Conversations With History: Reforming American Health Care



this program is a presentation of uctv for educational and non-commercial use only welcome to a conversation with history I'm Harry Chrysler of the Institute of International Studies our guest today is george c Halverson who is chairman and chief executive officer of kaiser foundation health plan and company and kaiser foundation hospitals he's the author of numerous books his most recent one health care will not reform itself mr. Halverson welcome to our program good to be here where were you born and raised I was actually born in northern Minnesota raised in a very small town up in the backwoods my parents were both from that same town so I come from a very small town my father and grandfather were mayor's of the town my mother was deputy mayor they were all school teachers so I come from a teaching family in rural Minnesota 11 gets a sense that that state in that part of the country has a real cooperative spirit yes based in cooperatives and the the Scandinavian origins of many of the people who settled there yes we were co-opted members we the coop sample store was a block from our house the co-operative culture the culture of collaboration was a big part of the community and again co-operative governance of the gas station the grocery store the hardware store was all part of what I grew up with so later years actually healthpartners is the largest healthcare co-op in the world and so I actually went from being in a town with coop stores to running a healthcare co-op and how did you and I felt very comfortable I loved running after go up and and what was the trajectory here what did your education impact your choice of career or was it just just kind of a natural evolution based on this this environment that you grew up in well I sort of accidentally and got into health care I was in communications and I saw a job opportunity for an underwriter and at the Blue Cross plan and I thought underwriter meant assistant writer so I applied for the job after they got over being amused about it they hired me into a different job which was actually a writing job but then they trained me as an underwriter and I went through the underwriting training and kind of fell in love with the business I fell in love with the thought process and the thinking involved in the numerical interactions and ended up as an underwriter for Blue Cross plan and then I have all from that into doing provider contracting and setting up their network of care providers and I have all from that to running a health plan that they started one of the first network HMOs in the country and I've been a CEO of one health plan or another since 1976 so I've been doing this for a very long time ah which raises an interesting question which is students watch this program and I always like to pursue the question what are the skills involved in leadership in the health field I think the health leadership isn't that much different than other fields at what you need to have is a I think really good sense of what your organization is all about why does it exist what's it here for you if it's here to make a profit then you've got one agenda if it's here to provide service you have another agenda but I don't think you really do a good job you don't succeed really well leading an organization running an organization unless you have a clear sense of what you want the organization to do and then as a leader you need to help get other people aligned with that agenda you need to recruit the right people you need to promote the right people you need to help people figure out strategies and plans and operational processes and in health care health care is about taking care of people the essence of health care is that you have a patient that you know healthcare kind of boils down to the patient and so you need to figure out what do we do as an organization that's going to make life better for each person who becomes our patient so you need the whole team things like that and so it's not just that it shouldn't just be on your mission statement you need to have all the people who work there in their heart know that what this organization is about taking care of the people and if you teach that preach that model that then you're much more likely to have an organization that works and does the right kinds of things and the field of healthcare and is one where there seems to be a tension between what value will prevail and what what I have in mind here is on the one hand it's about caring it's about the big philosophical issues life and death providing the care for people who might not be able to pay and so on but on the other hand in our present environment we're really concerned about cost and keeping medical costs down is that a tension that that comes up a lot or is it easier to reconcile those two things than then seems apparent it in first instance well I think the people who believe that there's an inherent conflict there are they're missing the the point of what the opportunities are we have an incredible opportunity in this country to make care better a lot better and by making care better make it less expensive so right now diabetes diabetics consume thirty two percent of the cost of Medicare which is a big piece of Medicare its fastest growing disease in America we only get care right for diabetics eight percent of the time in America so if you look at how often we get care right and the fact it's thirty two percent of the cost of care if we got care right for diabetics eighty percent of the time would cut the number kidney failure as an American half would cut the number of amputations and a half there's this huge opportunity and the opportunity isn't a ration care to diabetics that there would be stupid the opportunity is to get care right for diabetics and make sure we deliver best care and as a result of that we don't need to do amputations we don't need to do the eye surgeries that result from inadequate care so this huge opportunity the other thing in diabetes document that for a second is there's a great opportunity to go upstream its fastest growing disease in America if people walk 30 minutes a day four days a week the number new diabetics would be cut in half they lose 20 pounds on top of that the number of diabetics goes down by sixty percent so the fastest growing disease is the largest single use of money for Medicare we get cut the number of new diabetics in half by sixty percent just by walking in losing a little weight and we don't have right now as a country up a macro agenda that's aimed at that and we should work this is inappropriate for us I think I think it's a missed opportunity for us not to identify a few of these really high leverage opportunities and then to take steps of the country to move in those directions well what is it in a leadership role that that leaves organizations and systems not to see these opportunities I think this is in part a question about creativity and it's also but it also seems to be related which is a theme that comes out in your work about embracing technologies and the opportunities that they present yeah that this two sets of issues one one set of issues is the business model of American healthcare is set up to reward exactly the wrong things so the business model of healthcare does not reward keeping seniors from having broken bones because every single senior with a broken bone is a forty thousand dollar hospital admission and a lot of profit and if you prevent the senior from breaking about and you get nine for it same thing is true in asthma attacks we should be able to prevent half the asthma attacks there is no reward for an independent provider to prevent asthma attacks there's no reason for hospitals to be involved preventing asthma attacks even the worst case is hospital-based infections a patient that's a twenty-thousand-dollar admission that gets a horrible infection in the hospital now becomes a hundred-thousand-dollar admission if the world were right that would be penalized situation and instead it's financially rewarded there's no hospital in America that would ever ever ever damaged a patient or do anything they get a patient with to have an infection but the fact that there are absolutely no upside most hospitals if you took away their readmissions and you took away the bad outcomes and the readmissions would actually find themselves financially challenged and you think about that for a second think how bizarre that is so the financial model is set up to do reward exactly the wrong thing and what we wanted to do is report health we went up to reward best care we want to reward having fewer complications and you can get there so and then the second part of the equation is why doesn't health care use computers when everything else in the economy is as computers every every other part of the kind of is heavily computer based in health care as almost no computerized data relative to care and the reason for that is there is no business model that rewards that for most of healthcare most of healthcare again if you computerized the model of care if you identify people at high risk of breaking bones if you follow up on their care and track their care make sure they have fewer broken bones what you end up with is the surgeons have fewer surgeries to do the hospitals and fewer admissions they're putting that computer system in and making care better cuts their revenue so why would they define name one other business that computerized to damage their financial condition you can't find one now now there seem to be two problems here one is that that the insights that you're having and this is is true in your books which I highly recommend because they really lay out some of these problems in great detail is to have these insights you really have a system systemic view of the enterprise and I guess what what what one runs up against and one wonders about is what American healthcare is built on is the individual practice in pieces and you even call that your analysis shows that what we're we're talking about is a system built on piecemeal work the individual practice the individual practice you point out that only four percent of physicians in the United States or in practices with the team of 50 doctors and so on so so there is a there is a systemic way of saying things which quantitative analysis and would help us see the issues in part and computers will help us solve those issues but you're trying to put that on an environment which is built on the individual doctor the individual patient and their their very human concerns about their work and their own treatment well even the the world that we live in with all the individual doctors those doctors have no connections right now eighty percent of the care comes from people with chronic conditions and comorbidities and comorbidities means multiple conditions and that means in this country more than one doctor and right now there are no linkage as the doctors all these solos private doctors can't link with each other they give no mechanisms no tools no forms no processes no computer systems and in fact if they try to link in some cases they run up against HIPAA violations and they end up with being a violation of the privacy and secrecy laws and so what we've done is we've taken this piecemeal segmented solo practice environment where everybody practices in a little bitty silo dealing only with incidents of care and then we put processes in place to keep a communication from happening which is bizarre and then we set the system up so that if anybody does do a better job they make less money and in any other industry if you went to Mercedes and said every time your car gets better we're going to reduce the amount of money you get and if your car gets are really good we're going to take away your fifty percent of revenue Mercedes would never get better as a car this isn't hard I mean you just have to apply the basic principles of economics to health care and realize that if doctors were rewarded for functioning in teams teams will happen if they're rewarded for having fewer heart attacks fewer heart attacks will happen but when you're only rewarded for having more heart attacks with increasing number heart attacks I mean it this isn't there isn't very complicated when you boil it down to the essence and people keep saying why don't computers approve of health care well computers wouldn't improve any other industry either if the consequence of using a computer was at your profits went away and you lost patience with me lost customers I guess what I'm hearing here is a problem of Education that the the route that we could take to reform medicine and health care is is very clear and there there's real resistance and is it because people are irrational they're afraid they are emotionally involved in their own healthcare and they don't want to make these changes I don't think that would be the way I would interpret it I think everyone is totally emotionally involved nor health care that's true and I also believe that if people could make meaningful decisions about where to have your heart surgery or where to have your knee surgery or where to where to go for your cancer treatment the life expectancy there is so much between cancer treatment programs they have for stage three pancreatic cancer or better choice prostate cancer you get three times as many survivors at five years we go to the best institutions at compared to the worst consumers would want to know that if you had prostate cancer you would want to know who is what survival rates and consumers would bancos the reason consumers don't make those decisions now is they don't have the data the data is not available data consumers can't make that decision your chance of dying of a cabbage of coronary artery bypass surgery varies by a factor of almost 10 the best sites have about a one percent death rate and the worst sites have abound almost a ten percent death rate consumers should know that before you have that surgery consumers who want to know that consumers aren't resisting making smart decisions for emotional reasons they're resisting making smart decisions because nobody's giving them the data so what we need is a new marketplace it is heavily informed by real data we need to know that the survival rate statistics think of one person you've ever known who's had stage three pancreatic cancer and a doctor said here's your two treatment programs in this one you'll live six months this one you lost seven months that database isn't shared with the patient and so patients are many uninformed decisions in a wide range of areas but I don't blame it on the patient I blame it on the fact that we've set up an economic model that doesn't give anybody any data to use to make good decisions so so what what you're arguing if I can restate it here in especially in your books which I recommend I showed one of them but let me show another one health care reform now which lays out an agenda for the United States in this this environment that we have that technology allows us to have control of data goes in a new way and that combination of data and technology to make that data available to patients to doctors and 22 epidemiologists who are studying the statistics would empower us to kind of re-engineer the environment of healthcare and transform the system exactly and we can't transform it without data if you don't know I give you an example of sepsis sepsis is a infection that is often fatal right now it's the number one cause of death in California hospitals so more people die of sepsis then died of cancer or liver disease or heart problems and so sepsis is a major problem and most hospitals don't know what their sepsis death rate is they don't track it they don't use it the patients have no clue and when you take a look at sepsis you know that it's two percent of the patients and twenty percent of the deaths so for starters so the question is what can you do about the twenty percent of the desk if you have the data then you can work backwards from the data and say we're going to identify sepsis patients faster we look at sepsis that the magic in sepsis is a little tiny bit technical is a very quick response you have a golden hour and you need to respond within that hour and in most hospital settings somebody thinks the patient might have sepsis to try to run a blood test there may or may not get a priority on the blood test if they don't get a priority the patient isn't big trouble if they do get priority the blood tests and they run back to the floor there's a yard sepsis then they say okay anybody here ready to deal with sepsis and there may or may not be a doctor that may or may not be a nurse available there may or may not be any the supplies when it's okay we quickly need some medication can anybody get in then they run down to the pharmacy and then you've got this circus going on for okay quick good to skip the steps and stuff up there and get up for three if you miss that an hour then the death rate is doubled and if you do it right you've got a process that says sepsis this could be sepsis that test gets top priority goes right to the lab gets immediate priority to get the response back and they say yeah it's app says and then they say push the button in sepsis room on steam room 427 and the team is in the room with the medication with the supplies and with that that kind of team we've cut the death rate on sepsis by two-thirds for though for the hospitals who put that in two-thirds cut in the death rate okay patients don't even know that would sepsis is going on and we could not have cut that death rate if we had measured attracted thought it through work at it systematically set goals and then so the whole key to the process is to figure out what you want to fix measure that and then track your your improvement and then put processes in place to fix it that all takes process thinking most hospitals have very minimal process thinking most hospitals in America reinvent had to write about in my books at write about reinvention change at every shift change every floor of the hospital different procedures for things and when the nurses are leaving at the end of their their duty yeah there has to be a changing of the guard exactly and so what you need is you need the nurse who is leaving to tell the new nurse here's the patient here Sally Sally needs these three things you need a process to do that it usually takes about 40 minutes per shift front and back to do the change the one nurse is telling the other nurse watch this patient for such-and-such right and what happens is because it's usually done orally with a little bit of paperwork what happens is that it's just like remember the old game you play in the classroom we whisper something to somebody in the front row and then it goes the next to a next one next one next one well that happens on chef changed so by the time you've done 12 shift changes which is you know basically three days of care you you've ended up with misinformation about patients Don Berwick wrote a magnificent book where he talked about his wife being in the hospital and he basically had to the best hospitals in America made at least one error every day and most of those air were shift changed kinds of errors a person getting the medication wrong so what you need but again it's it's very simple if you know that then what you can do is you can say that standard is that let's let's have a common approach let's ask the same questions let's have the same document let's have the same piece of paper let's make sure that the shift change happens a say in Florida floor shift the shift and that it happens the same at midnight as it does at eight in the morning and when you do that then you get a whole different level of care quality information the quality information goes way up and you cut the amount of time necessary to do it in half but because most of American healthcare is a right about my books is so local so situational and so invented on the spot there's no system inis to it and so people don't look at issues like errors at shift change they don't look at errors like wrong site surgery they don't look at sepsis responses and so it's it's like the chaos you see on the TV shows on the ER shows you know that constant chaos what's really pathetic is that actually fairly accurate you end up with this kind of in way too many settings not everywhere but way too many settings you want to with that kind of a situational chaos is the mode of delivering care and everybody gets your drawing on Rosh and everybody you know people who do that I think that's the way the world ought to work in our immersed in the desolate that when you fix it people like the fix and then tend to go with a better approach so if we went back to our nurses and said at shift change why didn't you just you know do it any way you want and kind of invented on the fly two years ago they would have said yeah that's what it works today that say no i would i would feel insecure now changing shift without making sure i had all of the information all the medications all the instructions all the guidelines and then so process can improve my health care but it's so seldom does which is one of the things that drives me absolutely crazy which is why i go back again to the issue of rationing you know people keep saying we got a rash and care in America no we don't need to ration care we need to get care right let's let's go there first you earlier in your career you were involved in building healthcare cooperatives in Uganda and he wrote a book about it a fascinating book let me show audience healthcare co-ops in Uganda and you said something in there that I want to read it to you back I believe that the skills set needed to keep a United States contracted care network thriving is pretty much the same skill set needed to start a brand new health care provider network in a developing country so on the one hand conceptually there are common elements and how we improve the system but then you go on to say and I'm not saying these contradict each other these two statements but rather they inform each other once I solutions do not fit all countries I had learned quickly not to assume that all american solutions worked everywhere local problems needed local solutions so rather than simply applying Americans Solutions to Uganda we focused entirely on what was actually needed in Uganda now what I find interesting is that we can take this analysis and really apply it to American health care today you know sense that you're arguing that there are common elements of process and common opportunities that would allow us to actually deal with the local conditions in the way right that's really the challenge but but I guess the problem in my mind is to really change things don't you you almost need a revolution because you always push up against the resistance from the piecemeal nature of the system the individual doctor who basically is does not have electronic records of his patients who basically wants to make decisions for the patient that are inconsistent with the opportunities the technology would bring that's a problem isn't it well it is a problem but one of the things I've learned actually started health plans in Jamaica assorted health plans in Santiago Chile helped it to health plans in Spain and I did health plans in Uganda and helped a plan and get started in Nigeria so I have worked in a number of countries and one of the things I've learned is that you can't just take American template and its entirety drop it in anywhere I think of the work that's foolish than the model doesn't work it do you can't take when the number one issue in America is some thing to do with like to stay in the hospital and you go to a third world country where there's no hospital clearly that that solution set isn't going to transfer but what does transfer is a sense that we need to focus on the patient we need to focus on Team care we need to make sure that the patient gets care that's based on medical best practices and algorithms and so what does transfer is the science of Medicine but a lot of the process infrastructure and then some of the financial parts don't transfer we got to Uganda you just said we had to run the health plan for ten cents a month administrative costs I think well I mean dime a month we saw we said what do we have to do to get down to a diamond month he could we transplant an American Blue Cross system into Uganda and run it for a dime a month and the answer is no so what do we have to do to get you have to boil the health plan down to the essence so you get rid of claims and what you have instead is you have a physician in a hospital who are prepaid for a package of services so nobody fails and claims processing is just incredible waste of time effort money because you're right spend all your time filling in all this information is then somebody else they spin all kinds of time working out and it sent it back to somebody else you go through the accounting you had this piece of paper going back and forth three times to generate a check for peace of care and that's irrelevant to the whole process of actually blue Frank here so in Uganda we took these little coops we collected milk and tea leaves and coffee beans and whatever the premium was and we turned that directly into care by going to the local caregiver collectively purchasing the package of care so we eliminate all the administrative costs relative to clients completely wipe them out we wiped out all of the the the membership and billing by having the collection be in that form in what we had for each family was one ID card for the entire family there was a photograph of the family that we embossed and we put the health care information on one side in the family picture on the other and so the family would take it with them so we eliminated paperwork with laminated bills we eliminated claims and we actually ran it for a dime a month so then the question is and by getting it down to the essence so the question is what does that teach us here so if we come back to the US where we've got an administrative costs and it's just massively higher what can we think about how do we get us down to a diamond month so one of the things we're doing in Kaiser Permanente is we're actually trying to emulate Uganda model yeah by going entirely paperless by having a try medical record by having electronic billing electronic enrollment having every single thing connected electronically so we can eliminate all those layers of of non value-adding expense relative to processing all the pieces and we're on our way we actually have now 26 of our hospitals were recognized last year for being paperless sorry for being paperless hims people recognized 26 kaiser hospitals as being among the top three dozen most paperless hospitals in America but that's actually an extension of the learning from those little villages in Uganda where we set up the co-op's because we said in Uganda how do we eliminate every non essential thing but still do the essential things and same thing is true if kaiser permanente can become entirely paperless then we can change our administrative infrastructure and have the resources focused on care delivery and not on processing claims so so it seems that we should take a moment to talk a little about Kaiser because Kaiser has become this extraordinary petri dish shall we say for testing new possibilities that technology offers and and let's talk about the uniqueness of that system because across-the-board paperless data at the fingertips of the patient emails between doctor and patient doctors you before you were talking about the lack of connection between doctors you you you you go in for a hip transplant and the doctor doesn't know i should say hip replacement the doctor doesn't know that you're on certain heart medication but all now going paperless interconnectivity that is all at the fingertips of the patient and the doctor and then in addition I guess you're creating this extraordinary data bank of information which can track the systemic causes of ailments rather medication so talk a little about that yeah one of the things we just did in that regard we now have 10 million electronic medical records so we have the largest electronic medical record in the world and it's completely interactive it's a real time so the doctors have all the information with all the patients all the time so when you're in the room with your doctor that information flow is pretty complete and then you can email your doctor we've set up connectivity when I was just traveling a short while ago I had my medical record in my pocket I had a little insert and put it in there and so it was just a very nice process and the reason we can do that is because we are vertically integrated because we have all the pieces we Kaiser isn't split into little pieces so we have hospitals we have clinics we have labs way of pharmacies all of the pieces are part of KP and the really nice thing for us to be a microcosm is that we have prepayment so you pay a premium to Kaiser as a Kaiser member and then we get to take the premium and figure out how to do the right things with it in the rest of the world and broken bones is we cut broken bones by forty seven percent we did that because we have prepayment from our members and we figured out who's at high risk of breaking bones and we put care plans in the computer for those people and that every single nurse doctor who interacts with them interacts in the context of a care plan that we've actually had a huge cut in broken bones and twenty-five percent of the people over 72 get a broken bone die within a year so that actually improving the death rate is improving everything but we saved a lot of money we saved about 60 million dollars by doing that and for anybody else that would have been 60 million dollar loss in revenue and for us because we're prepaid there was no loss of revenue for us it was just better care and if anything reduction in expense and that's a very different model and we I often say that we were bigger than 42 states in 140 countries and so we think like and we have all of the Cure components so we think like a country we have ministers of health from other countries come two kinds are all the time without the Minister of Health in my office in the last year from Germany Ireland Switzerland Netherlands Minister klinke from the Netherlands has been here a couple of times we we have a whole series of interactions with the other countries that were bigger than Norway so we spend time with the minister of health from Norway we have an exchange program with some care sites in Sweden and so what we're doing is we're learning from those folks and their learning from us and they think like us they think because we have accountability for total population as they do and then we've got a total budget because our total revenue comes in we don't make more revenue by doing more transplants we make more money by getting care right and having better outcomes so and the fact that we're not for profit is also very nice because now for problem means I don't have to go to Wall Street every month and explain to a bunch of stock analysts what we're going to do to maximize our quarterly revenue if we miss our quarterly revenue everybody knows that be going to be a republic about it but so what I mean stock prices don't go down nobody's investment portfolio is diminished and so so you're you're in a way free from the market but you're using market ideals a market that that's been directed by insight so to speak right to to increase efficiency yeah we're free from the stock market but we are totally involved in the in the care market and the insurance market so we're selling premium side by side against Blue Cross Blue Shield at novell point cigna so we compete with those guys all the time and so patients make choices improving choices so we have to have a better price better product that our outcome than they do to survive Muhammad Yunus talks about social businesses these those are two kinds of businesses in the world kind that are about built around a profit and the kind that are built around the mission they're both totally legitimate is mr. a second second built around a mission yeah so units just wrote in another wonderful book and the book is about social businesses and the nature and construction social businesses and he basically says the social business because the Grameen banks that he set up our social businesses he's now done some I hospitals and social businesses and the whole concept of social businesses it functions as a business competes in the world with other businesses and the purpose of it is to achieve a rich mission is loans to poor women and whatever and we're sort of like that we're social business and we're about delivering health care to our members and I love the fact that i do not have to go to Wall Street and fight for my stock price you sit in the meetings and when you look at the law the number one accountability of somebody who basically hands stockholders there's a fiduciary responsibility to the stockholders in what I have is an ethical accountability to our members but the stock prices don't float around based on whether or not we have done something so we can invest Kaiser Permanente we invested four billion dollars left by medical record and for blends a lot of money and we made that investment without flinching because we knew care would be better on the back end of that and if you were a different company out there in a for-profit world you had to go back to the wall street analyst and say and here's exactly what our profit margin is going to do based on that investment it would have been a tougher investment how do you account for the emergence of a plate Kaiser the Mayo Clinic Cleveland their their similarities with the models it's sort of so different from the way the American Medical system has evolved so I guess there are two questions one is how do you explain Kaiser's emerge on the one hand and then what are the lessons that you can actually implement for the broader American system because I think it's very clear even in your own writings that tomorrow we're not going to wake up and and the whole country it was going to be Kaiser all right though the kaisers male Cleveland Clinic guising or this half a dozen large medical groups in the country where the physicians all practice together multi-specialty they have absolutely no downside if you are at mayo and you refer to a colleague inside male that doesn't affect your income anyway you don't lose a surgery you don't lose most places the doctor makes referral loses a surgery that the changes the amount of money they have to pay the kids tuition in college okay at mayo it's no impact so mayo is built around best care Mayo is built around the patient neo is built around a culture of doctors who are collaborative and collegial and dr. select into that Mayo is salaried physicians Kaiser Permanente salaried physicians Cleveland Clinic soured physicians guising you're salaried positions there's another in addition to be multi specialty groups these are groups that have chosen a compensation model where they want the doctors to make every single decision based on the best interest of the patient and make no decisions based on the personal income they weren't decouple personal income the decisions that's a very elegant and clean model in most of American health care is built around if a doctor turns somebody down for surgery that's six thousand dollars they're not going to get well how many how many surgeries do you not see definitely we do see same thing on scans at each of those settings the scanning team is submerged into the overall structure and the rest of the world every scanning units a profit Center and they do as many scans as they can do they do whether people need them or not and the fact that a scan is equivalent of a thousand x-rays doesn't get mentioned to people who are getting the scan I mean if I said would you go and I have a thousand x-rays this year and then have another thousand x-rays next year a thousand actually you'd say heard you're kidding and then people come to you and say you know you should have a scan and then you need a baseline scan you shall follow us again and they don't tell you about the thousand everything so in a system like Mayo they know that they know exact radiation count they know exactly what it's about the keep track of the accumulated radiation can for their patients over time because they're about to patient not about the billing opportunity what what are the systems that are in place to continually monitor accountability the accountability that I think comes from bureaucracy and human error when you think of a group process you know your immediate fear might be well this is going to be a bureaucracy I'm not going to have the hands-on of the you know the skilled professional and so on what are the the mechanisms there and then there's always human error you get to correct the system Union in those groups yeah in degrees yeah oh yeah the mechanism in the group says first of all there's a selection process to get into the group's I mean most provider networks anybody who raises their hand has a license and science of papers in and in if you go to Leia where you go to KP we probably have eight candidates now for every available job in most of our areas and so we go through a screening process people are interviewed and so we pick people who we think of the right skill set the right culture or the right disposition want to work in a team environment because some people don't want to work in a team environment some people just want to be solo people and that's fine but they should be so love people but other people want to be in a team and they want to be part of a team so what we do is we go through a selection process and then we go through a screening process and then we make sure that if there are outliers or people are not performing or if there are problems that they're dealt with and then so that the top priority is patient we need to make sure the patients are getting the right here and so there is an internal feedback loop as well and then there's a lot the creasing amount which is really good of external quality tracking and so we're now beginning to you can now find out the coronary artery bypass surgery mortality rate in hospitals ten years ago nobody had a clue either the hospital's didn't know and now if there are ways of finding it out it's not easy you can't find it out in a hurry you certainly can't find an L when you're on the operating table and trying to figure out where to go for your surgery but but it's now available which is huge step forward be because we can look at that data we can sit down again as a care team as a care system we can look at our data now and we can say here's where we are and that compares to these guys in that compares to these guys and and if these guys are doing better than we are why what's that all about you don't know that but when we first started measuring infection rates in our hospitals every single Hospital basically passed the test of knowing the right thing to do and we saw a variation that was quite startling to us actually but there's some hospitals with the very best in some hospitals were down bottom third and so what we've done is we've moved on everybody up so now three years after we started that program the the worst hospital is better than the best was when we started when I was actually chart on that in my most recent book showing that progression but the thing that was fascinating is the people who had the lowest dot on that chart the hospital and lowest i absolutely believe they're doing a great job they were completely they would pass any lie detector test you at a given and they would have passed because they believed they were doing all the right stuff they knew the right stuff and then when they found out they weren't necessarily doing all the right stuff and there was an inconsistency and some of the people weren't no and it wasn't until it became a process point in a data point and they started measuring following up that they learned and then once they learned done they can fix it but you can't fix something you're not aware of and you you can't aspire to something if you don't know what's possible so the data points are really important and so going forward is part of your question going forward we need to identify the data points that are the most relevant data points for American healthcare and some of those should be cancer survival rates we should have that data available to us because people with cancer should be able to make those choices and some of the data should be about heart surgery survival rates and some of the data should be about the percentage of patients with diabetes with kidneys fail we should be looking at the outcomes and based on the outcomes letting patients make meaningful choices then we also need to get as much team based payment as we can so the kind of model that the Kaiser hands where we get a capitation we get a prepaid about is a really good bottle for team care because the Mike can come out of the team fact i'll tell you a horrible story that's and it's actually I don't remember which of the two books it's in but one a city and in the southern US some very smart people working with the community clacks decided to create team care and they did it using a computer model so they could have set up an exchange a computer registry for all of their patients who were very poor who had comb we had diabetes and congestive heart failure a corner artery disease and they put care plans for those patients in the computer and that every time those patients came in no matter which doctor saw them because they had rotation of doctors and clinics for poor people and some of the doctors volunteer or somewhere permanent they had a rotation but no matter who saw the patient they have the data about the patient they do the care plan for the patient and they could interact with the care plan they cut the number of hospital admissions for those patients in six months by seventy-three percent they cut by setting the literal and so they had a huge improvement of quality care and you know what happened to the program the hospital that was hosting it tilted and they killed it because they needed those admissions when you cut your admissions by seventy-three percent in your entire revenue stream is based on so they actually killed the program that was providing the best care in town because they needed the admissions so so what look the if the country cannot become like Kaiser how do we move in that direction I I think you believe that that they're real possibilities is a kind of cyber integration talk a little about that was a little bit like the thing I just talked about what those folks did was a form of cyber integration yeah they couldn't they weren't a vertically integrated like Kaiser but what they did do was they did identify for patients who had multiple health conditions a mechanism so that each of the doctors dealing with them had all of information you can do that electronically you have to have a discipline about it you have to actually have the data you have to have someone maintain the data but it's all doable so you can take all of the solo doctors in america and you can actually get them to work together in teams if there's a if there's a mechanism but every team has to have the structure and a captain yet if somebody a primary care doctor somewhere in there who's looking at all the work in this patients make sure there's a plan in their care plan and then you need to have everybody else in team interacting with a database but if you do that even outside we do it naturally because we have all the data an electronic medical record and all of our patients our primary care doctor but you can do that in a non kaiser setting in a couple of community clinics have proven you can do that Denver Health has done some of that work contender for again their case for the poorest population so I truly believe there is a cyber keizer or a virtual Kaiser that should be created in just about every place you got patients with comorbidities and I think what people can do is learn from what we're doing because the stuff that we're doing is working so we're cutting the number of broken bone we're cutting the number of kidney failure is we're cutting a number of whatever and the fact that we're having success should encourage other people to go there but then what you have to have is you have to have something in the business model it gets people there so then you have to have the employers in a given community saying to their health plans we're only going to use you if you have team care and if they say we're only going to use you if you have team care than the put team care in place and tim kerr has its own benefits in its own positive outcome so you don't need to put every single doctor on it instead of plain what you have to do is you have to have teams that exist and function are supported but you could do that if employers wanted to do that major employers in the given community wanted to say we want our doctors all to be doing teamwork for our diabetics or congestive heart failure patients they could mandate that their health plans come up with a connecting mechanism and they could do that I after reading your books I went back and looked at a summary and what was passed under Obama's legislation that finally got through what grade do you give that legislation in the context of what we've been talking about the Kaiser model in the context of the importance of interconnectivity in the context of re-engineering the environment to create a market in which there are incentives to do good care how do you I think what i can say is a health care reform in america has to have three pieces and the first piece has to be coverage or form we've got to get the insurance reform right we're the only country in the world that doesn't cover industrialized country it doesn't cover all of its citizens so you have to do that we need to do that that's foundational you gotta get we gotta do it you hit you can't fix one only forty seven percent of the kids with as we're getting right care one of the reasons for that is there all kinds of kids who have no coverage but if every kid in America has coverage then you can fix asthma care so what I always say is first coverage second care and we need to get the carriage and lined up we have to have fewer patients diagnosed absence we have to have fewer kids with asthma we have to pick some major issues and fix that and we can fix that and then the third agendas cost be in the cost its third not second if you try to put costs higher then you started doing things about rationing or then it's about pain differently or something that is a different world but if you say we're going to fix care and then because we have half as many hospital admissions we're going to have less cost on that side that's the right model so its coverage care costs in the bill that was passed points us down a path toward coverage it actually has many provisions that tee up the care so the trick is now going to be in the execution it's going to be how well the secretary sebelius take the 270 shells that she hands in the bill secretary she'll do this secretary shall do that there's about 270 of them in the secretary shall track hospital infection rates the secretary shall have exchanges that have Secretary shall make sure that the computer systems connect with each other it's a whole bunch of shelves in that bill the shelves weren't discussed bunch in the debate hmm but they're there if you go through and read the bill the the next couple years are going to be about the shells that were even talked about on the debate and so we're going to see a world where the proof is going to be in how well how well we execute against the shells we should be able to make a lot of progress the progress isn't guaranteed it's not inherent it's not slam dunk but it is teed up and then so the the Secretary has a bunch of powers and the ability to convene people that I've been to move collectively in a good direction so it's going to be a performance issue at this point and if the secretary does the kinds of things that I think are possible and I think the secretary I think Secretary Sebelius wants to go in those directions I think she is directionally correct on those topics I think she's trying figure out right now and I frankly was personally extremely encouraged when they picked Don Berwick to be they haven't seen this because if you think about you could pick the politicians be head of CMS you could have picked an administrator you could have picked a bureaucrat CMEs is Sam I'm sorry Medicare Medicaid no okay Medicare Medicare yeah so the Medicare Medicaid programs report to see on this along with chapter the children's program and so there's a huge chip the CMS buys for more care twice as much care is the British national service it's a huge purchaser care in America forty percent yeah exactly it's a huge meh it's a massive and so the CMS job is a really big job and we have never used it in this country in any way to improve the quality of care some small stuff but nothing significant nothing major and so when you look at who runs CMS you can put in a bureaucrat you can put in somebody who's made a lot of political skills so they can lobby Congress or whatever and what they did was they reached out to the head of the intrigue of IH I which is the Institute for Healthcare Improvement Don Berwick who is a Harvard physician who has been the quality guru in in America for a number of years and Don about 10 years ago started a program called hundred thousand lives and he basically said a hospital did these couple of things they can save a hundred thousand lives next year and he went around himself and he proselytize and he managed to persuade enough hospitals to sign up and they saved more than hundred thousand lives and so he done has this track record of quality improvement health care so when when they picked on to run CMS and his background is to quality improvement in healthcare that to me is very encouraging one final question when we running out of time so a brief answer what lessons do you think students to draw from your career and and the life experiences we've discussed that that might influence them if they're interested in in working in the health care fear they in the healthcare field any simple lessons um find something that you love to do to do they send my father used to say if you have a job you love you never work a day in your life so finance find something that you really like doing that you want to wake up in the morning and go do and to the extent you can do that that's not always possible that's one thing second thing is be open to new approaches new avenues I'd never would have gotten to Uganda and I said that doesn't make any sense for for where we are but look for adventures in your career look for learning opportunities and then learn everyday to the extent you can be in a perpetual learning mode because there's always people who can teach you things and there's always things you can learn from ever setting and so learn enjoy learning and learn every day on that note mr. Halverson I want to thank you for being here I want to show your book again because i think it's a it's a very readable statement of where we need to go in healthcare and you really tell us what the title says healthcare will not reform itself I want to thank you very much for taking the opportunity to have you here thank you thank you and thank you very much for joining us for this conversation with history you

2 comments

  1. Halvorson is a not-so-brilliant Liar, dude! Anyone with first hand experience with Kaiser can easily refute 90% of what he says about the KP system. His experience is NOT representative of most KP patients!
    Do your own research & remember, Halvorson has no Health care provider training of any kind. He is 1st & foremost a PR man.

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