US – add to malpractice insurance premiums and likely eventually find their way into the health system as a whole in the form of higher costs. In short and as usual for litigation in this country, we all end up paying the costs of excessive litigation.

Of course, the US is one of the few countries in the world that does not have the so-called “English Rule” or to put it bluntly, the loser pays (the winner’s legal bills). The rational behind this rule is not to impair an injured party’s access to compensation for legitimate cases but to impede the type of gaming of the system that goes on too frequently with personal injury attorneys. Dr. Kirsch’s case is just one example of suing every physician who ever saw the patient regardless of merit or encouraging prospective clients to file suits by taking them on contingency.  These tactics  are designed to maximize the statistical probability that at least one case will yield a large settlement before trial thus minimizing risk and maximizing reward for the firm.This is especially important since the majority of malpractice cases that go to trial are won by the defendant! The key strategy is to cast a wide net and try to settle early.

But as we see in Dr. Kirsch’s case, these aborted merit-less cases still incur costs in the initial and intermediate litigation period that must be compensated for. A 1992 analysis of a 1980s era experiment in Florida with the English Rule found that that not only were more claims dropped in the initial litigation period with fewer cases being settled but cases that went to trial had a higher chance of success and settlements were generally larger, all of which suggests that the merit quality of the cases improved overall.

Ohio’s 2005 statute that requires an “affidavit of merit by a properly qualified expert with respect to each defendant against whom expert testimony is needed” also allows for extensions to made for “good cause.” What causes would be good? How about not being able to find a qualified expert witness to certify a case as having merit because your case has none? It would seem that this statute is somewhat self defeating in its aim to reduce costs by limiting access to only cases with merit. Either the plaintiff is able to dredge up some paid expert with questionable qualifications to certify the case or waste even more time and money with extensions trying to find any expert to certify a case that even the expert prostitutes won’t touch! A better system is to utilize a pretrial screening panel that decides the merits of a case and has been shown to improve case quality and reduce costs.

Just as there are plenty of wasteful medical practices that increase overall costs, there are wasteful legal practices that increase overall costs and measures can be put in place for both without limiting access to medical care or to be compensated as a result of injuries from medical malpractice.

by Thomas Dahlborg

What is your healthcare organization’s Vision Statement?

What is your specific role in ensuring that your organization achieves this vision? How often do you assess the impact you are having on this achievement?

Does your organization have a culture that allows you to ask questions such as: Does this new initiative align with our vision?

In Hoshin Planning, there is a term known as “catchball.” Catchball is a top-down, bottom-up communication and negotiating process where the collective wisdom of an organization is gathered to develop a focused plan that aligns the entire organization to achieve its vision. When done successfully, this process improves outcomes, saves resources (capital, human, etc.) and improves morale as individuals, teams, departments, etc., know exactly how they are contributing to the end goal.

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Successful healthcare organizations ensure that the “alignment of the entire organization” truly means that every individual’s role within the organization is defined, specific, measurable, action-oriented, attainable, realistic, timely, understood (by the individual and the organization) and aligned with the key critical initiatives required to achieve the organization’s vision ["SMART" goals plus]. This is absolutely critical and yet it is not enough in healthcare.

Truly successful healthcare organizations also must have a culture (a container) where all organization members feel safe, empowered and are expected to raise concerns regarding areas of focus, initiatives and projects that appear to be misaligned with the organization’s vision. Members need to not only be safe, but praised and recognized for the courage and commitment to do so. And yet this is still not enough in healthcare.

These same people must also feel safe, empowered and expected to raise concerns with the vision of the healthcare organization itself. Working in healthcare, we all have made a commitment–a commitment to the greater good and to helping to position individuals and communities for true healing.

Is your healthcare organization’s vision in line with a greater good?

If so, fantastic…now you can use wonderful “off-the-shelf” tools and processes to create amazing aligned, focused and engaging plans and measure and share the impact.

If not, it’s time to re-engage your organization and re-establish an aligned vision. If your organization’s vision is not aligned with a commitment to a greater good, you’re wasting limited time and resources and not honoring your organization’s key commitment. (Take heed: You also have an obligation to do so.)

We have great opportunity to significantly improve healthcare in America. And by choosing to work in healthcare, we also have taken on a commitment to a greater good. Time is short, as people and communities are not being served–and in some cases are being harmed.

Truly successful healthcare organizations that are honoring their commitment to the greater good will integrate all the above.

Thomas H. Dahlborg, M.S.M., is executive director of the physician practice True North Health Center, where he focuses on improving growth while ensuring access for the uninsured and the elderly. He has 21 years of experience creating competitive advantages, analyzing customer expectations, and developing and implementing focused and aligned strategic deployment plans. Formerly he served as the chief business strategy officer at Network Health, a comprehensive Medicaid health plan based in Cambridge, Mass.; and was COO of the U.S. Family Health Plan at Martin’s Point Health Care in Portland, Maine.

by Dr. Kenneth H. Cohn

In my last post on Hospital Impact, I discussed events that are taking place now to change the way care is delivered to U.S. citizens with pre-existing conditions and to retirees who are not yet eligible for Medicare. I would be remiss not to mention another development on the horizon that is affecting hospitals and physicians: Accountable Care Organizations (ACOs).

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ACOs provide care for a defined patient population and are accountable for quality and cost associated with the care they provide. Because the providers assume varying degrees of financial risk, they can receive higher bonuses for achieving quality and spending goals.

The Patient Protection and Affordable Care Act Section 3022 requires the Secretary of Health and Human Services (HHS)–Kathleen Sebelius–to establish a Shared Savings Program by January 1, 2012, in which authorized providers contract with the Secretary to manage and coordinate care for Medicare beneficiaries for three years. Acceptable providers include group practices, networks of practices, hospital-physician partnerships and other groups that the Secretary deems appropriate.

ACOs must:

* care for at least 5,000 patients.
* have a sufficient number of primary care professionals.
* have defined processes to promote evidence-based medicine.
* coordinate care through telehealth, remote patient monitoring and other enabling technologies.
* meet patient-centered criteria established by the Secretary, such as the use of patient and caregiver assessments or the use of individualized care plans.

Keep in mind that 18 months is a short time to put together an ACO that meets the approval standards of HHS, as well as the standards of existing antitrust and anti-kickback regulations. As I mention in my ACHE seminar, the exact type of model is less important than the process by which a healthcare organization selects the model.

Successful processes are:

* Transparent: Conducted in an open manner without hidden agendas.
* Held in a spirit of inquiry rather than advocacy: Physicians want to feel invited for their unique perspectives rather than asked to rubber-stamp a previously made decision.
* Iterative: Recognizing that decisions made about models are the beginning of a journey rather than the end of the decision-making process.

In coming together, successful ACOs will need to reframe anger from disruptive global economic change into energy to transform into entities that cut costs and improve quality simultaneously. The old silos between clinical care and finance and operations are breaking down.

Do we live in interesting times, or what?

Ken is a practicing general surgeon/MBA and CEO of HealthcareCollaboration.com, who divides his time between providing general surgical coverage and speaking, writing, teaching, and consulting on physician-hospital relations. Please learn more about what he does by visiting http://healthcarecollaboration.com.

At least it teaches compression only CPR.

Related content here.

Via Kevin.

This video illustrates the Trojan Horse principle of integrative medicine departments, which Orac has often pointed out. The speaker starts out with some plausible alternative modalities (hypnosis, biofeedback), then moves gently into the real woo of Tai Chi, Yoga and even the teachings of Larry Dossey.