Salmon Upstream, LLC

Developing and implementing real-world community solutions.

For-profit Media…in the best possible light (Injustice Exposure, Episode 4)

Even with our tremendous new methods of connectivity, any search for the truth has to be undertaken with an open and properly shaken can of skepticism.

“You can’t trust the media.”
Even with our tremendous new methods of connectivity, any search for the truth has to be undertaken with an open and properly shaken can of skepticism. The old wisdom, “consider the source,” is often difficult at best; and it is impossible to fully appreciate the influence of money, even when things are presented to the end user as unbiased and completely noble in purpose.

I want to share with you an example that I hope will help demonstrate my point, because it is an example of for-profit media at its best: the national ranking of cancer centers. This is a very American method – competition – of encouraging peak performance in an absolutely critical arena. Competition drives progress, and We the People have a right to know who is best. What could possibly go wrong?

It was almost exactly a year ago: Tuesday, January 24, 2017. As we were finishing our multidisciplinary lung cancer conference, one of our radiation oncologists complained to me that a patient had pulled up our ranking as a cancer center in US News and World Report while sitting in the waiting room. When he saw that we were given a score of 23.5 out of 100, he decided that he should go elsewhere for his treatment. And so he did.

A bit of background: 99.999% of people in the healthcare profession, from the top to the bottom, are incredibly passionate about what they do. (Unfortunately, you read about the 0.001% of shmucks who give the rest of us a bad name, but that’s another issue all together…) So when this guy walked out because US News essentially said we suck? We went ape shit.

First, we pulled the ranking: (it’s here).

And then we started diving into the details. And I started making phone calls.
By mid-morning, I managed to get Ben Harder – the head of medical reporting for US News and the guy in charge of organizing the ranking system – on the phone. And I gave him a bit of constructive criticism. Which is a way of saying that I gathered up the collective anger and frustration that all of us at the cancer center felt while struggling to deliver the best care to our patients in a world of increasing (misguided) regulation and legislation, wadded it into a somewhat abrasive ball, and stuffed it up his proverbial ass.

And then I told him that he needed to remove us from the rankings. Like now. Because here is the reality: no matter the intentions, he is involved in patient care. People are quite literally making treatment decisions based on this information. So if that information is not accurate – even if it is interpreted incorrectly – then what they are doing is very wrong. A guy walked out of an office and chose a different plan. That’s real.

This is part of his email response to me (you better believe I saved them all):

“Your patient’s care is most important. You described your patient being concerned about the 23.5/100 score that Centra Lynchburg General Hospital received in Cancer, so please let me first address what that score represents. The score was correctly calculated using the data and methods described in detail in the Methodology Report for the 2016-17 Best Hospitals: Specialty Rankings. Importantly, 23.5 is *not* a bad score. In fact, only about 600 hospitals out of more than 4,000 acute-care hospitals nationwide scored higher. Most hospitals don’t even meet our rigorous criteria (as described in the methodology report) to receive any score at all. Please feel free to share this information with your patient if you feel it would help him or her make a more informed decision.”

I tried to explain that most patients aren’t going to see a 23/100 as a good score no matter how you slice the bread…that didn’t work.

I did my homework and read the criteria they use (the link is there if you are having some insomnia). Straight away, I picked up a problem: a third of the ranking of cancer centers is based on whether or not you are accredited by the National Institute of Health (NIH). We are not a teaching hospital, and the NIH only credentials academic centers. We are accredited by the Commission on Cancer. So we took a 33 point hit for being exactly what we are.

I also reached out to a friend that sits much higher in the world of cancer care than I do, and got confirmation of a notion that for years had been threatening my inner sense of right and wrong: it’s all a business, both sides. US News has built a reputation for these rankings, and because people will respond to them, businesses – including top academic medical centers – play the game. Very seriously.

Example: at one time, a ranking criteria was the percentage of staff at the hospital that had LinkedIn accounts. So the administration simply mandated that all physicians create LinkedIn accounts. I doubt seriously that a patient dying of pancreatic cancer (since none of us at any level have good therapeutic options) gave a happy crap that their doc was “connected”.

I will give credit to Mr. Harder for taking the time to talk to me, and for taking me seriously. I invited him to come and tour our facility, to get a better understanding of the impact on a place like ours (they are just a few hours north, and I offered to pay his airfare out of pocket). Maybe if he could see what he was doing, he would be inspired to do things differently. But I don’t think he ever really got it, nor was he in a position to make any meaningful changes. Let’s face it, US News and World Report is not going to stop doing things like rating colleges and hospitals. It is their business, it sells copy, it is one of the ways they make money. If he tried to rock the boat, they would just dump him in the water and find someone else to write the story.

But this is the press – the free press, mind – at its best. And we are not going to tell them they aren’t allowed to rank hospitals. But if there are real issues here, why on earth will we continue to use the same system in a way that is dramatically more dangerous (elections) for a system that is dramatically more important (the government)???

But I am off on that tangent again…

Maybe you are thinking my complaints aren’t valid, or that the magnitude of the issue is relatively small. I think if you understood how much is done by any healthcare entity – I don’t care if it is a single-provider doctor’s office or the Mayo Clinic – to attract patients…things with limited or no genuine improvement in health, the time and expense… you might think differently. I shouldn’t have to remind you that healthcare is continuing to get more expensive, and complexity is a major if not the number one contributor to rising costs. It is hard to get your head around how much money is consumed in the complexity of delivering healthcare, and I am not talking about complex treatments. I mean paperwork, regulatory agency box-checking, bureaucratic red tape, the incredible amount of time that is wasted. And time is money. Especially if it is cardiothoracic surgeon time.

There is really only one way to change how we behave: money. I used to think it was money or regulation, but if you try to change us with regulation, we just figure out how to game the system and it all comes back to money (see Obamacare). But that doesn’t mean we can’t fix the system, you just have to understand the rules of the game instead of trying to pretend something else will work.

If we want to change the way we care for cancer patients, we have to build a system that makes those changes financially beneficial to the administering entity. Because cancer centers use accreditation and rankings as means of attracting patients, the trick is to get those accreditation and ranking systems to insist on better cooperation with rural centers. And that’s exactly what we are going to try to do. First, we are completely restructuring ourselves and how we deliver care here. Next, we will build those cooperative processes with the centers we use for our specialty care. And then, we will see if we can have those systems become model for the rest of the country. And not just for community care centers like ours, but the large academic centers as well.

Start local, lead by example, national impact. There is no part of the plan that isn’t worth the effort.

And then US News can chew on that for a bit.