Fee-for-service is the wrong way to keep score

In today’s Globe and Mail, André Picard points out the foibles of Canada’s (mainly) fee-for-service (FFS) physician payment system.  Good points, but nothing new:

FFS is open-ended

FFS doesn’t value efficiency or cost-effectiveness

FFS creates an incentive for over-consumption/production

Alternatives to FFS carry their own baggage.  Capitation systems pay physicians a lump sum to provide all care for a group of patients.  That removes the incentive to over-treat, but there may still be gaming of the system.  Physicians may “skim the cream” by enrolling only healthy patients in their practice.  Same money, less work.  There’s also a temptation to offload patients with complicated/time-consuming conditions to specialists.

Pay-for-performance models compensate physicians when their patients achieve certain outcomes, often using surrogate measures like rates of screening mammographies or hemoglobin A1c.  There has to be reliable data collection in place, in addition to a way to disentangle the involvement of multiple care-givers.  Also, doctors may give attention to conditions whose outcomes are measured, while neglecting other problems.

Picard concludes:

There is no magic bullet waiting to be grasped, no single alternative payment scheme that will rein in health care costs.

 But there is a need to have the discussion, to experiment, to find a model that remunerates doctors fairly yet allows cost controls and improves delivery of health care to patients.

Very polite.  How about something a little more pointed…

In The Best Practice, Charles Kenney quotes George Halvorson, CEO of Kaiser Permanente, lamenting “a fundamental flaw in American health care: improperly aligned financial incentives.”:

“As a pure business model, health care is winning,” he says.  “Health care is taking all…your money and is doing it without having to be particularly accountable in how the money’s spent.  Based on that, health care will never, ever reform itself.  The model is too lucrative.”

 “There are no billing codes for cures.  There are no billing codes for outcomes.  There are no billing codes for care improvement.”

 “Providers,” he adds, “don’t do what they’re not paid to do.”

Of course, he’s talking about American medicine – things are different in Canada, right?

If we were to take André Picard up on his challenge to “experiment”, what would that experiment look like?  Maybe I’m mentally constrained by the fact that my income would be at stake in such an experiment, but I think the government/payor should be prepared to take the big risk first.  

If there is a trial of pay-for-performance, provincial medicare should totally abandon tracking volumes of service.  For most of the “alternate funding plans” (read: salaries, but don’t say it out loud because it spooks the docs) that I’m aware of, the physicians are obliged to “shadow bill”, that is, they continue to track their service volumes.  They have to do this because the health ministry thinks they will slack off if they are on salary.  And, truth be told, they might do just that. 

Which is exactly what we want!

FFS fosters over-service.  Over-service means inappropriate care and fruitless cost.  Taking away the incentive for over-service is exactly the reason for an alternate funding plan.  So, get rid of shadow billing.

But, how can we make sure the docs aren’t golfing all day?  Actually, golfing half the day would be fine, as long as the other half is spent providing appropriate, high-quality, timely, patient-centred care.  Measure it.  Report it.  

Celebrate the fact that doctors are working less, as long as they are producing the results we want.  And, for goodness sake, keep paying them the same.  It's a bargain.  Docs who are over-servicing generate tremendous downstream costs - CT scans, inappropriate surgery, unnecessary prescriptions.  Appropriate, high-quality care will be cheaper.

Perhaps we’re doing doctors a disservice by making money the sole outcome measure for their work.  If doctors seem to always have their eye on the dollar sign, maybe it’s because it’s the only target we’re giving them.  

Who has the nerve to rewrite the rules of this game?

50ish man, loves long walks on the beach, and Quality Improvement

Last week, someone asked me what was new and exciting in urology.

I dread that question.

Usually, I have to rack my brain for some new technique or piece of equipment that will wow the person.  Surgical lasers are a good bet, but new technology isn't as riveting to civilians as it is to surgeons.

But this time, I blurted out "Doing things better in the OR".  And I realized that I really am excited about quality improvement - even more so than getting a new laser.  And the best part was that he was excited to hear about quality improvement as well.

We talked about the surgical checklist and about the ways the Saskatchewan Surgical Initiative  aims to improve care.  He was genuinely interested.  I think it was because he could see the impact QI could have on him and his family and friends.  While a new surgical technique or instrument may help a limited number of people, system changes affect everyone.

Before this conversation, I avoided talking about QI in healthcare because, frankly, it sounds a little nerdy.  Now, I think it may turn into my go-to ice-breaker.

Don't hide your passion!

Inspire! hits it out of the park!

Saskatchewan’s Inspire! Healthcare Quality Summit (April 20-21) in Regina was amazing! About 650 people visited poster displays, attended workshops, heard “Saskatchewan stories”, and participated in a CEO/leadership roundtable discussion.


The highlights for me were the keynote addresses from Maureen Bisognano, John Toussaint and Richard Shannon. Each brought their own perspective to healthcare quality improvement and patient safety, but they all have a common attribute: They tell a compelling story. Their presentations revolve around the experience(s) of actual patients. They introduced us to these people, and told us about their lives and how they had been affected by defects in healthcare. That was the springboard to presenting systemic data and solutions, and then return to the individual patient’s story to remind us all of why we were there: Improving care for each patient. Memorable!

Many people describe themselves as being passionate about a cause; Richard Shannon wears his passion on his sleeve. He is on a crusade against hospital-acquired infection. You can read about his story in the excellent book, The Best Practice, but if you have a chance to listen to him in person, take it.

A welcome surprise was Premier Brad Wall visiting the summit and expressing his appreciation for the quality improvement work being done in Saskatchewan healthcare. It was very gratifying.

There are already plans for a 2012 Inspire! event in Saskatoon. I think we can make it even better than 2011.

I would like to hear more patient voices. Perhaps each day could start with a short presentation from a patient, or their family, highlighting the impact (whether positive or not) healthcare has had on their lives. There were excellent poster presentations from healthcare workers, highlighting various quality improvement and patient safety initiatives. Maybe there is a way to invite patients and families to create posters about their experiences, both telling their story and making suggestions for improvement. There could be workshops specifically for patients: story-telling, advocating for your own care, community involvement and political advocacy.

Front-line caregivers should be more involved. It may be difficult to take a lot of staff away from clinical responsibilities, and there will be limitations on physical space at the venue, but perhaps the keynote sessions could be broadcast around the province, or recorded and made available to staff.

Inspire! has started off on such a high note, it’s exciting to imagine where we can take this event next year.

Poll results are in! Minority victory declared.

Thanks for voting in the Dark Side poll.  Here are the totally unscientific results:

Be perkier and cheerier: 12%
Keep the same tone: 56%
Dig deeper and get darker: 30%

(39 respondents)

These questions weren't validated with a test audience, so they may have been ambiguously worded.  For example, the "Dig deeper and get darker" people may be encouraging me to work in my garden and get a tan this summer.  Who knows?

While the majority think that status quo is good, I'm intrigued that 30% want to see more depth in my writing.  I'm going to declare a minority victory.  What was the point of a poll if you're not going to abide by the results? Well, this is a blog and not a constitutional democracy.

I'm going to interpret "digging deeper" as meaning plumbing internal depths rather than more intensive reportage.  I'll try to be more thoughtful my own feelings and behaviour around my work and healthcare in general. 

Thanks again for taking part.

97% fail - redux

"Bohica" throws down the gauntlet with a passionate comment about 97% is not a passing mark!  She's from Saskatchewan and now lives in the US.  She'd like to retire in Sask., but is worried about access to medical care.  She describes specialist availability where she lives like this: I get an apology if I wait longer than a week.

Enviable.  But, she also has suggestions on how to achieve this.  Essentially, we need to get rid of all the triage steps in the referral process.  As she says:

Remove First Referral Letter, which can be sent while waiting for your first appointment (appointment having already been made).

Remove Referral by Triage 

Remove Letter reviewed by oncologist (he will have the letter by the time your appointment rolls around).

Your GP gets your results and calls the triage clerk and says, "I have this person with prostate cancer/symptoms of prostate cancer. When can I get him in?

Great idea.  Make the appointment first, then fill in the details later.  I like it, probably because it's very much what our clinic already tries to do.  

If all consultants were to implement this process, there's one element essential for its success: Trust.  I need to trust that the referring doctor is going to send all the necessary information if I "give up" one of my time slots.  It's not quite as selfish as it sounds.  

Occasionally, a referred patient may not actually have a urology problem.  For example, I will sometimes have patients referred to me with a hernia or kidney failure.  When I receive such a referral, I'll let the referring doctor know which specialist would be more suitable for their patient's needs.  It would have been a waste of time for that patient to see me.  (FYI: I would still get paid for the visit.) 

Sometimes, a referred patient may have a problem that could be dealt with by the referring doc, with advice from the urologist.  In this case, a reply letter obviates a consultation visit.

Most of the time, I want to know about the patient's situation ahead of time so that I can coordinate necessary testing with the consultation appointment.  This saves the patient travel time and expense, and let's me provide "one-stop-shop" service.

Although it feels uncomfortable to put it this way, specialists are reluctant to give referring docs (or rather, patients) free access to our available time, because we don't trust that the patient has a problem that needs our attention, or that appropriate investigations will be done prior to our consultation.

We can build that trust through better communication.  Our best example of this is our streamlined hematuria referral process.  We provide family doctors with a template of tests that we ask to be completed when they refer someone with blood in the urine.  If these tests are done in advance of the consultation (and if the doctor has our hematuria template, they usually are done), then we can consolidate the visit and necessary testing into one visit.

In 97% is not a passing mark, I mentioned that one of the few doctors I, as a specialist, refer patients to is an oncologist.  Even though my referral letters are (I think) quite complete, they still have to go through the triage process, which delays the patient's visit.   This means that the oncologist doesn't trust me.  

I'm very pleased to see the wait time targets mentioned by Colum Smith in today's Star-Phoenix.  

(Saskatchewan Cancer Agency) has set aggressive goals for patient care during the next five years — including that every patient be contacted within 24 hours of referral and that 90 per cent of them be seen within one week after referral, said Dr. Colum Smith, vice-president of medical affairs for the cancer agency

Developing trust between referring physicians and consultants will surely play a big role in reaching that goal.

Great design in the strangest places

For the 50% of you who have not had the pleasure, let me explain what a urinal is.  A urinal is a porcelain bathroom fixture that marks the location of a pool of urine on the floor.

I wish I were joking.

Urinal designers have done their best to encourage "accuracy".  Urinals are almost wrap-around in their design, but still...  Don't wear your good shoes.   Something is missing. (Ha! Good one.)

I came across an interesting innovation while I was in Amsterdam earlier this month.  I'd heard of this concept before, but had never seen it.  This urinal was in the convention centre:

And in close-up:

The image is a little blurry (one doesn't linger over composing the shot when holding a cellphone over the urinal in a public washroom.  FYI.), so I'll point out that it's a fly on the side of the urinal. Or rather, it's a sticker with a picture of a fly, stuck on the bottom of the urinal. (The protruding, and somewhat off-putting, shadow near the bottom is from the flush handle.  Don't let your imagination run away with you.)

This urinal was in a restaurant:

A picture of a candle! Nice.

These elegant (!) examples of innovative design are supposed to encourage the user to be more accurate. I didn't actually collect data on this, as I thought I had already pushed my luck enough by taking photos in the washroom.  However, according to this article (read down to the end), Amsterdam's Schiphol airport noted 80% less spillage after implementing the urinal targets.

Good design can be delightfully simple (recent examples here and here).

Now if only someone could design a way to stop guys from talking on their cellphones while using the urinal.

I wish I were joking.

Have I gone over the the Dark Side? Cast your vote!

Can anyone lend me one of those donut-shaped pillows to sit on?

'Cause I just got spanked!

Check out Dale's comments about a recent post regarding CIHI's reporting on wait times.  As you see from my response, I stand by my opinion, but something else he said - "Swing back to the positives you used to write..." - got me thinking.

The content and tone of this blog has evolved over 4 years.  Longtime readers know that I started with straightforward reporting of our Advanced Access/Clinical Practice Redesign work.  It was pretty peppy stuff.  We were able to accomplish a lot and make some significant improvements in our urology practice.

Then, as we realized that factors outside our practice limited what we could change, I started to become interested in the broader healthcare system.  I remain committed to working for quality improvement and want to be a positive influence, but every day, I see many examples of how the system fails patients and wastes resources.

I write this blog for a few reasons.  First, writing helps me clarify my thoughts on a subject.  I may start with a vague notion in my mind, and the discipline of writing about it helps organize my thoughts.  Many a post has been started, then discarded when a seemingly blinding insight evaporated.

I also want to spark discussion.  It's really satisfying to me when someone tells me they read something here and talked with a friend or coworker about it.  A controversial topic is more likely to be discussed.

Finally, I want to challenge myself to be open with my thoughts and feelings.  While I am truly encouraged to see the efforts and successes of others working to improve healthcare quality, I wouldn't be honest to myself if I were just cheerleading in this blog.  There's so much to be done, and the pace of change is frustrating.

But, let's see what you think.  Maybe you feel I should go back to the good old days of rah-rah.  Or maybe you prefer my "Blue Period".  Take the poll at the top of the right-hand column.

Oh, about that pillow...

Multi-tasking one more time: This time it's evidence-based!

Serendipity strikes!

I'm just back from a fantastic week at the International Forum on Quality and Safety in Healthcare in Amsterdam.   (By the way, if as the first assignment of a new job, your boss flies you to Europe, take that job!)  In addition to all the terrific presentations and discussion around quality improvement and patient safety, a major topic of conversation was the popularity of bike-riding in the Netherlands.  Aside from the novelty of seeing people cycling to work in suits and lugging briefcases, many of us commented on the prevalence of people using their cell phones while biking.  It looked like pretty unsafe multi-tasking!

Which reminded me of my recent experience of averted multi-tasking in the OR.

Which had led to comments on an advisory from the British Columbia College of Physicians and Surgeons on the same topic.

And then, while I was catching up on one of my favorite podcasts - CBC's Spark - I found a discussion of multitasking while bike-riding, followed by a review of research on multi-tasking.  By a Stanford professor, no less!  Check out the podcast here (the first 15 minutes are about multi-tasking), but here's the spoiler: "Multi-tasking" is rapid-transition distraction.  Stop it.

(Unabashed gushing: I love the Spark podcast.  It's about technology, but as they describe themselves "It’s not just technology for gearheads, it’s about the way technology affects our lives, and the world around us." You can subscribe here.

OR chatter: Let your patient be your guide

In follow-up to a recent post about paying attention in the OR, Greg Basky posted a comment about an incident in B.C.   A patient was concerned that intraoperative hockey chatter would distract the surgeon from the operation, done under local anaesthetic.  A couple of things struck me about this story.

First, this type of chatter goes on all the time.  I usually talk with men while I'm performing their vasectomy and they often comment that it helps them relax and distracts them from what's going on.  For a routine procedure, it doesn't distract me.  If I need to focus more on the procedure, I'll stop talking.  There's only the two of us in the room, so I wouldn't be having a conversation with a third person.

But, this is utterly beside the point.  It doesn't matter that I can chat without being distracted.  What matters is how the patient feels about the conversation.

I engage in the conversation just enough to get the man talking about something he's interested in: family, work - even hockey...  It's a deliberate technique to make him more relaxed.  (I've heard people suggest that, when driving a car, you're less distracted by a conversation with a passenger than you would be by talking to someone on your cellphone, even with hands-free.  I'm not sure why, but I think it's a similar situation if the surgeon is having a conversation with the patient vs. a third party.)

However, some men prefer that we not chat, and instead want to use their own method of relaxation.   That's fine with me.

Surgeons and OR staff may scoff at the idea that they could be distracted by mere conversation.  I disagree with that, but would let that point stand in the absence of evidence to the contrary.  However, we can't ignore the effect it has on patients and their perception of care.  The case reported to the B.C. College of Physicians and Surgeons is undoubtably the tip of the iceberg.

As I mentioned in the previous post, I think that casual chatter in the OR can be relaxing during a long case.  It has its place.  But, when patients are awake during procedures, we need to be aware - to the point of hyper-sensitivity - of their needs and perceptions.  (Note to the OR staff in my room: That's the reason why, when we're operating on someone using spinal anaesthetic, you might think the cat's got my tongue.  I prefer not to chat unless it's related to the operation we're doing or about to do.  You may think I'm giving you the silent treatment because I'm upset about something.  I'm not (usually).  I guess I could have explained that to you previously.  Like 20 years ago.)

The second thing that struck me was the content of different articles on this story.  Take a look at the National Post and the Leader-Post versions.  The Leader-Post (and Calgary Herald and Vancouver Sun) versions included Registrar Heidi Oetter's comments that our behaviour in the OR should be patient-centred, whether related to conversations or choice of music.  I would be interested to know why the National Post editors chose to strike those comments in their version.  Those comments are the soul of this issue.

I'm catching the Saskatchewan wave!

What's new with you?  How about me?  Oh, not much...  Just a NEW JOB!

As of this month, and for the next year, I'm going to spend half my time doing my usual clinical work in urology, and dedicate the other half to working with Saskatchewan's Health Quality Council (HQC).  HQC has contracted with me to develop a physician quality improvement fellowship program, support HQC's Clinical Practice Redesign (CPR™) work and, I suppose, be general clinician-about-town.

It's an incredible opportunity for me.  I'm excited about it, yet anxious at the same time.

I'm excited because it's a chance to have dedicated time to work on a large-scale quality improvement (QI) effort.  I've enjoyed working "informally" with HQC for over 4 years.  Our office's Advanced Access/CPR™work has benefitted hugely from HQC's support.  But, even with the generous donation of time (mine and theirs) from my partners, it's still work that's done off the side of my desk.  Clinical responsibilities always trump quality improvement work.  (If that last sentence made you cringe, then join the club!)

I'm excited because HQC does an amazing job of promoting QI work in Saskatchewan, and I know that they're never satisfied with the pace with which QI is moving.  They are steeped in QI and measurement and I look forward to learning from all the enthusiastic staff.

I'm excited because creating a physician QI fellowship has the potential to expand QI expertise and leadership widely in Saskatchewan.

I'm excited because this is the first major professional upheaval I've had in 20 years of practice.

And, I'm anxious because this is the first major professional upheaval I've had in 20 years of practice.

For 2 decades, I've been the boss and the expert.  In my office, the hospital and the OR, I usually have the final say.  Technically, I am accountable to my patients, colleagues, regulatory groups, health region, and the government insurance board, but no one has ever explicitly told me what they want me to do, nor what the specific deliverables of my job are.  In my HQC consulting work, there will be explicit expectations and timelines.  My work will be scrutinized on a peer-to-peer basis.  I am utterly unaccustomed to this degree of transparency.

I'll be learning on the job.  I have no experience in developing training programs.  I feel uneasy about it already.  In my regular work, I like the fact that I have previously come across most clinical conditions and don't have to struggle with a management plan.  After 20 years, urology is comfortable.

And that's what motivated me to take this leap.  I felt comfortable.

I've heard it said that it takes 10-15 years for surgeons to develop their practice to the point where they feel comfortable.  Even though there is always ongoing professional development - learning new techniques and treatments, and abandoning outdated ones - the ride does get smoother after that many years.  Why not just enjoy the ride until retirement?

I'm taking this job partly because I see so much that we can do better for our patients (ourselves!).  There is so much untapped energy and potential in clinicians.  We all want to do a great job, but don't have the time or tools we need to make improvement changes.  I have felt the great satisfaction that comes with making clinical improvements, and I'd like to share that with colleagues.

I'm taking this job partly because of the example set by my senior partners.  The two of them - one retired, one on the cusp of retirement - have been deeply involved in medical politics and quality improvement all through their careers.  They recognized that their responsibility and influence extended beyond the one-to-one patient encounter of clinical practice.

I'm taking this job partly because of the incredible support of my other partners.  When I proposed switching to half-time clinical practice, we all knew that it would be a significant burden for them.  Their response? Unanimous and without hesitation (well, that they let show to me, anyway!): Do it!  Thank you all.

But, mostly, I'm taking this job because there's something palpable happening in Saskatchewan healthcare.  The government is supporting the Sask Surgical Initiative.  Specialty practices are starting to explore pooled referrals and other aspects of CPR™.  Health policy makers regularly refer to the Patient First review as a basis for decision making.  Momentum is building.

I want to paddle out and catch this wave.

Wish me luck!