Wednesday, May 12, 2010

Partners in Health

My boss - Dr Anthony Shih - is co-author of the chapter "Achieving the Vision: Payment Reform" in the recently published book "Partners in Health", available in Hardcover and Kindle.

"The combination of visionary leadership, knowledge, and superb timing makes this book a winner. Health care is evolving toward collaboration and integration, and this book is essential reading for anyone wishing to change the relationships between hospitals and physicians."—Donald W. Fisher, PhD, president and CEO, the American Medical Group Association

"This book is a must-read for anyone committed to a high-performance health system. It spells out the practical steps that will move us toward an accessible, coordinated, patient-centered system of care. Its recommendations for payment and regulatory reform underscore the urgency of comprehensive health reform if the current misaligned incentives are to be changed to support those on the frontlines in providing the best care with prudent stewardship of resources."—Karen Davis, PhD, president, The Commonwealth Fund

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Monday, May 3, 2010

Should Paul Levy be More Transparent?

As many of you already know, health care transparency evangelist Paul Levy, CEO of BIDMC in Boston, is having a bit of of trouble with his professional life apparently colliding with his personal life. Details are unknown, but include an inappropriate relationship with a subordinate. Mr Levy apologised to his staff via e-mail for his lapse in judgement, and little else is known.

The Boston Herald has run a few pieces about this, and sent a reporter down to Ohio where Mr Levy was speaking about health care transparency at a conference. The Herald is having a grand old time asking a transparency leader to be transparent about this particular incident, basically flogging the story as "Mr Transparency has something to hide" while Mr Levy ducks the reporter and tells everyone at the conference not to talk to the media.

So the question is probably a valid one. If you are a thought leader and public speaker on transparency in the hitherto opaque world of health care business and outcomes, shouldn't you tell us all who you're having sex with and when?

Hmm, now that I say it out loud, it doesn't sound so valid. But let's examine it a little more.

What is health care transparency, and why do so many of us give a damn about it? For me, it's a question of fair trade. I am expected to participate in an allegedly free market but I cannot know the price of goods and services before consenting to the purchase. I am expected to participate in an alleged free market but I cannot acquire adequate data to compare providers of goods and services on their quality, efficiency, or ability to render the services required.

Transparent Deck Repair

My new house has a deck that is falling apart, and I need to repair or replace it. If my deck were my appendix, I would dial a number, a dispatcher would send a contractor and his crew to my house, I would flash an insurance card that he will gladly accept. Later, I will find out that two of his staff do not actually accept my deck insurance, and I will have to pay retail for the railings. Later still I may find out that this particular deck builder has had three decks fall down after he left, but the previous owners were forbidden to tell anyone. I will call the department of housing asking why they can't tell me this, and they will say I am unable to adequately use the information without drawing potentially wrong conclusions.

Later still, I will get a bill that includes a bunch of vague billing codes but the words "wood" and "nails" will be nowhere on there. I will realise I can't afford the portions that my insurance didn't cover, and I will sell my house to pay for my deck.

Obviously, this is absurd, but it is the current state of play in health care. So that gives us the common sense reason. So why should I be in a position to demand transparency? It's a free market, right?

Wrong. Taxpayers prop up the system in a number of ways, and by dint of anyone taking public funds, we immediately expect accountability. Seeing as we're talking hospitals, let's take a look.

Most hospitals operate as non-profits, thereby evading huge property tax bills. That's money out of our public pocket. Yet many of these non-profits pay multi-million dollar executive salaries. The oft-quoted argument is that "we need to pay competitively to keep these execs out of the private sector and in our non-profit", but of course the bulk of the market is non-profit so that argument doesn't truly hold.

Then we pay taxes to reimburse these non-profits when they come across someone who (shock, horror) can't pay. The hospitals go begging at the state kitty and we pay again.

And of course, about half of all the money in health care comes directly from the government via Medicare and Medicaid payments.

So, we want accountability. We don't have it, so we demand transparency in order to hold people accountable.

Accountability is not Universal

Now, Paul Levy has done something for which he needs to be held accountable. To whom is he accountable? The Boston Herald? Me? Who?

Seems to me that while, yes, he could have made mention on his blog and twitter feed and the rest of it that something was going on, the details are not ours to know. He is accountable to the board of directors. There is talk of some severance package for the female staffer in question, and if this be the case then there is the added accountability of misuse of funds. But it is the board whose job it is to be transparent here. Transparency is not about knowing everything about everyone at all times. And those of us who preach transparency in health care have no additional requirement to confess our personal sins in the newspaper.

Over at one of my other blogs,, I have received an e-mail from a business editor named Frank Quaratiello at the Boston Herald with the title "Interesting Story" and a copy of the Herald piece. I don't know Mr Quaratiello, but I assume he believes the story has something to add value to the health care transparency debate.

I will not be posting it on as it is not about health transparency.

Is there a newsworthy story there? Yes, a major CEO and public figure has proven himself to have had a lapse in judgement, requiring his Board to take action. That is news. Should he resign? Maybe, that's between him and his Board. Do I or anyone else not involved with running that hospital have a right to know the who, what, when and where of the story?

Not at all.

Hot Dog Never Events

If a surgeon made a mistake on the operating table and cut off the wrong leg, are we immediately entitled to know everything he's ever done in and out of the hospital? Should we expect him to rush to update his Facebook feed "just chopped off the wrong leg, brb, chopping off the other one"? Maybe one time he put mustard on his hot dog instead of ketchup. Surely this should have bearing on his ability to perform surgery? At the least shouldn't I know he can't tell his condiments apart?

No, the transparency is in the knowledge of the event, and the efforts made to avoid it happening again. Transparency is about good, useful data that fosters better, more informed decision making.

It is my opinion, and my opinion only, that a figure with as much publicity as Mr Levy should not avoid the fact entirely on his many outlets, especially given his use of his blog as a glimpse in to his personal as well as his professional life. The modern world and its modern communications channels necessitate that we bloggers and tweeters and users of the Web cannot but give up much of our privacy, and separating personal from professional has never been harder now that we are all profiled and LinkedIn'ed.

I myself have been at the wrong end of making poor judgement in a professional setting. When your work is your play, when you are passionate about your work and your goals it can be hard to separate professional from private. Hell, most people I know who are as dedicated and hard-working as I think I am don't have time to have a personal life, and it's easy to fall into the trap of allowing your professional life to substitute for a private one at times. Been there, done that.

But I have no interest in knowing any medical provider's personal intimacies, and neither should anyone be particularly holier-than-thou when talking about Paul Levy.

I don't defend what he did, we all make mistakes and we all have to pay for them. If his Board thinks his judgement lapsed enough to warrant them losing confidence in his executive leadership, so be it. But this pious outpouring that he should be fully documenting his tribulation for all of us to benefit from his transparency is nothing but sanctimonious codswallop.
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Disclosures and Disclaimers


My employer is compensated through funding to provide analytical research, technology solutions, and Web-based public and private health care performance reports by the State of New York, the State of Illinois, the Centers for Medicare & Medicaid Services, the Agency for Healthcare Research and Quality, the Commonwealth Fund and Bridges to Excellence. I am not being compensated by any of these organisations to create articles for or make edits to this Web site or any other medium; and all posts authored by me are as an individual and do not represent my employer or the agencies I work for.