The oath of office that he took reads:

 I solemnly swear that I will support and defend the Constitution of the United States against all enemies foreign and domestic; that I will bear true faith and allegiance to the same; that I take this obligation freely, without any mental reservation or purpose of evasion; and that I will well and faithfully discharge the office upon which I am about to enter. So help me God.

My son is living his passion to become a naval aviator.

Well-meaning friends have asked me if I am concerned for his safety. They point to the hazards of an aircraft carrier, where approximately 65,000 pound fully armed aircraft accelerate from 0 to over 150 mph in 3 seconds, launched by catapults, whose controls are set by 20-somethings with an average of 2-3 years experience. And then, there are the landings on a slippery flight deck bobbing up and down, with only four arresting wires to halt the plane.

Knowing that arguing would be futile, I respond, “Sure, any parent would be concerned for his child’s safety. One never stops being a parent.”

But deep down, I feel secure because aircraft carriers embody the five principles of high reliability organizations:

• Preoccupation with failure: focusing on predicting and eliminating catastrophes rather than reacting to them
• Commitment to resilience: assuming that systems can fail in unanticipated ways and learning to contain errors quickly by discussing and practicing responses to systems failures and near misses
• Deference to expertise: de-emphasizing hierarchy to gain input from people with the greatest knowledge relevant to the issue at hand
• Reluctance to simplify: accepting that work is complex and that failures are multi-factorial
• Sensitivity to operations: understanding how processes really work and paying attention to a broad range of factors, such as distractions, availability of needed supplies and personnel, and length of time people have been on duty

Why is healthcare generally not as reliable as aviation? 

As Jack Barker and I discussed in Collaborate for Success!, aviation utilizes organizations such as the Federal Aviation Administration (FAA) to develop and enforce regulations and the National Transportation Safety Board (NTSB) to investigate accidents. Furthermore, aviation has a mechanism through the Aviation Safety Reporting System (ASRS) to report near misses and errors that impact safety. Widespread use of medical guidelines and a process for reporting all medical errors that is not subject to legal discovery are in their infancy.  Healthcare professionals face difficult transitions changing their status from craftsmen to people that value safety and interchangeability.  Distinguishing between iatrogenic injury and complications due to disease often is a judgment journey.

One hospital system journey that gives me hope is the Sentara Safety Initiative which began in 2002 when hospital leaders became frustrated with the pace of change.  Dr. Yates, VP and medical director for clinical effectiveness, wrote that the missing piece was a stronger organizational culture focused on patient safety.  A group of 14 physicians and 2 nurses developed 5 behavior-based expectations (BBEs):

• Pay attention to detail: using the mnemonic SAFE (Stop, Analyze, Focus, Evaluate) to focus attention on the task at hand and decrease skill-based errors
• Communicate clearly, using clarifying questions and repeating back orders
• Have a questioning attitude, empowering healthcare professionals to stop actions when unsure about their safety
• Handoff effectively, using the 5P checklist to ensure successful transfers (Patient/ Project, Plan, Purpose, Problems, Precautions)
• Never leave your wingman, using peer checking and coaching when appropriate

To convert expectations into organizational habits, supervisors provide everyday feedback on BBEs which serve as core competencies on performance reviews. Managers use walk rounds to reinforce safety culture behaviors and make sure that shift-change reports, handoff reports, and pre-procedure briefings are handled appropriately. As in aviation, staff receive encouragement and recognition for reporting near misses and unsafe events. Meeting patient safety goals is a criterion for medical staff reappointment.

Hospital leaders use a system call Real-time Behavior Based Monitoring to monitor overall performance. One quarter of variable executive compensation is linked to achieving safety goals, as is one half of the annual employee gainsharing bonus.

In 2 ½ years, Sentara decreased ventilator-associated pneumonia 84% and device-associated bloodstream infections 63% (Yates GR et al. 2004. Sentara Norfolk General Hospital: accelerating improvement by focusing on building a culture of safety. Joint Commission Journal on Quality and Safety 30: 434-542.). They experienced a 50% reduction in events of harm per 10,000 adjusted patient days system-wide (McCarthy D, Blumenthal D. Committed to Safety. Commonwealth Fund pub. no. 923; 2006:17:165-200).

Sentara has shown that they can enhance culture change by embedding tactical safety improvement projects in a larger organizational strategy. They have promoted a virtuous cycle of organizational culture driving behaviors which drive improved outcomes that reinforce the safety culture and improve reliability.

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2010, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

©2010 Healthcare Collaboration. All Rights Reserved.

Dr. Cohn speaking on Physician Recruiting, Contracting, and Retention Strategies

I believe that this Congress of the American College of  Healthcare Executives was the best educational forum that I have ever attended.  Imagine Congress passing major healthcare legislation the same week that over 4,000 healthcare executives met in Chicago to discuss implications of healthcare reform.  I felt that I was part of the present, especially as Mike Fecher and I addressed over 100 people re: Field-Tested Physician Recruiting, Contracting, and Retention Strategies.  I found it provocative that nearly everyone conducted exit interviews of departing physicians to ask why they were leaving, but nobody in the room asked physicians who had been with them at least five years why they stayed and what they could do to make their time more productive.

Some of the many highlights of this outstanding meeting included:

• Maureen Bisognano’s Building Strong Connections Between Cost and Quality, in which she encouraged leaders to “think outside the building,” to improve safety, engage patients in improved self-management, reduce arbitrary individual variation, root out waste, and create a culture that supports the delivery of cost-effective care
• Chuck Mowll’s Best Practices of High-Reliability Hospitals, in which he cited Sentara’s practices of putting red tape around medication dispensing machines to warn people not to interrupt the person using them, using simplification experts to review processes, and encouraging staff to comment on any safety issues that concern them
• Nate Kaufman’s Proven Strategies to Enhance Performance Under Healthcare Reform, in which he encouraged participants to view upcoming challenges as thrills rather than threats as they approached physicians to break even on Medicare by strategic cost reduction, rebalancing payer contracts, recruiting clinical stars, improving coding, revenue cycle, and patient flow, developing an embedded medical group, selectively adding fixed costs, and auditing all financial relationships with physicians
• Ruth Brinkley’s Positioning Yourself for Success, in which she summarized the six ingredients for career success: competence, confidence, courage, resilience, humor, and people
• Gerry Ibay and James Higgins’ How to Succeed as an Early Careerist, in which they described the capacity for deep listening, challenging one’s own point of view to hear others’ perspectives

Although I usually do not stay through Thursday, I was glad that I did this time, to attend Kathleen Bartholomew and Joe Bujak’s Of Lions and Lambs: Transforming Physician-Nurse Communication.  They dressed in costume to role-play disrespectful dialogue and its effect on clinical and financial outcomes, especially in causing people to take out frustrations on colleagues who had nothing to do with the harmful interaction. 

They pointed out that depersonalization protects power and autonomy and that we need to come to know each other as people by celebrating successes rather than focusing solely on mistakes.  When respected physician and nurse leaders come to consensus on behavioral expectations to which everyone is accountable, the majority of those who transgress will apologize and those who don’t will leave.  Safety and clinical quality establish the moral high-ground.

What do you think?

• Does the prospect of healthcare reform make you excited, fearful, or ambivalent
• Can we build a strong connection between cost and quality
• What physician-hospital collaboration do we need to do to break even on Medicare reimbursement
• Do nurses and physicians where you work share behavioral expectations to which everyone is held accountable to improve healthcare communication

As always, I welcome your input to improve healthcare collaboration. 

Kenneth H. Cohn

© 2010, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

©2010 Healthcare Collaboration. All Rights Reserved.

In An Interview with Stuart Altman, this distinguished healthcare economist mentioned Altman’s Law, that  advocacy groups seek to preserve the status quo rather than adopt another plan that might disadvantage their interests.

January 21, 2010, in Citizens United v. Federal Election Commission, the Supreme Court voted 5-4 to remove limits on contributions from corporations and unions for “electioneering communication.”  Hailed by some as a victory for the First Amendment right of free speech, to at least one skeptical surgeon, it means that free speech just became more expensive, as limitless contributions pour in to influence 535 votes.

Kudos to David Harlow for getting it right in his commentary, Holy Mackarel: Scott Brown, Health Reform Redux and What Can (Should) Happen Next: “it is time to think about other avenues towards the improvement of the health care system in this country.”  Reform efforts will go on while Congress is embroiled in partisan gridlock.  As David mentioned, states have become the learning laboratories.

Medicare demonstration grants in Colorado, New Mexico, Oklahoma, and Texas continue to investigate the merits of value-based purchasing of healthcare services.  Patient-centered medical home projects, as described in Engaging Physicians to Adopt Healthcare Information Technology, represent a continuous, proactive, consumer-directed approach to care coordination.

In My Inadvertent Oncology Fellowship: Why I Remain Optimistic About Healthcare, I concurred with fellow Massachusetts surgeon Dr. Atul Gawande, that healthcare reform embodies an iterative journey, where we test different hypotheses in our learning laboratories, because no one has sufficient knowledge to assert that one way of delivering care will work for all our citizens. Dr. Gawande concluded in Testing, Testing:

But if we’re willing to accept an arduous, messy, and continuous process, we can come to grips with a problem even of this immensity. We’ve done it before.

As I mentioned in “Embracing Complexity,” in Better Communication For Better Care: Mastering Physician-Administrator Collaboration, face-face conversations are the only sustainable way that people can deal with complex situations in which predictability is diminished, experience does not guarantee success, and relationships are key. 

Complexity facilitates interest group politics, as members on all sides struggle to convey their message in 30 seconds or less.  In Collaborative Sensemaking, I described the critical role that healthcare leaders must play in interpreting and explaining disruptive marketplace changes and framing what is required for successful healthcare delivery.

Finally, I thank my mentor, Lee Kaiser, who in Collaborative Gnosticism, wrote:

Most people and most organizations see themselves at the center of the universe, which leads to egocentric, self-interested approaches that facilitate exploiting others for competitive advantage, hardly a sustainable approach to differentiation and the service of others… There is no economic, social, or political solution to the current healthcare crisis.  Spirituality, based on abundance, collaboration, and sharing provides the only solution because it makes problems disappear.

As always, I welcome your input to improve healthcare collaboration, even if sometimes I feel (to paraphrase Churchill) that we embrace it only after we have exhausted all other alternatives.

Kenneth H. Cohn

© 2010, all rights reserved

Disclosure:

I have not received any compensation for writing this content.  I have no material connection to the brands, topics and/or products that are mentioned herein.  David Harlow is a friend, colleague, and coauthor with me of Field-tested Strategies for Physician Recruitment and Contracting.  Please check out his HealthBlawg.

©2010 Healthcare Collaboration. All Rights Reserved.

The parallel with healthcare is what compels me to write today.  Laurence Barton, who was VP for crisis management at Motorola, calls sabotage the undisclosed crime in Crisis Leadership Now: A Real-World Guide to Preparing for Threats, Disaster, Sabotage, and Scandal. 

He wrote that today’s saboteurs take many forms that are not easy to identify.  People with access to an organization pose a great likelihood of compromising safety. Colleagues may hesitate to report statements or incidents because they fear embarrassment if they are wrong or retribution if they are correct, leading to inaction until it becomes too late to prevent a tragedy,  similar to what happened at Fort Hood. 

Clearly, there is no way except in retrospect to know when a crisis will hit.  Therefore, it behooves all of us to prepare.  Ian Mitroff and Gus Anagnos wrote in Managing Crises Before They Happen that organizations should review their vulnerability in the following six major areas:

• Economic, for example,  events stemming from the current recession
• Information, for example, loss of proprietary data or protected patient health information
• Physical, for example, a machine that works improperly that puts patients’ and/or employees’ health at risk
• Human resource, for example, loss of key personnel in an accident or due to a pandemic
• Sociopathic, for example, terrorism, kidnapping, or baby abduction
• Natural disasters, for example, fire, flood, tornado, or hurricane

We need a systematic approach to crisis management because in today’s complex interlinked environment, crises in one area may spread to others, for example, a flu pandemic in which 30% of healthcare workers are unfable to work, that compromises patient safety due to inadequate staffing. 

When I traveled to China in 2006 to speak at The First People’s Congress on Healthcare Communication, I learned that two Chinese characters symbolize The English word “crisis”: danger and opportunity.  The opportunity here lies in breaking down siloed communication and providing a forum where all stakeholders, including physicians, can make their complementary views known.

What do you think?

• Although it is natural to attribute blame when something goes terribly wrong, what are the systemic things that we can do ahead of time to prepare for and possibly prevent sabotage and other crises where we work
• Have you experienced situations where one crisis led to another
• Years afterward, what positive aspects emerged from going through a crisis with your coworkers

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2009, all rights reserved

©2010 Healthcare Collaboration. All Rights Reserved.

I don’t see why we should need to resort to degrading, immature tactics to get doctors to do what everyone knows they should do in the first place.

This comment, from a VP at a midwestern hospital during a discussion of healthy competition at a recent ACHE seminar that I taught, surprised me.  He was the first to protest the strategy of using competition whenever people felt frustrated by the difficulty of herding cats, in reference to physicians’ different concept of teams compared to administrators.

He was a veteran of the corporate healthcare industry at General Electric, where people performed according to expectations or disappeared.  The concept that administrators had influence but lacked control over physician behavior was foreign and still unsettling to him.

I explained that physicians are not alone in their feline DNA.  University professors also tend to display greater interest in and loyalty to their subject matter and colleagues than to the setting in which they teach.  So do most members of professional guilds, who derive prestige, income, and autonomy from mastering their craft.

We ended the discussion by agreeing that in environments in which he had worked previously, CEOs shaped the culture more by a top-down approach than by bottom-up strategies like healthy competition.  In Collaborative Culture, I wrote that most physicians prefer bottom-up processes to top-down edicts. They have told me that they much prefer being inspired to being supervised.

The only way that I know to develop a common culture is to allow physicians to play a role in shaping it.  One of the barriers to improved physician-hospital collaboration lies in overcoming physicians’ skepticism that they are invited to meetings to bless decisions rather than to provide input into making decisions. 

As I mentioned during my ACHE seminar, we can:

• Build on areas of agreement rather than argue about what we feel is right
• Focus on how we can make better use of scarce resources like physicians’ time
• Celebrate all wins to build lasting partnerships that improve patient care 

Perhaps the recent unanimous recommendation of a Massachusetts state panel to switch from fee-for-service to global payment will spur improved physician-hospital communication.

 What do you think?

• Do contentious issues like billing offer the potential to bring physicians and hospital leaders closer together
• Is some provider autonomy necessary to provide individualized patient care, mindful of the risks of heightened variability
• Do you know of any techniques more effective than face-face conversation in rectifying our differences and improving patient care

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2009, all rights reserved

©2010 Healthcare Collaboration. All Rights Reserved.

I know from conversations with some of you that this is a trying time and empathize with the challenges that you are facing.  As I wrote in Collaborative Confessions, change feels like failure when we are in the middle of it, something that achievement-oriented professionals are programmed to resist. 

It reminds me of a time February 1996 we nicknamed the Valentine’s Day Massacre, when I lost my job at a VA hospital because of a budget cut, along with four other part-time physicians and surgeons because as part-timers, we had no seniority rights.  Because my wife wanted to remain in New England, I applied to the Dartmouth Tuck School MBA program, so that we could continue living in our home.  None of my male colleagues thought that what I was doing was a sound idea.  One admonished me, “It sounds like you are jumping off a cliff, hoping that you will find your wings before you crash to the ground.”

In contrast, all ten women with whom I spoke told me that as one door was closing, several more would open up with opportunities that took advantage of my talents more than my present job as Associate Professor of Surgery and Chief of Surgical Oncology at the VA.  I asked the tenth woman why she thought that there was such a difference in replies:

Men derive most of their self-esteem from their careers and fear change, while we women are hardwired to deal with change.  We go to high school and college, some to graduate school, some get married and have children, but whatever we do, change is a part of our lives every single day.

The next time that I heard the term “hardwiring” was in Quint Studer’s book Hardwiring Excellence, in which he defined hardwiring (p.2) as ingraining systems and tools that recognize what is right and what is working well.  Its importance is to serve as a method for sustaining gains after a leader leaves an organization (p.18).

Through this journey, I learned that results come from hardwiring agendas, evaluations, communication, training, selection, discharge phone calls, thank you notes, and more.  This way, the hardwired behaviors drive the system even if the leaders change.  This is crucial since most staff and physicians will work at a facility longer than the average CEO.  Hardwiring excellence supports the organization’s values and sustains the gains. 

Part of Studer’s journey was turbulent.  He recalled (p.12) a friend who listened to his complaining about problems at a hospital where he worked and handed him an envelope with three decals to post on mirrors in his home, car, and office that said, “You’re looking at the problem.”   It brings to mind the recently deceased Michael Jackson song, “Man in the Mirror” which he sang at the 1988 Grammy Awards.  Change is indeed difficult, as Studer recalled (p.12):

I had heard that I was part of the problem before in the early 90′s, but I just didn’t believe it…. I said to Tim, a housekeeping employee, “This place looks terrible.” He looked back at me and said,”The fish starts rotting at the head.” I didn’t know what he meant then.  I thought that was because I didn’t do much fishing.  Now I know he was speaking about leadership.

I summarized in Collaborative Confessions my own recent struggle with change as I found what I do had become a “discretionary expense.”  I bypassed denial and went straight to anger, but by admitting that I did not have the answers and obtaining coaching assistance, I have emerged at a wiser, more sensitive, and more accepting place.  A surgical colleague who is now a hospital Chief Operating Officer lamented,”It took me over half my life to recognize that by relinquishing control, I gained influence.” 

I have learned, as Christopher Cornue alluded in, “Where did all the strategists go?” that:

• We all face danger of extinction in this troubled economy
• Making myself indispensable requires active, ongoing effort
• Email alone is insufficient for staying in touch with a rapidly changing marketplace
• Pain can be a powerful motivator
• Daily exercise boosts serotonin and can keep depression manageable
• Forcing myself to write down three things for which I am grateful every night helps me keep my  helplessness in perspective
• I can permit myself to grieve (briefly); as a colleague advised, “It’s OK to visit pity city as long as you don’t live there.”
• More importantly, I can reward myself at the time and place of my choosing, which has helped the local ice cream parlor thrive despite difficult times
• I can be in touch with the majority of my body composition that is liquid and flow in occasionally different directions when a customary route is dammed
• In “The Question Behind the Question”, John Miller points out that the only question that matters does not begin with “who” or “why,” but “what can I do?” or “how can I help?”; perhaps my experience is teaching me to substitute “I” for “they” when I form the words, “If only….”

What do you think of my mentor’s comment that change feels like failure when we are in the middle of it?

• Do you agree with Michael Jackson’s lyrics, “If you want to make the world a better place, take a look in the mirror and then make that change.”
• What are you grateful for
• How difficult is it for us men whose self-esteem derives predominantly from our careers to access our 23 maternal chromosomes that are hardwired to deal with change
• Where do we turn next

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn

© 2009, all rights reserved

©2010 Healthcare Collaboration. All Rights Reserved.

Through Executive Book Summaries to which I subscribe, I came across a provocative recently published book, The Innovator’s Prescription: A Disruptive Solution for Health Care, by Clayton Christensen, Jerome Grossman, and Jason Hwang.  Although I do not usually summarize books that I have not read in their entirety, the content motivated me to alert readers to this 441 page tome, in the hope that others will agree that perfection can be the enemy of good, to paraphrase Voltaire.  I give thanks to the beeper gods and godesses who permitted me to read the summary and write a blog post while providing general surgical coverage in Maine this weekend.

Warning: something in this book is bound to upset and unnerve all of us who may not realize how invested we are in the present non-system of care.  What I write should be viewed more as confessional than prescriptive.

The premise is that the need to transform expensive, complex offerings into higher-quality, lower-cost offerings is not unique to healthcare.  For example, Dell’s entry into the personal computing marketplace forced IBM to reevaluate its business model and focus on providing value-added business consulting services rather than building personal computers as its primary source of revenue.

According to the authors, healthcare provides two distinct services:

• Solution shop: activities that focus on diagnosing patients’ problems
• Value-adding processes: activities that fix problems that have been diagnosed in solution shops

 The reasons that the two services must be separate is that solution shops need to be paid on a fee-for-service basis; they require advanced technology and specialized expertise.  However, value-adding processes are outcome-driven,  can sell their output for a fixed price, and (for example, Geisinger Clinic’s Proven Care for heart bypass grafts and hip replacements) can warrantee results.  Only when the organizational resources, processes, and business model are focused around a job-to-be-done, can they be integrated and optimized to obtain outcomes as close to perfection as possible.

Therefore, the authors recommend that hospitals build distinct facilities (or at least a hospital within  a hospital) to deconstruct their activities operationally into solution shops and value-adding processes.  In the future, general hospitals will no longer be able to subsidize low-volume non-standard solution-shop (diagnostic) services with high-volume value-added work (procedures).

The authors feel that only a minority of chronic diseases, such as Alzheimer’s, Parkinson’s, lupus, epilepsy, and infertility necessitate a multidisciplinary solution shop.  The majority of chronic illnesses are rule-based, meaning that they can be competently managed by an individual caretaker; rule-based diseases include hypertension, osteoporosis, HIV, type I diabetes, and myopia.  The rules for treating many rule-based illnesses are so widely accepted that nurse practitioners can care for these patients without compromising clinical outcomes.

We cannot count on traditional physician practices to police patients to enforce compliance with therapy.  The business models that can help patients succeed are different from those that diagnose and prescribe the original treatment plan.  The authors cite as examples disease management companies like OptumHealth and Healthways.  That only a fraction of patients are cared for by disease management companies and integrated providers like Kaiser Permanente and Geisinger suggests an opportunity for those willing to embrace change rather than cling to familiar models. 

The Patient-Centered Medical Home represents an opportunity for primary care physicians to provide systematic, patient-centered, coordinated care management processes.  The Patient Centered Medical Home is a health care setting that facilitates partnerships between individual patients, their personal physicians, and when appropriate, the patient’s family. Care is facilitated by registries, information technology, health information exchange, and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

The authors feel that quality results from proper integration of care and that lower costs come from focus that promotes lower overhead.  Large employers are initiating disruptive change by outsourcing the care of patients to coherent solution shops for diagnosis and to integrated providers for patients’ treatment plan and compliance monitoring. 

Similar technologic disruptive forces introduce patients to devices that have provider experience built into their logic circuits, which will allow patients to monitor their own health in an improved fashion, for example scales and blood pressure cuffs, that wirelessly transmit patients’ daily weight and blood pressure to nurses experienced in the management of patients with congestive heart failure, that help patients thrive outside expensive hospital settings.

I ask with anticipation, “What do you think,” because a book like this lends itself to wide-ranging discussions on a variety of topics, including:

• Do we need a more coherent business model to guide 21st century US healthcare
• What are the strengths, weaknesses, opportunities, and threats implicit in The Innovator’s Prescription
• When is the ideal time and where is the ideal place to start

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn
© 2009, all rights reserved

©2010 Healthcare Collaboration. All Rights Reserved.

I admit that in previous posts( Gotcha and Uncollaborative Insurance ) I have complained about what I felt were arbitrary regulations on physical therapy for cancer survivors like me who sustained spine injuries and back and neck pain as complications of lifesaving therapy.

I cheered the decision that sent $6.6 million from Aetna to business owners due to a violation of Maine state law that requires small-group insurers to spend at least 75% of premiums on medical claims [Modern Healthcare 39(17)16].

Yet, today, in the spirit of Mother’s Day, I have chosen to focus on what I agree with in Karen Ignani’s article [Uniquely American Solution: Collaboration, leadership required to bring change. Modern Healthcare. 39(17)20-21]. Anticipating criticism from readers who become as frustrated as I do with caring for patients amid denial codes, telephone calls, and burdensome paperwork and regulations, I disclose that I have received no money from anyone in the health insurance industry. On the contrary, I send Harvard Pilgrim Healthcare nearly $17,000 in annual premiums.

Here are points from her recent article on which I agree with Ms. Ignani:
1) Successful reform will require a comprehensive cost-containment strategy: I hope that physicians and hospital share with insurers, pharma, and device manufacturers in the sacrifices required to bring costs down considerably. I support insurers converting to a universal claim form which will save providers time and administrative staff costs.  I also support regulations that increase transparency for physicians and organizations who receive payments from drug and device companies for research, consulting, and speaking.
2) Preventive care and screening reduce future catastrophic outlays. I would be willing to sign a 5-year contract with my insurance company in return for a guarantee that premium costs would not rise more than the agreed upon amount, so that they could reap the benefits of their investment in my wellness
3) Investing in anti-obesity and anti-smoking campaigns can improve the health of the nation and reduce related costs. Even though I am not overweight and do not smoke, I support these efforts.
4) Providing scholarships and loan forgiveness for physicians specializing in primary care will help provide and sustain the workforce necessary to achieve the above objectives. In the Southern Surgical Association Presidential Address, Dr. James O’Neill stated, “I believe that the reason many students are selecting so-called “lifestyle specialities” characterized by shift work, is because these fields are relatively protected in terms of reimbursement under Medicare and other insurance reimbursement.  This is primarily because of enormous student debt, now averaging close to $200,000 and rising, an insidious influence…  Currently, no one is taking responsibility for this and it is up to us.” [Journal of the American College of Surgeons. 208(5),659.] The sooner we institute this reform, the better. 
General surgeons, especially those who work in rural settings, deserve to be included in the primary care category; without our active assistance, emergency departments, intensive care units, and medical wards cease to provide comprehensive care.  General surgeons allow a hospital function as an acute-care facility that can provide life-saving care to our communities.
5) All of us can do better. Amen
6) Acting now to identify reductions in all sectors can provide significant relief to purchasers of healthcare insurance, improve the solvency of the Medicare trust fund, and free up resources to finance healthcare reform. No disagreement here either.

The following are some ways that we physicians can make it easier to reach a sustainable equilibrium:
1) Invest in interoperable electronic health record software that allows us to share data without the need to re-enter it into our computers
2) Use software displays that show us clearly the results and date of previous laboratory testing and imaging studies, so that we avoid duplication
3) Obtain palliative care consults for patients entering the intensive care unit to avoid squandering limited resources on patients at the end of their lifespan for whom there is little hope of extended survival. Questions about rationing need to give way to questions about how we can deploy scarce resources more effectively
4) Support legislation that requires patients to fill out living wills signed by their next of kin and power of attorney when they apply for/ renew their health insurance coverage. This is especially important for aging patients before significant cognitive decline occurs
5) Play a greater role in health education not only for individual patients but also in schools and public forums
6) Be more pleasant and rethink conspiracy theories to cultivate mutual respect. As I wrote in Facilitating Physician Engagement, breakthrough innovation occurred at the Pittsburgh Regional Health Initiative once participants moved from an accusatory, “Why don’t you …” approach to a more welcoming, “What if We …?”

What do you think?

• What reforms do you support in the upcoming healthcare reform debate
• What can we do better
• As you look into the mirror, what would you like to change 

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn
© 2009, all rights reserved

©2010 Healthcare Collaboration. All Rights Reserved.

• I was in Chicago last month attending the ACHE Congress, where I received the Dean Conley Award for the best article appearing in a healthcare management publication; that article, “The Tectonic Plates Are Shifting: Cultural Change vs. Mural Dyslexia” is available on my website
• I attended The System Seminar on Internet marketing, where I implemented a new tool, Kampyle, that allows visitors to my website to offer constructive feedback; please use it to hep me serve you better by clicking here
• I revised my slides for my upcoming ACHE seminars on Practical Strategies for Engaging Physicians May 6-7 and July15-16, 2009; the seminar  includes new material on physician employment contracts and engaging healthcare professionals in innovation
• I participated in 6 radio interviews and 1 television interview on general topics relating to healthcare; you can listen to them by clicking here (note, the TV interview was taped to air June 6, 2009; more details to come soon)
• I traveled to my mother’s house in Buffalo, NY for Passover, the subject of this post

As many of you know, Passover celebrates the Jewish people’s escape from Egyptian bondage.  To me, it represents the hope of Spring and the potential of transforming current difficulty into triumph:

“On this night, long years ago, our forefathers hearkened to the call of freedom.  Tonight, that call rings out again, sounding its glorious challenge, commanding us to champion the cause of all the oppressed and the downtrodden, summoning all the peoples throughout the world to arise and be free.”

Our family’s tradition is for my mother to read about the four children, summarized below (the “he” is intended to refer to both male and female children):

• The first kind of child is the wise child.  He loves Passover; he is eager to celebrate the holiday exactly as it ought to be celebrated, and he asks his father, “What are the decrees, the statutes and laws which the Lord our God has commanded concerning Passover?”
• Another kind of child is the irreverent child, who is scornful and does not feel as though he is part of the whole celebration.  He asks his father, “What does this service mean to you?”
• The third kind of child is the simple child who is naive and very shy.  He would like to know what Passover means, but does not know how to ask about it.  So he asks merely, “What is this all about?”
• The fourth kind of child is the one who does not even realize that something unusual is going on.

Although my mother refers to me as “the curious child,” in truth, I have been all four children at various times of my life.  One of the pluses of being a cancer survivor is that my faith has been tested and strengthened in the process.  For me, Passover is a time to reconnect with family and celebrate what unites us rather than being consumed by our differences.  I leave with a sense of hope that extends to my work and is especially important in these challenging economic times, where the outcome is certain (we will prevail), but the timing is everyone’s guess.

In the spirit of Passover, what are your thoughts?

• Can you allow yourself to feel any optimism as flowers and trees bloom
• Do you escape from bondage as you complete a task that has been oppressing you
• Can you celebrate the child in you that asks questions, regardless of whether they are wise, irreverent, or naive

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn
© 2009, all rights reserved

©2010 Healthcare Collaboration. All Rights Reserved.

This episode began when I received a notice dated 2/11/09 notifying me that the cost of my family coverage plan would increase from $1785.96 to $1929.68 per month, an 8% increase that would push my family’s cost  to over $23,000 annually, considering the $25 copay per visit and the $15/$30/$50 tiered drug copay.  As a solopreneur with two kids in college and predictable expenses with unpredictable cashflow, I felt that a win-win negotiation was in order.  I printed information from a variety of Harvard Pilgrim policies on the Commonwealth Connector and called Harvard Pilgrim last Thursday to discuss my options.

I mentioned (see Gotcha: A surgeon dissects patient-centered care) my frustration with insurance company micromanagement of physical therapy (PT).  I explained that a limit of 60 consecutive days of physical therapy did not work for me because a seizure sustained as a complication of chemotherapy for lymphoma in 1981 resulted in compression fractures of my spine, chronic pain, and limitation of motion.  Knowing that I would have to pay full price for PT after 2 months despite paying out nearly $23,000 in premiums did not buy me peace of mind.  I stressed that nobody in my family smokes cigarettes, has high blood pressure, or is obese.  Other than my spine issues, we have no chronic conditions.

I asked, “What can we do to reach a mutually beneficial outcome?”  You would have thought that I was asking for permission to desecrate the American flag.

“We can’t change PT coverage,” she protested.

“Nonsense,” I replied (I confess that I used a different compound word that had the same number of letters; it just came out in the heat of the moment).  “If a human being can write an arbitrary, capricious rule that has more to do with managing cost than managing care, a human being can promote wellness by changing that arbitrary and capricious rule!  Why aren’t there limits to spine surgery or MRI scans that cost a lot more than PT?”

I continued, “I know that you can’t change the rule, nor do I expect you to.  All that I ask is that you convey my request to the people at the top of your organization that make the rules.  I want you to know that I want to stay with Harvard Pilgrim if we can find a way to accommodate my family’s needs.”

She thanked me for my comments, and we hung up.

The tragedy of the conversation is that (to paraphrase Jerry Maguire) she could have had me at hello.  Perhaps I am naive to think that a mere surgeon/MBA/author-blogger could have a mutual dialogue with a company that reported operating income of $22.6 million on revenue of $2.6 billion for 2008. Net income for 2008 was $48.1 million.  As of December 31, 2008, total membership for Harvard Pilgrim was 1,068,000, an increase of 38,000 members from 2007.

I am not suggesting that Harvard Pilgrim is a bad company.  I know that it is ranked number 1 in New England by a variety of measures.  I learned in business school that the definition of a good customer is someone who keeps a company in touch with the marketplace.  I know from having traveled over 500,000 miles in the last 6 years to over 40 states in the US that many of us in the middle class are feeling squeezed and we’re not gonna take it anymore.

In a memorandum to the heads of all Executive Departments and Agencies dated February 27, 2009, President Obama wrote that government should be transparent, participatory, and collaborative.  Shouldn’t these principles apply to healthcare insurance companies as well?  If we want better healthcare outcomes, we all need to work more interdependently. 

As I wrote in Facilitating Physician Engagement, it took years of meetings of healthcare professionals at the Pittsburgh Regional Health Initiative before questions shifted from the accusatory, “Why don’t you…?” to a more systems-based reflection, “What if we…?” (“Socioeconomic Issues Affecting Healthcare Collaboration, p.48, in Cohn KH. Collaborate for Success! Breakthrough Strategies for Engaging Physicians, Nurses, and Hospital Executives, Chicago: Health Administration Press, 2006).

What do you think?

• What would you like to say to your healthcare insurance company
• How can citizens who are not part of big companies promote a more patient-friendly wellness agenda
• Is now the right time raise these issues

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn
© 2009, all rights reserved

©2010 Healthcare Collaboration. All Rights Reserved.