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Title: NOTE: To appreciate this presentation [and insure that it is not a mess], you need Microsoft fonts:


1
NOTE To appreciate this presentation and
insure that it is not a mess, you need Microsoft
fonts Showcard Gothic, Ravie, Chiller
and Verdana
2
Part 9Tom Peters EXCELLENCE.
ALWAYS.New Master/21 August 2008
3
Slides at tompeters.com
4
Ten PartsP1.1, P1.2, P1.3,
P1.4/GenericP2/LeadershipP3/TalentP4/Value-add
ed LadderP5/New Markets P6/The
EquationsP7/ImplementationP8/13 Guru
GaffesP9/HealthcareP10/ The Lists
5
Part nine
6
Some Reflections On the sorry state of American
health, circa 2008, and the sorry state of the
delivery of Healthcare, and why the twain
rarely meet and how easy it would be to do a few
things right, such as remind adults of a certain
age to take their aspirin Tom Peters/08.21.2008
7
This presentation has taken me about 10 years to
producesome recent books took me over the top.
Nonetheless, it is an amateurs viewalbeit a
65-year-old amateur with skin in the
game. These gray-background slides are notes
on the preceding slide. I have chosen not to use
the Notes feature of PowerPoint, because so few
in fact avail themselves of notes in that
formatand I am optimistic that some of you will
read the notes slides in this format.
8
45
9
Keep this in mind. (Throughout this
presentation.)
10
37
11
Keep this in mind. (Throughout this
presentation.)
12
Some Reflections On the sorry state of American
health, circa 2008, and the sorry state of the
delivery of Healthcare, and why the twain
rarely meet Its about a whole lot more than
health insurance! Tom Peters/08.21.08
13
This presentation is not about Hillarycareor
Obamacare or McCain-care. While the perverse
nature of financial incentives is discussed
(e.g., their bias toward medicine and away from
health), this is not a treatise on financing
overall or the of uninsured. It focuses on my
turfthe operational aspects of healthcare
delivery. There is an enormous amount to do in
healthcare within our grasp today, and not
dependent upon new legislation.
14
Outline 22 Chapters
15
  • Bottom Line (??) U.S. Life Expectancy
  • My Take
  • John Hammergrens Take
  • K.I.A. Wounded A House (Hospital) of Horrors
  • How It Works (And Feels)
  • 6. You Must Be Your Own Boss!
  • 7. Over-treatment!!!!!!!!!!!!
  • 8. F.Y.I. The Dominating (!) Role of Healthcare
  • in the American Economy
  • 9. Pick of the Litter Our Best Hospitals?
  • 10. See No Evil A Culture of Cover-up
  • 11. And They Call It Science I The
  • Overwhelming Lack of Treatment Validation
  • 12. And They Call It Science II Astounding
  • Geographic Treatment Variation

16
  • 13. Shining Star, A/The
  • 14. IS/IT The Dark Ages Saga Continues
  • 15. K.I.S.S./Keep it simple, stupid Un-sexy
    Stuff Could Save Tens of Thousands of
  • Lives and Extend Hundreds of Thousands
  • of Others
  • Organizational effectiveness Tools that would
    put the focus on the patient
  • Wellness-Prevention No Good Deed Goes
  • Unpunished
  • 18. From Healthcare to Health
  • The Oughtas
  • 19. Healthcare Meets Health The Case of
  • the Planetree Alliance
  • 20. My concerns, My Ideal
  • 21.TPs Nobels
  • 22. Some Resources

17
1. Bottom line (??) U.S. Life Expectancy
18
45th. Rank of U.S. life
expectancy, ltBosnia, Cuba
19
Problems notwithstanding, many-most Americans, at
the end of the day, consider their-our healthcare
to be the best in the world. If so, why do we
rank behind the likes of Bosnia and Cuba in life
expectancy? Our global life expectancy rank?
Forty-five. (And falling-dropping-plummeting.)
20
This life expectancy is sorta the point,
isnt it or am I missing something?
21
Id think this (life expectancy) would
(obviously) be the principal point of the
overall exerciseits not How much healthcare do
we get? but How healthy are we? Right???
22
This life expectancy is sorta the point,
isnt it or am I missing something? Should
I, for instance, measure my health by number of
operations, or number of tests, where, More
Better Health?
23
Pay by procedure is the operative (insane)
funding algorithm in our healthcare systemthere
is no premium on helping us get healthy in fact
there are severe penalties for so doing.
24
Bottom line 1900-1960, life expectancy grew
0.64 per year 1960-2002, 0.24 per year, half
from airbags, gun locks, service employment
Source Best Care Anywhere Why VA Healthcare
Is Better Than Yours/Phillip Longman
25
Historically, much-most of the gain in
life-expectancy comes from non-health system
factorsespecially cleanliness and nutrition in
the past.
26
37th. World
Health Organization/WHO rank of
U.S. health system performance
27
More.
28
State of Healthcare/U.S.A.Spend more
per capitaOverall system performance/WHO
37th Relatively low life expectancyHigh
of uninsuredSource Consulting, 07-08.06
29
State of Healthcare/U.S.A.Spend more
per capitaOverall system performance/WHO
37th Relatively low life expectancyHigh
of uninsuredSource Consulting, 07-08.06
30
Stunning.
31
Americas elites are very good at attracting
money and prestige, and they have a huge
technology arsenal with which they attack death
and disease. But they have no positive medical
results to show for it in the aggregate and many
indications that they are providing
lower-quality care than the much-maligned HMOs
and assorted St. Elsewheres. Source Best Care
Anywhere Why VA Healthcare Is Better Than
Yours/Phillip Longman
32
Stunning.
33
2. My Take
34
The Healthcare14 U.S. Healthcare Trauma
in 2008 U.S. Life expectancy rank 45. WHO,
overall American healthcare system performance
37 (1 in cost). Access Denied to 10s of
millions un/underinsured. Unnecessary annual
health-system deaths 200,000-400,000 or
more. Performance/top med centers Problematic
re quality of care and follow-up. Over-treat
ment (meds, tests, procedures) Pandemic. Use of
hard evidence in medical decision-making Spotty
at best. Collection of evidence based on
reported treatment errors Low. Use of S.O.P.s
in treatment regimes Spotty. Incentives for
appropriate care Low. Incentives for
in-appropriate care High. Emphasis on
prevention and wellness Low. Emphasis on
chronic-care Low. State-of-the-art IS/IT
Rare. Fixable without legislation or major
societal changeeg can by and large be improved
dramatically without some form of mandated
universal access to care and in the absence of,
say, a full-fledged War on Obesity. (Evidence in
support of this proposition is the fact that in
every category starred above there are Pockets of
Excellencehospitals and other health-service
organizations, facing the same realities as their
peers, that really get it.)
35
Data to follow.
36
DVM/Lyme/2005-2008Multip
le diagnoses (gt5)Specialist self-certaintyHe
alth deterioration failed to produce urgency-
communication.Virtually no communications
between specialistsFollow-up very spotty
unless bugged incessantlyLost major test
results, and mis-placed 3 or 4
occasionsNear fatal drug mistake (one nurse
takes charge)Effectively, disinterest in
chronic-careLack of curiosity in general
37
Home in Vermont, I happened to run into a vet
(Doctor of Veterinary Medicine), who has dealt
with Lyme disease for years. In the course of a
half-hour conversation, these points arose. Alas,
none were in the least surprisingand, of course,
they are the observations of an expert.
38
3. John Hammergrens Take
39
Skin in the Game How Putting Yourself First
Today Will Revolutionize Healthcare Tomorrow
John Hammergren (CEO, McKesson) Phil Harkins
40
John Hammergren is the CEO of 100 billion
McKesson Corp. In a 2008 book, he paints a bleak
picture of U.S. healthcare systemic
performancebut als sees steps that would improve
things dramatically.
41
25 to 30 percent of our 2.2 trillion
goes to wasted care in the form of preventable
errors, incorrect diagnoses, redundant treatment,
unnecessary infections, and extra time spent in
the hospital. and another 20 to paperwork
Source John Hammergren Phil Harkins, Skin
in the Game How Putting Yourself First Today
Will Revolutionize Healthcare Tomorrow
42
Stunning.
43
140,000,000 illegible prescriptions per year
John Hammergren Phil Harkins, Skin in the
Game How Putting Yourself First Today Will
Revolutionize Healthcare Tomorrow
44
1,500,000,000,000 claims per year30
errors15 lost25 paper-basedSource
John Hammergren Phil Harkins, Skin in the Game
How Putting Yourself First Today Will
Revolutionize Healthcare Tomorrow
45
Stunning.
46
I can receive a BlackBerry message from a
colleague climbing a mountain, yet I still show
up at a doctors office and after a 45-minite
wait learn that my hospital test results have
not arrived weeks after they should have.
John Hammergren Phil Harkins, Skin in the
Game How Putting Yourself First Today Will
Revolutionize Healthcare Tomorrow
47
Stunning.
48
Up To 500,000 Lives The medical system has
been unable to turn proven remedies into everyday
care. Half the people who need to be treated to
prevent heart attacks are not treated and half
who are treated are treated inadequately.
Patients go home with the wrong drugs or the
wrong doses or misimpressions about the
importance of taking their medications.More
55 chance of receiving the best recommended
carewhich means getting scientifically
appropriate, evidence-based medical treatment
The New York Times, from John Hammergren
Phil Harkins, Skin in the GameHow Putting
Yourself First Today Will Revolutionize
Healthcare Tomorrow
49
Stunning.
50
The private insurance industry has little
incentive to see people live healthy lives beyond
65 when their customers automatically drop out of
the employer-based system and enter the
government-based system.John Hammergren
Phil Harkins, Skin in the Game How Putting
Yourself First Today Will Revolutionize
Healthcare Tomorrow
51
Stupid
52
How will you know when the healthcare industry
has finally entered the 21st century? When
error rates at hospitals are close to zero. When
doctors and nurses use evidence-based protocols
in your treatment. When you can decide how much
to spend on treatment, and you have the
information and the opportunity to determine the
best value. When your primary care physician is
in charge of your extended care team, operating
as your command central. When all members of
the medical communitynurses, doctors,
pharmacists and specialistswork together
seamlessly on your behalf. When their combined
efforts are tracked, measured, and reported
onand the insurance reimbursements awarded to
them are based on performance. When you see
that hospitals, pharmacies and doctors are
working harder in all aspects to make sure you
are an informed consumer who has trust and
confidence in the services they offer and the
prices they charge. John Hammergren Phil
Harkins, Skin in the Game How Putting Yourself
First Today Will Revolutionize Healthcare
Tomorrow
53
Hammergren says we know the shape of revised
system
54
25 to 30 percent of our 2.2 trillion
goes to wasted care in the form of preventable
errors, incorrect diagnoses, redundant treatment,
unnecessary infections, and extra time spent in
the hospital. Team-based medicine, bar-code
prescription scanning, evidence-based
medicineall of these are systems and innovations
that are being put into place to eliminate waste
so that we can re-apply the money.John
Hammergren Phil Harkins, Skin in the Game How
Putting Yourself First Today Will Revolutionize
Healthcare Tomorrow
55
Hammergren says we know the shape of revised
system and the way to get from here to there.
56
4. K.I.A. Wounded A house (hospital) of horrors
57
Quality COULD IT TRULY BE THIS AWFUL?
58
3DHC 5YI
59
3DHC 5YI3 days healthcare-caused deaths
5 years of American soldiers deaths in the Iraq
WarNot including most of the deaths forgone
annually if prevention-wellness became the
primary arm of health-healthcare industry
60
Quality of care is the problem, not managed
care.Source Institute of Medicine (from
Michael Millenson, Demanding Medical Excellence)
61
Study Medical Errors Affect 20 Percent of
Patients headline, Boston Herald
62
RAND 50, appropriate preventive care. 60,
recommended treatment, per medical studies, for
chronic conditions. 20 , chronic care treatment
that is wrong. 30 acute care treatment that is
wrong.
63
Typical statsmore to come.
64
Welcome to the Homer Simpson Hospital, a/k/a
The Killing Fields
65
American life expectancy is relatively lowand
the delivery of healthcare in the U.S. is
notoriously unsafe.
66
CDC 1998 90,000 killed and 2,000,000 injured
from hospital-caused drug errors infections
67
This 1998 report was a shocker and bitterly
contested by the healthcare establishment. Now
its taken for granted, and perhaps
understatessignificantly. More grim estimates
follow.
68
HealthGrades/Denver 195,000 hospital deaths per
year in the U.S., 2000-2002 equivalent of 390
full jumbos/747s in the drink per yearmore than
one-a-day.Comments There is little evidence
that patient safety has improved in the last five
years. Dr. Samantha CollierSource Boston
Globe/2005
69
1,000,000 serious medication errors per year
illegible handwriting, misplaced decimal points,
and missed drug interactions and
allergies.Source Wall Street Journal
/Institute of Medicine
70
Throughout, we will see that much of this
horrorshow is the product of simple
problemse.g., bad handwriting.
71
The Institute of Medicine calculated that drug
errors on average, one per patient per
visitvarious sources some estimates go as high
as one-per-patient-per-day, on average alone add
on average nearly 5,000 to the cost of every
hospital visit. Overtreated Why Too Much
Medicine Is Making Us Sicker and Poorer, Shannon
Brownlee
72
Hospital infections kill an estimated 103,000
people in the United States a year, as many as
AIDS, breast cancer and auto accidents combined.
Today, experts estimate that more than 60
percent of staph infections are M.R.S.A. up from
2 percent in 1974. Hospitals in Denmark, Finland
and the Netherlands once faced similar rates, but
brought them down to below 1 percent. How?
Through the rigorous enforcement of rules on hand
washing, the meticulous cleaning of equipment and
hospital rooms, the use of gowns and disposable
aprons to prevent doctors and nurses from
spreading germs on clothing and the testing of
incoming patients to identify and isolate those
carrying the germ. Many hospital administrators
say they cant afford to take the necessary
precautions. Betsy McCaughey, founder of the
Committee to Reduce Infection Deaths (New York
Times/06.06.2005)
73
1-in-7 Chance of Medical Mishap Health Ministry
ReportSource Headline, The Press,
Christchurch, NZ, 0216.08 (odds of a screwup
during a hospital stay)
74
When I climb Mount Rainier I face less risk of
death than Ill face on the operating table.
Don Berwick
75
Berwick is the uber-guru of the patient safety
movement.
76
The results are deadly. In addition to the
98,000 killed by medical errors in hospitals and
the 90,000 deaths caused by hospital infections,
another 126,000 die from their doctors failure
to observe evidence-based protocols for just four
common conditions hypertension, heart attack,
pneumonia, and colorectal cancer. TP total
314,000 Source Best Care Anywhere Why VA
Healthcare Is Better Than Yours/Phillip Longman
77
1m42s
78
The 314K per year, very conservative, translates
into an unnecessary death every
one-minute-and-forty-two seconds. ....
79
59
80
... which in turn translates into 59 unnecessary
deaths in the course of a healthcare
presentation, a little over an hour long, that I
recently made.
81
Plus God alone knows how many casualties in
doctors offices, Tom Thom Mayer
82
Thom Mayer, renown ER doc and consultant on
patient-centric care, reminded me that the grim
stats above leave out the likes what goes on in
docs offices all over the land. (Arguably a
staggering number in its own right.)
83
I had done what doctors do well in this country,
which is to treat people when they come in with a
disease. My patients had good medical care but
not, I began to think, great healthcare. For
most, their declines, their illnesses, were
thirty-year problems of lifestyle, not disease.
I, like most doctors in America, had been doing
the wrong job well. Modern medicine does not
concern itself with lifestyle problems. Doctors
dont treat them, medical schools dont teach
them and insurers dont pay to solve them. I
began to think that this was indefensible.
Henry Lodge, Younger Next Year
84
Also left out are the folks whod be with us if
the system focused on healthwellness,
prevention, etc..
85
Experts estimate that more than a hundred
thousand Americans die each year not from
illness but from their prescription drugs. Those
deaths, occurring quietly, almost without notice
in hospitals, emergency rooms, and homes, make
medicines one of the leading causes of death in
the United States. On a daily basis, prescription
pills are estimated to kill more than 270
Americans. Prescription medicines, taken
according to doctors instructions, kill more
Americans than either diabetes or Alzheimers
disease.Source Our Daily Meds How the
Pharmaceutical Companies Transformed Themselves
into Slick Marketing Machines and Hooked the
Nation on Prescription Drugs Melody Petersen
86
And on it goes ....
87
Primary-care docs Second-class
citizens.Sources too numerous to mention
88
The people who ought to be the gatekeepers who
would oversee the co-ordination of specialists
workthe dis-organized results thereof which are
responsible for most of the likes of the
prescription-med errorsare secondclass citizens
in the specialist-centric World of Modern
Healthcare.
89
1m 28s
90
Maybe I undershot on the earlier slide???
91
In 2006 when Time magazine had the brilliant
idea of asking doctors what scared them most
about being a patient, three frequent answers
were fear of medical errors, fear of unnecessary
surgery, and fear of contracting a staph
infection in teaching hospitals. Best Care Any
where Why VA Healthcare Is Better Than Yours,
Phillip Longman
92
The docs get it And you?
93
Put a muzzle on that boy.
94
In my 30 years of speechifying, I have said a few
controversial thingsin fact I have a bit of a
reputation for so doing. But no one has tried to
put a muzzle on me. Well, no one except the
American Hospital Association. When the CDC
98,000 hospital deaths study appeared, it was
fought tooth and nail by the establishment. I
was appalled by the statisticmostly as a
prospective patient. Along the way, I used the
stat in a talk (the CDC is a pretty damn reliable
source!) and then I got a messagethe first and
only time in my careerfrom my speakers bureau.
The American Hospital Association is a big client
of theirs. And the AHA chief executive had called
the president of the speakers bureau and more or
less demanded that he order me to shut upand
quit propagating that scurrilous number.
Naturally the speakers bureau told him that my
content was up to me, not them. I was of course
delightedit suggested that the number was
correct, and that I had drawn blood. But my point
here is that this was the only time in three
decades that such censorship has been sought. (Of
course I can see why the AHA was embarrassedthey
damn well should have been!! And still should
be!!)
95
5. How it works (and feels)
96
Journalist Tim Noah writes about his wifes
cancer treatment in a high-rep private med
center Much of our effort involved retrieving
information from one source and sending it to
another. This wasnt something we could count on
happening on its own. Very expensive blood test
results, we observed, had perhaps a 50 chance of
being misplaced under a pile of faxes and
therefore not finding their way into Marjorie
Williams medical chart. So we made a habit of
getting the labs to fax to our house. Films of CT
scans would be misfiled perhaps 30 of the time
and thus become permanently irretrievable. So I
took my checkbook to all of Marjories CT scans
and purchased my own spare copy on the
spot. Source Foreword to Best Care Any where
Why VA Healthcare Is Better Than Yours, Phillip
Longman
97
My most memorable brushes have been with an
eminent surgeon, Marjorie Longmans wife, on
the receiving end of cancer treatment wrote in
her next-to-last column for the Washington Post,
whose method is to stride into the examining
room two hours late, pat your hand, pronounce
your certain death if he cant perform an
operation on you, and then snap at your husband
to stop taking notes, since he cant possibly
follow the complexity of the doctors thinking.
Source Best Care Anywhere Why VA Healthcare
Is Better Than Yours/Phillip Longman
98
These are all too common reports. Patient safety
guru Don Berwick, a renowned M.D. and Harvard Med
School faculty member, was moved to his
vociferous patient-safety advocacy, not by
analytic deduction, but by the insane frequency
of errors in his wifes treatment at a
prestigious Boston medical center.
99
6. You must be your own boss!
100
He shook me up. He put his hand on my shoulder,
and simply said, Old friend, you have got to
take charge of your own medical care. Source
Hamilton Jordan, No Such Thing as a Bad Day, on
a conversation with a doctor pal following
Jordans cancer diagnosis)
101
Longman (his wife, Robin, treated for cancer)
The more time we spent in the Lombardi Center
and Georgetown hospital, the more I was disturbed
by the way they managed the little things. I
was similarly shocked at how little the various
specialists involved in her care seemed to
consult with one another, or to keep up to date
on the results of tests. There seemed to be
little attention given to managing information
and coordinating care. I came away feeling that
no patient should ever enter a hospital without
having some kind of fulltime advocatea caring,
calm, shrewd relative or friend at
least. Source Best Care Any where Why VA
Healthcare Is Better Than Yours, Phillip Longman

102
For the patient, the immediate answer to this sad
state of affairs is to become ones own
healthcare quarterbackand to quit trusting the
guys in the white coats.
103
TP Just one second, please. You do know Ive
got a pacemaker, lower limit only, 60bpm, no
defib? And that I take 150 mg of Coumadin a day?
In 3 of 4 cases, in a 2-day period, the
answer was in part, at least, No including
set-up for an echo stress cardio test (reading
and results dependent on the above info)
104
My own pitiful experienceI was and am enraged.
(March 2008, prestigious Boston medical center.)
105
7. Over-treatment!!!!!!!!
106
3
107
This section buggers the imagination.
108
The big cause of skyrocketing healthcare costs
has been increasingly intensive use of
technologies and treatments that, when we look at
their effects on the population as a whole, have
brought only negligible improvement in public
health and longevity. Best Care Any where
Why VA Healthcare Is Better Than Yours, Phillip
Longman
109
The previous slide and the next four that follow
presumably require no elaborationexcept for me
to say that I could have offered a 20-slide
array, not just these few, had I so desired.
110
We spend between one-fifth and one-third of our
healthcare dollars, an exorbitant amount of
money, between five hundred and seven hundred
billion dollars, on care that does nothing to
improve our health. Source Overtreated Why
Too Much Medicine Is Making Us Sicker and
Poorer, Shannon Brownlee
111
400,000 heart bypass surgeries, 1,000,000
angioplasties per year Yet recent studies show
that only about three percent of the patients
who receive such operations benefit from them
most would be better served just taking aspirin
or low-cost beta blockers. Source Best Care
Anywhere Why VA Healthcare Is Better Than
Yours/Phillip Longman
112
Americans undergo millions of testsMRIs, CT
scans, blood teststhat do little to help doctors
diagnose disease, and sometimes lead them to find
and treat conditions that would never have
bothered their patients had they never been
found. We undergo back surgery for pain in the
absence of evidence that the surgery
works. Source Overtreated Why Too Much
Medicine Is Making Us Sicker and Poorer, Shannon
Brownlee
113
Dartmouth Professor Elliott Fisher and his
colleagues discovered that patients who went to
hospitals that spent the most and did the most
procedures were 2 to 6 percent more likely to
die than patients that went to hospitals that
spent the least. Source Overtreated Why Too
Much Medicine Is Making Us Sicker and Poorer,
Shannon Brownlee
114
The most powerful reason doctors and hospitals
overtreat is that most of them are paid for how
much care they deliver, not how well they care
for their patients. Overtreated Why Too Much
Medicine Is Making Us Sicker and Poorer, Shannon
Brownlee
115
Teach to test is the Achilles heel of our
education systemthe only acquired skill is
test-taking and the essential love-of-learning
is diminished, not enhanced. Likewise, pay for
procedure is the perverse centerpiece of our
healthcare systemdenigrating the very health
for which we were intended to care.
116
Hospital intake interview with yours truly,
Boston, March 2008Physicians Assistant What
did your mother die of?TP Too many
specialists.PA No, really?TP Really!!
117
Hospital intake interview, Boston, March
2008Physicians Assistant What did your
mother die of?TP Too many excellent
specialists.PA No, really?TP Really!!
118
Hospital intake interview, Boston, March
2008Physicians Assistant What did your
mother die of?TP Too many excellent
specialists who never communicate/d with one
another .PA No, really?TP Really!!
119
I was not joking. As the end hove in sight, my
Mom was being treated for a sizeable number of
problems (she was 95) it seemed as though no
more than a couple of days passed before she was
over-reacting to one med that other docs were not
aware of. Theyd cut that one back, then enhance
another. At 95, she was simply wearing outbut
her overload of non-coordinated specialists
pretty clearly pushed her out the door. (This is
not just my conclusion, but that of a couple of
my M.D. pals.)
120
If we sent 30 percent of the doctors in this
country to Africa, we might raise the level of
health on both continents. Dr Elliott Fisher,
Center of Evaluative Clinical Sciences,
Dartmouth Medical School (Overdose, Atlantic,
Shannon Brownlee.)
121
Hes not kidding! (Elliott Fisher is one of the
real super-heroes among those trying to push the
rock-of-reform up the mountain of med system
resistance.)
122
America has twice as many hospitals and
physicians as it needs. Med Inc., Sandy Lutz,
Woodrin Grossman John Bigalke
123
Ditto Fisher.
124
PD(USA) gt PD(J G F I S UK A NZ
C M B A) gt G(USA) gt HEX2(USA) U.S.
spending on prescription drugs in 2005
(250,000,000,000) is greater than the combined
spending on prescription drugs by Japan plus
Germany plus France plus Italy plus Spain plus
the United Kingdom plus Australia plus New
Zealand plus Canada plus Mexico plus Brazil plus
Argentina (all except Mexico, Brazil and
Argentina have longer life expectancies than we
do) and our prescription drug bill also is more
than our gasoline bill and two times more than
our higher ed bill. Source Our Daily Meds How
the Pharmaceutical Companies Transformed
Themselves into Slick Marketing Machines and
Hooked the Nation on Prescription Drugs Melody
Petersen
125
PD(USA) gt PD(J G F I S UK A NZ
C M B A) gt G(USA) gt HEX2(USA) U.S.
spending on prescription drugs in 2005
(250,000,000,000) is greater than the combined
spending on prescription drugs by Japan plus
Germany plus France plus Italy plus Spain plus
the United Kingdom plus Australia plus New
Zealand plus Canada plus Mexico plus Brazil plus
Argentina (all except Mexico, Brazil and
Argentina have longer life expectancies than we
do) and our prescription drug bill also is more
than our gasoline bill and two times more than
our higher ed bill. Source Our Daily Meds How
the Pharmaceutical Companies Transformed
Themselves into Slick Marketing Machines and
Hooked the Nation on Prescription Drugs Melody
Petersen
126
Again, words like insane or ridiculous or
outrageous are the only ones that come to mind.
127
a grossly overprescribed nation Arnold Relman,
professor emeritus, Harvard Med former editor,
The New England Journal of MedicineSource Our
Daily Meds How the Pharmaceutical Companies
Transformed Themselves into Slick Marketing
Machines and Hooked the Nation on Prescription
Drugs Melody Petersen
128
Creating a disease from a slide by Neil Wolf,
Pharmacia, at the 2003 Pharmaceutical Marketing
Global Summit (Philadelphia) Source Our
Daily Meds How the Pharmaceutical Companies
Transformed Themselves into Slick Marketing
Machines and Hooked the Nation on Prescription
Drugs Melody Petersen
129
I am not an instinctive basher of the
pharmaceutical industry. Yet the evidence is
clearthe industry has repeatedly made mountains
(worth billions) out of mole-hills. (Or
no-hills.)
130
8. F.Y.I. The dominating (!) Role of
healthcare in the American economy
131
Whats Really Propping Up the Economy
Healthcare has added 1.7 million jobs since 2001.
The rest of the private sector? None.Source
Title, cover story, BusinessWeek, 0925.2006
132
U.S. Healthcare Expenditures2008
2.2 trillion2016 4 trillion Source
John Hammergren Phil Harkins, Skin in the Game
How Putting Yourself First Today Will
Revolutionize Healthcare Tomorrow
133
We spend over 2,000,000,000,000 on healthcare
in Americaand it is also our engine of job
growth. Increasingly, healthcare economics are
American economics.
134
9. Pick of the litter Our best hospitals?
135
Generally, the more prestigious the hospital you
check into, and the more eminent and numerous the
physicians who attend you, the more likely you
are to receive low-quality or even dangerous and
unnecessary care. Source Best Care Anywhere
Why VA Healthcare Is Better Than Yours/Phillip
Longman
136
Flabbergasting.
137
The more doctors and specialists around, the
more tests and procedures performed. And the
results of all these tests and procedures? Lots
more medical bills, exposure to medical errors,
and a loss of life expectancy. It was this
last conclusion that was truly shocking, but it
became unavoidable when Dartmouths Dr. Jack
Wennberg and others broadened their studies. They
found its not just that renowned hospitals and
their specialists tend to engage in massive
overtreatment. They also tend to be poor at
providing critical but routine care. Source
Best Care Anywhere Why VA Healthcare Is Better
Than Yours/Phillip Longman
138
Dartmouths Dr. Jack Wennberg and others
found its not just that renowned hospitals and
their specialists tend to engage in massive
overtreatment. They also tend to be poor at
providing critical but routine care. For example,
Dartmouth researcher Elliot S. Fisher has found
that among Medicare patients, who share the same
age, socioeconomic, and health status, their
chances of dying in the next five years are
greater if they go to a high-spending hospital.
One reason is that patients in high-spending
hospitals with lots of specialists and high
technology are also less likely to receive many
proven routine treatments e.g. aspirin, flu
vaccine. This general lack of attention to
prevention and follow-up care in high-spending
hospitals helps to explain why not only
heart-attack victims but also patients suffering
from colon cancer and hip fracture stand a better
chance of living another five years if they stay
away from elite hospitals and choose a
lower-cost competitor. Best Care Any where
Why VA Healthcare Is Better Than Yours, Phillip
Longman
139
The more doctors and specialists around, the
more tests and procedures performed. And the
results of all these tests and procedures? Lots
more medical bills, exposure to medical errors,
and a loss of life expectancy. Source Best
Care Anywhere Why VA Healthcare Is Better Than
Yours/Phillip Longman
140
Flabbergasting.
141
10. See no evil A culture of cover-up
142
culture of cover-up that pervades
healthcare Source Best Care Anywhere Why VA
Healthcare Is Better Than Yours/Phillip Longman
143
One begins to feel that there is no end to the
insults to which patients-citizens are subjected
by this most modern of American industries.
144
When a plane crashes, they ask, What happened?
In medicine they ask Whose fault was it?
James Bagian, M.D. former astronaut, now
working with the VHA
145
Success Through Positive Acknowledgement of
FailuresWernher Von Braun, re the Redstone
missile engineer who confessed to a screw-up
and was awarded a bottle of champagne. Award to
the sailor on the aircraft carrier Carl
Vinsonfor reporting a lost tool on the deck
(that could have caused a crash). Amy Edmonson on
successful nursing unitswith the highest
reported adverse drug events.Source Karl Weick
Kathleen Sutcliffe, Managing the Unexpected
146
Reward admissions of mistakes it can be done.
147
Ken Kizer/VA 1997 culture of cover-up that
pervades healthcare Patient Safety Event
Registry looking for systemic solutions, not
seeking to fix blame on individuals except in the
most egregious cases. The good news was a
thirty-fold increase in the number of medical
mistakes and adverse events that got reported.
National Center for Patient Safety Ann Arbor
148
The VA gets it. (Again.)
149
thirty-fold
150
The enormity of the possible improvement is
staggeringperhaps one of the few hopeful signs.
151
11. And they call it science I overwhelming
Lack of treatment validation
152
stunning lack of scientific knowledge about
which treatments and procedures actually
work. Source Best Care Anywhere Why VA
Healthcare Is Better Than Yours/Phillip Longman
153
Here we go again flabbergasting.
154
The high rates of surgery were not being driven
by patients, but rather by doctors. They had no
idea how different their practices were from
their colleagues.. Wennberg came to an
unsettling conclusion. Medicine wrapped itself in
the mantle of science, yet much of what doctors
were doing was based more on hunches than good
research. In fact, as research would show over
the coming decades, stunningly little of what
physicians do has ever been examined
scientifically, and when many treatments and
procedures have been put to the test, they have
turned out to cause more harm than good. In the
latter part of the twentieth century, dozens of
common treatments , including the tonsillectomy,
the hysterectomy, the frontal lobotomy, the
radical mastectomy, arthroscopic knee surgery for
arthritis, X-ray screening for lung cancer,
proton pump inhibitors for ulcers, hormone
replacement therapy for menopause, and high-dose
chemotherapy for breast cancer, to name just a
few, have been shown to be unnecessary,
ineffective, more dangerous than imagined, or
sometimes more deadly than the diseases they were
intended to treat. Overtreated Why Too Much
Medicine Is Making Us Sicker and Poorer, Shannon
Brownlee
155
As unsettling as the prevalence of inappropriate
care is the enormous amount of what can only be
called ignorant care. A surprising 85 of
everyday medical treatments have never been
scientifically validated. For instance, when
family practitioners in Washington were queried
about treating a simple urinary tract infection,
82 physicians came up with an extraordinary 137
strategies.Source Demanding Medical
Excellence Doctors and Accountability in the
Information Age, Michael Millenson
156
85
157
The Search for Quality It All Begins on the
Autopsy TableSource Chapter title, Severed
Trust Why American Medicine Hasnt Been Fixed,
George Lundberg
158
Learning organizationthe typical hospital
aint.
159
Most people think that quality of care is
defined by medical interventions, such as a hip
replacement, lens implant, or coronary bypass
operation, but genuine quality of care is defined
by action based on good information. Definitions
of quality are often counterintuitive. Multiple
lab tests do not constitute quality medicine.
Entrepreneurial physicians have a greater stake
in doing more than in doing good. Medicare, for
example, provides funding for autopsies of every
hospitalized beneficiary, and good science
suggests that at least 30 percent of deaths
should be autopsied. Very few are.. In fact,
lack of autopsy is the ultimate cover-up in
medicine, and the signature of poor quality care.
The whole issue of patient safety is based on
honesty, and the autopsy is central in a system
that finds truth, deals with it honestly, and
tries to improve patient care.Source The
Search for Quality It All Begins on the Autopsy
Table, chapter title, Severed Trust Why
American Medicine Hasnt Been Fixed, George
Lundberg
160
12. And they call it science II Astounding
Geographic treatment variation
161
In health care geography is
destiny.Dartmouth Medical School 1996 report,
from Demanding Medical Excellence Doctors and
Accountability in the Information Age, Michael
Millenson
162
Sound absurd? Read on.
163
What Wennberg and his Dartmouth colleagues
found was that medicine was all over the map,
literally. If Wennberg had been using a
microscope to look at medical care in New
England, his team was now standing on a
mountaintop looking at the entire nation, yet
they were seeing precisely the same patterns he
had found in Vermont and Maine. Only now they
could tell it wasnt just tonsillectomies
hysterectomies and prostatectomies were being
used far more in one region than another. It was
CT scans, office visits, cardiac
catheterizations. It was blood tests and
hospitalizations, back surgery, chest X-rays, and
knee replacements. In one part of the country,
practically every woman with breast cancer was
still getting a mastectomy long after clinical
trials had shown that a breast-sparing lumpectomy
with radiation was just as effective. In another,
babies were being put in neonatal intensive care
when they didnt need it. They found that
patients with back pain were 300 percent more
likely to get surgery in Boise, Idaho, than in
Manhattan. Doctors affiliated with Harvard
Medical School admitted patients to the intensive
care unit four times more often than their
colleagues at Yale University School of Medicine.
Arthroscopic knee surgery which would later be
shown to be entirely ineffective at treating knee
pain due to arthritiswas performed five times
more often on arthritic patients in Miami than
Iowa City.Overtreated Why Too Much Medicine Is
Making Us Sicker and Poorer, Shannon Brownlee
164
Geography Is DestinyE.g. Ft. Myers 4X
Manhattanback surgery. Newark 2X New
Havenprostatectomy. Rapid City SD 34X Elyria
OHbreast-conserving surgery. VT, ME, IA 3X
differences in hysterectomy by age 70 8X
tonsillectomy 4X prostatectomy (10X Baton Rouge
vs. Binghampton). Breast cancer screening 4X NE,
FL, MI vs. SE, SW. (Source various)
165
Geography Is DestinyOften all one must do to
acquire a disease is to enter a country where a
disease is recognizedleaving the country will
either cure the malady or turn it into something
else. Blood pressure considered treatably high
in the United States might be considered normal
in England and the low blood pressure treated
with 85 drugs as well as hydrotherapy and spa
treatments in Germany would entitle its sufferer
to lower life insurance rates in the United
States. Lynn Payer, Medicine Culture
166
Almost funny. (If the stakes were not so high.)
167
Practice variation is not caused by bad or
ignorant doctors. Rather, it is a natural
consequence of a system that systematically
tracks neither its processes nor its outcomes,
preferring to presume that good facilities, good
intentions and good training lead automatically
to good results. Providers remain more
comfortable with the habits of a guild, where
each craftsman trusts his fellows, than with the
demands of the information age.Michael
Millenson, Demanding Medical Excellence
168
Nothing has changed since our Science paper in
1973. Dr Jack WennbergNothing of course,
except the fact that American medicine has
swelled into a behemoth industry equal in size to
the entire economy of Italy.SB Overtreated
Why Too Much Medicine Is Making Us Sicker and
Poorer, Shannon Brownlee
169
35 years.
170
13. Shining star, a/the
171
Whats needed in the U.S. is nothing short of a
medical revolution and the VHA has gone further
than most any other organization to revamp its
culture and systems. RAND
172
There is an exception among big systemsthe
Veterans Administration/VA hospitals. And yes,
everyone is amazed. (Mr Longmans book, Best
Care Anywhere Why VA Healthcare Is Better Than
Yours, is a masterpiecerequired reading for any
healthcare professional, as I see it.)
173
Ken Kizer, 1994, per Longman reorienting the
VHA away from a system that emphasized acute care
delivered in hospitals by specialists and toward
one that put overwhelming emphasis on prevention
and patient-centered management of chronic
conditions. Best Care Any where Why VA
Healthcare Is Better Than Yours, Phillip Longman

174
Ah, health is the goal! (What a fascinating
idea.)
175
Because the VA lacks any financial incentive to
engage in overtreatment, it saves money by
avoiding unnecessary surgery and redundant
testing. Best Care Any where Why VA
Healthcare Is Better Than Yours, Phillip Longman

176
No doubt at all, the VA incentive scheme, the
antithesis of the mainstream programs, is a big
help.
177
VA costs up 0.8 in 10 years, Medicare up
40.4 (Note VA patients older, sicker, poorer
and more prone to mental illness, homelessness,
and substance abuse ½ gt 65, 1/3 smoke, 1/5
diabetes vs 1/14 overall chronic diseases,
frailtyespecially vulnerable to medical errors
) Source Best Care Anywhere Why VA Healthcare
Is Better Than Yours/Phillip Longman
178
Key point, the VA is dealing with a tougher than
normal populationso they arent blessed with any
systemic advantage on that score.
179
2003, New England Journal of Medicine
publishes quality study results 11 measures of
quality compare VA and fee-for-service plans. VA
significantly better on 11 out of 11
2004, Annals of Internal Medicine, RAND
study VA vs commercial managed care VA
outperforms all other sectors of American
healthcare in 294 measures of quality
National Committee for Quality Assurance
top-rated, JHU, Mayo, Mass General In every
single category the veterans healthcare system
outperforms the highest-rated non-VA hospitals
Source Best Care Anywhere Why VA Healthcare
Is Better Than Yours/Phillip Longman
180
Wow.
181
E.g. On-time appointments, appointment with
specialist, Institute for Health Care
Improvement/Don Berwick VA is
spectacular Best Care Any where Why VA
Healthcare Is Better Than Yours, Phillip Longman

182
Pretty damned impressive. (Understatement.)
183
VA/Strengths/Foci Safety Evidence-based
medicine Health promotion and wellness
programs Unparalleled adoption of electronic
medical records and other information
technologies Source Best Care Anywhere Why VA
Healthcare Is Better Than Yours/Phillip Longman
184
The VHA gets it! E.g. Laptop at bedside calls
up patient e-records from one of 1,300 hospitals.
Bar-coded wristband confirms meds. National
Center for Patient Safety in Ann Arbor. Docs
and researchers discuss optimal treatment
regimensresearch center in Durham NC. Doc
measures guidelines e.g., pneumonia
vaccinations from 50 to 84. Blame-free
system, modeled after airlines. Whats needed
in the U.S. is nothing short of a medical
revolution and the VHA has gone further than most
any other organization to revamp its culture and
systems.Rand
185
14. IS/IT The dark ages saga continues
186
Shockingly, despite our vaunted prowess in
computers, software and the Internet, much of our
healthcare system is still operating in the dark
ages of paper records and handwritten scrawls.
American primary care doctors lag years behind
doctors in other advanced nations in adopting
electronic medical records or prescribing
medications electronically. This makes it harder
to coordinate care, spot errors and adhere to
standard clinical guidelines. Worlds Best
Medical Care?, New York Times, August 2007
187
Dark ageshere we go again!
188
Some grocery stores have better technology than
our hospitals and clinics. Tommy Thompson,
former HHS SecretarySource Special Report on
technology in healthcare, U.S. News World
Report
189
Were in the Internet age, and the average
patient cant email their doctor. Don Berwick,
Harvard Med School
190
Home Depot does a better job of tracking a box
of nails than your local hospital does in
tracking you. Overtreated Why Too Much
Medicine Is Making Us Sicker and Poorer, Shannon
Brownlee
191
VA/Strengths Safety Evidence-based
medicine Health promotion and wellness
programs Unparalleled adoption of electronic
medical records and other information
technologies Source Best Care Anywhere Why VA
Healthcare Is Better Than Yours/Phillip Longman
192
Information technology group of off-the-radar
experiments, performed surreptitiously by the
Hard Hats. Dr Kenneth Dickie, 1979, brought
together, as VistA, 20,000 software protocols
originally written by individual doctors and
other professionals working secretly in VA
facilities all around the country This
unique, integrated information system has
dramatically reduced medical errors at the VA
while also vastly improving diagnoses, quality of
care, scientific understanding of the human body,
and the development of medical protocols based on
hard data about what drugs and procedures work
best. Source Best Care Anywhere Why VA
Healthcare Is Better Than Yours/Phillip Longman
193
The VA got it earlyand with a homegrown system!
194
As with many other institutions, the software
these VA high priests wrote, or more often
procured from private vendors, wasnt very good,
in large part because the people who actually had
to use it had little role in its development.
Best Care Anywhere Why VA Healthcare Is
Better Than Yours, Phillip Longman
195
Homegrown makes all the difference, especially
where adoption is concerned, the Achilles heel of
most systems.
196
Scanner Skunkworks project started in Kansas,
1992, hand-held scanner, idea from nurse Sue
Kinnick when she observed usage in rental-car
return area. It wound up eliminating some
549,000 errors by 2001 there was a 75 decrease
in errors involving the wrong medication, a 62
decrease in errors involving the wrong dosage, a
93 reduction in the wrong patients receiving
medicine, and a 70 decrease in the number of
times nurses simply forgot or didnt get around
to giving patients their meds. Source Best
Care Anywhere Why VA Healthcare Is Better Than
Yours/Phillip Longman
197
Again, the numbers are staggering. Im hardly
suggesting that putting this system in place was
a cakewalkon the other hand, the basic idea is
hardly rocket science! (Most of these
breakthrough ideas arent e.g., rewarding the
reporting of errors so that learning can ensue.)
198
Our entire facility is digital. No paper, no
film, no medical records. Nothing. And its all
integratedfrom the lab to X-ray to records to
physician order entry. Patients dont have to
wait for anything. The information from the
physicians office is in registration and vice
versa. The referring physician is immediately
sent an email telling him his patient has shown
up. Its wireless in-house. We have 800
notebook computers that are wireless. Physicians
can walk around with a computer thats
pre-programmed. If the physician wants, well go
out and wire their house so they can sit on the
couch and connect to the network. They can review
a chart from 100 miles away. David Veillette,
CEO, Indiana Heart Hospital
199
It helps to have a greenfield facilitybut this
is also a non-VA demo of making effective IS the
centerpiece of the enterprise.
200
15. k.i.s.s./Keep it simple, stupid Un-sexy
stuff Could save tens of thousands of lives and
extend hundreds of thousands of others
201
A lot of the fix is very straightforward in
fact, the systems infatuation with clever,
complex tools is part of the problem. (A big
part of the problem.)
202
The simplest treatments often fall through the
cracks making sure a patient knows how to use an
asthma inhaler, for instance. And when doctors
and hospitals try to deliver the right kind of
care, such as keeping track of a heart patients
weight gain , they lose money. Overtreated
Why Too Much Medicine Is Making Us Sicker and
Poorer, Shannon Brownlee
203
More on the perverse losing money for doing the
right thing in a moment.
204
For most Americans, the two biggest determinants
of what kind of treatments they receive are how
many doctors and specialists hang a shingle in
their community and which one of them they happen
to see. The more doctors and specialists around,
the more tests and procedures performed. And the
results of all these tests and procedures? Lots
more medical bills, exposure to medical errors,
and a loss of life expectancy. It was this last
conclusion that was truly shocking, but it became
unavoidable when Dartmouths Dr. Jack Wennberg
and others broadened their studies. They found
its not just that renowned hospitals and their
specialists tend to engage in massive
overtreatment. They also tend to be poor at
providing critical but routine care. For example,
Dartmouth researcher Elliot S. Fisher has found
that among Medicare patients, who share the same
age, socioeconomic, and health status, their
chances of dying in the next five years are
greater if they go to a high-spending hospital.
One reason is that patients in high-spending
hospitals with lots of specialists and high
technology are also less likely to receive many
proven routine treatments e.g. aspirin, flu
vaccine. This general lack of attention to
prevention and follow-up care in high-spending
hospitals helps to explain why not only
heart-attack victims but also patients suffering
from colon cancer and hip fracture stand a better
chance of living another five years if they stay
away from elite hospitals and choose a
lower-cost competitor. Best Care Any where
Why VA Healthcare Is Better Than Yours, Phillip
Longman
205
Aspirin saves lives. (Lots of.)
206
K.I.S.S./Keep It Simple, Stupid Wrong site
surgery The most effective part of the drill is
simply asking the patient, in language he can
understand, to state (not confirm) who he is, his
birth date or social security number, and what
hes in for. Source Best Care Anywhere Why VA
Healthcare Is Better Than Yours/Phillip Longman
207
And your name is
208
If God spoke to me by saying, Mark, youre down
to your last three words What would you want to
say to your fellow humans that would make the
most positive impact? It would be a close call
between Love Thy Neighbor and Wash Your Hands .
A close third would be Move, Move, Move. Mark
Pettus, M.D., The Savvy PatientThe most
important thing you can do to keep from getting
sick is to wash your hands. CDC/National
Center for Infectious Diseases
209
Sanitary revolution mortality in major cities
down 55 between 1850 and 1915Source Tom
Farley Deborah Cohen, Prescription for a
Healthy Nation
210
Compression hose would mostly fix the
hospital problem According to the American
Heart Association, up to two million Americans
are affected annually by deep vein thrombosis. Of
those who develop pulmonary embolism, up to
300,000 will die each year. ... Deep vein
thrombosis also is among the leading causes of
preventable hospital death. Even more disturbing
is the fact that, according to a U.S.
multi-center study published by two of ClotCare's
editorial board members, 58 of patients who
developed a DVT while in the hospital received no
preventive treatment despite the presence of
multiple risk factors and overwhelming data that
prophylaxis is very effective at reducing these
events. Marie B. Walker, clotcare.com, March
2008
211
One study I came across concluded that you could
save 20,000 lives per year in UK hospitalsby
issuing compression hose-socks to virtually every
hospitalized patient. (As I said, we aint
talkin rocket science.)
212
The EMS MythSpeed has never saved anybodys
life. Period. W.H. Leonard, Medical
Transportation Insurance ProfessionalsAmbulance
, accident site to hospitalSource USA Today
213
I am always amused, in a perverse sort of way,
when I come across stuff like this. Urban legend
Speeding EMTs in ambulances are mainly a turn-on
for speeding EMTs in ambulances.
214
20 not get prescriptions filled50
use meds inconsistentlySource Tom
Farley Deborah Cohen, Prescription for a
Healthy Nation
215
Market ForcesRediClinic.CheckUps.Take
Care.MinuteClinic (We treat these 16
rules-based disorders/ Go-no go tests.15
minutes.39)WalMart.CVS.Target.Walgreens.RiteA
idSource FT (10.06.06) NYT (12.31.06)
216
I am an unabashed champion of such
non-conventional healthcare delivery
vehicleshospitals are fighting them tooth and
nail. (Hilariously, hospitals have declared them
unsafetalk about pots calling kettles black!)
(Interestingly, these convenient-
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