Does Profit Really Ruin Health Care?

by JHI Staff on December 23, 2013

There’s an argument that seems to be echoing through the media and in many public circles these days: That the U.S. has an absurdly costly and ineffective health care system, and the reason is that much of it is provided by and paid for by the private sector, rather than the government. Though this case is made in many places, this article in the New York Times from early in 2013 laid it out in particularly strong terms. A small excerpt:

From the high administrative costs incurred by health insurers to screen out sick patients to the array of expensive treatments prescribed by doctors who earn more money for every treatment they provide, our private health care industry provides perhaps the clearest illustration of how the profit motive can send incentives astray. By many objective measures, the mostly private American system delivers worse value for money than every other in the developed world... . Improving the delivery of social services like health care and pensions may be possible without increasing the burden on American families, simply by removing the profit motive from the equation.

The argument, as exemplified by this article, is grossly oversimplistic—if not plain, flat-out wrong. Let’s start with the claim that our system provides terrible outcomes. As I and many, many others in health care have pointed out time and time again, it’s not at all clear that our health care system produces lousy results. As someone who constantly travels internationally to meet with health care leaders, government officials, clinicians and other health care stakeholders of all stripes, I can positively report that U.S. health care quality by and large remains the envy of most of the world.

Yes, we spend more than other nations—in most cases a lot more. There is a complex picture behind our higher costs. Yet pundits and others in the media keep pinning the entire problem on single, simple factors. Some say it’s because hospitals simply charge too much. Some say it’s because U.S. consumers have no incentive to price shop. Others say our health care providers’ incentives are all backwards. And then there’s the claim, as per the Times article, that it’s because we don’t just turn all of health care over to the government. (Perhaps tellingly, the author cited a small, 30-year-old study of sedatives at southern Wisconsin nursing homes as evidence for what he suggests is the general inferiority of for-profit care.)

Bad news: the problem of the high cost of U.S. health care is due to all of these things, and many more. (For example, one often overlooked factor is that Americans can on average afford to pay much more for health care than most of the rest of the world, so we opt for a much more elaborate and costly health care system.) At the same time, it is not really any of these things. That’s because there’s no good consensus of evidence that changing any one of these factors will substantially lower our health care costs. We need to tackle the big picture, and in many ways. (Something that the Affordable Care Act—for all its initial woes, potential shortcomings and controversies—aims to do.)

As we struggle to come to grips with these complexities in order to get a handle on costs, I have to question how helpful it is for pundits to point the finger at simplistic causes and solutions. And the notion that the whole problem can be laid at the doorstep of the private and for-profit components of our health care system is perhaps one of the most simplistic of all these claims.

Johns Hopkins Medicine collaborates around the world with public, private not-for-profit, and for-profit health care providers and payors, just as we work with both the public and private sectors here in the U.S. I don’t see any clear pattern in terms of whether one of these sectors does a much better job than the other two, either in holding down costs or boosting patient outcomes. As an academic medical center we happen to be private and not-for-profit, and we’re proud to be mission-driven. But I also see both government agencies and for-profit companies here and overseas create, invest in, support and run highly admirable health care systems. And I see all sides, including private non-profits, fall short in some systems, too.

Clearly, the battle to bring better health care to more people at a lower cost can’t reasonably be reduced to a question of profit versus not-for-profit—even putting aside the obvious political futility in the U.S. of trying to shift all health care responsibility to the government. We need thoughtful solutions, and a path to come together to develop them.

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What Inspires Improvement?

by JHI Staff on December 11, 2013

In our collaborations with health care providers around the world aimed at improving quality, safety and access, every project is unique. But one thing that’s pretty close to universal is encouraging our collaborators to strive for international accreditation. Typically we’ll work with them to achieve Joint Commission International accreditation, which is the most widely recognized hospital accreditation around the world—and one of the toughest to get, too.

We encourage taking such a tough road because it’s not enough to simply hold up general improvement as a goal. We firmly believe that what inspires real improvement in a difficult field requires commitment to a tangible, specific achievement, and a chance to earn a sense of genuine accomplishment at succeeding. For our collaborators, shooting for JCI accreditation serves that purpose. We’ve seen it result in a range of impressive improvements again and again.

In fact, all hospitals, including Johns Hopkins, should be continuously working toward the next level on the improvement scale, no matter the starting point. In our case, we recently set our sights on a particular measure to strive for. Since 2011, the Joint Commission has published a list of hospitals it calculates are “top performers” based on each hospital’s ability to document near-perfect compliance with at least four standard-of-care, evidence-based clinical processes addressing heart attack, surgical care, stroke and other conditions.

For the first two years, no Johns Hopkins Medicine hospital made the list. Why? It’s tempting to make excuses, and we certainly had a few. Compared to most hospitals that made the list, academic medical centers like Johns Hopkins Medicine tend to deal with patient populations that are larger and often sicker, and operate several different hospitals, leading to complex environments in which it can be especially challenging to maintain extraordinarily high rates of process compliance. In fact, almost no medical center or teaching hospital made the list in the first two years; the list was dominated by community hospitals.

But after the publication of the first Top Performer list, our leadership, right up to the level of the president and trustees, firmly and explicitly committed to doing what it takes to make the grade. And with the release of the Joint Commission 2013 report, we learned we succeeded. Not only did our flagship hospital here in Baltimore make the list, but so did two other Johns Hopkins hospitals: Sibley Memorial in Washington, D.C., and All Children’s Hospital in St. Petersburg, Florida.

Here’s an excerpt of what an article about the 2013 Top Performers list in HealthLeaders Media had to say about the Johns Hopkins effort to make the list, quoting our own Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality, and senior vice president for safety and quality:

Hospital teams made a checklist of why such projects fail, tackling them one-by-one so that performance on process measures for heart attack, heart failure, pneumonia and surgical care all exceed 95%.

For one of the measures, “We reduced the time between arrival and treatment of heart attack patients requiring immediate care from around 90 minutes, the national benchmark, to an average of 66 minutes,” Pronovost said, which required collaboration between emergency responders, interventional cardiologists, nurses and support staff.

“Now, the hospital’s heart attack team is often activated before the patient even reaches the emergency department,” he said.

Clearly, making the needed improvements wasn’t easy. But our teams were inspired by the goal, and rose to the occasion. It’s exactly the sort of inspiration we work hand-in-hand with our collaborators around the world to ignite among their teams, often by getting everyone to rally around the JCI accreditation process.

Our collaborators have, in general, done extremely well in meeting these challenges and achieving accreditation. But outside of our collaborators, there remains a daunting gap between what it takes to be a high-performing hospital that reliably delivers high-quality, safe health care, and what the populations of many parts of the world are getting from their local health care providers. Consider: To make the Joint Commission top performers list, a hospital has to document a 95-percent compliance rate with key clinical processes, many of them involving state-of-the-art medicine. But according to the HealthLeaders Media article, research has shown that just for hand-washing hygiene among clinical care providers in hospitals, the median compliance rate globally is 40 percent.

That gap is why we’re dedicated to working internationally to help health care organizations improve. And we remain dedicated to continuing to improving our own health care delivery at Johns Hopkins Medicine. To make next year’s Top Performer list, hospitals have to document compliance with at least six different clinical processes, rather than only four—and one of the six has to address tough standards for perinatal care. Obviously, we won’t have a chance to rest on our newly won laurels—and we wouldn’t have it any other way.

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Where’s the Data on Global Health Care Systems?

by JHI Staff on December 9, 2013

Improving the accessibility, quality and cost of the health care delivered by a single hospital to a surrounding community is a big challenge. It’s one that we at Johns Hopkins Medicine International (JHI) face all the time, alongside our many collaborators around the world and our parent organization, Johns Hopkins Medicine, with its domestic network of hospitals in multiple states.

But relatively speaking, we have it easy. Or so it feels when I compare the tasks we face with those faced by policy-makers and industries charged with improving not just individual hospitals, but entire national health care delivery systems. Think about just a few of the critical questions that must be tackled in that daunting endeavor. What sort of payer system best leads to good, affordable health care for tens or hundreds of millions of people? What sort of government regulation improves health care delivery without unnecessarily burdening it with costs and inefficiencies? What mix of private and public hospitals provides the best outcomes and value?

Answering these and many other crucial questions would be hard enough if decision-makers had plenty of data about how different approaches to health care delivery have worked in different countries. But, in fact, good country-by-country data on exactly how systems perform can be hard to come by in much of the world—and in many ways, studying how health care systems perform relative to one another is a nascent endeavor.

Ironically, we actually have some data on the lack of sufficient data about health care delivery systems. In a research paper on the subject published in the journal Health Research Policy & Systems, the authors note the following:

To our knowledge, there have been no efforts to develop a comprehensive profile of the available research evidence addressing topics related to governance, financial and delivery arrangements within health systems, and implementation strategies that can support change in health systems, and the products derived from them.

In other words, there isn’t even a good way to find out what data is available on this subject. Particularly lacking, the authors note, are studies that look at the impact of financial and governance arrangements, both of which are obviously critical to how health care systems perform. The authors also quote from a 2009 New Yorker article by respected physician-author Atul Gawande, who wrote:

[The U.S.] Congress has provided vital funding for research that compares the effectiveness of different treatments, and this should help reduce uncertainty about which treatments are best. But we also need to fund research that compares the effectiveness of different systems of care – to reduce our uncertainty about which systems work best for communities. These are empirical, not ideological questions.

Part of the problem is that while many researchers and organizations have been involved in international public health efforts, far less attention has been paid on a cross-border basis to formal health care delivery systems. That imbalance is becoming more and more of an issue as low- and middle-income countries, bolstered by booming growth in their middle classes, turn their attention to health care.

At JHI, we are already affected by that lack of data. Shortages of good metrics on what approaches to health care delivery work best in a given country, or across many countries, sometimes makes it harder for us and our collaborators to determine the best way to set up an individual hospital.

That’s why we’ve taken a specific focus with our collaborators on establishing useful metrics that will be invaluable going forward. As we build our own databases here, we’re also building a tool for looking on a cross-country basis at what works best where. But we still have a long way to go to develop the sorts of data assets that will really help answer these questions. And in any case, this isn’t something we can do on our own. The real solutions will come when data is successfully pooled from thousands of hospitals around the world.

As more organizations turn their attention to global collaborative health care, that goal should grow within reach. Such pooled-data efforts will certainly pay off in better decisions here in the U.S. and other highly industrialized countries. But these countries already have at least pretty good health care systems, and though we all struggle mightily to improve them, it takes a lot of work to eke out relatively small gains. In low- and middle-income countries, on the other hand, the potential exists for vast improvements, perhaps even with modest tweaks to how systems are set up. Those populations will be the real winners.

We’re determined to keep moving forward in terms of trying to get the needed data to do our part in helping to make all this happen, and we hope we can join others in that effort. I’ll keep you posted on our progress. And if you have any suggestions, I’d appreciate hearing about them.

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Should Physicians Blog?

by JHI Staff on December 4, 2013

It used to be that aside from the tiny percentage of celebrity physicians featured in magazines or on TV, the only way to get a doctor’s opinion was to be in his or her office. Today, on the other hand, you can instantly get tens of thousands of doctors’ opinions on just about anything, thanks to the fact that physicians—like everyone else—have increasingly come to embrace social media. Be it blogs, Facebook, Twitter, email or text messaging, doctors are online, eager to provide medical advice and otherwise opine on an endless array of topics.

In many cases, physicians are participating in the social-media presence established by their hospitals or academic institutions, while others are reaching out on their own. Either way, getting out there via social media is a way for physicians to promote recognition and credibility, bring in new patients, and influence the practice of medicine. As one physician put it in a New York Times blog post, “Doctors need to be on social media because ‘that’s where the patients are going to be.’” (She was herself quoting another blogging physician.)

But is this massive physician presence on social media actually good for patients? Needless to say, there are pros and cons:

Pros

  • ŸPatients have more opportunities to get qualified medical advice on issues of concern to them. Access to trusted information from a doctor can be especially important these days, given how many unqualified opinions about health issues are presented in unregulated online forums.
  • ŸWhen a pressing health issue comes up, consumers can find out immediately what doctors have to say about it. No matter how obscure a condition, physicians have weighed in on it online—and that can be a real anxiety reliever in a crisis.
  • There are opportunities to seek tailored advice. Many physicians take questions on websites, blogs and on their Facebook pages, or interact via Twitter. Some new cellphone-based services are specifically designed to let physicians dispense advice to individuals via messages or chat.
  • The online world provides physicians with opportunities to inform patients on a wider range of issues than what might normally be discussed in a visit to the office, providing helpful background and perspective to medical issues. As Baylor College’s Bryan Vartabedian, a blogging physician who specializes in exploring the role of social media in medicine, puts it in a post expanding on this point:

The capacity to be public really amplifies the fact that we all have passions, missions and roles in the world. Being front and center with a footprint and identity forces us to think about where we fit in the world. It was easy to be elusive when the world was private and our existence was restricted to an exam room. But now we’re part of a wide-open, networked world. This capacity to share and create exposes us for who we are and what we believe in. Being here is an act of intimacy.

Cons

  • ŸThe online world often highlights to an easily misled public the advice of doctors who take controversial stands with which most doctors would disagree. That can lead to unfounded health scares, for example, or the neglect of potential effective treatments in favor of less-proven treatments.
  • The ready availability of online advice might lead people to be less motivated to get the one-on-one time they need with their doctors.
  • As more doctors come to feel that maintaining an online presence is necessary to staying competitive in the field, they may have to take time away from their already overly packed schedules and practices to do it.
  • Most online pronouncements are not fact-checked or filtered in any way, and there is no way for consumers to validate the physician’s credentials or qualifications to provide the advice. Given a new online pulpit, some physicians may not be able to resist expounding on subjects that go beyond their expertise. Most laypeople don’t have any way of knowing the limit of a physician’s expertise, and may be too trusting.

Overall, I’m a big believer that technology, including and perhaps especially the online world, is in a position to do wonders for the cost, quality and accessibility of health care. That’s especially true in regions of the world, and even communities in the U.S., where high-quality health care hasn’t been widely available.

But technology needs to be applied judiciously, and physician online activity is no exception. It’s an ongoing experiment, and while I hope physicians keep at it, I also hope they’re responsible about reminding people of the limitations of online advice. Hopefully in the future there’ll be mechanisms for keeping the quality of the advice high, and for making sure it’s presented with the appropriate qualifications.

In the meantime, keep in mind that even when the online advice comes from a doctor, it’s a good idea to validate it with a second (or third) source.

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A little while ago I came across an article that provides a thoughtful analysis of the question of whether the U.S. health care system’s emphasis on new technology and innovation is largely responsible for our higher costs as compared to the rest of the world. Here’s a brief excerpt (and please note this is the author, Bloomberg journalist Megan McArdle, describing other people’s beliefs that she doesn’t entirely share):

Cost growth, the argument goes, is largely driven by innovation. Not necessarily good innovation—quite a bit of time was spent [at a conference] denigrating Proton Beam facilities (used for cancer treatment) that cost in the tens of millions of dollars and don’t seem to do patients much good, yet whose total number is set to double between 2010 and 2014....[Many argue that] if you want to control costs, you need to stop third-party payers from paying for new technologies.

I need to point out a few things before jumping into this tricky subject. First, it’s probably a mistake to spotlight the availability of high-tech, leading-edge health care as an isolated issue, because it’s bound up in many ways with other trade-offs in health care policy. McArdle does note that, but it’s still easy to jump to the conclusion that technology is the main problem behind higher costs. (There’s no doubt it could be part of the reason—it’s just more complex than that.)

Another critical point to consider is not just whether a new technology provides better outcomes, but how much improvement it offers in balance with cost. This is, in a way, an “un-American” question in that it goes against the grain of our health care culture. We have grown up in a system where everyone, in theory, has a right to the most effective treatment available, whatever the costs (apart from elective treatments, and those considered experimental). This culture is so engrained that if you had a serious illness and your doctor told you there was a treatment that would give you a 20 percent better outcome, but because it was 40 percent more expensive he or she couldn’t prescribe it, you’d probably be shocked, appalled, and perhaps even outraged.

This is related to the “no-skin-in-the-game” problem I’ve written about before, which leads the U.S. population to be highly price-insensitive in health care, but highly quality-sensitive. And that aspect of our health care system tends to make possible the investment in leading-edge, sophisticated new technologies that often deliver relatively small improvements at large incremental cost.

As McArdle points out, while the problem is obvious, it’s also easy to see a good side—namely, access to a constantly evolving stream of ever-more-effective treatments. The effectiveness vs. cost balance is a choice we can rationally make as a society; it’s only irrational if we feel entitled to the leading edge of health care, but demand that at the same time our health care costs be brought into line with that of most of the rest of the world. (In the rest of the world, insurance or governments rarely cover the leading-edge treatments if they don’t provide a substantial improvement over less-costly treatments. Those who can afford it can pay out-of-pocket to get it.)

Having said all this, I believe there’s a way we can have our cake and eat it, too. When we think of health “technology” and “innovation,” we tend to think of a new imaging device, a new electro-mechanical artificial organ, a robotic surgery system, or a new drug developed via leading-edge genomic approaches. But innovation in health care can be a process change, such as a new way of keeping track of surgical instruments, or a new approach to billing patients. It could be the discovery that an older, relatively cheap drug can be made more effective in different doses, or for other disorders. Increasingly, it’s better ways of helping clinicians stay connected to their patients, with tools like cellphone apps.

Unlike the more dramatic forms of technological innovation in health care, these and many other types of innovation can be introduced in ways that could dramatically lower costs, even while improving outcomes. Who could object to that? So before we point at innovation and technology as the enemy, let’s clarify our thinking about it. We may yet be able to come up with a health care system that provides leading-edge care without the massive extra costs.

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Into Africa

by JHI Staff on October 24, 2013

What Johns Hopkins Medicine International (JHI) does differs in some ways from the more conventional approach to improving health around the world. The more familiar approach, typically driven by NGOs, charitable institutions, and public health agencies and schools, often involves funding efforts that reach poor people in their daily lives with health-promoting supports, be it vaccines, antibiotics, clean-water initiatives, education, and much more. Needless to say, such efforts are hugely worthwhile, and have done vast amounts of good throughout many regions.

JHI, on the other hand, is largely focused on collaborating internationally to build and improve sustainable health care systems, with an eye to providing more people with better access to higher-quality, safer hospitals and improved clinic care globally. The “sustainable” part is a key component of our mission. Essentially, we see health care efforts as sustainable when they are built around public or private models that ensure there will be sufficient ongoing revenues to keep the efforts going, and even expanding and improving them, far into the future.

Everyone deserves good access to high-quality, safe care, and wherever in the world there’s a lack of it, or room for improvement (and I’d argue there's always room for improvement), we’d like to be involved in collaborations. The challenge we face is that undertaking these sorts of revenue-dependent projects in sustainable ways is difficult in less affluent regions of the world. We’re very proud of the work we’ve done, and continue to do, in regions where patient care is funded for most of the population by insurance and government agencies, or where patients can afford to pay out-of-pocket. But it has been a longstanding passion of ours—and of mine—to try to find ways to extend our work to regions where a large percentage of the population are poor, uninsured, and not covered by government health care.

That’s why I’m very pleased that we’ve just formalized our first collaboration in Africa. The effort is centered in Lagos, Nigeria, and is aimed at expanding and improving care at a string of clinics operated by Me Cure, clinics that currently offer diagnostic services and that will be adding outpatient ophthalmic care. We hope to extend the effort beyond ophthalmology in the coming months and years into other areas of specialty care, as well as to expanding it geographically.

Juan Carlos Negrette, one of our regional managing directors, has been working tirelessly in Africa for a couple of years now, building his understanding of the region’s needs and resources, getting to know potential collaborators, and shaping business models that would create productive collaboration opportunities. We understood the challenges of building sustainable health care there, and knew it would take a while. But we were confident we would find ways to make it work, and now it appears we have a solid beginning.

It’s important to understand that we’re not claiming we have a magic formula for providing top-notch health care in a sustainable way in low-resource environments. (No one does.) In countries that lack universal health care, models for sustainable care have to be based on bringing in patients who can afford to pay, either out of pocket or through insurance. That means these programs have to take hold and grow mostly on the strength of an emerging middle class. Nigeria does indeed have a growing middle class, and that segment of the population will largely fuel the growth of this work.

As we see here in the U.S. and in many other countries, the investment that a strong middle class is able to make in their own health care can make it possible to provide affordable care to the poor. That’s the model we’re operating on, and we believe over time we can work with our collaborators to build sustainable health care infrastructure that can serve whole populations in developing countries. (Our Bharat Family Clinic project in India is another example of an effort that will be driven by middle-class patients, but that is expected to also improve health care access to many poor people.)

This progress is energizing. Certainly, it’s just a beginning, and there’s much to be worked out before we can claim success. But I’m convinced that it will come. Needless to say, I’ll keep you posted.

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A Look Inside the 2013 JHI Partners Forum

by JHI Staff on October 14, 2013

Two weeks ago we hosted the Johns Hopkins Medicine International (JHI) Partners Forum, our annual meeting of leaders and clinicians from our international affiliates, representing what is likely the largest network of health care collaborators in the world. JHI is now engaged in global collaborative health care contracts in more than 30 countries, and this forum provides an extraordinary opportunity to get a sense of what challenges are on the minds of health care leaders in different regions, to assess how these challenges vary with geography and culture, and to discover what we all have in common.

Perhaps most importantly, Partners Forum gives us a joint platform to share our thinking on how to face these challenges. Not that many solutions are universal across regions or health care systems—as I’ve noted in this blog many times, solutions have to be adapted to local needs, resources and culture, and some translate more easily than others. Hence the theme of this year’s forum: Developing Local Solutions to Global Health Care Challenges.

What attendees tend to find most valuable about the Partners Forum is simply the chance to informally talk face-to-face to their global counterparts from other health care systems, comparing notes, strengthening bonds and sowing the seeds of future collaborations. But a big, more formal part of this forum involves holding panels and presentations open to all attendees. Just writing about the ideas that were laid out in these sessions could keep me busy blogging for a year—and I will zoom in on some of them in future posts.

But for this post, I’ll just share a few tidbits that provide a sense of the range of topics embraced by Partners Forum attendees, and the key takeaways.

Emergency medicine

  • Emergency medicine no longer deals mostly with people facing life-threatening health crises—that is, true “emergencies”—but instead with patients who need more routine diagnosis and treatment, making the emergency department “the source of episodic care” throughout the world. So forum attendees were told by James Scheulen, chief administrative officer for the Johns Hopkins Department of Emergency Medicine, who also described some of the work he’s done with Anadolu Medical Center in Turkey around disaster preparedness.
  • Francisco Holguin, who heads the Institute for Emergency Medicine and Trauma at University Hospital of Fundacion Santa Fe de Bogota in Colombia, described the vast strides the Institute has taken by building up its emergency medicine team with experienced clinicians who specialize in the field, and using an emergency medicine curriculum designed at Johns Hopkins.
  • Attendees heard about a new ED patient flow monitoring app for iPhones at Al Rahba Hospital in the United Arab Emirates, as well as the creation of a collaborative network of emergency department clinicians at hospitals throughout the UAE—a network that may become global in coming years.

Patient safety

  • Most hospital professionals see patient safety as someone else’s responsibility, noted Javier Contreras, the CEO of Hospital Punta Pacifica in Panama City, Panama. But hospitals like his that have stepped up efforts to protect patients now ensure that physicians, nurses, pharmacists, technicians and administrators all see themselves as being directly responsible for playing a key role.
  • Steve Kravet, who heads Johns Hopkins Community Physicians, described how he is working with India’s Bharat Family Clinic—which has plans to open hundreds of clinics across India—to boost preventive medicine efforts in that country. Such measures are critical in all countries, he argued, including the U.S., given that 97 percent of patients who receive care from Johns Hopkins Medicine “never touch a hospital bed.”

Oncology

  • Guillermo Garrido Lecca, CEO of Peru’s Pacifico Salud, an integrated health care system, talked about how his organization became involved in providing oncology care after the costs of providing third-party oncology care to its customers tripled over a three-year period. Now Pacifico Salud performs 120 exams per day that are strictly focused on preventive medicine, and has increased the number of oncology services it offers from three to 30.
  • At Tawam Hospital in Abu Dhabi, access to a large national insurance database on patient procedures has allowed analyzing oncology-related data with an eye to improving quality and capacity planning, according to Tawam Chief Operating Officer Steven Matarelli. Tawam has also added a linear accelerator for cancer treatment, and the country’s only palliative care unit.
  • Jane Shivnan, executive director for clinical quality and nursing for JHI, suggested that nurses may be able to play an important role in oncology research by assessing patient quality of life, a critical consideration currently missing from most studies.
  • Mengfeng Li, vice president of first-time Partners Forum participant Sun Yat-sen University in Guangzhou, China, described the sort of culture change that health care institutions must go through to create top-notch research programs. (Sun Yat-sen is currently collaborating with JHI to that end.)

Reflecting back on this year’s Partners Forum, I was struck by the strong feeling of community that was apparent in every aspect of the activities. I think most outsiders would have had a hard time telling which attendees were based here in Baltimore and which were representing institutions from elsewhere on the planet.

Not that we’re all exactly alike, but we certainly continue to discover how much we have in common, and how much there is to share. And that’s really the point of the Partners Forum, and, in fact, of everything we at JHI and our collaborators are doing together.

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Focusing in on Employee Wellness

by JHI Staff on October 7, 2013

It’s pretty well accepted in the health care community that one of the big tasks in front of us is finding ways to support patients—and the whole population—in adopting healthier lifestyles. I’ve written here and here about the critical role that behavior plays in taming obesity, cardiovascular disease, cancer, Alzheimer’s, and other non-communicable chronic disease, and health care’s mandate to do something about it.

But how do we get people to adopt healthier diets, to exercise more, to see their clinicians regularly, to take their meds, and in general pay more attention to their health and the behaviors that affect it? I wrote about one straightforward scheme in Dubai to incentivize the population to take better care of themselves: simply have the government hand citizens a check if they improve their fitness profiles. But most governments aren’t ready to start paying people for healthy behavior. And the unfortunate fact is that we in health care haven’t yet figured out how to motivate and support most patients in making these tough behavioral leaps. So who actually is in a position to provide the nudges and incentives that are so critical to getting people on board with healthy lifestyles?

One clear answer is employers. In some ways the workplace is the ideal forum for facilitating behavior change. It’s a somewhat controllable environment, people are in it for half or more of their waking hours, and employers have the authority and means to create any sort of reasonable conditions in it. In fact, much of the progress made in reducing smoking rates in the U.S. surely owes to changes that have made the workplace highly non-conducive to the habit, and to the social and other supports that the employers have made available to those who wanted to quit. But can employers play a role in changing people’s diet, exercise, and other health-related behaviors?

Employers certainly have a terrific incentive to try, even beyond simply caring about the well-being of the people who work for them. Healthier employees are obviously more productive employees. Consider obesity alone: Studies suggest an obese person is likely to lose nearly a decade of life compared to non-obese people, and those early deaths are preceded by a host of ailments that lead to absences and reduced effectiveness in the workplace. Studies have estimated the lifetime productivity loss for an obese person at about $150,000.

In the U.S., there’s a direct financial incentive to improve the situation, in that employers’ staggering health care costs can be significantly cut by improved employee health. But in any country, regardless of the payer system, high health care costs are a burden to everyone, and any path to reducing them will ultimately financially benefit employers at least as much as it does others. Make no mistake: behavior-related poor health is a global problem. The populations of many nations around the world are currently on track to reaching obesity rates of two-thirds within a decade, according to the Organization for Economic Cooperation and Development.

What can employers do to help employees improve their health-related behavior? Needless to say, it’s inappropriate to take heavy-handed, threatening or restrictive approaches to pushing employees to make changes, no matter how good the intentions. I don’t think most employers would be foolish enough to, for example, fine employees caught enjoying a donut or other treat, or to threaten to discipline or even fire employees who don’t participate in company exercise programs. Rather, the best approach is to create an environment that gently and positively leads people in the right direction.

Employees will change if they’re incentivized to change, if they’re constantly receiving cues and prompts and nudges, if they get good support and encouragement from those around them, and if they receive effective guidance and information. At Johns Hopkins Medicine we have a program that, among other things, provides a modest financial reward to employees who report improvements in their health-related lifestyle. In our own offices we have small locker rooms with showers to make it easier for anyone who’s up to getting in some exercise before, during or after work, and we’re bicycle-friendly.

There are a growing number of resources available to help both employees and employers do the right thing with regard to facilitating behavior change. I’ve written about some of the cellphone apps that are springing up to provide support. In addition, there are dozens of companies that specialize in helping employers design, implement and operate healthy behavior programs for employees, and to get the maximum payoff from them. Insurers are on board, too, and most will assist employers and employees with resources and incentives. Obamacare has employer incentives built in as well.

I think we’ll look back a decade from now and shake our heads at how oblivious employers have been to the opportunities to help employees get healthier and more productive, and to reduce our costs. After all, there aren’t that many ways we can do a lot of good for others while benefitting ourselves in concrete ways. Having an effective employee health-improvement plan is surely one of them, and I hope more of us start to act on it. We are certainly working on ways to do better here.

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We at Johns Hopkins Medicine International (JHI) recently announced our newest collaboration, with Hospital Moinhos de Vento (HMV) in Brazil. We’re always proud when our growth takes us into a new country, and Brazil is a particularly important country to be involved with—in fact, it’s one we’ve had our eyes on for a few years. With a population of 200 million and the sixth largest economy in the world, Brazil’s influence is increasingly extending well beyond Latin America to the global stage. What’s more, with a strong and growing middle class, Brazil is already committed to widely accessible, high-quality health care, and is constantly raising the bar.

HMV is an especially impressive institution for us to collaborate with there. The hospital’s home base of Porto Alegre is only the tenth largest city, but it’s a major industrial hub and the largest in the southern part of the country. The city is already renowned for the quality of its major hospitals, and HMV stands out even among this group. That means that we’re not there to make an emerging hospital a good one—rather, our collaboration is intended to support an excellent regional hospital in its quest to become a world-class provider of health care. Indeed, while HMV already draws patients from all over southern Brazil, it has its sights on becoming a health care destination for patients from neighboring countries, including Uruguay, Paraguay and Argentina. We’ll definitely be working hard to keep up with HMV’s ambitions and sense of urgency, as laid out in a solid strategic plan that sketches out the hospital’s planned growth and improvement through 2020.

These admirable ambitions will see us working closely with HMV as it builds up its expertise in several specialties, including neurology and neurosurgery, imaging, cardiology and oncology. HMV will also be drawing on Johns Hopkins’ Comprehensive Unit-based Safety Program (CUSP), widely regarded as state of the art in patient safety. (Peter Pronovost, who heads the Armstrong Institute for Patient Safety and Quality here at Johns Hopkins, spoke at the signing of our historic agreement.) We’ll also be working together to set the highest possible standards for nursing at HMV—in most of the world, progress in making nurses full and equal members of the patient care team alongside physicians lags behind what top health care providers in the U.S. have achieved, and HMV is eager to close that gap.

We’ve found HMV to be aligned with Johns Hopkins when it comes to a number of critical challenges in health care today. Like us, HMV is increasingly focused on better managing chronic disease, such as cardiovascular disease, cancer, diabetes and Alzheimer’s, as a means of both improving population health and reducing the costs of health care. It also, like us, recognizes that high-quality patient care does more than treat physical disease—it also addresses other aspects of patient wellness, including patient comfort, emotional state and lifestyle.

And particularly impressive about HMV is that it shares our belief in the importance of academic medicine’s tripartite mission: patient-centered care, biomedical research and clinician education. HMV already has a significant research program—unusual for most hospitals outside the U.S. and Europe—and is eager to work with Johns Hopkins to expand the program to become a full-fledged clinical research center. HMV also intends to seek the type of academic accreditation that will enable it to bring in clinical residents and fellows, and plans to establish a school of nursing.

HMV isn’t wasting any time, either—they’ll have a team of nurse leaders here at Johns Hopkins in just a few weeks for close observation, and two of our top nursing experts, Jane Shivnan and Patricia Dawson, will be heading down to HMV. The clinical and administrative exchanges will be flying fast and furiously from now on, and we intend to supplement those physical visits with video grand rounds, among other forms of knowledge transfer. David Abreu, the experienced JHI Global Services director responsible for Brazil, tells me HMV is already jointly arranging with us to hold a multi-day program there in just a few months that will provide specialty-care workshops for physicians and nurses.

I was truly energized by my trip to Porto Alegre for the signing event—and already looking forward to spending more time with our newest colleagues.

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Why Hospitals Aren’t Like Google

by JHI Staff on August 27, 2013

At the end of my last post, I asked (and gave a hint of an answer to) this question: Should hospitals act like other businesses? As I put it:

Should they be aggressively marketing their services, and trying to find ways to raise their profit margins to fund improvements and the acquisition of new technology? Aren’t these sorts of pure business behaviors and goals at odds with the mission of trying to improve patients’ and communities’ health and saving lives?

I think the answer is: No, hospitals shouldn’t be exactly like other businesses. But they can be almost like other businesses in most ways, and can do an even better job in fulfilling their health-related mission as a result of it. Indeed, not running a hospital like a business invites a whole new set of potentially serious negative implications for patients.

Let’s zoom in on this last statement. If a private hospital, whether for-profit or not-for-profit, stopped trying to manage its costs and keep its revenues high enough to at least cover those costs—the two essential elements of a business—then it would eventually cease to exist. And before it would reach that point, it would be crippled by financial losses that would almost certainly lower the quality and breadth of care it could provide. This is certainly not a good thing for patients and communities they serve.

For public hospitals—that is, hospitals primarily funded by government—that’s not really a problem. But no matter what the country or municipality, taxpayers can’t and won’t allow the sinking of infinite amounts of government funding into health care. That means there will always be a gap between what the government can reasonably fund, and what at least some of the population will want to get. Private health care exists to fill that gap. The mix of public and private health care varies country to country. In some countries, like the U.S., private hospitals end up providing most health care. In others, like the U.K., it’s almost the opposite, but it’s still an important part of the system.

At Johns Hopkins Medicine International, we work with a range of both public and private partners, and often become involved in hospitals that are public-private partnerships. We’ve seen that all of these models can work well. But while private health care is typically an essential part of the health care landscape, if not necessarily the main part, there’s no getting around its one limitation: The money it takes in as payment for those services has to at least equal, on average, over the long term, what the services cost to provide. That’s why it has to be run much like any business, including engaging in marketing efforts to bring in customers.

OK, so what’s the problem? Why can’t a private hospital just operate like any business might and try to enlist marketing to squeeze as much revenue as possible out of customers? Well, that approach can work pretty well if you’re Google or General Motors, and your sole goal is to maximize profits. But health care is not an unbridled business; it has heart in it; it is a community trust. Society wouldn’t want much to do with a health care provider that placed high financial margins ahead of doing a good job with its mission of saving lives and relieving suffering.

The fact that there’s a good-of-society element to health care prevents private hospitals from being purely commercial sorts of ventures. To put it another way, private health care organizations face a tension between mission and sustainability. It’s a dynamic that’s present in all of our projects all around the world, just as it is for Johns Hopkins Medicine here in Baltimore. We are dedicated to doing the most to deliver high quality patient health, but need to ensure that whatever it is we do will be covered by the revenues needed to keep doing it into the foreseeable future.

Great hospitals find a way to balance those sometimes opposing forces, so they can provide the best possible care to as many patients as possible, while taking in enough revenue to sustain the operation. The balance might be different in for-profit versus not-for-profit hospital systems, in that not-for-profit need only cover their costs, while for-profit thrives by doing at least a bit better than that. But while for-profit health care providers may be less mission-driven and more revenue-driven than their not-for-profit counterparts, they still have to keep that good-of-society mission in mind.

I think every country in the world is still wrestling with the various tensions that arise from the desire to provide populations with good health care and the fact that doing so is a costly endeavor. Neither government nor free-market solutions, nor any combination, has yet proven perfect anywhere. We’re certainly trying to help our colleagues around the world get ever closer. If you know a place, let me know—and if an ideal solution does arise somewhere, I promise to let you know about it!

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