Keith Marple

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Kate Burton Marple

Kate Burton Marple was born yesterday, April 18th, at 10:44AM, weighing 7 lbs. 1 oz. Mother and daughter are healthy, home now, and feeling fine.

While all of that is true, this standard announcement doesn't begin to reflect the incredible experience of her birth. 

It's 6 in the morning, and Yin gently shakes me awake, wide-eyed. "I think it's time," she says. At that moment, adrenaline kicks into action. My mind snaps into hyper-awareness, thoughts racing at a mile a minute. Even eyesight is heightened, and details like threads in fabric pop with extreme clarity. This state lasts throughout the experience.

We call the doctor to let him know we're coming, get ready, grab our packed bags, and jump into the car.  Yin's in a good mood, not too worried, except for every 6 minutes or so when she has a contraction.  She kids me about still obeying the traffic signals when there's nobody around and we're rushing to the hospital. The thought had crossed my mind, but I take it as a sign of good character that I decided against it.  

It's 7, and we're checked in to an exam room at Mt. Auburn Hospital, and Yin's hooked up to the heart rate and contraction monitors.  Nurses and docs going through a shift change.  Nothing to do at this point but wait.  It's here that I begin to reflect on the significance of the baby.  For some reason, this birth makes me much more aware of our mortality.  I find myself looking at Yin's teeth and gums when she smiles and thinking of her skull hidden underneath, the brief wink of our time on earth, and the incomprehensible beauty of the human soul, that spark of life.  In another hospital bed 1000 miles away, my last remaining grandparent lies insensible, medications hallucinating away the pain of a broken hip.  Unbeknownst to her, the family she created is about to get a little larger.

I shouldn't give the impression that during this time I am morose or remote.  In fact, the anxiety and weightiness gives me an irrepressible "gallows" humor, an almost inability to stop making jokes.  Yin's cracking up, and eventually begs me to stop when the laughs are making her contractions more painful.

It's 9, and we're moved into a birthing suite.  Roomy, lots of red oak, views of suburban Cambridge.  Trying to take Yin's mind off the pain, we compare it to the other hospitals she's given birth in.  Nurse Leesha and Dr. Yun check in occasionally, remaining compassionate but utterly calm.  Yin's contractions are increasing in frequency and severity.  

It's 10, and the contractions are so severe now that Yin doesn't want to speak so she can conserve her energy.  While Yin isn't one of those mothers who screams and curses at their partner at this stage of labor, I know that she doesn't like to talk or be asked any questions.  Any words of encouragement feel hollow and condescending.  All I can do to express my concern at this point is to be present, to hold her hand, and occasionally whisper "I love you."  In fact, my feelings of love for her are overwhelming; as I watch her suffer mightily for our family, I feel that I've never loved her more than in this moment.

And maybe that's because my heart is expanding to make room.  

It's 10:44, and after 3 quick, breath-held pushes that have the clinicians commenting about Yin's strength, baby has arrived, looking vibrant and beautiful and new.  Her cries are soon comforted by her mother's warmth, and Leesha and Dr Yun are leaving the room spotless as I hold back tears of joy.  She's so tiny, and yet she fills the room with her incredible potential.  I want to hold and love her, to protect her, and to share with her this flawed and yet miraculous world. 

Kate Burton Marple was born yesterday, April 18th, at 10:44AM, weighing 7 lbs. 1 oz. Mother and daughter are healthy, home now, and feeling fine.

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Accountable Care Orgs: Design and Implementation

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HSMA: A Fond Farewell

The Health Services Management Association is the Boston University School of Management's student-run club for people interested in the health care delivery industry and its related services.  Our mission is to foster a community of like-minded students and alumni through events that educate, entertain, and enlighten.

I had the honor and privilege to serve as the club's President this year, which was a very rewarding experience.  I got to stretch my wings a little bit, create and work towards a shared vision, and experiment with new leadership techniques.  But the best part was getting to work with an incredibly talented team of people who all care about the industry; it was an experience that's going to be hard to replicate in the "real world".  

Everyone contributed their piece to the club's goals, each in their own way.  I'll talk about what was accomplished at the end, because it's a long list, but I want to talk about how I felt working with each member of the team.

Andrej Ausing: Lots of fun, but also gets the job done.  A great speaker and natural leader.  Cool in a way I'll never be (this picture notwithstanding), but always friendly and welcoming.

Michelle He: Totally dedicated, a self-starting achiever who goes over and above with everything she does and never has to be asked.  Truly loves the healthcare industry, and it shows.

Jeff Keesing: Hard to believe he's transitioning into the industry; he's immersed himself in health care and is as knowledgeable as anyone. Calm and collected, I always knew I could count on him.

Sayaka Koseki: An absolute joy to work with. Always looking for more ways to contribute, smart, thoughtful and conscientious.  Lives to help the globe's neediest people; the world needs more Sayakas.

Ivan Ross: The rare combination of creative thinking and technical savvy, brought new solutions to any problem we were facing.  His great attitude and global perspective will serve him well in the years to come.

Alex Schwarzer: The emotional leader, intuitively knows just the right thing to say in the moment.  Organized, detail-oriented, and effective, he will make an incredible clinical leader, which was the goal all along.

Becca Selgrade: Smart.  Insightful.  Well-connected.  Deep industry knowledge.  Easy to work with, builds consensus, a true team player. Clearly bound for greatness.

Marcel Tam: A uniquely talented individual whose unflagging dedication to serving the poor is a personal inspiration to me.  Wants to become a PCP for all the right reasons, but anything less than organizational leadership is a waste of his immense skills.

As you can see, we had a pretty remarkable collection of talent, and their hard work and sacrifice for the community really showed in our results.  We more than quadrupled the number of events that we created for our members compared to the prior year, all while spending less and streamlining our marketing.  And we couldn't have done it without the support of our advisors, the always-helpful Mark Allan, Ceri Gerrish, and Kristen Fischer.  Some of the year's highlights, with quotes of participant feedback, include:

3 prominent CEOs - Professor, before quoting the speakers: "Did any of you go to the panel this week?  They had some really interesting ideas."

4 prominent COOs - "This event was a great experience to hear from these distinguished speakers."

5 health care provider tours - "That was a great place with great leaders."

2 panels of alumni speakers - "This sparked my interest in health sector management."

2 authors - "We really want to explore this idea further."

5 community-building events - "No suggestions for improvement, it was a very good event."

4 IHI Workshops - Alum: "It's so great to see our ideas come to life."

I'm so proud of what we have accomplished, and so it's with a mixture of relief and sadness that I turn the keys over to Katy Perkins and her able team, who are ready to take the club on to bigger and better things.  

I want to end by personally thanking all of the members of our team.  Thank you guys, for always doing what was needed, for supporting each other, for understanding as I learn the ropes of leadership, for creating new ideas and making them a reality.   I look forward to watching you grow in your careers and in your lives.  Remember, dream big.  Let's help people by the thousands.

[keithmarple-blog]

The New ACO Regulations

Interesting discussion on Paul Levy's blog about the merits of the new CMS Accountable Care Organization definitions.  I'm arguing that they're a small step in the right direction, without much support.

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Interesting post from one of my favorite bloggers about the current state of multiple sclerosis treatments.  As you can see, there's no cure, and existing treatments only treat the symptoms.

Our school's health care delivery club decided that all of the educational and networking events we've been holding at our school were not enough; we also wanted to incorporate our own personal missions to treat and eradicate disease.

To that end, we're walking in our local MS Walk to try to find a cure for this debilitating disease.  If you're at the school and you would like to walk with our team, sign up here.  If you're not local, but you'd like to contribute to this cause, please donate here.  Science has done amazing things to improve our lives, and yet there are still diseases like this one where more research is needed to find a cure.

stuffsickpeoplehavetoputupwith:

[Disclaimer - My answer here is very detailed and contains some basic information you probably already know, since I figured I’m also potentially addressing many people who don’t know a lot about MS]:

If by “work” you mean “destroy the immune system,” then yes, it does.

MS is widely regarded as an autoimmune disease, meaning that the body’s own immune system, for some reason that is not well understood, begins attacking the body’s own tissues. In the case of Multiple Sclerosis, the immune system attacks myelin, a fatty substance which coats the axons of neurons in the brain and spinal cord. When myelin is destroyed, communication between the brain and certain parts of the body is disrupted and eventually cut off entirely, resulting in numbness, paralysis, blindness, and a host of other MS symptoms.

Currently, the only treatments that exist for MS consist of either a.) “modulating” the immune system; b.) suppressing the immune system; or c.) destroying the immune system. “Modulating” in this case usually means suppressing, although some medications, like Copaxone, work by attempting to trick the immune system rather than suppressing it.

Chemotherapy is not considered a “first line” treatment for MS, and often times not even a ”second line” treatment. What this means is that it’s usually not a neurologist’s first or even second choice to treat a patient. The catch is that all first and second-line treatments for MS eventually become ineffective as the disease progresses and patients worsen in spite of being treated with first and/or second-line medications. When this happens, the next step is chemo.

Chemo does not cure MS.

There is no cure for MS.

By destroying or severely weakening the immune system, the neurologist and the MS patient merely buy some more time.

In a nutshell: the first step is always to just suppress or try and trick the immune system to slow down the disease. When that fails (as it nearly always inevitably does sooner or later), the next step is to destroy the immune system. It’s kind of like that famous line: “We had to destroy the village in order to save it.”

All treatments for MS—-including chemo—-do is buy time. Nothing more.

—

Some resources with information about MS:

1. “High time for HiCy?” - This is an article about the use of “HiCy” —- High-dose Cytoxan, i.e. - chemo, to destroy the immune systems of patients. The hope was that it represented a cure for the disease. Years later it is known to yield only mixed results for MS patients. Some MS patients have undergone HiCy at Johns Hopkins, only to relapse (become sick again with MS) mere months after undergoing the brutal procedure. I know because I spoke with many of these patients personally. I only know of one individual whose MS virtually disappeared for several years after undergoing HiCy. Eventually, though, his MS came back.

2. Discussion among MS patients in a moderated forum about the use of chemo. Link here. Novantrone and Cytoxan are chemo.

3. PubMed overview on MS here.

4. Wikipedia article on MS (good quality info.) is here. See especially this section, where treatment options are discussed.

—

Response to reinedelaseine14’s comment on this post.

[keithmarple-blog]

Disruptive Innovation in Healthcare

One of the themes that's captured our imagination this school year has been the idea of disruptive innovation in the healthcare market.  Last fall, Marcel Tam invited Dr. Jason Hwang, co-author of The Innovator's Prescription, on campus to explain how Clayton Christensen's concept of disruptive innovation applied to healthcare.  With health care costs spiraling out of control, the idea that new business models could change the cost structure in an industry with too many entrenched interests and infrastructure was very appealing.

This last week we created an event to follow up on this idea. We wanted to find companies in the industry that embodied this idea in practice.  Katy Perkins and Andy Lippman, part of the next leadership team for the Health Services Management Association, put together a panel that included Dr. Andrew Sussman, President of the CVS MinuteClinic, and Dr. Joe Jabre, CEO of TeleEMG.  

Both of these companies are successful in part because they move care down the health care continuum.  And, of course, because their leaders went through the BU Health Sector MBA Program!  TeleEMG moves neurologic diagnostics from the specialist setting to the primary care office, and MinuteClinic shifts simple tests and procedures from the primary care office to nurse practitioners in a retail setting.  This ability to move care "down the chain" offers major benefits:

 - Less costly.  Dr. Sussman estimated that MinuteClinic was 40-80% less expensive than traditional environments.  Both patients and the system as a whole benefit from this reduced cost.

- Improved access: Specialist visits in Mass. are months out.  PCPs are one-to-two months out.  A nurse at MinuteClinic can be seen the same day.

- Equal quality: Both MinuteClinic and TeleEMG, because of their visibly controversial business models, have been tested extensively to ensure equal quality.  The MinuteClinic goes through JHACO audits, where auditors visit 60+ national CVS outlets simultaneoulsy.

Mark Allan, our program director and the moderator of the panel, asked about the resistance these companies have experienced from existing providers to their new business models.  Dr. Jabre was honest that neurologists had mixed feelings about his technology.  Dr. Sussman minimized the cultural resistance, and suggested that as the industry moves from fee-for-service to capitated ACO models, more and more provider organizations will be seeking out the MinuteClinic because it can offer services at a cost that other providers can't duplicate.

The panel was very enlightening, and although there are reasons to be skeptical, I hope that our distinguished panelists are right about the future of disruptive innovation in healthcare.  The best way for our industry to curb its rampant cost problem would be for healthcare to function like most industries, which have seen incredibly disruptive solutions like the personal computer or Netflix totally change the landscape for the better.  Incumbent providers beware.

Related articles

A Disruptive Solution for Health Care (blogs.hbr.org)

[keithmarple-blog]

Another story about hospitals rerouting patients into more expensive procedures - this time it's just that the patients are newborns.  I'm never surprised when provider organizations (or anyone) act in their financial best interest.  It's human nature, and can be rationalized many ways, as evidenced by the quote from Dr. Hankins in the article.

This is exactly why we need global payments and ACOs.  The conversation for providers would change from "How can we increase these profitable procedures to cover these unprofitable ones?" to "How can we keep this patient healthy in a cost-effective way?"  At that point we'll just have to watch out for providers dropping or denying the sickest patients, just like some insurers were notorious for doing.  Another case of people just following their incentives.

[keithmarple-blog]

Commonwealth Care - How Well Is It Working?

The Commonwealth Health Insurance Connector Authority, the state agency that acts as insurance broker for the subsidized Commonwealth Care commercial insurance offerings, recently posted membership survey results.  These results were presented to the Connector Authority's Board of Directors, and they highlight both the successes and the challenges still ahead for Massachusetts health care reform.

On the positive side, the Health Connector appears to have been successful in providing insurance options that are comparable in features and benefits to employer insurance plans.  84% of members were extremely satisfied with their insurance plan, and 86% of members rated the range of services offered as excellent, very good, or good.  Most members felt that the copays and premiums were reasonable and were able to pay their medical bills without difficulty.  Because of this, the plans have been able to attract a sustainable mix of members with an overall good health profile.

Where the plan has been less successful is in limiting overall health care costs.  The theory of universal health care reform was that the cost of free care for the uninsured would be reduced, and that those costs would be shifted to cover the insurance subsidies.  Newly insured members would then be more likely to seek preventative care and less likely to use expensive ER visits.

So far neither of these theories have come to pass.  This year Massachusetts allocated $880 million to pay for Commonwealth Care, and only experienced a $310 million dollar reduction in payments to Health Safety Net providers who serve the uninsured.

Trips to the ER have increased as well.  The CDC found that, on average, about 20% of people will visit the ER in a given year, and that holds true for both insured and uninsured populations.  Compare that with the 33% of surveyed Commonwealth Care members that visited the ER in the past year, and you can see that insuring everyone hasn't yielded the expected returns in hospital utilization.

So what's the problem?  In a word, access.  54% of surveyed members reported that they were denied access to providers, because many providers won't accept Commonwealth Care's lower reimbursement rates.  One of my family members uses Commonwealth Care, and found that the few local PCPs who would accept it were all booked 3 months in advance.  This lack of access leads directly to unnecessary ER visits - 39% of the CC members who visited the ER could have been seen by a regular doctor instead, had one been available.  Remove those unneccessary ER visits, and you're back at 20% of the Commonwealth Care population/year, right in line with national averages.

What's the solution?  Unfortunately, higher reimbursement for Commonwealth Care plans.  It's simple supply and demand - to get adequate access for members, you must increase reimbursement to widen the pool of physicians willing to accept the insurance plans.  To help offset costs, plans could increase copays for ER visits, offering stronger negative incentives for members who might use the ER out of convenience (43% of reported visits).

While the Health Connector appears to be well managed and aware of the issues at hand, the challenges that state insurance regulators and legislators face are an unfortunate harbinger of the national budget shortfalls to come.

Related articles

Massachusetts Health Care Plan Gets High Marks: Poll (huffingtonpost.com)

Most consumers satisfied with state-subsidized health care, survey shows (boston.com)

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Our Tour of the Yawkey Center for Cancer Care

Boston University's health services management club, HSMA, was privileged to experience a guided tour of Dana-Farber's new Yawkey Center for Cancer Care. The building, Dana-Farber's first patient-care-only facility, just opened in January. If that weren't exciting enough, our tour guide was none other than Janet Porter, Dana-Farber's dynamic COO.  I want to express our heartfelt thanks to Janet, who was incredibly generous with her time in giving us this memorable experience, and Mark Allan, our BU Health Sector Program Director, who helped make the connection.  The tour was incredible, and I know that everyone who went was touched by the experience.  In attempting to condense everything we learned, I hope to be able to give others a chance to learn from our experience.

There were three major topics that we discussed in our tour:

Building Design

Touring the Yawkey Center was an eye-opening experience.  The attention to detail in its design and execution was visible everywhere.  Janet discussed the principles by which they designed the building, and I'll discuss a few and an example of how they were reflected in the final design:

- Patient Safety: Non-slippery floors were selected throughout the building.  Railings at multiple heights are available on stairways.  Every exam room in the building has exactly the same layout, so that providers always know where to find the supplies they need.

- Infections: Chairs were selected with the minimum amount of creases in the material, because those creases are where germs live.

- Patient Flow: The building layout was designed with the most common patient flow in mind, and patient waits are continuously monitored.  Consequently, the wait times for every step in the process have been reduced.  A current patient noticed the improvement on her first visit.

- Supply Flow: Separate hallways were built for supplies and linen, to keep them out of the patient flow areas.

- Clutter-Free Work Environment: A minimum of equipment is present in exam rooms and nursing areas.  Everything has its designated place (PEEP), and no beds or equipment were loose in the hallways.

- Green Design: The building received a Silver LEED rating, and features many green elements, including a living rooftop.

- First Impressions: A patient's first impression often is their most lasting memory of the organization.  Care was taken to make the entryway and underground parking entrances as aesthetically appealing as possible.

- Donation Integration: In a unique Gene Display installation in the building, donors can write a custom message on one of the "genes".  I'll admit that I got choked up reading the message of a child who wouldn't exist if her mother hadn't been saved at DFCI.

Patient Integration

We were lucky enough to have our visit scheduled immediately before the Patient and Family Advisory Council, and got to meet many DFCI's most involved patients. It was remarkable to hear how patients were involved in all of the building design, from the patient flow and building layout, to the healing garden where patients and staff can rest and relax. Some of the patients had been serving on the council for more than a decade. Janet did admit that while Dana-Farber had been setting a model for the industry in listening to their patients, that they had a distinct advantage as a cancer center, both in their patient makeup and patient loyalty to the organization.  

Career Development

We ended our tour with a brief overview of Janet's career, and she gave us some valuable advice about how to advance our own careers.  She first urged us to keep in touch with our friends from school, because people hire their friends first. She also encouraged us to be aggressive in asking to meet and shadow people in the jobs that we hoped to have.  Lastly, she modestly tried to impart that her job was really not that difficult, although I think that's she's just too humble to take credit for a remarkable career.

During our whole tour, and also while Janet was telling us about her background, I was reminded that one of the most important roles of a leader is storytelling.  To create and sustain a vision, it's essential to have stories that explain the organization's goals in meaningful terms.  Janet spoke almost exclusively through powerful stories, and I think that's part of what makes her such a great communicator and leader.  I hope someday to lead as well and have work as meaningful, and regardless of Janet's protestations, I think that's a very ambitious goal.

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As a former thru-hiker (a.k.a. The Fool on the Hill, GA-ME '98), this brought back some serious memories.  I could still identify a lot of the places.  He missed out by not taking any pictures of the shelters though!

[keithmarple-blog]

The Essence of Self-Leadership

This will be the first post in what I hope to be a continuing series about the most important concepts that I've learned in business school.  Title ideas anyone?  I'm hoping that reviewing these concepts will be helpful for others, but I'm also trying to ensure that I don't forget these big ideas as quickly as I learned them.

One of the encompassing ideas I've learned at business school is that before you can lead others, you must have a strong understanding of yourself.  A confident and successful leader is a reflective leader, someone who knows who they are, where they are going, and where their contributions fit in the larger mission.  This is the concept of self-leadership.

Self-leadership begins with a clear understanding of your values.  What are the values that determine your choices in life?  What really matters to you?  In class we have used a couple of exercises to attempt to suss these out, including taking a broad list of values (family security, recognition, friendship, wealth, etc) and winnowing them down to a personal core.  What was most helpful for me was to draw a career satisfaction timeline, charting my personal fulfillment over time.  Looking for trends, I noticed that the best times in my career have been the periods of challenge and personal growth.  

But it's amazing how often these core values can be conflicting.  For instance, my desire for personal growth and development, and the subsequent decision to go to business school, are in direct conflict with my precious work/life balance (read: time with the kids).  A reflective leader understands him/herself well enough to ensure that their decisions are well-aligned with their personal motivations.

So a leader's values are the fundamental building blocks of his/her character.  But how can a leader rally others to work towards those values?  Kouzes and Posner argue that a leader must find the shared values of their team, and then set the example for their team.  Personify those values.  Show others how much you care about your beliefs.  Leaders set the social norms for their teams by showing with their actions what they truly believe is important, for better or worse.  

But setting the example doesn't just mean always working hard and being honest. Goleman et al. posit that teams also take their emotional cues from their leader, and further that a team's productivity is a direct result of their shared emotional state.  If a leader is negative, unsure, or abusive, this will be reflected in the team's mood - and results.  Conversely, if a leader consistently exudes positivity and confidence, the team will follow suit.  

This makes it imperative for a leader to be aware and in-control of their emotions. This skill is known as emotional intelligence, and while difficult to master, it can be improved with practice.  Awareness and control of one's own emotions may be the most difficult aspect; they're a natural, physiological reaction.  The key to controlling strong negative emotions is to step away - a break will let the "spike" of emotion pass and the reason can take over again.  

An effective leader not only knows his own emotions, but is in touch with the emotional temperature of his team.  I've never felt that this was difficult - it's the rare person who doesn't display their emotions across their faces.  The tougher part is saying the right things to change that mood.

Recently I've been experimenting with these self-management techniques in my own leadership role in our health sector student organization.  Although I've been incredibly pleased with the progress we've made as an organization and the events that we've hosted for our membership, I noticed an emotional disconnect with my team.  It's totally understandable - they're graduating, job searching, moving - school is starting to feel a lot less important.  

So I've made a conscious effort to do two things during our regular meetings: bring a high level of energy, and spend time reconnecting our work with a larger vision, and defining that vision as a team.  And the effect on the mood is palpable; the team gets excited, new ideas are generated, and the team re-engages.  The one time I didn't put in the prep work to think about my emotional message, I immediately regretted it, and vowed not to hold another meeting without addressing the larger vision.

And in the end, I think that's the essence of self-leadership: the constant struggle to define, and then embody, the best leader and person that you can be.

Related articles

How To Increase Your Emotional Intelligence (lockergnome.com)

Emotional Intelligence Predicts Job Performance, Study Shows (physorg.com)

[keithmarple-blog]

Recalled

Intel recently issued a recall for the motherboards for its new Sandy Bridge chipset, and I've been hit twice.  I just built a new PC for my parents to replace their dying one.  They'll be without a computer when I rip their faulty mobo out of their PC, send it back, and wait for a replacement.  And my current desktop needs a new mobo, but because motherboard manufacturers learned of the recall at the same time as consumers, so there are currently very few available on the market and no high-quality ones expected until April.

But what struck me about this situation was how poorly Intel handled it, and how little thought was given to its customers.  The people affected by the recall are Intel's core consumer base: high-end early adopters.  Read that announcement again.  Not one mention of their customers; only how Intel's first-quarter profitability will be affected.  Not only that, but Intel never once expresses remorse about how its customers will be affected.  Weeks after the initial announcement, customers were told that they were being thrown on the mercy of their individual retailers.

This lack of concern for customers and partners does not surprise me, given the market dominance that Intel has long enjoyed.  It's easy to lose sight of your customers when there's no major competition.  But it will be interesting to see if the CPU giant is ripe for a fall with new Davids entering the market.

[keithmarple-blog]

The future of healthcare.