Sickened and stressed runners poured into our makeshift hospital. A runner stumbled in and vomited into a bag. We helped him onto a cot, where he sat shivering. “You’re OK,” a nurse said gently, wiping his face. But his core temperature had dropped to 96 degrees, and he began having violent rigors. We brought him Mylar blankets and hot bouillon. Nearby, a woman with intense hamstring spasms fell onto a cot; a runner with liver disease trembled with asterixis, his eyes roving in wild saccades.

Suddenly, there was a loud, sickening blast. My ears were ringing, and then — a long pause. Everyone in the tent stopped and looked up. A dehydrated woman grabbed my wrist. “What was that?” she cried. “Don’t leave.” I didn’t move. John Andersen, a medical coordinator, took the microphone. “Everybody stay with your patients,” he said, “and stay calm.” Then we smelled smoke — a dense stench of sulfur — and heard a second explosion, farther off but no less frightening. Despite the patient’s plea, I walked out the back of the tent and saw a crowd running from a cloud of smoke billowing around the finish line. “There are bombs,” a woman whispered. My hands began to shake.

Read the full piece here.

In a striking settlement of a high-profile case, a Harvard doctor who said she endured years of sexist treatment at Beth Israel Deaconess Medical Center will collect $7 million — and will have the hospital’s pain clinic named in her ­honor.

Employment lawyers said the hospital’s settlement with Dr. Carol Warfield, its former chief of anesthesia, appears to be one of the largest for a gender discrimination case in Massachusetts. Ilene Sunshine, a lawyer who represents defendants in bias suits, said it seems “enormous,’’ though she pointed out that it is hard to compare because settlements usually remain confidential.

The agreement — in which the hospital and other defendants did not admit doing anything wrong — closes an embar­rassing stretch in the ­Harvard teaching hospital’s ­illustrious history.

Warfield, who became chief of anesthesia in 2000, said Dr. Josef Fischer, former surgery chief, discriminated against her because she is a woman, openly ignoring her in meetings and lobbying for her ­removal from her job. When she complained to Paul Levy, then chief executive, she ­alleged, both men retaliated against her and forced her out.

Readers, is this an anomaly or does it reflect significant cultural change? Surgeons have such a reputation as the arrogant cowboys of any hospital staff; is that truly changing? Does this suit send the message that it must? Read the full Globe story here.

Hospitals that plan to stay in business in Massachusetts are either creating or joining Accountable Care Organizations (ACOs). Today we have a new one of these large “all care under one umbrella” groups: The Beth Israel Deaconess Care Organization (BIDCO) includes the hospital, its physicians’ group and two affiliated hospitals. BIDCO is in talks with Cambridge Health Alliance, Signature Healthcare in Brockton and a few other organizations about joining.

Dr. Kevin Tabb, who runs the hospital (Beth Israel Deaconess Medical Center), says ACOs offer a new and better way to deliver and pay for care.

“For a very long time,” says Tabb, “we’ve taken care of sick patients, doing a good job while they’re here and not thinking about them a lot after they leave the hospital. That felt like a broken model.”

Now, says Tabb, “we’ll think about patients not only when they’re here at the hospital, but after they leave,” and when they are well. Why haven’t doctors and hospitals done this in the past? Tabb offers two reasons: Doctors and hospitals haven’t had the structure to do this and they weren’t paid for keeping people well. Thus the new world, built around the structure of an ACO and financed by a global payment.

If you’ve been seeing a doctor affiliated with Beth Israel, you might be wondering, how does this affect me? Dr. Stuart Rosenberg, who will co-chair BIDCO representing physicians, says “for the first time, we are able to really look at the patient and assess their health care needs no matter where that might be provided.” A doctor will no longer have to see a patient in her office to get paid for delivering care.

Under an ACO and a budget that lets doctors decide how to spend money on patients’ care, doctors are “developing care plans that are limited only by our imagination and the law,” says Rosenberg.

He illustrates with the example of Mrs. Jones, a patient with a chronic disease who isn’t taking her medication, is skipping doctor’s appointments and comes to the emergency room when her blood pressure or diabetes get out of control. BIDCO could send a nurse to visit Mrs. Jones, give her rides to appointments and follow-up with phone calls. And the amazing thing, says Rosenberg, is that we can “provide that personalized care and actually save money on top of it.”

Sounds pretty good, huh? But if you have private insurance or MassHealth, there may be a catch. Your doctor will want you to get all or most of your care within his network. He’ll want to make sure he keeps track of you, and he’ll want to avoid writing a check out of his budget to a competitor, especially if that competitor, say Brigham and Women’s, charges more than Beth Israel does to help a woman deliver her baby.

Rosenberg says the doctor’s main allegiance will be to patients and helping them find the best care. Tabb says I’m wrong, that patients won’t face restrictions on where they can go for care. But I’m hearing otherwise from patients at several hospitals that are under a global budget.

We have a growing number of ACOs in Massachusetts, six, officially, and a handful of hospitals that say they’re ready to adopt the model. How does BIDCO expect to stand out? Tabb and Rosenberg say their emphasis on and investment in primary care will be unique. Some of the other ACOs would disagree, which sounds to me like an opportunity to bargain. Hey, ACOs, what can you do for me? After all, we keep hearing, this is not the nineties, when putting doctors on a budget blew up amid patient backlash. This time, money for doctors and hospitals is supposed to be tied to proof that we are healthier because we’re getting the care we need. So ask for that free massage, why not?

Tabb and Rosenberg will co-chair BIDCO, putting doctors and the hospital on equal footing for decisions, financial and otherwise, and the resulting successes or failures.

BIDCO expects to grow, to perhaps double in size, according to Rosenberg. The press release says hospitals and physician groups that join will “have the flexibility to remain as independent entities.” And then a couple of lines down we read, “hospitals and physicians will collaboratively enter into fully aligned risk contracting.” Translated, that means that if all goes well, everyone makes money, but if one hospital or group of doctors messes up, everyone pays.

So how will BIDCO balance “independence” and “collaboration”? Hey, says Tabb, “if this was simple, a lot of people would have done it a long time ago.”

BOSTON – Reducing preventable harm in hospitals often starts with small, low-tech steps: brushing the teeth of patients on ventilators; using low-rise beds and socks with safety treads on both sides; completing a surgical time out before mounting a blade on a scalpel.

Those small steps have yielded big results at Beth Israel Deaconess Medical Center – from a 90 percent reduction in ventilator-associated pneumonia since 2006, to progress in reducing patient falls with injury and in helping to avoid wrong site surgeries. They are some of the key lessons learned and implemented after the hospital declared the then “audacious goal” to eliminate preventable patient harm by 2012.

Those safety steps may seem obvious now, but of course, hindsight is always easy. Yes, “after the fact, it seems obvious,” said Dr. Kenneth Sands, the hospital’s senior vice president for health care quality, but “you need to have that ‘Aha’ moment.” Consider luggage, he said; he spent years lugging around bags because no one had thought to put wheels on them. “The good news is that some of these things are very simple and not technological,” he said, “but they are sometimes only obvious in retrospect.”

More from the hospital:

BIDMC has posted a video on its public website that chronicle three stories that represent how the issue is being addressed:

Preventing ventilator-associated pneumonia
Ventilator-associated pneumonia is a problem that can affect between 10 to 20 percent of intensive care patients who need assistance breathing. Bacteria can collect in the breathing tube and work its way into a patient’s lung and contracting VAP can double a patient’s risk of dying.

By implementing a VAP bundle of five specific, seemingly small steps – elevating a bed at 30 degrees, brushing a patient’s teeth daily, preventive treatment against stress ulcers and deep vein thrombosis as well as daily “sedation vacations,” when patients are awakened daily to see if they can come off the vent – BIDMC achieved a 2,000-case reduction of VAP since 2006. Factoring in the $20,000 cost to treat a case of VAP, this translated into $40 million not spent. With so many patients leaving the hospital sooner, the medical center was also able to forego construction of a new $8 million ICU…

Preventing falls
A similar back-to-basics approach was applied to reducing falls with injury, some of the most common, disabling, and expensive health conditions encountered by adults, especially older adults. In a hospital, a typical fall rate in general and medical-surgical units is four to five falls per 1,000 patient days.

“Over the years we’ve really looked at every fall and looked at if there was something different we could do to prevent that fall and we’ve added many different strategies over the course of the last five years to enhance our fall prevention standards,” says Kim Sulmonte, RN, BIDMC’s Associate Chief Nurse of Quality and Safety.” Those strategies revolve around supplies and equipment, process changes and patient education and communication.”

Sulmonte acknowledges “we’ve not reached our goal. Our goal really is zero falls with injury and we will continue to refine our standard over time and reviewing each case to see if there’s anything we can do differently to prevent falls in the future.”

As a result of these efforts, BIDMC’s total of preventable falls with serious injury has decreased from a high of 10 in 2009 to 3 in 2010, 1 in 2011 and 1 through mid-September 2012.

Instituting a new time out procedure in surgery
The staff-based approach also led to an innovative way to ensure that the “time-out” – a universal safety protocol to prevent wrong site surgery – is taken before every surgical procedure. At the suggestion of a OR nurse, scalpel blades cannot be attached to the handle until the time-out is performed, an extra step of prevention so that an operation cannot begin until the surgical team completes a checklist.

A 95-year-old Jewish man and his 94-year-old wife storm into the rabbi’s office and tell him they want a divorce — now.

“Calm down, calm down,” the rabbi tells them. “Sol, Goldie, you’ve been married, for better or worse, for richer or poorer, for over seventy years. Why get a divorce now?”

“We would have done it long ago,” Goldie huffs. “But we were waiting for the children to die.”

The news that brought that old chestnut to mind concerns a somewhat opposite phenomenon: After 60 years of working closely together, Hebrew SeniorLife and Beth Israel Deaconess Medical Center are taking a step a little like a marriage. They have signed a formal preferred provider agreement.

“After 60 years, we decided to make it official,” said Beth Israel Deaconess Medical Center spokesman Jerry Berger. “There was never a formal written agreement. This is the first formal written agreement.”

The looming next stage of health reform is prompting many hospitals to get their organizational ducks into a row. Last week brought the announcement that Partners Healthcare and South Shore Hospital had moved a formal step closer.

From today’s press release:

BOSTON – After 60 years of a close working relationship, Hebrew SeniorLife and Beth Israel Deaconess Medical Center, along with Harvard Medical Faculty Physicians at BIDMC, have signed a formal preferred provider agreement. The agreement is a recommitment of a 60-year clinical affiliation which aims to provide the highest quality, cost-effective hospital and post-hospital care, including ensuring seamless transition between institutions.

Driven by a commitment to reduce avoidable hospitalization and readmission, the goals of the agreement are to improve transitions of care for patients, other quality care metrics such as improved access, as well sharing of electronic medicals records to ensure timely and accurate communication about patients shared between institutions.

It also expands the possible scope of services beyond Hebrew SeniorLife’s traditional post-acute and long-term care. Potential areas of future collaboration include home health, evidenced-based prevention and wellness services, and programs for healthy aging communities.

…

While the agreement is not exclusive, the clinical affiliation reflects a strong preferential relationship. Each of the three parties – HSL, BIDMC and HMFP – will also collaborate with other health care providers to serve specific geographic diversity of their patient populations.

…

HSL and BIDMC will also focus on programs to improve communications between patients and families and their primary care physicians and specialists when patients are transferred between facilities, ensuring clarity about each patient’s clinical status and a seamless transition of care plans and goals of care.

Answer: The former chief of Beth Israel Deaconess Medical Center maintains his popular blog, once called “Running a Hospital” and now “Not Running a Hospital.” He speaks widely on improving hospital quality and safety. And he has just announced that the book he’s been working on is out: “Goal Play! Leadership Lessons From The Soccer Field.”

He writes:

It will come as no surprise to my readers that I have self-published this book, using Createspace.  That service provides a remarkable set of tools to any budding writer.  You can order the book here.  It will be available on Amazon in about a week.

Proceeds will go in part to the non-profit Massachusetts Youth Soccer GOALS program and he asks for feedback at goalplayleadership@gmail.com.

I confess: Though Paul Levy has many vivid and worthwhile lessons to share from his eight years running Beth Israel Deaconess, I immediately jumped to Chapter 9, titled “I’m sorry” and subtitled “What happens when you really let down your team?”

After all, his last months at Beth Israel Deaconess were shadowed by a major scandal about his personal relationship with an employee, and though he was otherwise renowned for setting new standards of transparency, many of his readers felt he never gave a full enough account of what happened. Would he now?

I’d give that a qualified yes. If you’re hoping for juicy details, forget it, but he does acknowledge the mistake of “deciding, shortly after I became CEO, to hire a close personal female friend into a new position where she, first directly and later indirectly, reported to me.”

He describes the delayed fallout of that decision and how he handled it, but perhaps most interesting are the lessons he draws. Should there be a formal mechanism to save leaders from their natural tendency to have poor judgment about their own behavior or how it can be perceived? Yes, indeed. He writes:

It turns out, though, that the solution is pretty straightforward. It is based on ensuring that there is a performance review and governance structure that is sufficiently well constructed to protect you from your own errors. The simplest approach would be to require an annual 360-degree review as part of a leader’s term of office. This kind of review would comprise confidential and anonymous interviews of people from various parts of the organization. Those interviews would uncover the leader‘s hidden problems and would enable his or her supervisors to point out concerns and together design plans for remediating them.

Readers, thoughts? The full book on createspace is here.

Nothing like fresh eyes — fresh, informed eyes. (Dr. Tabb made the unusual migration eastward after many years at Stanford.) Here, in a lightly edited chat, he shares his perspective on the state’s health care scene, including his impression that many of us fail to appreciate just how exceptionally rich in excellence we are: “If you take any one of these great institutions alone and put them in any other city, they would be the medical center,” he said, “and we’ve got many.”

Californian colleagues questioned his decision to move to the difficult, competitive health care landscape of Boston, he said — not to mention the nasty weather he would face. His response:

If you really care about effecting change, there has never been a more interesting time, at least in modern history…And Massachusetts is the epicenter of change. We here in Massachusetts are at least five years ahead of the rest of the country in terms of what is going on around experimenting with new models for delivery and health care reform. And the rest of the country will get there but they’re not there yet. I don’t know if people here in the Commonwealth and in Boston understand just how closely the rest of the country is looking at what is going on here as a view of what the future will look like.

Well, certainly, we’re aware that Massachusetts health care has great political resonance, both because of Mitt Romney’s involvement in the state’s health reform and because the federal health overhaul made use of the Massachusetts model.

I’m talking about more than that. Some of what I’m talking about is legislation, but it’s not just legislation. If there were a magic wand and the legislation were to go away tomorrow, hypothetically, you would still see forces here that are forcing really pretty rapid change in health care delivery models that have nothing to do with any single piece of legislation. So it’s a combination of the legislation and regulators, but also of economic forces and, I think, the forces of innovation that exist at this time. Nobody has a monopoly over that.

One problem with past approaches was dividing care into silos: ambulatory vs. hospital; treatment of the sick vs. keeping people healthy. But it was also siloed in terms of thinking of problems and solutions as hospitals separate from payers separate from pharmaceutical companies separate from patient. First of all, we all bear some responsibility for the current situation, although none of us, including hospitals, bear all of the responsibility. And I wouldn’t want to see solutions solely attempted on the backs of a single sector. But we all are only going to be able to solve this together because siloed approaches siloed haven’t worked in the past. The economic forces are aligning here to require us to work together.

Which economic forces?

Clearly the trend of spending on health care nationally and here in Massachusetts is not sustainable. It’s got to change. We feel it, and our patients feel it perhaps more acutely here than in many places. So we’re willing to talk about other models of care that make a lot of sense from a policy perspective, a patient perspective, but have never aligned with the economic incentives before, that all of a sudden do.

I think many physicians and clinicians and patients knew intuitively that it makes sense to take care of people before they get sick, to take care of people in their own communities, to coordinate care. But the system has been geared in a different way, towards, ‘We will incentivize you to do more of whatever it is you do.’ Well, again for the first time, that’s changing. There is no question.

Here’s a concrete example. A significant portion of BIDPO, our physician organization’s population and contracts with payers are now ‘at-risk.’ [Editorial note: 'At-risk' means the doctors aim for an annual budget along with quality benchmarks, and can gain or lose money depending on whether they meet it.] This is not just talking about things, this has actually happened. I think we’ve passed the tipping point here in Massachusetts. The rest of the country has not. I think you’d hear similar things from my colleagues here and throughout the state.

I’ve been here exactly 60 days. I’ve spend most of my time outside the walls of this institution for two reasons. One is, I think w’ere in very good shape. We’re very well run. This is not a turnaround situation. We’ve got a good team in place and I’m very comfortable with where we’re at at this moment.

Also, I spent time outside the four walls of this hospital because the really important changes are going to happen externally as well. So I’ve been to almost every hospital in Boston, which in any other city you could do in a day. And that means going to see people who are collaborators and friends but also people who are competitors. I’ve also been to close to 20 community hospitals outside of Boston, which has been fascinating.

At your initiative?

Absolutely. It’s really important because that’s where much of the care of the future will be delivered, in those community hospitals. It’s not new that Academic Medical Centers want to partner with physician groups and community hospitals, but the type of partnership we’re talking about is very different from the types of partnerships we talked about in the past. In the past we thought about, ‘How do we get more referrals here downtown?’ That’s not the model for the future.

The model for the future is that there will always be a place for good academic medical centers to do the very complex things that can’t and shouldn’t be done elsewhere, to do the incredible research and the outstanding education we do. But if we’re honest with ourselves, there are many things that we do here downtown that don’t have to be done here, that can be done at a level of high quality and at a different cost structure, and in people’s own communities. We need to learn to partner with others in a variety of different models. It’s going to require huge change, and I wouldn’t underestimate the difficulty of that. This is something we’ll all go through. Those of us that understand and change quickly will thrive.

It’s going to require something else on our parts — it may require a level of humility that academic medical centers in general have not always been known for, and an understanding that there is knowledge that resides here but there’s a wealth of knowledge that resides out there too.

How do you keep your revenue flow up if you’re reducing referrals to your mother-ship hospital?

We need to be part of a larger ecosystem so that we can do the things that are really appropriate to do here. And there’s a lot of it, there is, and if you’re part of a large enough ecosystem, there’s that. And we need to share in risk models so when there’s benefit, we share in that as well. I think it’s a combination of models, and this is finally an alignment around good policy, what’s good for the patient, what patients want, and the way things are structured. And that hasn’t been aligned before.

What changed?

A combination of legislation and economic pressure and a realization from many of us that the model is broken.

But to be clear, we’re just at the beginning of that change and I wouldn’t want to make the claim that it’s all done, or it will all be easy, or by next year this will be done. This will be a lengthy process and painful in nature. Painful because change can be hard and it’s very different from the way we’ve done things before. But there are a lot of people who are really ready to do it.

There are a variety of opinions and I think there’s not going to be a single path forward. There will be a number of different paths, which I think will work and make sense.

But we’re expecting just one payment reform bill to come out of the legislature in the coming months…

I think it will accelerate the things we’re hearing about. Without specifics, the concern with a single bill is as much about unintended consequences as it is about intended consequences. I don’t have a specific issue because you don’t know what will happen, but it’s well known that when changes are imposed with a large single stroke — you sometimes get consequences you don’t intend. That said, I think it will accelerate change.

So what will the health care scene here look like in five years or so?

We’re going to see much more focus on wellness. I think you’re going to see all of us heavily taking on risk. I think you’ll see us partnered in new and different ways, with more of an emphasis on care provided in the community.

What else have you seen on your travels?

I think there’s an understandable combination of some optimism about the fact that forces are aligning with a fair amount of anxiety by a lot of parties trying to understand their own place in an ecosystem that hasn’t yet formed. I think that’s maybe the overarching theme.

And it really doesn’t matter who you talk to, everybody’s still trying to figure out where are they going to be in all of this, and there aren’t clear-cut answers. This is a sort of naturally anxiety-inducing time. But again, I think those institutions that are forward-thinking and don’t wait for it to happen to them, but start to make those changes now, will do just fine.

Drs. Jerome Groopman and Pamela Hartzband are a Longwood-style literary power couple: both on the staffs of Beth Israel Deaconess Medical Center and Harvard Medical School, and widely read in prominent publications from The New Yorker to The New England Journal of Medicine. We spoke this morning about the lessons that can be learned from the vivid stories and psychological insights in their new book.

I derived two takeaways from “Your Medical Mind.” First, you need to be aware of your own biases on medical decisions: Are you a minimalist when it comes to treatment, or a maximalist? Do you tend toward the natural or the technological?

Second, you need to understand decision dynamics that are common to all of us: Our tendency to be influenced disproportionately by what happens to people we know, for example. Our greater willingness to take a risk by not taking action than by doing something.

The federal Agency for Healthcare Research and Quality has just come out with a succinct cheat sheet, a list of questions to ask your doctor, from ‘What is the test for?’ to ‘Are there any side effects?’ I wonder if you could generate on the fly a list of the questions you should ask yourself before you finalize any medical decision?

1. What is my medical mindset?

JG: The questions you refer to from the government are generic questions, and they’re valuable. But the questions you should ask yourself first are: What is my medical mind? Am I a maximalist, so I believe in being proactive, ahead of the curve, doing everything and more? Or am I a minimalist, so I believe that less is more?

PH: And to expand upon that: Are you somebody who likes the latest technology, do you have a technological orientation? Or are you somebody who is more in tune with natural remedies and prefers to go that route?

And finally, are you a believer or a doubter? The believers are people who believe there’s a solution to their problem and they’re going to find it and go with it. And the doubters are people who worry about side effects and unintended consequences, the people who are risk-averse and worry the treatment will be worse than the disease. So that’s your first question: What is your medical mindset?

2. What are the numbers?

PH: The next question has to do with numbers: Where am I in the numbers? Which numbers apply to me and which don’t?

JG: When I looked at those [AHRQ] questions, they said, ‘Ask your doctor about the outcomes of the surgery or treatment.; And I think what’s important is that the really informed patient is aware of the fact that those numbers, first of all, may or may not apply to you as an individual, because often they come from clinical trials that don’t have many women, or many elderly people –

PH: Or they don’t include somebody with diabetes, or kidney problems, or other illnesses.

JG: And also, how the numbers are framed is really important. Drug company advertising is obviously framed in a way to make the benefits seem maximal, and often the way we hear information on the Internet or in the newspaper or from other sources is: ‘This reduces your risk by 30%,’ and that sounds like a major impact.

But the question to ask is, ‘For my individual case, what is the likely outcome if I do nothing?’ And that gives you the starting point, and then you can assess how much the impact of the drug or surgery may have on you, with that understandable bit of information.

It puts it into the right context of whether your initial chance of a heart attack or a stroke or whatever might be so extremely low that 30% of a very, very small number is still very small. It’s like the woman we describe in the book whose chance of a heart attack is 1 in 100; that’s very different from an overweight man who’s already had a heart attack, is a smoker and has high blood pressure.

3. What is influencing me as I decide?

PH: And the third question would be: Are there outside or inside influences that are impacting me that I haven’t thought about?’ And the biggest one is other people’s stories, what’s termed by psychologists as ‘availability.’

If your Aunt Susie has a terrible side effect from a particular medicine, you won’t want to take it. But you need to integrate that information into the numbers: How common is that side effect? Did she have some other reason to have that side effect that doesn’t apply to you?

And conversely, if somebody you know or heard about had a fabulous result from a particular surgery, you may be dying to get that surgery, leaping forward, but maybe you should hold back a little and find out how likely that fabulous outcome really is.

Part of what I came away with from ‘Your Medical Mind’ is that the gray areas in medicine are so huge that even if I do my very best to make a good medical decision, I may still end up — my word, not yours — screwed. I could have a bad outcome. Can you help me with that? Is it all about just avoiding later regret?

JG: That’s a really important point. You can have an incredibly competent surgeon and wonderful attentive nursing in an excellent hospital, and an honest surgeon will tell you, ‘I can do everything right, and the hospitalization goes perfectly, and the outcome is still not good, the person is left with pain and irritation.’

We show this quite vividly in the book with Lisa Norton and Carl Simpson, two people having surgery, elective surgery but for really bothersome orthopedic problems of the type very common among baby boomers.

Carl is disappointed that his knee still has limitations and discomfort, but he has no regrets because he didn’t make the decision blindly and he followed a process that was true to his medical mind. While Lisa, who also has an unsatisfactory outcome, is not only disappointed but just filled with regret an self-blame, which is an enormous burden.

And I can speak to that personally because I made a really bad decision with my back. I was having a lot of back pain and I didn’t really go through a process that allowed me to step back and not just give my maximalist believer mindset free reign. And I’ve regretted it, and I’ve learned from it, but I’ve learned from it a very hard way. So I think that medicine is uncertain, and there is this very large gray zone, and anyone who guarantees, like a recent insurance company ad — ‘You know you’ll have the right outcome’ — that’s just not true.

PH: You can’t guarantee a good outcome.

JG: You can be confident that you went through the right process, and the decision was right for you, and you may be disappointed but not racked with regret. That’s one of the goals of the book.

Note: You can read an excerpt of “Your Medical Mind” on NPR books here. And the authors are scheduled to be featured tomorrow on Radio Boston between 3 and 4 p.m.

Uber-economist Lawrence Summers, former secretary of the U.S. Treasury and former controversial president of Harvard, spoke yesterday at the inaugural Health Policy Symposium at Beth Israel Deaconess Medical Center. He’s back at Harvard now as a professor, and mostly speaks at note-taking speed, but I’ve had to paraphrase here and there. I’ll begin with the ending, which felt a bit like the kind of “Go forth and do good work” benediction he might have offered graduating Harvard seniors:

“This is all very, very difficult. And I guess the thought that I would want to leave you with, assessing this debate from the outside, is that if there is a happy end to this tale — if, looking back from 2030, we’re seeing that not just was the arc of justice bent towards liberty but the arc of health care costs was bent toward flatness —  if that is what we look forward to, I think it is less likely that it came from a sweeping act of Congress and it is more likely that it came from widely emulated innovation in individual settings.

That it came from hospitals that found creative and inventive way to improve the quality of care and cut costs, and then whose procedure was so compelling that it had to be emulated elsewhere.

That it came from cities where coalitions of hospital providers and major employers worked out improved reimbursement understandings, found ways of fine-tuning reimbursements so that costs grew less rapidly.

We are much more likely to succeed, both with respect to the cost-containment challenge and with respect to the closely related quality challenge, from the bottom up than we are from the top down.

So my hope…would be that just as we live in a remarkable period of scientific innovation, we can live in a remarkable period of institutional innovation — and, if you like, social scientific innovation that points toward emulatable solutions to these problems.

President Clinton used to say that there was no problem in American education that had not been solved somewhere in America, and I suspect that most of the problems in health care have been solved somewhere in America. And our challenge is to match scientific innovation with innovation in patterns of practice, in provision of incentives, in monitoring and rewarding of outcomes.

It’s a feature of exponential growth that the stakes get larger every year. I think we are going to succeed with respect to broadening the availability of coverage very substantially, but I cannot claim that we’re securely on a path toward better cost-containment or improvement of quality. I think that’s the task for all of you.”

Now back to the beginning:

There are three broad sources of dissatisfaction with health care:
-Unequal access
-Costs are too high and rising too rapidly — and no outcomes justify spending an extra $1 trillion.
-An increasing sense that health care does not work as well as it could.

“There is better information technology in the typical 7-11 than in the median medical facility in the United States. That it is estimated that 100,000 people a year die due to avoidable medical errers in a country where less than 3 million peope die each year is more than a little bit chilling.

Almost anyone who has been in a hospital, including some of the nation’s leading hospitals, reports that either there were signficant errors in the delivery of medicines or that such efforts were avoided not through the work of the hospital but through an alert family member. There is almost no one who feels entirely safe all of the time in one of our major hospitals. And make no mistake, a reasonable estimate of needless fatalities due to avoidable in-hospital errors is comparable or greater than the estimates that arise from inadequate access to our hospitals and to medical care at all.”

All three of these problems constitute the health care agenda if health care is to make a greater and more effective contribution to our national economy…

“We have adopted the most libertarian, most market-oriented, most with-the-grain-of-the-market system approach to universalizing health care that is possible. We have in essence required that everyone get health insurance. Why have we done that? We could, as candidate Obama proposed during the campaign, have called for universal availability at an attractive price and then said, ‘It’s your tough luck whether you do or you do not get the insurance.’ What’s clear is that that does not work. If there’s universal availability of insurance then there’s no reason to purchase it until you get sick, and if only sick people purchase it, the whole thing unravels.”

If you wish to have universally available health insurance without discriminating against the sick, which defeats the whole point, there’s now almost no disagreement that there is no alternative but to have a mandate…It is an ineluctable consequence of the decision that you want to have a reaosnably priced insurance policy without discrimination…It’s the most pro-market, conservative way of achieving that objective.

It is not intellectually legitimate to argue that there’s some other way of having universal health care that will work and will somehow go more with the grain of the market system. That, by the way, is the reason why ObamaCare is far to the right of the proposals that Richard Nixon and Bob Dole put forward.

We now have this system. It is, to be properly understood, it is an expansion of government in order to make health care universally available and it is pretty close to the minimum expansion of government’s role that is consistent with making health care universally available. I believe that we’re a better country for it. I believe that ultimately it will be regarded as remarkable that such a universal system was not in place.

It is profoundly counterintuitive, and it is in some sense legitimately counterintuitive, to argue that bringing in a system of universal health care will somehow cut costs. And the reality is that about $1 trillion is going to be spent on health care that would not otherwise be spent on health care because of the 50 million people who didn’t have health coverage.

I wish it were true that because people went to regular doctors and clinics rather than ERs, the total cost of health care would be lower. I wish it were true that greater preventive care will reduce total costs. But…”[like the Republican argument that cutting taxes leads to greater revenues] the liberal Laffer curve is that making health care more widely available will cut costs in a way that will make total health care costs cheaper is equally not true.

How then does one think about controlling health care costs?

“It’s important to recognize that no one has great answers.

I like to divide public policy problems into two categories:
There’s a set of problems like the budget deficit or peace in the Middle East, where you kind of know what the answer is but the politics are impossible.

There’s another set of problems where even if you could be the czar you’re not entirely sure what to do, and I’d regard the growth in health care costs as having sub-elements of the second problem.”

There are four broad ways to control health care costs:
1. Simply pay less; drive down reimbursements.
But very few people believe that you can achieve large permanent savings simply through reimbursement controls.

2. Control incentives on the individual side: In some areas, there’s no question it works; if you tell parents they have to pay in full for their children’s glasses, they’re likely to scrimp on their children’s glasses, but it’s not altogether clear that that’s a positive thing.

To be sure, probably, less extensive health insurance would operate to encourage some economies on people’s part but even that raises a very, very deep question. It is not possible to logically believe two things: You can believe that health care should be market-oriented and you can believe that the rich and poor should get the same health care, but those two beliefs cannot be held consistently.

The rich and the poor do not get the same houses, the rich and the poor do not get the same clothes. The rich and poor do not eat equally fresh foods.

My judgment: There are things you can do at the margin — to put more co-insurance in, to discourage frivolous use.

But I am indifferent to it financially and annoyed psychologically every time I walk into the Harvard Health Clinic because I have a sprained knee or a potential strep throat and somebody asks me for $15. I say to myself, ‘If this $15 isn’t going to discourage my behavior then why are we doing it? And if it is going to discourage my behavior, is that really something we want to be doing?

3, and probably most promising: the realignment of provider incentives.
The way it’s frequenlty put is that instead of paying people for doing procedures we pay people for keeping people healthy. Wouldn’t we have a better system? And the answer is yes, we would.

4. Miscellaneous, including malpractice reform.
[If malpractice reform] were only one-third as good as the average physician believes it is, which is about my guess, it would still be an enormously good thing.

Now please re-read the top, which was the ending. Readers, thoughts? Can bottom-up really work?

I think about Massachusetts as being five years ahead of the rest of the country. I think the things that are already happening here will happen elsewhere, they just haven’t happened yet. Specifically about global payments, that is one way to attack the issue of rising health care costs, although I don’t think it’s the only way. I think all of us are going to need to become more effective and global payments is one way of getting there, but it’s not going to be the panacea, to tell you the truth.

[Would you support it as one of the ways of getting there?]

I would, with the caveat that especially academic medical centers have a unique place in the health care environment, they serve unique populations, and we’re going to need to take that into account as we figure out how we’re going to change.

[How would you take that into account?]

Like all academic medical centers, we take care of very sick, very complex patients — and very sick, very complex patients don’t always lend themselves to simplistic plans. So I think we just need to make sure we take that into account as we look at global payments. That being said, as we look at global payments, all of us in academic medical centers are going to have to make some changes in how we think about health care. Specifically, that means we’ll have to think about taking care of patients across the continuum of care, and that means not just here in the hospital when they’re really sick.

From the Beth Israel Deaconess press release on Kevin Tabb’s appointment:

As the CMO at Stanford, Tabb had broad strategic and operational responsibilities, which included physician network strategy; clinical quality and patient safety initiatives; regulatory and medical staff affairs; and graduate and continuing medical education. He was previously chief quality and medical information officer at Stanford, where he oversaw primary care, outreach clinics and the Stanford Cancer Center. Prior to joining Stanford, Tabb led the Clinical Data Services division of GE Healthcare IT.

Tabb, who is 47, received his MD from Hebrew University-Hadassah Medical School in Jerusalem, Israel, as well as his undergraduate degree from Hebrew University. He completed his residency in internal medicine at Hadassah Hospital. Raised in Berkeley, CA, Tabb emigrated to Israel at the age of 18 and served in the Israel Defense Forces, the country’s military service.