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Healthcare Camouflage

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Open the New York Times last weekend and there were two articles concerning healthcare quality in the United States.  The first recounts the efforts by New York State government to close or consolidate hospitals with high patient-harm rates.  The first indication that such closures are exceedingly difficult is the necessity of creating a special, independent commission.  When elected representatives lack the spine or the consensus to do that for which they were elected, an independent commission is often the solution of choice.

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Written by rcrawford

December 12, 2008 at 6:24 am

A New Blog is Born

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Over the last several weeks, I’ve been hard at work with the start of the new school year and semester at UNC.  For the first time, I am teaching Healthcare Policy for the Bachelors of Science in Public Health program, in addition to the Quality Improvement class for the Executive Masters students (Masters in Healthcare Administration, plus the occasional Masters of Public Health student).  After a summer focused on consulting projects, it is great to again have a chalk board at my back and brilliant students to my front.

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Written by rcrawford

September 9, 2008 at 8:21 am

Newsletter – February 17, 2008

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This USA Today article questions whether cultural disparities between a largely Caucasian physician community and a more diverse patient population accounts for health-outcome disparities. This strikes me as interesting on a number of fronts. First, it has been a recent focus of my marketing class, as we’ve covered the materials related to cultural differences and the necessity of providers to accommodate an increasingly diverse patient population. Second, my quality improvement class has indicated a growing belief that the physician practice community is similarly reflecting the melting pot of America.


For hospital administrators, this indicates the need to take into account not only language translation as an operational necessity (to avoid miscommunication when family members are used as interpreters), but the increasing need for multi-lingual signage in larger facilities, an understanding of cultural uniqueness (such as gender-appropriate physicians for Islamic patients), and accomodation of dietary practices (when not in conflict with best-practice medicine).


Perhaps, more interesting still, is the position of a former student, Frank Shelp, MD, who argues that the superior outcomes enjoyed in Europe’s socialize-medicine is largely attributable to a more homogeneous population. Under this logic, the question is not “What are we doing wrong (in the US) and what are they doing right?” Instead, there is no question, because healthcare does not control the cause of the disparity (i.e., the demographic mix in the US).


This article from Seattle outlines the settlement of a government lawsuit against Caremark for $1.7 million (out of a $41 million multi-state agreement), in which the pharmacy benefits manager was accused of urging practitioners to switch patient medications. The switch, as recommended, argued that doing so would save the patient unnecessary costs. In order to do so, however, additional diagnostic testing was often necessary, and the new medications may not have provided the promised savings. Assuming, for the sake of argument, that the company was acting with the best of intentions, this may represent an unintended consequence of change – just as we initially witness added costs associated with adoption of electronic medical records (prior to realizing anticipated savings). For healthcare executives, this further urges the adoption of the rule of twos and threes – namely, that new initiatives take twice the seed capital and three times as long as originally projected. This rule typically applies to new entrepreneurial startups, but delays and cost inflation apply to new initiatives by established firms, as well.


The Minneapolis-St. Paul Star Tribune is reporting on the uncertainties and consternation for senior management at United Healthcare, following announcement by the New York attorney general of a probe into the company’s practices. Under the heading of “full disclosure,” I should mention that I own stock in United Healthcare. My purpose in mentioning this article, however, is not to, either, defend or oppose the company’s practices. Instead, it is to note that this second-day, follow-on article is consistent with an earlier blog entry describing the expandable news cycle — with initial reports and a long sequence of sustaining articles. For healthcare executives, this is an important recognition. It urges strong establishment of corporate leadership focused on customer satisfaction, quality, and public relations/marketing. At a time when the industry is questioning whether the Chief Marketing Officer should occupy a C-Suite position, there is nothing like defending bad news in the press to settle the issue. The time to bring the Chief Marketing Officer in to the boardroom is not after the fact.


It has been a week since my last newsletter or blog contribution, which is longer than at any time in the past. This is a particularly class-focused semester, teaching a seminar at the start of the semester and marketing and quality improvement classes during the semester. Consequently, my weeks are filled with teaching and grading assignments, and this newsletter will be shorter than most.


Allow me, therefore, to do three things at the close of this newsletter. First, I would like to reiterate the purpose of the newsletters, which is to use local newspaper articles from around the country to identify health-care market trends before they become broadly recognized and disseminated by consultants in their white papers. Once that happens, the professional healthcare executive works on a treadmill, constantly seeking to catch up with what the competition knows.


In addition to daily reading of the New York Times, Wall Street Journal, Washington Post, the Chicago Tribune, and the Los Angeles Times (using the Factiva service) and weekly reading of Time, Newsweek, US News, Business Week, and Forbes (primarily the healthcare and economic content) I rely heavily on the daily newsletters provided by Healthleaders.com. I also have the table of contents for the New England Journal of Medicine, Journal of the American Medical Association sent by email and scan the content of Health Affairs magazine (each of these last items is subscription based).


This may seem like a great deal of reading for a busy professional, but my focus is on topics that influence the future direction of the industry and those providing a different perspective and density of content (as opposed to filler, fluff, and flatulence). Most of what is published fails this test, and I move through the materials quickly. Life is too short to live it as other than a news snob, so the Time Magazine article on whether the Sports Illustrated Swimsuit edition is porn gets ignored (no matter how hard it may be to pass up).


The second item that I would like to reference is the availability of thought-leader materials that are increasingly offered free of charge on the web. MIT is offering course content for its classes free on the web, Harvard’s faculty has just voted to require opting out of providing journal articles authored by faculty, and, within the realm of healthcare management, UNC is providing the syllabi for courses offered through the School of Public Health – which reference the texts employed. The MIT and UNC offerings provide working executives who have been out of business school for some time an opportunity to stay abreast with best practices without returning to the university for added training. Of course, seminars, extension courses, and other continuing education offerings are important, because so much of what is published and provided at the local bookstore represents a waste of perfectly good trees.


The final recommendation for professionals seeking actionable content is Knowledge@Wharton. Their book reviews, alone, are excellent, and they provide executives with an early description of recent publications that are likely to influence professional practices at the executive level. Here is an example of their coverage of marketing (traditional and on-line) or a report on changing international capital flows from the Davos conference.


And, lastly, my favorite mind-candy web site is www.ted.com. What comes in second? How about http://www.kurzweilai.net/ ?


Written by rcrawford

February 17, 2008 at 9:03 pm

Newsletter — February 7, 2008

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Medical error deaths in Pennsylvania. We are all customers with something of a common experience. On a Saturday morning, if you head off to Wal-Mart and purchase a new toaster oven, you fully expect that the oven will work. If it does not, you take it back for a refund. For the customer, there is certainly a cost (typically measured in gas mileage, but including the time invested in the purchase and return, as well). For the retailer, costs are significantly higher. This, of course, would include reduced reputation, the logistical costs associated with returning the defective product to the manufacturer, and the cost of warehousing, both, the defective product and the necessary replacement – plus ancillary costs associated with marketing, in order to churn replacement customers into the system as dissatisfied customers head off to the competition.

In healthcare, there has been a tacit expectation that, when medical errors occur, we will be paid for our services. Under this system it has never been precisely explained why the almighty smiles with such benevolence on us uniquely. It may be argued that tort liability represents an expected healthcare cost, but tort liability applies to other industries (recall the Firestone tire cases and, more recently, the lead-paint-Mattel issues). Perhaps it is the advanced degrees, the lab coats, the stethoscopes, and the other accouterments of healthcare that make us special, but, increasingly, such deference is in short supply among payers – including the big kahuna, CMS (the Centers for Medicare and Medicaid Services). The states, especially, are increasingly opposed to paying for medical-error with Medicaid patients. Today, we have the latest such report, coming to us from the Philadelphia Inquirer, extrapolating the medical error rates from a small number of prominent counties in Pennsylvania to the state at large.

Interestingly, there is a comment in the article indicating that one member of the medical community believes it unlikely that such an extrapolation is accurate. Surely, we are not killing so many patients as these projections suggest, the respondent asserts. These figures, however, strike me as being perfectly reasonable (even an understatement of the reality). Over the last several years, I’ve had close connections with some senior members of the Pennsylvania government and gave testimony in support of legislation designed to reduce the medical error rate. From those sources, I understand that nosocomial infections kill 19,000 Pennsylvania patients per year. Consequently, the figure of 1,500 deaths due to medical error in other categories strikes me as being in the ballpark.

California –Emergency-Room Problems Threaten, Both, Patients and Emergency Rooms. Overcrowded conditions, patients stacked in the hallways awaiting available rooms, a patient writhing and dying in the waiting room, an un-attended patient leaving in disgust and dying on the sidewalk across the street are all recent stories from California hospitals facing loss of CMS accreditation, according to this Los Angeles Times story. California, however, is not like Pennsylvania, and, to our credit, no practitioner is quoted claiming the problem is not as significant as this description indicates. Instead, the problem is blamed on lost capacity. Like the previous story, however, there is a quality improvement aspect and opportunity, in the face of financial constraints. While quality improvement is largely viewed as a means by which to increase customer satisfaction, the process improvement component of CQI is designed to increase cost savings through improved operational efficiency. The problem with CQI, however, is a required and sustained level of commitment that borders on religious fanaticism. Quality Improvement is not, therefore, the hallmark of the merely average provider.

Is Iowa the Solution? A recent an unprecedented surge of patients during the month of January in Iowa provided local hospitals and emergency rooms with a real-world opportunity to test their emergency plans. While this wasn’t the long anticipated bird flu or terrorism-related surge, in many ways it was a more challenging experience – with patients arriving with nearly every conceivable diagnosis. Better approaches to triage, closer monitoring of room and bed status, use of conference rooms as patient-treatment wards, cots lined-up in the hallways, private rooms converted to semi-private, and coordination of patient volumes across multiple hospitals described the severity of the challenge. As indicated in this Des Moines Register article, the established emergency plans were helpful (indicating their utility), but those plans needed to be abundantly flexible, taking into account an assortment of changing scenarios. Today, most hospitals across the nation have emergency plans, but, as the Iowa experience indicates, the simple presence of such plans is not sufficient.

Just as Edwards Deming is considered a founder of CQI, Genechi Taguchi holds the same status for Six Sigma. While Taguchi is best known for his engineering approaches, the core of his method is to create systems that are so robust they will work flawlessly in the worst possible circumstances (as opposed to normal, the average, or the expected). This, of course, would apply to emergency and mass casualty events. As any military planner will assert, the time for such planning is not in the heat of battle, while suffering from the fog of war.

After the bombing in Oklahoma City and the execution of staff alerts in New York City on 9/11, hospital administrators gave press conferences congratulated themselves on the fast response undertaken by their facilities. At the time, I wondered how much of that response was a consequence of executing an established emergency plan and how much of it was accomplished by adrenaline and the application of good judgment in a moment of crisis. Since then, I have learned that both occurred. The emergency plan was initiated and modified on-the-fly. The plans were good but they were not sufficiently robust (as designed) to accommodate what was, arguably, something less than the worst-case scenario (bird flu, dirty bomb, etc.).

Pediatrician Training At Specialty Hospitals Confront Threat Of Federal Government Funding Cuts – Ohio. The Dayton Business Journal reports that a current budget proposal in Congress would cut funding for pediatrician training at specialty hospitals. As indicated in previous postings and newsletters, the federal government is increasingly desperate to halt the impact of health care inflation on government programs — which now accounts for 17 percent of expenditures. This is especially true of Medicaid, as evidenced by federal funding cuts in recent years.

Children, of course, are disproportionately represented among America’s indigent population – the poor tend to have larger families. There is, of course, a significant cost to be borne (literally and figuratively) if failing to provide adequate health care to America’s children, regardless of their financial status. Poor health care diverts student attention during the K-12 years, undermines learning, predicts lifelong poverty and lower incomes (with accompanying cost to government), is a predictor of crime (violent and otherwise), and, perhaps most egregious of all, deprives the totality of the population of this demographics’ future contributions (an especially important consideration in a globally competitive economic system). All these negatives are a consequence of unsustainable health-care inflation … and the boomer generation has not yet begun to retire.

Iowa Proposal Takes a Different Approach to Children Health. This Chicago Tribune article describes an Iowa plan to provide health care coverage to all children in that state – taking an entirely different position on the subject. This, of course, is just a proposal, but I cannot help wondering whether, if successful, the Iowa Legislature will experience “buyer’s remorse,” once the full price of such a change confronts payment by government. This is precisely the situation taking place in Massachusetts, following their new healthcare structure enacted a couple of years back — under then-governor Mitt Romney.

The Big Dig in Massachusetts. Some Massachusetts lawmakers are shocked to discover cost overruns that are projected at $600 million over 10 years for the new state health care plan. That plan was designed to reduce long-term health care costs for the state. The state, however, appears to have identified a solution – increase tobacco taxes.

Several years ago, the state attorneys general secured windfall payments from the tobacco industry, designed to compensate the states for smoker health-care costs. The states gladly accepted the payments and promptly spent the money to build roads, bridges, parks, and on other, non-healthcare initiatives. Very little money was spent to reduce smoking. Doing so would run contrary to the State’s interest – given the sin tax revenues collected on each pack of cigarettes.

In a related story from earlier this week, this blog reported on two stories indicating that obesity and smoking are not responsible for health care cost inflation. In fact, the opposite is the case, with both groups costing the healthcare system less (because both groups die sooner) than healthy patients. While the proposed Massachusetts tax raises the issue of equity, by asking smokers to finance a disproportionate amount of health care costs, such a proposal seems doomed to failure on two fronts.

If the proposed tax increase prompts a reduction in smoking, tax revenues from tobacco would decline. Presumably, this would prompt government to increase tobacco taxes, which would further prompt a reduction in smoking and a new decline in tax revenues. In the insurance industry, this death spiral is known as “adverse selection.”

The second problem with such a proposal is that it does nothing to address the drivers of health-care inflation, which would remain unmolested and free to promote increasing health care costs.

One Response To The Proposed 10% Cut In Medicare Compensation. Earlier this week, the Bush administration submitted its budget proposal for 2009 (following the State of the Union address). That proposal includes significant cuts in funding to Medicare (previously reported here). As the previous newsletter item indicates, we are witnessing systemic hiccupping in advance of Boomer generation retirements, as the federal government seeks the means by which to meet its health-care commitments, in an environment where medical inflation exceeds wage growth by more than double each year on average. If Medicare compensation were low, we would expect to see a practitioner rebellion in Florida – the bellwether state for retiree health care. Indeed, this Tampa Bay Online article indicates that two thirds of Sarasota practitioners plan to cease accepting new Medicare patients unless compensation improves.

That, however, is not the important part of the story. Recall that Medicare + CHOICE was the precursor of Medicare Advantage. Medicare + CHOICE confronted a similar problem of inadequate compensation and received the same response from Florida practitioners. More importantly, institutional payers (insurance) under the Medicare + CHOICE were exiting in droves, stranding as many as 400,000 enrolled seniors per year. This prompted the demise of the Medicare + CHOICE system, a one-time Clinton-era kickback to institutional payers, the undermining of faith and confidence in HCFA (leading to the name change to CMS), and the creation of the Medicare Advantage system (with its higher reimbursement rates).

There was, in fact, significant objection by Senator Charles Grassley and others when the kickback to institutional payers was promptly handed over to hospitals and physicians by the insurance industry. This objection was based on government’s hope that the insurance industry could be bribed or seduced into Medicare Advantage participation, but the insurance industry rightly noted that a growing number of physicians and hospitals were on the verge of bankruptcy. A Healthcare Advisory Board analysis at the time indicated that over one third of hospitals in the United States were in the red.

At the time, my students and I concluded that government’s “solution” would do nothing to halt healthcare’s hyperinflation. Hyperinflation is defined as yearly inflationary rates in excess of 30%. Healthcare has been averaging growth in excess of wage inflation by more than 200% since 1980. Accounts receivable charges by hospitals and physicians, however, are not a source of health care inflation, according to a recent Congressional Budget Office report (see earlier report). We, therefore, came to the conclusion that any solution not directly addressing the sources of health care inflation stood little chance of reversing it. Less than a decade later, we appear to have been right.

Minnesota Sees Things Differently. Two special task forces designed to seek answers to the rising cost of health care in Minnesota are reporting their results. The first is a task force established by the governor, who thanked the committee members for their service and indicated that he plans to largely ignore their recommendations.

This may, however, be a positive, since those recommendations largely mirror the Massachusetts approach (described earlier). The recommendations, of course, would include an increase in tobacco taxes (which were increased by $.75 per pack recently) and a state law mandating purchase of health insurance. It appears, the governor has been talking with the good people in Massachusetts.

The portion of the special committee’s proposals that the governor does like includes improving school lunches to undermine childhood obesity and legislatively preventing hospitals from charging indigent patients higher rates than provided to insurance. As mentioned previously, obesity is not a significant driver of health-care costs inflation, and it seems unlikely that mandating parity in compensation between the indigent and insurance will provide significant savings. The indigent, after all, are, by definition, poor.

Nevertheless, the state believes that these two proposals and a coordinated effort between government, insurance, practitioners, and patients will cut health care costs by $12.3 billion between now and 2015. All of this is described in a Minneapolis-St. Paul Star Tribune article.

The Pennsylvania Plan. The governor’s office, which initially sought to pay for increasing health care costs with a tax on employers not providing employer-based insurance, is now advocating a 10% increase in the tobacco tax, according to this Pittsburgh Gazette article. Beyond the realization that, at this rate, smokers will eventually pay for 90% of healthcare, the governor’s plan seems to ignore the reality that the Speaker of the House of Representatives is a smoker.

The governor has wisely decided against an obesity tax. As every male in the US understands, there is but one safe response to the question “Honey, does this dress make me look fat.” Government, in short, does not want to get into the business of answering that question.

US Health Care System Unsustainable, According to New AHA President. William Petasnick, the chief executive of Froedtert & Community Health, is the chairman this year of the American Hospital Association. He recently gave an interview, with the Milwaukee Journal Sentinel, in which he describes the US healthcare system as “unsustainable.”

First and foremost, we want to use the coming election as an opportunity to begin the debate about our health care system. And it ought to be a debate about ideas for improvement. What we are hoping to do is get the candidates really talking about how do we provide coverage for all? How do we focus in on wellness? How do we create a better health system that is more affordable and more efficient? How do we create a health system in which quality is measurable? And how do we get a better information flow through interoperability? We want to be certain that the next president and congressional leaders are committed to working for change. We don’t believe the current system is sustainable in the long term.

Why isn’t this man a Governor?



Newsletter – February 3, 2008

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Medicare / Medicaid Budget Proposal. After several years of consecutive budget cuts by the federal government to state Medicaid programs, a New York Times article this weekend describes the budget proposal due for submission on Monday, February 4, 2008. The opening paragraph reads:

“In his new budget, to be unveiled Monday, President Bush will call for large cuts in the growth of Medicare, far exceeding what he proposed last year, and he will again seek major savings in Medicaid, according to administration officials and budget documents.”

With the boomer generation slated to enter retirement starting in less than two years, the high and increasing cost of health care in the United States represents a growing burden on the federal budget. The majority of those costs strike Medicare, where the most significant expenses associated with senior care appear. More than 70% of health-care costs are incurred in the last five years of life, and, with average life expectancy in the United States approaching 80 years, the brunt of this financial burden falls on Medicare. Medicaid, which is part of the same government office, represents an easier target for budget cuts, given the comparative power of these two constituencies – senior citizens and the poor. It is not, therefore, surprising that the lion share of cuts have struck Medicaid in recent years, nor is it unexpected that cuts are planned for Medicare given our close proximity to 2010 and the start of the boomer retirements.

As mentioned in previous postings, today’s 47 million seniors (those over the age of 65) will nearly double by the year 2030. This is 10 years after the Centers for Medicare and Medicaid Services (CMS) project insolvency of Medicare in 2020, and 2020 is a decade after the first of the boomer generation retirements in 2010. This increasing level of fiscal hiccupping is something that I and my students my projected nearly a decade ago, and it is something that I predicted during testimony in support of cost-reduction legislation in Pennsylvania several years ago.

Bird Flu. Roughly a year ago, bird flu was everywhere in the news. Today, however, it is barely mentioned. The majority of reported cases come from Indonesian, and the World Health Organization, as reported in this New York Times article, indicates the following:

“The virus is known to have infected at least 357 people around the world in 14 countries, killing 224 of them, according to the World Health Organization. Experts say that because of poor reporting of infections and deaths, the true number could be much higher.”

Not everything in health care is “doom and gloom,” and the recognition that bird flu has not spread more widely represents a success story, to date. Keeping my fingers crossed, I cannot help but connect this story with the previous one concerning budget cuts for Medicare and Medicaid. The Medicare population is consistently the most at risk for any form of flu, while the Medicaid population often represents one of the most significant vectors for communicable disease in the United States. This is largely a consequence of poverty and the inability to afford regular health care. While many complain that America’s poor increasingly use the emergency room as their primary care physician of choice, few who make such statements recognize the singular fact that, even for this demographic group, the emergency room is not an E Ticket at Disney World or high on the poors’ list of entertainment options.

Nevertheless, just as Katrina represented a significant embarrassment to the federal government, reductions in Medicare and Medicaid spending may constitute a similar threat to the reputation of government if bird flu ever meets its potential as a global pandemic. It is only then that the proposed and recent funding cuts will receive the close scrutiny it warrants today.

Invention and Innovation. Stanford psychiatrist Albert Bandura, who initially conducted research on dysfunctional behavior, ultimately focused on the psychology that makes superlative performance possible. More recently (nearly 50 years later), Charles Manz and Henry Sims (“The New Super Leadershp”) have returned to the subject, verifying much of Bandura’s work.

Both indicate that the most common trait of superior performers is a high tolerance for recurrent failure. Of course, there are other attributes that contribute to this outcome, as well. Frustration is also helpful, since it provides motivation and causes the subconscious mind to work on a problem even after we have mentally moved to more immediate concerns.

This tolerance for recurrent failure, however, cannot be emphasized enough. It represents the daily existence of most medical science researchers, who typically work for decades toward identifying the next advance. In their case, there is no guarantee of ultimate success, and each day represents just another in a long string of what many may consider daily “failures.” There are, in fact, decades worth of failure leading to nearly every Nobel Prize, and, for every Nobel Prize winner, an abundance of similar researchers complete productive careers without ever achieving that pinnacle.

This represents a significantly different take on the subject of innovation, inspiration, and accomplishment than is the norm. Most believe that the eureka moment arrives in a flash, rather than as a consequence of long and persistent labor. This next article, however, notes the fallacy of that bias.

Double Dipping. Sometime back, researchers studied the five second rule for a cookie dropped on the linoleum floor. It appears that five seconds is not sufficient time for bacteria to attack the cookie. Double dipping – the practice of returning a partially consumed tortilla chip to the salsa –, however, appears to be a different matter. Researchers with nothing better to do have concluded that the practice does, indeed, spread bacteria, according to this CNN article. Personally, I would prefer they diligently fail at finding a cure for the common cold (which hit the Crawfords last week) than spend their days confirming what my mother and common sense suggest are right, reasonable, and true. [Not every story in the news is worth reading, but some make us more competitive at Trivial Pursuit.]

High Operations Tempo Leads To Lower Military Morale. As an old combat arms officer, I am understandably concerned about the military and the current state of its morale. Over the last year, I’ve spoken with a number of military members (something on the order of 15) and have come to the conclusion that morale is significantly lower than at any time in my memory – including those dark years during the Carter administration, when funding was scarce, and during the first term of the Clinton administration, when the nation was pursuing a “peace dividend.” The military, it appears, has come to the same conclusion, according to this CNN article.

This represents a healthcare issue because soldier suicides are up, as are self-inflicted injuries. What does not appear in that article is what I am hearing from members of the Reserves and National Guard. Until recently, most members of the Reserves and Guard entered service never expecting foreign deployment, much less employment in a war zone. Repeated deployments and separations from family, however, are taking a toll, even if national support for the military is significantly better than during Vietnam.

This should not suggest that I am opposed to our presence in Afghanistan or Iraq, however. During my time in the military, I was privy to the classified reports concerning Iraq’s former dictator, and I remain surprised that he did not have weapons of mass destruction. Nevertheless, suicides and self-inflicted injuries are up 20% over last year, and are roughly double pre-9/11 levels.

Nightly Ritual. It was a nightly ritual that extended well beyond my son’s toddler years. Over the objections of mom, I was the enabler of my sons nighttime stalling routine. In an effort to delay his bedtime, my son would attempt to engage me in conversation on any subject he believed I would find interesting. And, as he would wind down from the day, laying there in bed, with me sitting on the edge, his mind would become pliable, open, and receptive, and it was then that I would impart those lessons that I believed most important.

I told him not to take drugs, because, at his early age, his mind was still growing, and the death of a single nerve cell represented the death of all the subsequent cells that single cell would become as it divides. I described all the negatives associated with smoking, above and beyond the risk of lung cancer. I told him that during his grammar school, middle school, and high school years he would confront an abundance of opportunities to mess-up his life but few opportunities, beyond good grades, to make his future successful. Those opportunities, I explained, would arrive when he entered college; which would be less likely if he became an unplanned parent.

Chief among those opportunities to mess up, I explained, would include overvaluing the opinions of his contemporaries. As an adult, I said, he would care little for what his neighbor thought; focusing, instead, on the strength of his marriage, raising his children to be the best adults they could become, paying the mortgage, succeeding at work, and earning a graduate degree. His friends of today would be gone tomorrow and barely remembered, so peer pressure and bullying should be put into perspective. Neither, I asserted, were worthy of him as perpetrator and both could be profitably ignored as the victim.

Today, he is an honors and advanced placement student at one of the top 50 high schools in the country, and, as a junior, the volume of his “junk” mail from colleges and universities around the US far exceed that which is addressed to his parents. I mention all this because of a CNN article on the aftermath of a suicide prompted by bullying.

Sometimes, there are more important things than a good night’s sleep.



Healthcare Recruitment in Small Town Settings — HR & Marketing

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A former student of mine is a hospitalist in Boone, North Carolina. Among all the students I have taught over the years, she is one of the brightest, and her resume of attending the top med schools, including a residency at M.D. Anderson, supports that conclusion.


Boone, North Carolina is something of an emerging market. It is located in the mountains of North Carolina, which would ordinarily imply a rural healthcare setting, but it is an attractive destination for vacationers, as well. She and her husband were first attracted to Boone because he is a concert organist and a professional opportunity presented itself in the area. In addition to her direct treatment of patients, she holds a leadership position at the local hospital, and she is thriving – finding the experience as rewarding as any during her years as a practitioner.


In talking with her about her life in a semi-rural environment, she describes it in almost philosophical terms. As a practitioner, the work speaks to that which first compelled her to practice medicine – the connection to patients and their families, the ability to make a significant difference in the lives of others, and the time available to pursue outside interests (such as reading, music, etc.). It isn’t that the big city holds no attraction for her. Instead, the small-town lifestyle is more attractive, including an income sufficient for frequent trips to New York City and the major capitals of Europe – where her husband is in high demand.


Shifting gears, slightly, this week in the online forum area for my quality improvement class, one of the discussion threads centers around the difficulties associated with attracting physicians to rural settings. It started when a student described the difficulty recruiting and retaining hospitalists at his rural, full-service hospital. The discussion has naturally gravitated toward the topic of employee satisfaction (a legitimate CQI subject) and, in this case, the related issue of practitioner recruitment (HR) and marketing.


Other physicians in the class, when pressed, describe the common concerns that urge newly minted physicians to avoid rural health-care settings. These would include fears concerning the frequency of on-call rotations if not part of a large group of similar specialists, comparative income, inadequate facilities and non-state-of-the-art equipment, boredom, and the quality of the local schools for their children.


Several years ago I did a consulting project on this topic with a small rural hospital in eastern North Carolina. The largest, multi-specialty group practice in the area had, en-mass, affiliated with an academic medical center 40 miles down the road and had stopped local admissions. This was particularly devastating to their cardiac and cancer services, and it placed a significant constraint on ER coverage. It was, therefore, imperative to find replacements quickly.


As we worked through the project, it was suggested that we target our recruitment efforts on small medical schools, especially those located in small metropolitan statistical areas, rather than the top medical schools in the Northeast. It was even suggested that we consider newly minted physicians trained at less-reputable offshore medical schools. I urged the opposite approach, believing that a targeted marketing approach, touting the charms of small-town life, would be attractive to a small niche segment of new graduates coming out of the top schools. What we discovered was that both approaches worked if marketing the small-town setting as speaking to that which attracted physicians to the practice of medicine originally. The ability to get to know your patients, have an active social life, enjoy the role of respected community leader, and, in short, all the positives that defined the Andy Griffith Show and Mayberry, North Carolina.


In my e-mail inbox this morning was an newsletter from Healthleaders.com, with an article titled “Survey Compares Rural and Urban/Suburban Physicians.” http://www.healthleadersmedia.com/content/204394/topic/WS_HLM2_COM/Survey-compares-rural-and-urbansuburban-physicians.html The article references a survey conducted by healthcare recruiter LocumTenens.com on this very topic, and the results were not only similar to that earlier experience, the responses from rural practitioners were eye-opening. They love their jobs, they love the environment, small towns are a great place to raise children, they feel professionally rewarded, and the local healthcare facilities are as state-of-the-art as found in larger towns and cities. It seems those that actually work in rural settings believe it the best kept secret in healthcare.


As the American population ages and the Boomer generation enters retirement, rural health care will increasingly confront demand for its services. Those in early retirement may initially head off to Florida but become “boomerang boomers” as they age, their health care needs expand, and they return “home” to live closer to their working age children. In this environment, rural provider recruitment across all healthcare specialties will become increasingly important. For the executive leadership of small-town hospitals, the key to success follows from an effective and coordinated combination of two, often-silo-ed, departments – namely, HR and marketing.

Increasingly, effective management represents a holistic exercise (combining the talents of multiple departments). Practitioner recruitment in small town settings represents just one significant example.