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Sunday, July 12, 2015

The Health Care Handbook 2nd edition, a nice survey of our non-system

I'd bought and read the first edition when it was first released. A good read. Highly recommended, notwithstanding that it's necessarily "a mile wide and an inch deep."

Saw it touted on THCB last week, wherein they cited the chapter on MedMal: "The Health Care Handbook: Medical Malpractice."

Medical malpractice and how to fix it appears to be a mess—a crucially important mess, based on how often it comes up in society. Which raises the question: Is the problem overstated?

Health services researcher Aaron Carroll made the graph shown below to illustrate the costs of medical malpractice in the context of total health spending. While the costs of defensive medicine—$47 billion—are nothing to sneeze at, it’s also clearly not the primary driver of high health costs. Accordingly, Carroll indicates that tort reform will do little to reduce costs.
I responded in the comments by citing David Marx's "Just Culture" book ("Whack-a-Mole") chapter on MedMal reform.
Retiring the Medical Malpractice System

Medical mishaps and healthcare-acquired infections cause an estimated 200,000 deaths every year in the U.S. alone. That’s losing, every year, nearly 67 times the number of people lost in the September 11 terrorist attacks. Roughly 40 times the number of soldiers lost in Iraq and Afghanistan during the first seven years of warfare. Five times the number lost in automobile accidents. Each year. Almost 550 people every day, 1.8 million total since the IOM report was issued in 1999. That’s the cost of medical mishaps and healthcare-acquired infections. Short of disease, it’s the most likely cause of your own untimely death. In terms of national crises that lead to physical harm, it’s at the top of the list, ahead of war, crime, suicide, and automobile accidents combined.

Perhaps you wonder why we’re apparently all so sanguine about 200,000 preventable deaths each year—I know I do. Maybe it’s because they happen one at a time? Losing fifty or 200 airline passengers in a single accident or thirty soldiers in one insurgent attack is so much more dramatic; these events always lead the evening news. But one person inadvertently killed at your local hospital? It rarely does. And so, that one individual’s family is left to find their own way to wholeness. It is the medical malpractice system that offers hope, often on giant highway billboards put up by plaintiff attorneys: Hurt by your doctor? Call us!

What would the medical malpractice system look like here in the U.S. if we adopted the New Zealand approach? Answer: It would simply go away. We would retire it.

So what would this accomplish? Medical malpractice attorneys make two claims: 1) that the current system provides a needed remedy for those who are injured, and 2) that it deters future malpractice. Malpractice attorneys make the claim that injured parties rightly deserve some financial protection against the threat of unanticipated harm. I agree, and so do the New Zealanders. New Zealanders actually make the claim for all injuries, for whatever cause, not just those caused by healthcare misadventures.

Remember the report that said $587 billion is wasted in our U.S. tort system? In the area of medical malpractice, only 2.5 percent of injured patients even use the system. More than 97 percent of patients harmed by a medical mistake either never know their condition was caused by medical mistake, choose their own health insurance to provide the remedy, or they simply go without any meaningful redress. Rather than continuing with a system that is motivated to limit payouts, we could actually replace our current malpractice system with a no-fault system that would provide a remedy for all injuries received through the malpractice of a healthcare provider. As the New Zealanders say, we’ll do it as a matter of national responsibility. And, by the way, the New Zealanders claim that their overhead expenses are only 8 percent as compared to administrative costs as high as 55 percent here in the U.S. And speed, well, four months to benefits in contested claims in New Zealand, whereas we average fifteen to twenty months to settle torts in the U.S. Oh, and one last thing, purely from a perspective of equity. An external review of the New Zealand system identified that only 5 percent of ACC claimants would have been able to prove fault in the American system. Ninety-five percent of claimants would have been without a remedy here in the U.S.

So what about the second claim, the deterrent effect of medical malpractice claims? The effect is simply not there—at least as a substantive tool for reducing what is now estimated at up to 200,000 lives lost per year in the U.S. There is no evidence that our tort liability system substantially changes individual behavioral choices of practitioners—particularly if what they’re being sued for was a human error, by definition both unintentional and inadvertent.

Providers are apt to drift in their behavioral choices to places they believe are safe through personal experience, yet from a system-level perspective, appear risky. Take the CDC standards for hand hygiene, where rates of non-compliance among doctors are always lower than the compliance rate among nurses. It is generally the doctor, not the nurse, who gets sued for medical malpractice. Even with that increased threat of a lawsuit, doctors still lag behind in hand hygiene compliance rates.

In today’s malpractice world, attorneys are forced to wait until there is injury before they reactively move in to punish the surgeon who we knew all along was engaging in risky behavioral choices. It is a totally reactive system, when the real system safety question should be, “How do we help the surgeon before his risky behavioral choices lead to harm?” How do we empower the state regulator and the local health care team to help the surgeon make better, safer choices before harm occurs? Given that we humans often disassociate our behavioral choices from their future unintended consequences, there is little hope that the tort system can help practitioners make substantially safer choices.

Build a Safer Healthcare System

Unfortunately, there is a lot of work to be done in our healthcare regulatory system. As we’ve seen, many healthcare regulators, including the Centers for Medicare and Medicaid Services and most state Departments of Health, are still playing Whack-a-Mole in their regulatory policies and approach.

We do need to provide a remedy for those injured by medical misadventure. We also need to build a safer healthcare system. Yet, our trust is simply misplaced when we believe that the medical malpractice system will help with a cure for either of these ills. The approach must be different, Whack-a-Mole has run its course; it has outlived its usefulness, if it ever had any.

Tossing the medical malpractice system will in itself not solve the problems we have. First, we’d have to replace it with a no-fault system of insurance, such as New Zealand’s ACC or our own Workers’ Compensation system. That would take care of the remedy for those who have been injured. Next, regulators and healthcare administrators would have to shift their focus from the severity of harm and who caused the injury, to the design of the healthcare system and the control of behavioral choices within the system. Our no harm, no foul system of accountability in healthcare today, turning a blind eye until harm occurs, must end. As a society, we need to shift to a more proactive system where system design and behavioral choices are additional measures of accountability—in healthcare, in automobile accidents, in spilt milk at the dinner table.

In healthcare, administrators and practitioners should be required to obtain basic competencies in safety science—especially around the roles of system design and personal behavioral choices. We must teach practitioners that they can influence the design of the system, and that in their behavioral choices they have some control over the likelihood of the undesired adverse event. Doctors and hospitals should be required to disclose adverse events and critical near misses, both to the patient and to the state. Transparency and accountability go hand-in-hand. What typically occurs in secrecy today, even between regulatory agencies within the same state, must be made visible.

Doctors and other individual providers must be required to participate in a more effective system of quality assurance that would involve near miss reporting, analysis, and corrective action. Many in the general public do not realize that hospitals have no real oversight over physicians; many physicians work as independent contractors and are given “privileges” at individual hospitals. If the physician/hospital relationship goes awry, the hospital’s only recourse is often to rescind the doctor’s privileges—something they are not motivated to do given the doctor’s revenue-generating role. Practitioners cannot be allowed to work in isolation from a more formal system of quality assurance.

Most healthcare providers choose a life of service. They put themselves in harm’s way to take care of others. They expect a lot of themselves as professionals. Yet, they remain fallible human beings, regardless regardless of any oaths to do no harm. They are going to make mistakes and occasionally drift into risky places (see hand hygiene). The future of our nation’s health depends upon our ability to learn from their errors and at-risk behaviors.

Policy makers, regulators, educators, administrators, and professional organizations must work to help change the public’s perceptions about the appropriate accountability of healthcare providers. Accountability rests with practitioners’ choices, not their errors or their unintended outcomes. This paradigm shift creates more accountability rather than less. There are alternatives to Whack-a-Mole—alternatives that have a history of success.

President Barack Obama has said that we need to re-evaluate our systems and toss those that do not work. I heartily agree. Medical malpractice, America’s most sophisticated and expensive form of Whack-a-Mole, should be the first to go—if not merely to do the right thing for the professionals who dedicate their lives to the service of others, then for the millions injured and the 200,000 who are killed each year by a costly, ineffective healthcare system.

Marx, David (2012-06-06). Whack-a-Mole: The Price We Pay For Expecting Perfection (Kindle Locations 1722-1797). By Your Side Studios. Kindle Edition.

Askin and Moore et al have again done a worthy job. Kudos. Citing the Foreword:
Two years have passed since the publication of the initial version of The Health Care Handbook, the pioneering creation of two outstanding Washington University medical students, Elisabeth Askin and Nathan Moore. Strongly motivated by the recognition that many students entering the health professions had little knowledge of the organization, financing, and delivery of health care, they wrote a comprehensive, compact, interesting overview that elicited rave reviews from many individual and institutional experts. The Handbook is now in the hands of a large number of students and other interested parties, including health care institutions. A number of medical schools now use the Handbook as a foundation for relevant educational programs. 

The authors were correct; the Handbook satisfies a significant need. They also recognized from the beginning that there must be a second edition. Health care in America is changing significantly, fueled in part by the progressive implementation of the Patient Protection and Affordable Care Act (PPACA). A second edition would include important topics not included in the initial volume and improvements in quality and emphasis in response to very useful feedback from reviewers and readers. The goal is to continue to make the Handbook as useful as possible. 

Edition Two retains the fundamentals so aptly covered in its predecessor as well as its readable style— replete with appropriate, well-written revisions and new insights that certainly improve its educational value. Updating PPACA presented a special challenge because of the many unforeseen problems associated with the implementation of its major provisions. Given the likelihood of continued downstream uncertainties, the authors have appropriately emphasized the law’s key principles and explanations of policy issues in the news associated with the law’s rollout. There are timely additions such as a new chapter on quality and technology, a discussion of inter-professional education and teamwork among health professionals, and reviews of specific efforts to improve health care value, for example reducing avoidable hospital readmissions. Another point deserves emphasis. Health care has arguably emerged as the major domestic issue facing all Americans, in part because of its strengths, limitations, and changes. Expanding the health care literacy of students and practitioners in the health professions as well as the lay public is crucial to improving our nation’s approach to overall health status. To these ends, Edition Two of The Health Care Handbook is an excellent step forward. 

On a personal note, Elisabeth’s and Nathan’s careers have flourished despite the enormous time and effort this book has required. Elisabeth has become a resident in primary care at UCSF and Nathan is now a second-year resident in internal medicine at Barnes-Jewish Hospital. They have already contributed to the health literacy of our profession and are now full-time caregivers. We do attract outstanding young people to the study of medicine. 



Askin MD, Elisabeth; Moore MD, Nathan (2014-11-19). The Health Care Handbook: A Clear and Concise Guide to the United States Health Care System (Kindle Locations 151-175). Washington University in St. Louis. Kindle Edition.
The authors:

Why We Wrote This Book

When we were first getting interested in health care, a few years before starting medical school, we tried to cobble together an understanding of what health care even was. We found ourselves lost in a sea of confusion, faced with highly specialized publications that were often ideologically bent. Sure, generalized textbooks are out there, but even those seemed to focus on policy without explaining the huge world of research and drug companies that we kept reading about in the news. Besides, let’s face it: Textbooks are boring. Even a motivated student can only read so much from textbooks without being required to. 

In writing this book, we’ve worked hard to rid our knowledge base of huge gaps, vague opinions, and biased perceptions of some issues. But it shouldn’t be so hard, especially not for health professions students, and especially not in a nation where health care is such a huge, important, costly industry. We should make it as easy as possible to understand the U.S. health care system. 

Once we published the book, we tried to get as much feedback as possible— from students, from patients, from providers, from academics, from industry experts. This second edition has incorporated their feedback. 


The goal of this book is to provide a broad base of facts, concepts, and analysis so the reader gets a thorough overview of the American health care system. The goal is to be exhaustive in breadth rather than in depth, to make sure the reader never gets into an argument about health care only to have his or her opponent bring up a completely unfamiliar issue, to provide a baseline level of facts and analysis so that readers may go forth with the ability not only to understand and evaluate what they read but also to form their own opinions. 

At the same time, the goal is to balance accurate, nuanced, up-to-date content with a compact, readable format. Since nuance and brevity don’t usually go hand in hand, at times we have had to make concessions on one side or the other. 

Finally, a goal of this book is to impress a single theme upon the reader: Everything is always more complicated than you think. (If we could have underlined that phrase obsessively in each copy of this book, we would have.) It’s frustrating to know so much yet know so little; to think there’s a solution if only it weren’t thwarted by reality. But understanding these complications is necessary not only for understanding health care but also for developing informed, nuanced, realistic opinions. [ibid, Locations 196-216]
I would have to say, overall, "mission accomplished."

I like the extensive documentation links ("suggested reading").

apropos of some of my postings,
To quote from an amazing 2013 article in JAMA called “The Anatomy of Health Care in the United States”
“The breadth and consistency of the U.S. under performance across disease categories suggests that the United States pays a penalty for its extreme fragmentation, financial incentives that favor procedures over comprehensive longitudinal care, and absence of organizational strategy at the individual system level.” [ibid, Kindle Locations 305-308]
See my recent post The U.S. healthcare "system" in one word: "shards"

If you want a "deep dive" into health care delivery fragmentation, you can't do much better than Einer Elhauge. (And, it's now gotten quite personal for me.)

Moreover, a good deep dive into the daily worlds of physicians and nurses is cited in my post "Nurses and doctors in the trenches."

That post will also take you "back down in the Weeds'."

Relatedly, what of this so-called "Art of Medicine?" See my post The art of medicine consists of amusing the patient while nature cures the disease.

Speaking of systemic "deep dives," how about 'The American Health Care Paradox" I wrote about and cited in April 2014?


In light of my prior post "ObamaCare in the wake of King v Burwell at SCOTUS," wherein I reviewed Jed Graham's new book "Obamacare is a Great Mess," it's worth noting The Health Care Handbook's policy reform chapter, and its mention of the ACA:
Criticisms of the Affordable Care Act 

We are not endorsing these positions, and there are counterpoints to all of them. This section simply gives a voice to the ACA’s critics, in their own words, so you can see the range of opinion out there. 

It will make health insurance more expensive: “The law forces insurers to charge the same rates to the healthy and the sick. It mandates that insurers cover services that the government deems ‘essential,’ such as drug-addiction therapy, that most people don’t need. It forces young people to pay much more, so as to partially subsidize the elderly. There’s no such thing as a free lunch. All these new rules [will] make health insurance more expensive.”

It will increase government debt: “The Patient Protection and Affordable Care Act is fiscally dangerous at a moment when the United States is already facing a sea of red ink. It creates a massive new entitlement at a time when the budget is already buckling under the weight of existing entitlements. At a minimum, it will add $ 1 trillion to government spending over the next decade. Assertions that these costs are paid for are based on omitted costs, budgetary gimmicks, shifted premiums from other entitlements, and unsustainable spending cuts and revenue increases.”

It narrows networks too much: “[ T] he rules ObamaCare imposes to create a supposedly superior insurance product are resulting in an objectively inferior medical product. The new mandates and rules raise costs, so insurers must compensate by offering narrow and less costly networks of doctors, hospitals and other providers in their ObamaCare products. Insurers thus restrict care and patient choice of physicians in exchange for discounted reimbursement rates, much as Medicaid does . . . [e] verybody gets ‘free’ preventive checkups with no copays, but not treatment for a complex illness from specialists at an academic medical center.”

It leads to more government regulation and less free-market competition: “Americans want to have choice and control over their health care (including the doctors they want to see) and want those who provide health care services— insurers, hospitals, and other health care providers— to compete to provide them better care at lower prices . . . [ObamaCare] depends on a complex system of government mandates, inter-dependent regulations, and a highly involved, never-ending process of government decision-making that ultimately takes personal health care decisions out of the hands of American citizens.”

It is inefficient: “Obamacare was sold as a response to the alleged emergency presented by 40-odd million Americans’ lacking insurance. That number was hotly disputed at the time, but even if we were to take it at face value, getting the figure down to 30 million at a cost of more than $ 1 trillion is hardly a bargain.”

These are mostly criticisms from the political right. But the ACA doesn’t lack for critics on the left, too...

It doesn’t go far enough: “[ The ACA’s] approach to health care is fundamentally flawed. It is exceedingly complex. It perpetuates and entrenches the inefficient insurance model of payment for health care. It does nothing to address the rapacious pricing of pharmaceuticals. It ignores hospitals’ ‘medical arms race,’ in which they expand facilities and services based not on community need, but on potential for profit. It still burdens doctors and hospitals with multiple payers, abstruse coding and insecurity about payment for delivered services. It is subject to state-by-state sabotage. At its most optimistic projection it leaves at least 25 million people [uninsured].” [ibid, Kindle Locations 4014-4045]
As is the case throughout the book, the authors mostly just present facts and issues without taking sides. On the misnomer "interoperability":
The ability to share data is called interoperability, defined more specifically as “the ability of different information technology systems and software applications to communicate, exchange data, and use the information that has been exchanged.” It is also a major goal of health IT, as a step toward better health outcomes. Interoperability is very important in allowing different systems to work together, increasing efficiency, improving patient transfers, decreasing repeated tests, and, long-term, to creating standards for clinical decision-making nationwide. [ibid, Kindle Locations 2181-2185]
Missing from that is the core IEEE interop definition phrase "without special effort on the part of the user." See my rants on "Interoperababble."

On "CAM." The folks at Science Based Medicine would likely bristle at this gloss-over:
Complementary and Alternative Medicine: More than one-third of Americans regularly use complementary (used with conventional medicine) or alternative (used in place of conventional medicine) therapies, which include herbal or natural products, acupuncture, and homeopathic care. Most complementary and alternative medicine (CAM) is provided in an outpatient setting. Although some insurance plans provide reimbursement for CAM services, the majority of spending is out of pocket and totals more than $ 30 billion annually. 27 Upon hearing the rate of use and spending on CAM, it’s not surprising that the federal government has established a National Center for CAM to study the field. [ibid, Kindle Locations 489-494]
On healthcare "organizational culture":
Culture Change 

Quality and technology innovations have the potential to revolutionize the delivery of care and greatly improve patient outcomes. Two prominent innovations we have mentioned are checklists and Electronic Health Records (EHRs); both have great promise but neither has yet demonstrated a conclusive improvement in patient outcomes. That is perhaps because a checklist or an EHR is just one tool within a larger organizational culture that needs to change. 

An analogy would be a person who wants to get fit and healthy and buys a thighmaster. Fifteen minutes a day, he uses the thighmaster, but the rest of the day he continues to eat junk food and sit on the couch. We all know that’s not going to work (much to the authors’ chagrin). Although the thighmaster “works” as expected, without a change in his other behaviors and actions he will not obtain the outcome desired. The same issue applies with quality and technology innovations. As Lucien Leape says about checklists, “the key is recognizing that changing practice is not a technical problem that can be solved by ticking off boxes on a checklist but a social problem of human behavior and interaction.”

Susan DeVore and Keith Figoli wrote that “Health IT implementation represents a sweeping change away from business as usual to an entirely new approach in health care— one that will require process and behavior changes from nearly all health care workers. As such, it’s important to see the effort as an exercise in change management, not an IT initiative.” This is the real challenge of health quality and technology innovations. Keep this in mind when you read about new software tools that are going to totally fix health care— and when you read a few months later that they don’t live up to expectations. [ibid, Kindle Locations 2263-2277]
Indeed. "Talking Stick," anyone?

Again, overall, a very nice book. Good graphical data depictions. A handy, thorough survey reference. The authors are to be commended for taking all of this on while dealing with the rigors of Med School.


apropos of healthcare organizational "culture," an interesting post by Dike Drummond, MD:
Why Employed Physicians Quit - The BIG 3

In my work with hundreds of over stressed physicians, only about 30% must actually quit or change jobs to recover from physician burnout. The last straw in their decision is often one of these BIG THREE reasons employed physicians quit...

1) Employed Physicians Quit Because of a Toxic Culture

Most physician groups have no conscious culture or code of honor that binds them together to a standard of behavior.

If I ask a doctor to describe the culture of their group I often get blank stares. The question just does not compute.

In the absence of a consciously created group culture (this IS possible, BTW) most groups simply continue the culture of our residency programs. Competition, everyone working as hard as they can on their own personal gerbil wheel, no acknowledgement of humanity, never show signs of weakness, get out of the office as fast as you can, the biggest producer gets their way ... and on and on.

No wonder it is rare to feel your group is a "home" or that your partners "have your back".

If you are fortunate enough to find yourself in a situation where your group's culture is healthy ... you look out for each other and trust is actually a word you use do describe your partners ... savor it and count your blessings.

Most groups have nothing that binds them save a contract, reimbursement formula and a call schedule.

In the absence of a cohesive, supportive culture amongst the physicians, they are usually pushed around by a non-physician administration that focuses only on financial returns and work conditions slowly drift into the toxic range...
Talking Stick, baby. What BobbyG said. All of the cool, progressive tech and process QI in the world can be stymied by toxic culture.


I will be there. Registration link here.

More to come...

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