That may have been the common query from health care providers the world over after Cuban shared on Twitter that he intends to have his blood drawn and analyzed every quarter “for everything available” and that anyone who “can afford to” should do the same. It was just a few words from a mid-level celebrity on social media; then again, there are more people following Cuban on Twitter than there are adults living in Iowa.
Cuban, who owns the Dallas Mavericks professional basketball team but may be better known for the business “reality” show “Shark Tank,” insisted that he was simply advising people to build a base of personal health data for future reference. But anyone this obsessed with data isn’t going to just let it sit; they’re going to look for abnormalities, outliers, changes. And when they see one, no matter how small, they are going to take action because, after all, we are talking about health.
“More is not better,” health care experts told Cuban. The kind of overtreatment Cuban advocates wastes scarce health care resources and runs the risk of creating more waste through a ripple effect of possible tests and their results, which may produce either false positives or false negatives. Here’s how Dr. R. Adams Dudley from the University of San Francisco Center for Healthcare Value described the escalation:
- If a patient gets just five things checked in his blood every quarter, that’s the equivalent of 20 tests a year. (An activist patient like Cuban may be getting many more tests done.)
- Given normal variation, about 5 percent of tests may produce an unexpected result. That means out of 20 tests, “even one test is expected to be abnormal, even if (the patient is) healthy,” Dudley points out.
- Although doctors may suspect that nothing’s amiss, “we are trained not to just ignore an abnormal result, but to do further testing or even treatment,” Dudley points out. “That testing or treatment always involves risks.”
Cuban’s particular piece of advice undermines the value hospitals are working harder than ever to bring to the health care system. But, at the same time, hospitals are also trying harder than ever to get patients engaged in their health care. It is a delicate balancing act.
Problem is, despite health care providers’ efforts to carefully convey the more-is-not-better message, there will probably be more Mark Cubans in the future – a lot more. Health care blogger Andrew Holtz summed it up: “It won’t be long before the incessant data logging that is already widespread in sports sprints past the daily-steps tracking by a Fitbit to global monitoring of every breath and heartbeat… even analyzing our blood without those pesky phlebotomists. Look, the Apple Watch already has a blood sugar monitor add-on and it’s not alone.”
A stream of data will become a torrent that will “flow into a void of understanding,” Holtz predicted. But it doesn’t have to be that way, not when providers are prepared well ahead of the flood and not when patient-provider relationships are built through access to care and a medical home that is not hampered by income, geography, politics or regulations, including disconnected reimbursement policies.
That’s where IHA comes in – to get the information to hospital leaders and advocates, to share the hospital story with the public and to knock down the barriers to high-quality, high-value, patient-centered health care for everyone.
(From time to time, the blog features recipients of the IHA Iowa Hospital Heroes Award. These outstanding hospital employees come from across the state and work at hospitals of every size. They exemplify the courage, caring and community focus that are at the center of the hospital mission in Iowa.)
Having retired in 2008, Dr. Ronald Myrom is still a daily fixture at Palmer Lutheran Health Center in West Union and other health care organizations within his community. He regularly sees patients in area nursing and residential homes and fills in and provides back-up for the hospital’s urgent care clinic and emergency department.
In addition, “Doc,” as he is affectionately called, is currently the acting medical director of Palmer Hospice. He has taken his vision of providing quality care and dignity to terminally ill patients and has imparted it into the hospice belief it is today. This is evident by the many hours of devotion he gives to the patients, family members and the core members who make up the hospice team.
During visits, Dr. Myrom always gives 100 percent of his attention to each individual patient. He has an amazing bedside manner with hospice patients and this is shown through his compassion, dignity and respect he gives to each one of them. All of this is done at no cost to the agency as he volunteers his skills and time to serve the patients who live within our local communities. He does this because he truly enjoys giving back to people we serve.
Donating to the hospital’s foundation and various other community events, organizations and projects, he insists that no recognition be given to him and his wonderful wife, Michele. He simply gives as a selfless act of kindness knowing he is able to serve his community and the amazing people that call it “home.”
Such a humble man, Dr. Myrom continues to be as much of an engaged healer today as he was throughout his career. Dr. Myrom has “retired” yet continues to serve his community. We recognize his value and appreciate what he does for us – personally, professionally and philanthropically. We know of no one who has more dedication, care and compassion for a hospital, patients and a community as a whole.
The patient was dying and she knew it. In her mid-50s, she had been battling breast cancer for years, but it had spread to her bones, causing unrelenting pain that required hospitalization. Jeremy Force, a first-year oncology fellow at Duke University Medical Center who had never met the woman, was assigned to stop by her room last November to discuss her decision to enter hospice.
Employing the skills he had just learned in a day-long course, Force sat at the end of her bed and listened intently. The woman wept, telling him she was exhausted and worried about the impact her death would have on her two daughters.
“I acknowledged how hard what she was going through was,” Force said of their 15-minute conversation, “and told her I had two children, too” and that hospice was designed to provide her additional support.
A few days later, he ran into the woman in the hall. “You’re the best physician I’ve ever worked with,” Force remembers her telling him. “I was blown away,” he says. “It was such an honor.”
Force credits “Oncotalk,” a course required of Duke’s oncology fellows, for the unexpected accolade. Developed by medical faculty at Duke, the University of Pittsburgh and several other medical schools, “Oncotalk” is part of a burgeoning effort to teach doctors an essential but often overlooked skill: clinical empathy. Unlike sympathy, which is defined as feeling sorry for another person, clinical empathy is the ability to stand in a patient’s shoes and to convey an understanding of the patient’s situation as well as the desire to help.
Clinical empathy was once dismissively known as “good bedside manner” and traditionally regarded as far less important than technical acumen. But a spate of studies in the past decade has found that it is no mere frill. Increasingly, empathy is considered essential to establishing trust, the foundation of a good doctor-patient relationship.
Studies have linked empathy to greater patient satisfaction, better outcomes, decreased physician burnout and a lower risk of malpractice suits and errors. Beginning this year, the Medical College Admission Test will contain questions involving human behavior and psychology, a recognition that being a good doctor “requires an understanding of people,” not just science, according to the American Association of Medical Colleges. Patient satisfaction scores are now being used to calculate Medicare reimbursement under the Affordable Care Act. And more than 70 percent of hospitals and health networks are using patient satisfaction scores in physician compensation decisions.
While some people are naturally better at being empathic, said Mohammadreza Hojat, a research professor of psychiatry at Jefferson Medical College in Philadelphia, empathy can be taught. “Empathy is a cognitive attribute, not a personality trait,” said Hojat, who developed the Jefferson Scale of Empathy, a tool used by researchers to measure it.
“The pressure is really on,” said psychiatrist Helen Riess. The director of the empathy and relational science program at Massachusetts General Hospital, she designed “Empathetics,” a series of online courses for physicians. “The ACA and accountability for health improvement is really heightening the importance of a relationship” between patients and their doctors when it comes to boosting adherence to treatment and improving health outcomes.
“Demographics and economics are driving this,” said James A. Tulsky, one of the developers of “Oncotalk.” (The original course for oncologists has been adapted for other specialties under the aegis of Vital Talk.) “Baby boomers have higher expectations” and are less willing to tolerate doctors they consider arrogant or unapproachable, added Tulsky, director of the Duke Center for Palliative Care. A 2011 study he headed found that doctors who took the course inspired greater trust in their patients than those who did not.
While empathy courses are rarely required in medical training, interest in them is growing, experts say, and programs are underway at Jefferson Medical College and at Columbia University School of Medicine. Columbia has pioneered a program in narrative medicine, which emphasizes the importance of understanding patients’ life stories in providing compassionate care.
While the curricula differ, most focus on self-monitoring by doctors to reduce defensiveness, improve listening skills (one study found that, on average, doctors interrupt patients within 18 seconds) and decode facial expressions and body language. Some programs use actors as simulated patients and provide feedback to individual doctors.
Too Busy For Empathy
“In the 1980s, when I trained, the emphasis was on medical knowledge and technical skills,” said Debra Weinstein, vice president for graduate medical education at Partners HealthCare, the largest provider of medical services in Massachusetts. But in the past decade, “the profession has been more attuned to patient satisfaction and the connection between satisfaction and outcomes and incentives.”
Partners, which includes Mass General and other Harvard teaching hospitals, is requiring that its 2,000 residents take “Empathetics.” In a 2012 study involving 100 residents, researchers found that doctors randomly assigned to take the course were judged by patients as significantly better at understanding their concerns and making them feel at ease than residents who had not undergone the training.
Riess said that while some doctors have told her they don’t have the time to be empathic, the skill has proved to be a timesaver rather than a time sink. It can help doctors zero in on the real source of a patient’s concern, short-circuiting repeated visits or those “doorknob moments” doctors dread, when the patient says “Oh, by the way . . . ” and raises the primary concern as the doctor is headed out of the room.
Because a lack of empathy and poor communication drive many malpractice cases, a large malpractice insurer, MMIC, is urging doctors it insures to take the “Empathetics” course. Another benefit: Empathy training appears to combat physician burnout.
“Empathy training is naturally self-rewarding,” said Laurie Drill-Mellum, a former emergency room doctor who is chief medical officer of the Minneapolis-based insurer. “It gives [doctors] the love back,” she said, referring to the positive feedback empathic doctors receive from their patients.
‘Doctors Are Explainaholics’
Both Riess and Tulsky say their interest in empathy was sparked by personal experience. In Riess’ case, it was the flood of patients in her psychiatric practice a decade ago who spent their time in therapy discussing devastating interactions with doctors. “These are not just innocuous effects,” she said, “but often experiences that were profound and deeply affected people’s lives.”
Tulsky said that his father, an obstetrician-gynecologist in a solo practice, routinely talked about his patients at dinner. “His stories were about their lives, so I got this idea that medicine was about more than the illness,” he recalled. In medical school, Tulsky said, “I was very drawn to challenging moments in patients’ lives and volunteered to give bad news,” particularly when he believed other doctors would botch it.
“I saw a lot that disturbed me,” Tulsky said. One memorable incident involved his chief resident loudly berating a frightened, impoverished and very sick old man, saying, “If you don’t have this operation, you’ll die. Don’t you understand?”
Tulsky said that researchers have found that some doctors don’t respond with empathy because they are clueless when it comes to reading other people. Many others, he said, do recognize distress but fear unleashing a flood of emotion in the patient, and sometimes in themselves.
“Doctors are explainaholics,” Tulsky said. “Our answer to distress is more information, that if a patient just understood it better, they would come around.” In reality, bombarding a patient with information does little to alleviate the underlying worry.
The “Empathetics” program teaches doctors “how to show up, not what to say,” said Riess. “We do a lot of training in emotional recognition and self-monitoring.” That includes learning to identify seven universal facial expressions — using research pioneered by psychologist Paul Ekman — and to take stock of one’s own emotional responses to patients or situations.
Some of the course is explicitly prescriptive: Make eye contact with the patient, not the computer. Don’t stand over a hospitalized patient, pull up a chair. Don’t conduct a monologue in off-putting medicalese. Pay attention to tone of voice, which can be more important than what is said. When delivering bad news, schedule the patient for the end of the day and do not allow interruptions. Find out what the patient is most concerned about and figure out how best to address that.
One Doctor’s Experience
Andy Lipman has taken the Duke course twice: first as an oncology fellow in 2004 and last year as a practicing oncologist in Naples, Fla., when he felt in need of a “booster shot.” Oncology, he said, “is a full-contact” specialty with a high burnout rate.
Among the most important lessons Lipman said he learned during both sessions was to let go of “my own medical agenda, the desire to fix something or make something happen in that visit.” He learned to pace himself, monitor his reactions and talk less.
Every day, he said, he thinks about what he was told in 2004: “Never answer a feeling with a fact.” That means responding to a patient in a six-month remission from cancer who reports having a sore elbow by saying, “Tell me more about your elbow. This is probably scary stuff” and not “Your scans show no evidence of disease.”
One technique Lipman routinely employs is taking 15 seconds before entering an exam room to ask himself, “What is needed here?”
On the day he was interviewed, Lipman said, he used what he has learned with a patient with end-stage cancer. She was scheduled for a brief appointment but began weeping loudly as she told Lipman how alone she felt.
“I engaged, I expected the emotional response and I hung in there,” he said of the meeting, which lasted 45 minutes. “It felt good to me,” Lipman said, and he hoped it gave his patient some comfort.
Think of why the police exist and that popular synonym for police, “law enforcement.” That term is casually applied, but its use and popularity has real meaning and implications. In contemporary America, police officers are viewed as responders: they get the radio call, they speed to the scene in their vehicles and then they take care of business by, literally, enforcing the law.
But is that really what the police are for? Sir Robert Peel, founder of Scotland Yard and the father of modern policing, wrote nine principles for policing, the first of which states, “The basic mission for which the police exist is to prevent crime and disorder.”
The primary tactic for upholding that principle was the police patrol – the beat cop, on foot, scouting the neighborhood and interacting face-to-face with citizens. But the very meaning of patrol completely changed when revolutionary technology, in the form of automobiles and two-way radios, hit the streets and took police officers off the sidewalks and away from people.
This fundamental shift from proactive prevention to after-the-fact reaction was not viewed as a problem for several decades. In fact, some concluded that making arrests was the best that police could do because crime was too big and with root causes too complex for the police, as “law enforcement,” to prevent anything.
Many criminologists believe this shift contributed to skyrocketing crime in the 1970s and 1980s. It wasn’t until the mid-1990s, with the implementation of “community policing” and “broken-windows theory” (which says petty acts like vandalism, if not immediately addressed, lead to more serious crimes), that crime rates, particularly in big cities, turned decidedly downward.
What does any of this have to do with health care? Sir Robert wrote, “The test of police efficiency is the absence of crime and disorder, not the visible evidence of police action in dealing with it.” It could also be said that the test of health care efficiency is the absence of illness and disease and not merely the visible evidence of providers delivering care.
Yet, our society remains largely convinced that with the help of crime-fighting gadgetry, we can still arrest our way out of crime (just look at how policing is still depicted on television; is there really any difference between “Adam 12” and “CSI” except the technology?)
It’s not quite so bad in health care; people understand, perhaps more than ever, that illness and disease can be prevented. Still, there are strong expectations (all reinforced by an antiquated payment system) that health care providers, like law enforcers, exist for exactly the reason the name suggests; that health isn’t possible unless care is being provided, often in an intense and costly manner, and that indeed we can treat our way out of poor health.
It is obviously vital for hospital leaders and other providers to address that misguided perception. How? Once again, we turn to Sir Robert, who wrote that the police are simply “members of the public who are paid to give full-time attention to duties which are incumbent on every citizen in the interests of community welfare and existence.” Can’t the same be said of health care providers? Isn’t there more than a little similarity between broken-windows theory and population health?
Health care, like policing, is a partnership between providers and communities, where in the name of prevention each shares, in-part, the other’s role. The future for an effective, efficient and sustainable health care system depends upon transparently connecting with key communities – including government, business and payers – to cultivate those partnerships and ensure shared priorities are understood and best practices are adopted.
Medicaid, with 560,000 insured Iowans, is the second largest health plan in the state, providing health insurance to more Iowans than Medicare. Medicaid is a $4.1 billion program (including state and federal contributions) that spends 58 percent of its resources on 168,000 severely disabled individuals. Correspondingly, it spends 42 percent of its resources on the other 392,000 participants.
Two months ago, the Branstad administration announced its intent to contract management of Medicaid to private companies. Medicaid is currently managed by the Iowa Department of Human Services. The initial request for proposals indicates that the administration is willing to pay up to a 15 percent contingency to successful bidders, of which there will be at least four, putting into play $645 million of earnings per year to be divided among these successful bidders. The state also wants its costs reduced by $100 million per year.
At least 18 companies have indicated initial interest in managing Iowa’s Medicaid program; all but one are non-Iowa companies. The timeline for selection of bid winners is July 31.
This timeline and the notion of moving the entire Medicaid program to management by private entities begs many more questions than it answers.
First is the potential impact on private insurance rates in Iowa. Since the adoption and approval of the Iowa Health and Wellness Program by the Iowa Legislature and Branstad administration, charity care and uninsured rates in Iowa hospitals have plummeted. During the first 11 months of 2014, the number of people hospitalized in Iowa without insurance fell by 47 percent compared with the same period in 2013. With more Iowans now insured, hospitals’ charity care losses fell 31.5 percent, yielding a total 11-month improvement of $103.3 million.
Everyone understands there is no free lunch in health care. The $745 million (earnings plus savings) meal price for Medicaid managed care will come at someone’s expense. It most likely will come at the expense of charity care and self-pay cost reductions.
Second are the implications of Medicaid managed care on Iowa’s Medicaid innovation program. In the last three years, health care providers have come to the table with the state and Iowa’s leading private health insurer to design a program that aligns public and private interests in bringing greater value to Iowa health care. This effort recently resulted in Iowa being one of only 18 states awarded $41 million to further improve Medicaid outcomes.
The chief objective of Iowa’s Health and Wellness Program and the State Innovation Model (SIM) for Medicaid is to move Iowa’s health care system to one that rewards care coordination, resulting in higher quality and more efficient outcomes. Achieving this goal of care coordination and community networks is the SIM’s central focus.
The Medicaid managed care initiative also hinges on the establishment of community care networks. But as proposed, these concepts appear to compete with one another. Based on initial interest, the Medicaid managed care proposal presupposes that those in the best position to establish relationships at the community level throughout Iowa are non-Iowa insurance companies. The lack of clarity on how the SIM coordinates with Medicaid managed care threatens the opportunity and possibly the funding for improvement through the SIM.
This is not Iowa’s first rodeo with Medicaid managed care. The state’s first major initiative with managed care was with the introduction of managed behavioral health services 20 years ago. The results of that experiment are written across Iowa’s health care landscape today as hospitals routinely search for inpatient bed placements, community access to sub-acute care remains virtually non-existent and hospital emergency rooms are, for many, the only point of access to Iowa’s mental health care system.
The state should slow down, resolve questions of fundamental competing concepts and set objective benchmarks for those seeking to assist in managing one of Iowa’s most important constituencies. Perhaps then, Iowa can avoid similar access concerns being imposed on Iowa’s entire Medicaid program.