Curious Cat Management Improvement Blog » Health care

More Reasons to Avoid Layoffs

John Hunter — Thu, 11 Feb 2010 16:02:24 +0000

As its former head of human resources once told me: “If people are your most important assets, why would you get rid of them?”
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In fact, there is a growing body of academic research suggesting that firms incur big costs when they cut workers. Some of these costs are obvious, such as the direct costs of severance and outplacement, and some are intuitive, such as the toll on morale and productivity as anxiety (“Will I be next?”) infects remaining workers.
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research paints a fairly consistent picture: layoffs don’t work. And for good reason. In Responsible Restructuring, University of Colorado professor Wayne Cascio lists the direct and indirect costs of layoffs: severance pay; paying out accrued vacation and sick pay; outplacement costs; higher unemployment-insurance taxes; the cost of rehiring employees when business improves; low morale and risk-averse survivors; potential lawsuits, sabotage, or even workplace violence from aggrieved employees or former employees; loss of institutional memory and knowledge; diminished trust in management; and reduced productivity.
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As bad as the effects of layoffs are on companies and the economy, perhaps the biggest damage is done to the people themselves. Here the consequences are, not surprisingly, devastating. Layoffs literally kill people. In the United States, when you lose your job, you lose your health insurance, unless you can afford to temporarily maintain it under the pricey COBRA provisions. Studies consistently show a connection between not having health insurance and individual mortality rates.

Hospital Providing Better Health Care While Reducing Costs

John Hunter — Tue, 19 Jan 2010 13:30:25 +0000

Business Week has a good article on the strides one hospital has been able to make at reducing costs and improving quality. Hospitals: Radical Cost Surgery

Walk into Providence Regional Medical Center, in Everett, Wash., and you will see a hospital trying something different: It brings the equipment to the patient. In 2003, Providence opened one of the few “single stay” wards in the nation. After heart surgery, cardiac patients remain in one room throughout their recovery; only the gear and staff are in motion. As the patient’s condition stabilizes, the beeping machines of intensive care are removed and physical therapy equipment is added. Testing gear is wheeled to the patient, not the other way around. Patient satisfaction with the “single stay” ward has soared, and the average length of a hospital stay has dropped by a day or more.
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High quality at a low price. Every other industry strives for that combination, but a hospital that does both is all too rare. Providence and its cost-efficient brethren demonstrate that quality care can be delivered at an affordable price, provided hospitals can be persuaded to rethink decades-old practices.

The crazy world of hospital economics does not offer a lot of incentives to change. Both Medicare and private insurers reimburse on a piecework basis – known as fee-for-service – that encourages hospitals to treat more, prescribe more, and test more.
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Providence has also published data showing that infections, lengths of stay, and surgical complications have dropped since starting its own program.

But hospitalists are still controversial in many communities, because primary care physicians are wary of giving up control of their patients, along with their share of inpatient fees. Dr. Joanne C. Roberts, one of the first hospitalists at Providence, has not seen this conflict in Everett, possibly because most of the hospitalists and primary care doctors are associates at one large medical practice, Everett Clinic. That’s not true everywhere, she says. “In another community where I worked, independent doctors were pretty hostile. Everyone was trying to grab part of the money. That just doesn’t happen here.”
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In a study of 2,531 operations at Providence, Brevig reported that the incidence of transfusions was reduced to just 18% in 2007, from 43% in 2003, while the average patient stay was reduced by half a day. The changes have saved Providence an estimated $4.5 million.

Brevig has been proselytizing for his plasma practices at medical meetings, but to little avail. Only some 200 U.S. hospitals have a blood conservation program. Since patients are billed the cost of the plasma, doctors aren’t motivated to change their habits.

There are many more great examples of positive actions being taken in health care. But all you have to do is look at the overwhelming evidence of how amazingly poorly the health care system in the United States is doing to know that it is, overall, an enormous failure. For decades the enormous cost of supporting special interest groups that benefit from the current broken system have forced the rest of society to pay for their unwillingness to improve. We can no longer afford to accept the poor performance. We need to adopt the new ideas much more quickly and eliminate the taxes on the rest of society to support those that want to take an every increasing amount from society to support their outdated, failed policies.

Systemic Health Care Failure: Small Business Coverage

John Hunter — Sun, 27 Dec 2009 18:53:03 +0000

There are many significant problems with the medical care system in the USA. It makes sense that a system that costs over 50% more than other countries and has no better outcomes, from all that extra spending, suffers from many failures. Coverage for small business is one of the problems we face now – When Health Insurers Dump Small Companies:

In June testimony before the Senate Commerce Committee, Potter said insurers “dump small businesses whose employees’ medical claims exceed what insurance underwriters expected. All it takes is one illness or accident among employees at a small business to prompt an insurance company to hike the next year’s premiums so high that the employer has to cut benefits, shop for another carrier, or stop offering coverage altogether – leaving workers uninsured.”
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Joy Mosley, COO of Biotest Laboratories, a 77-person medical testing company in Minneapolis, recently got such a “requote” from her insurer, Medica, after an employee was diagnosed with pancreatic cancer. Medica covered the million-dollar treatment, but then said the large claim warranted $156,000 in additional premiums – a 72% increase.
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Not all entrepreneurs are equally vulnerable. About a dozen states prohibit insurers from basing premiums for businesses with 50 or fewer employees on workers’ health status. But in roughly three-fourths of the country, so-called ratings bands allow for considerable flexibility in pricing. In states with loose ratings bands, such as Texas and Nevada, one small company can be charged nearly 70% more than another. In Pennsylvania and Virginia, there are no ratings restrictions. No matter what state you’re in, ratings bands don’t apply to companies with more than 50 employees.

Just from an insurance perspective the companies are not providing what is needed. They are quick to say you can’t have healthy people remain uncovered and wait to buy insurance once for example, “their house is on fire” (they are sick). They are right. Well you also can’t have the insurance company cancel coverage during the fire and have a system that works.

Since a sickness can leave you at risk after the initial medical work is paid for it is not successful insurance that pays for the initial medical work and leaves you are risk for higher future costs (or completely uninsurable). After the initial medical bills have been paid you have this cost that the insurance did not cover – your increased riskiness to future companies. The insurers don’t what to cover you now that you are still on fire (or at least as they see it potentially still risk having an ember of your recent illness reignite your “fire”) and therefore they are not interested in insuring your burning house.

I understand that health insurance companies can see the future risk are higher for someone that has been sick. The problem I have is not with their desire to avoid covering risks that don’t provide adequate profit to cover their expenses and profits. The problem I see is this is a bad situation for the economic prosperity of those that must suffer from this system. The problem is, given this natural inclination of health insurance companies, why would we build a system based on having them make decisions on who gets coverage and who does not (because that is what happens).

This is but one, of many problems, with our current system. It can be partially addressed, while retaining the system that so many special interests have retained and continued over the decades. But, I am not sure why we should take our direction from those that that council the same old, proven failure of a system, over change.

Lean healthcare and improving the management of health care delivery is definitely one of the things we should continue to expand: healthcare improvement links.

Video Overview of the PDSA Cycle

John Hunter — Sun, 20 Dec 2009 17:00:37 +0000

Robert Lloyd, PhD From the IHI Open School’s, presents a nice overview of the PDSA Cycle (plan-do-study-act). The webcast includes an example of using PDSA to improve the discharge process for a hospital.

As I have said many times the keys to success are to turn the PDSA cycle rapidly, predict the results in advance, and analyze the results to continually improve. the Improvement Handbook is an excellent resource.

The IHI Open School is a great resource and exactly the type of thing organizations with a mission to improve performance should be doing. Provide resources online that are easy for people to access and then apply in their organization. See more management webcasts.

Blame the Road – Not the Person

John Hunter — Wed, 19 Aug 2009 21:19:22 +0000

The system is responsible for 90, 92, 94, 97% of problems – W. Edwards Deming. Fix the system, don’t blame the people. When you seek system fixes you approach situations differently than if you search for people to blame.

By the way, I am often asked about the data supporting Deming’s contention that the system was responsible for 97% of the problems. This statement was not based on a set of data but on Dr. Deming’s decades of experience. And he increased the percentage over time – as he learned more.

Roads that are designed to kill

Half blamed the runner, saying she should not have been running in the street at that hour. Half blamed the driver, for not paying close enough attention. Not a single writer blamed the road.
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Your streets are designed to kill people.
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Vision Zero started about 30 years ago, when traffic safety researcher Claes Tingvall got the idea that we didn’t have to accept road traffic deaths as a fact of life. Tingvall and his colleagues said that these deaths were not “accidents’’ but were predictable and preventable. And they set out to prove it.

One of the ways they began to protect people was to put barriers down the center of two-lane roads. They showed that this could be done cheaply. When Mylar – a strong polyester film – is supported by closely spaced plastic poles, it can keep cars from crossing the median. When the Swedes used this type of center barrier to separate the traffic going in opposite directions, they effectively prevented head-on collisions and the death rate on these roads fell by 70 percent to 80 percent.

Global health research shows more improvements can save lives. For example, Ghana put in rumble strips – small bumps spaced closely together – across all the roads leading into the capital city of Accra, reducing fatalities by 35 percent. Research has shown that speed bumps on roads are one of the “best buys” in all of global health.
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Most people think we are doing all that can be done to keep our roads safe. They are wrong. Road traffic injuries kill more than a million people a year worldwide, including 40,000 a year in the United States.

Is a situation killing 40,000 people in the USA a year a health care issue? It sure seems to me it would be. It probably isn’t a disease management issue though (some might try to say bad roads are a disease but I wouldn’t say that). I think this is one, of many examples, that shows that we have a disease and injury management system not a health care system (in addition to illustrating systems thinking, effective root cause analysis, PDSA, innovation, respect for people…).

Community Medical Care Successes

John Hunter — Thu, 18 Jun 2009 16:42:54 +0000

The Cost Conundrum by Atul Gawande, New Yorker (The Power of a Checklist was published there in 2007 by the same author)

For example, Rochester, Minnesota, where the Mayo Clinic dominates the scene, has fantastically high levels of technological capability and quality, but its Medicare spending is in the lowest fifteen per cent of the country—$6,688 per enrollee in 2006, which is eight thousand dollars less than the figure for McAllen. Two economists working at Dartmouth, Katherine Baicker and Amitabh Chandra, found that the more money Medicare spent per person in a given state the lower that state’s quality ranking tended to be. In fact, the four states with the highest levels of spending—Louisiana, Texas, California, and Florida—were near the bottom of the national rankings on the quality of patient care.
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I talked to Denis Cortese, the C.E.O. of the Mayo Clinic, which is among the highest-quality, lowest-cost health-care systems in the country. A couple of years ago, I spent several days there as a visiting surgeon. Among the things that stand out from that visit was how much time the doctors spent with patients. There was no churn—no shuttling patients in and out of rooms while the doctor bounces from one to the other. I accompanied a colleague while he saw patients. Most of the patients, like those in my clinic, required about twenty minutes. But one patient had colon cancer and a number of other complex issues, including heart disease. The physician spent an hour with her, sorting things out. He phoned a cardiologist with a question.

“I’ll be there,” the cardiologist said. Fifteen minutes later, he was. They mulled over everything together. The cardiologist adjusted a medication, and said that no further testing was needed. He cleared the patient for surgery, and the operating room gave her a slot the next day.

The whole interaction was astonishing to me. Just having the cardiologist pop down to see the patient with the surgeon would be unimaginable at my hospital. The time required wouldn’t pay. The time required just to organize the system wouldn’t pay.

The core tenet of the Mayo Clinic is “The needs of the patient come first”—not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. I asked Cortese how the Mayo Clinic made this possible.

“It’s not easy,” he said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focussed first on what was best for patients, and then on how to make this financially possible.

No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But, almost by happenstance, the result has been lower costs. [actually the Deming Chain Reaction]
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The Mayo Clinic is not an aberration. One of the lowest-cost markets in the country is Grand Junction, Colorado, a community of a hundred and twenty thousand that nonetheless has achieved some of Medicare’s highest quality-of-care scores. Michael Pramenko is a family physician and a local medical leader there. Unlike doctors at the Mayo Clinic, he told me, those in Grand Junction get piecework fees from insurers. But years ago the doctors agreed among themselves to a system that paid them a similar fee whether they saw Medicare, Medicaid, or private-insurance patients, so that there would be little incentive to cherry-pick patients. They also agreed, at the behest of the main health plan in town, an H.M.O., to meet regularly on small peer-review committees to go over their patient charts together. They focussed on rooting out problems like poor prevention practices, unnecessary back operations, and unusual hospital-complication rates. Problems went down. Quality went up. Then, in 2004, the doctors’ group and the local H.M.O. jointly created a regional information network—a community-wide electronic-record system that shared office notes, test results, and hospital data for patients across the area. Again, problems went down. Quality went up. And costs ended up lower than just about anywhere else in the United States.
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This approach has been adopted in other places, too: the Geisinger Health System, in Danville, Pennsylvania; the Marshfield Clinic, in Marshfield, Wisconsin; Intermountain Healthcare, in Salt Lake City; Kaiser Permanente, in Northern California. All of them function on similar principles. All are not-for-profit institutions. And all have produced enviably higher quality and lower costs than the average American town enjoys.

Hopefully those that have taken decades to get around to dealing with the health care crisis will listen to these success stories. I can’t understand how people keep saying we can’t afford to create a better health care system. We have the most costly system by far and we have worse result than most other rich economies. It seems we should expect better results for less money. The only way to get as bad results as we do for the huge cost is to keep doing what we are doing (or I suppose choose some option that does even worse than are very bad current system – though that seems a bit unlikely).

CEOs Want Health-Care Reform

John Hunter — Thu, 28 May 2009 12:36:29 +0000

Decades ago Dr. Deming emphasized the deadly disease of excessive health care costs in the USA. Since then, year after year, the situation has become worse (reaching $2.2 trillion in spending in 2007 – 16.2% of GDP). During that time senior executives has put forth very little serious effort (in comparison to the huge cost) to fix this problem. Finally, in the last few years, more and more senior executives are actively moving to address the ever worsening crisis (including, Howard Schultz, CEO at Starbucks).

They seem to be realizing that hoping the problem will just fix itself is not a great strategy. Finally senior executives are realizing they need to have the government address the systemic failures. Those executives need to keep up their efforts because those seeking to retain the system that doesn’t work, because they personally benefit from it, have been doing a great job of preventing progress for decades. Until a critical mass of senior executives demand change from Washington the chance of improving the relative performance of the USA health system in comparison to other countries is very bleak (we have just been getting more expensive and less effective [relative to other countries] over time).

CEOs Secretly Want Health-Care Reform

Carl T. Camden, CEO of Kelly Services (KELYA). Managing insurance for his vast, geographically dispersed workforce of temporary workers is horrendously expensive, he complains: “My health-care costs total more than my profits.”
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But in private, “CEOs overwhelmingly want out of this business,” says Benjamin Sasse, an Assistant Secretary of Health & Human Services under President George W. Bush who’s now an assistant professor at the University of Texas at Austin. “They just do not want to be seen as more willing to dump [benefits] than their competitors are.” Sasse says many CEOs he has talked with would even pay a new tax if it got them out of the insurance business.

Related: Many Experts Say Health-Care System Inefficient, Wasteful – Articles on Improving the Healthcare system – Applying Disruptive Thinking to the Healthcare Crisis – Our Failed Health-care System

Ivan Seidenberg, the Chairman and CEO of Verizon, has stated that the very nature of problems within the U.S. health care system mean that the health care market doesn’t function as a market at all.

CEOs Push for Systematic Reform of Health Care

“Some would say that given the state of our economy, we cannot afford health care reform,” said Gary Kaplan, M.D., chair and CEO of the Virginia Mason Medical Center. “But I think now, increasingly, given the state of our economy, we cannot afford not to have health care reform. It is clear to all of us we have a crisis. We have a crisis in coverage, affordability and quality.”

This is so true. How an argument that says we must accept the most costly system that doesn’t produce the best result because we can’t afford to have a more effective less costly system makes no sense. How is such an argument even accepted? But it is all the time. It is the “conventional wisdom.” Which doesn’t say much for conventional wisdom.

And that doesn’t even address that our system leaves tens of millions without insurance and forces poor economic decisions by millions of people. People are tied to their current jobs due to health care. If they want to go back to school, or go into business for themselves they must come up with huge health care premiums (if they can quality), take the risk their insurance won’t be dropped… It is an obvious friction on economic mobility if health care coverage is tied to your place of employment.

Waiting for C.E.O.’s to Go ‘Nuclear’ (2005)

The consuming Senate slugfest over judges (vital as they are) proves how Washington remains determined to fiddle while our biggest problem burns: a broken health care system that threatens working families and national competitiveness.

You would have to be a fool of a CEO to see a huge expense to your company rising every year in the USA more than inflation while you see the cost more contained in all the other countries your company operates in and not want the expensive broken system fixed. Now you might say it is someone else problem to deal with in 1982. By 1992 you have to be unable or unwilling to think of anything but the next quarterly report not to make health care reform a priority.

By 2002 you would have to not only be unable to think of the long term but unable to even see in your rear-view mirror. By this point the devastation caused by your fellow CEOs failures to get involved in fixing the health care system in the 1980’s and 1990’s was obvious. By 2009 many CEOs have understood what Dr. Deming told them decades ago. Those that still don’t, I really don’t understand. What are those CEOs thinking? They see one of their largest expense continuing to become worse every year and they don’t feel a need to actually address the issue effectively (especially when they can see their non-USA operations benefiting from much more effective health care systems). I just don’t understand that strategy.

USA Spent $2.2 Trillion or $7,421 Per Person on Health Care in 2007

John Hunter — Mon, 16 Mar 2009 13:54:37 +0000

Health spending in the United States grew 6.1 percent in 2007, to $2.2 trillion or $7,421 per person.
For comparison the total GDP per person in China is $6,100. This continues the trend of health care spending taking an every increasing portion of the economic output (the economy grew by 4.8 percent in 2007). This brings health care spending to 16.2% of GDP (which is yet another, in a string of record high percentages of GDP spent on health care). In 2003 the total health care spending was 15.3 of GDP.

With the exception of prescription drugs (which grew at 1.4% in 2007, compared to the 3.5% in 2006), spending for most other health care services grew at about the same rate or faster than in 2006. Hospital spending, which accounts for about 30 percent of total health care spending, grew 7.3 percent in 2007, compared to 6.9 percent in 2006.

Spending growth for both nursing home and home health services accelerated in 2007 (4.8% v. 4.0%). Spending growth for freestanding home health care services increased to 11.3 percent. Total health care spending by public programs, such as Medicare and Medicaid, grew 6.4% in 2007 v. 8.2% in 2006. In comparison, health care spending by private sources grew 5.8% compared to 5.4%.

Private health insurance premiums grew 6.0 percent in 2007, the same rate as in 2006. Out-of-pocket spending grew 5.3 percent in 2007, an acceleration from 3.3 percent growth in 2006. Out-of-pocket spending accounted for 12.0 percent of national health spending in 2007. This share has been steadily declining both recently and over the long-run; in 1998, it accounted for 14.7 percent of health spending and, in 1968, out-of-pocket spending accounted for 34.8 percent of all health spending.

The costs for health services and supplies for 2007 were distributed among businesses (25%), households (31%), other private sponsors (4%), and governments (40%).

Decades ago Dr. Deming included excessive health care costs as one of the seven deadly diseases of western management. We have only seen the problem get worse. Finally it seems that a significant number of people are in agreement that the system is broken. Still, admitting the system is broken is not the same as agreeing on how to fix it. The way forward to workable solutions still seems very difficult.

Full press release from the United States Department of Health and Human Services.

ER Checklist

John Hunter — Fri, 13 Mar 2009 19:17:10 +0000

The popular ER TV show highlighted the importance of using checklists in surgery yesterday.

Such powerful quality tools, like the checklist, are just waiting to be used. But far too many fail to use these simple improvement tools. And in health care those failures are potentially critical.

Applying Disruptive Thinking to the Healthcare Crisis

John Hunter — Thu, 19 Feb 2009 13:43:43 +0000

The Innovator’s Prescription: A Disruptive Solution to the Healthcare Crisis

Christensen spies symptoms of such disruptions bubbling up in the healthcare industry, such as molecular diagnostics, imaging technologies and high bandwidth telecom, and business model innovations. Integrated health systems like Kaiser Permanente have a leg up in deploying and optimizing these disruptive technologies.

The push for widespread healthcare reform must come from employers, who in spite of their declared intent to cut healthcare costs also know “they profit when their employees are healthy and productive.” Affordable healthcare, he concludes, “doesn’t come by expecting high end, expensive institutions or expensive caregivers to become cheap, but by bringing technology to lower cost providers and venues of care, so they can become more capable.”

Clayton Christensen is the rare management thinker that I feel real provides profound insights into thinking about management. There are many other good management thinkers that offer valuable idea, just most of them (in my opinion) really are presenting material in ways that offer managers a good way to take action on all the long known good management ideas that we fail to adopt successful for decades.

The first part of the video does a good job of providing an introduction to disruptive innovation. He makes the case that improving the health care system should applying the ideas of disruptive innovation because the current model is not likely to break the old ways of thinking. We certainly need to find ways to fix the broken health care system in the USA and these ideas are likely to be part of the solution in my opinion.

He believes that the proper stakeholder for taking responsibility for health care. Which I must say I find surprising. He acknowledges that employees say they don’t want to be in this role but he claims their actions show they are the most likely player to take up this responsibility. I am skeptical of that idea, myself.